In this segment we are going to discuss the neurofunctional acupunctural blueprint for the treatment of lateral epicondylar problems. We will avoid the terminology epicondylitis because of in time, epicondylantia, which is a pure descriptive term, is more appropriate and there is no demonstrable inflammatory component. Therefore we’ll remain faithful to that terminology.
Lateral epicondylar pain or lateral epicondylantia.
The first blueprint we always discuss is our general neurofunctional blueprint with a local [opera-forensic mental] input, an axial or a spinal-segmental input and extra-segmental input.
The elbow region and associated functional areas can be described anatomically as included joints of the elbow, the joints of the carpus that move the wrist and also it can include the joints of the glenohumeral region and the whole shoulder girdle, as that is part of the mechanics of the arm. From the neurostructural perspective that we always use to select the local input, we can start the analysis of the problem as usual with neurofunctional perspective movements that are involved in the pathology in the presentation of the problem. And they include flexion, extension, pronation, supination, as well as wrist dorsiflexion which involves carpal - radio-carpal joint as well as mid-radio-carpal joint.
So there, a good number of joints involved since pronosupination requires a coordinated action of three joints, the radio-humeral, the superior radioulnar and the inferior radioulnar. And therefore the complexity of the biomechanics of the elbow is sufficient to make the approach quite complex despite the reduced physical size of the area. Humeroradial joint, proximal radioulnar, distal radioulnar, radiocarpal and midcarpal, those would the most important joints.
And regarding the muscles that provide the motion for these joints will include muscles that go from the humerus to the radius or the ulnar, sometimes even from the chest wall as the short head of the biceps or the scapula as the long head of the biceps. And those go from there to the radius and the ulnar. So we have physical linkage between the three segments, the three mobile segments of the upper extremity, and that makes the elbow a unique functional area, anatomically and neurologically.
The muscles therefore are involved in elbow flexion. We have brachialis and biceps. We have elbow extension, mostly a function of the triceps and the inconnus, and then we have flexion on neutral pronosupination, function of the brachioradialus and the extensor carpi radialis longus and we have a number of muscles that provide the motor activity for wrist dorsiflexion, namely, apart from the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor digitorum, the extensor digiti minimi and extensor carpi ulnaris. Those would be all muscles acting on this joint and attaching anatomically on the lateral epicondyle of the humerus, which is the usual area for the pathological, pathomechanical changes at the structural level. Although in a neurofunctional model we are very concerned about the involvement of the many nerves that participate in the innervation of those structures.
But at the patho-physiological level it’s important to point out that oftentimes we find degenerative tendinosis at the attachment of the common tendon that occurs at the lateral epicondyle, and this common tendon involves the extensor carpi radialis brevis, the extensor digitorum represented here, the extensor carpi ulnaris underneath the extensor digiti minimi. So those four muscles, and we also have one of the two origins of the supinator. This is all taking place at the lateral epicondyle, so no surprise with such an array of different muscles pulling from that area, that irritation and inflammation acutely, and then a chronic inflammatory infiltrate is common. However, the symptoms as usual occur because of the nerve involvement and the important thing to know is which nerves supply these muscles and which nerves supply the joint. The joints are supplied by two sources by the cutaneous branches that innervate the skin that covers the joint and by the motor nerves that innervate the muscles that move the joint.
In this case, the cutaneous innervation we have represented here. This continuous yellow nerve is the posterior antebrachial cutaneous is a branch of the radial nerve - cutaneous branch of the radial nerve. We also have represented here as a solid line the muscular cutaneous nerve, terminal branch, which is the lateral and the brachial cutaneous nerve. So we have two cutaneous branches, sometimes overlapping in the territory. And those two, as they cross the joint, can give off articular branches. So we can act on the tranco musculocutaneous nerve higher up on the arm between the biceps and the brachialis. We can even go to the coracobrachialis on the anterior aspect of the shoulder. Once again, their anatomical connections between the shoulder and the elbow.
We have represented here also the most important nerve in this pathology, which is the radial nerve. The [tranco] of the radial nerve, after passing along the spiral groove, it pierces the lateral septum and goes lateral to the biceps and the brachialis and here gives off several branches for the muscles that attach above the lateral epicondyle, the brachioradialis, the extensor carpi radialis longus, and then the nerve branches into two terminal branches. The first one, the motor branch, is the posterior interosseous nerve, approximately three finger breadths distal to the lateral epicondyle. They are at the level of the supinator. Between the supinator and the extensor al carpi radialis brevis is the arcade of Frohse, and there the nerve passes and pierces that space and continues as the posterior interosseous nerve all the way to the carpus, innervating all the extensor muscles of the wrist, and then providing articular branches for this joint. Therefore it’s an extremely important nerve. There is weakness typically of wrist dorsiflexion, sometimes there is inability to full extend the fingers when there’s an involvement of this nerve. So we need to involve this nerve and this will become the number-one input in neurostructural treatment of lateral elbow pain.
The second branch of the radial nerve we’ve represented here along the medial edge of the brachioradialis and continues along the radius to innervate the dorsum of the V of the hand over the first and the second metacarpals, which are represented here by these branches over the first interosseous dorsalis muscle. Therefore, radial nerve is the master nerve of the lateral epicondylar problems and we can not only reach the nerve distally, as we can do here at the first interosseous dorsalis, the cutaneous branch, we can reach the nerve in different insertions that we’ll discuss in a minute over the lateral aspect of the forearm.
But we can also go to the proximal aspect of the limb and get the radial nerve as early as its exit under the teres major and before it dives deep to the long head of the triceps and then to continue deeper against the humerus along the spiral groove. We can get it here at the septum where the nerve pierces the septum, so therefore whether we analyze the problem from an articular perspective, a muscular perspective or a neurological perspective, all points towards the radial nerve and specifically towards the posterior interosseous nerve. And structurally everything points towards the extensors, the common extensor, the extensors of the wrist. There are four movements of the hand involved and are important. And also everything points towards the participation of the supinator and the antagonistic muscle, which is the pronator teres. So we need to include in the treatment the stimulation of the median nerve, whether directly over the tranc or at the pronator teres.
And here we have a list of the nerves we just discussed, the radial nerve, tranc, or the posterior interosseous nerve, the median nerve for the pronator teres, if we decide to go there, and then the cutaneous branches, the posterior cutaneous nerve of the forearm, the lateral antebrachial cutaneous nerve branch of the muscular cutaneous. With this we are well equipped and we have numerous insertion sites that I will discuss one by one in a second. Then, the addition of the spinal segmental level in the treatment, the axial input, will involve the C5, C8 segments, which they go from the shoulder, C5, C6, C7, C8. We could even include T1 because of the wrist extension. So those would be the segmental somatic levels. Therefore we will go to those vertebral levels and will stimulate the posterior primary rami at these levels. And then the segmental reflex vascular sympathetic level at the T1, T5 we can add a couple of needles bilaterally in order to facilitate the modulation of the sympathetic nervous system at these levels.
From a practicalist standpoint, this treatment being confined to a limb, to an extremity, is easier because we can position the patient as is being done here, exposing most of the area that we need to access and then we can proceed with a blueprint that touches the most relevant neurostructural levels we just described. Depending on the history, depending on the findings we will favour a little more one approach or another, but basically we are going to have to address a radial nerve territory to matter what.
One specific intervention that we may need to include at some point would be the treatment of trigger points, or tight bunts that may have developed associated with this muscle, particularly the extensor carpi radialis brevis. So sometimes we can find a very tight, tender snappy band here and we can use one of the techniques that we have to deactivate these trigger points. The in-line technique, where we will put four needles on the tight band and then connect electricity cross two-and-two needles and put electricity and make the muscle fatigue, contract and finally relax. We can also use a two-needle technique, another good technique to deactivate trigger points, in this case we have two electrodes to the two needles that go into the trigger point, and it’s been proven to be empirically a very effective technique to deactivate trigger points with no known reason why two needles would work better than one with electricity. But it seems to work better.
These are special interventions as well as tenoperiosteal [packing] at the attachment of the common extensor to stimulate the local cellular activity, which is a technique now improved further by certain practitioners who have - who use a galvanic current through the acupuncture
needle and the guided ultrasound and proceed to electrolize the tissue, the chronic inflammatory infiltrate on the lateral epicondyle, which allows then the neovascular activity and the new regeneration of the cells. Sometimes this technique has been combined with injection of growth factors or local cytokines and other structures that are going to stimulate cellular growth.
Sometimes injection of plasma - extract of plasma or PRP injections have been utilized for the same purpose. So there’s a strong local component all located on the lateral epicondyle.
Sometimes I’ve used the two-needle technique right on the epicondyle with a frequency ranging from 2 Hz to 125 Hz. Every ... of these interventions is an attempt to modify the stagnant cellular activity, which is the representation of the chronic inflammatory infiltrate. There is no regeneration, there is no positive cellular changes, just a chronic inflammatory infiltrate with low-quality granulation tissue and no proper vascularisation.
And that irritates, changes the biochemical environment, irritates nociceptors on some of these structures, periosteum, tandems - capsule of the joint and dad nociception makes the brain produce inhibition of these muscles and therefore produce the functional incapacity that is the structural-neurological connection between these elements. The good news is that restoration of normal neuromotor function by itself can reduce the processing of nociceptive signals and the spinal cord decreasing the dysfunction and the symptom.
So let’s see how we can execute a blueprint treatment for a lateral epicondylar problem. I would prioritize the radial nerve over other structures. Therefore I would always try to the posterior interosseous nerve. I would landmark at the lateral epicondyle and then I would go about three fingers breadth and then try to reach the nerve between the extensor carpi radialis brevis and the supinator. Definitely we may have [touched] a cutaneous branch ... is that burning a little bit, or?
Okay, we can always use the monopolar stimulator to check whether what we’ve had is contact with a nerve. Is that too strong? Let’s re-position because our goal is always a painless needling, and since I want to electrically stimulate this needle I need to be very comfortable. So I will double-check. Is that better now? Okay, and we’ll leave it there.
As the goal, the main goal in any treatment, acute or chronic, is always the modulation of sympathetic activity, one of the first needles - perhaps the first or second one should also go to the distal insertion on the dorsum of the hand where we can modulate sympathetic tone. The traditional large intestine 4 here, and the mid-level of the shaft of the second metacarpal in the belly of the first interosseous dorsalis. Again, this is a radial nerve territory ... and is also the motor point of the first interosseous dorsalis. Not a favoured insertion because it could be quite tender, so I’m going to reposition the needle. Let me know if that’s better there.
So I’m just repositioning the needle, maintaining appropriate stabilization of the area and proof positive that we need to be very gentle on our technique, since a neurofunctional approach we don’t want to trigger more nociception. We are trying modulate nociception, therefore we need the insertions to be comfortable, okay? So we’ll leave it there. It is well on the belly. That’s fine.
This one can be documented as a posterior interosseous nerve insertion or as a large intestine 10 prime. I will refer the traditional insertion sites but in our methodology we are targeting specific nerves.
Now it would be useful to include some of the structure that had been innervated by the radial nerve above the posterior interosseous’ independent existence. And those include the supinator muscle, the extensor carpi radialis, longus, brevis and the brachioradialis. All those muscles have been supplied by branches that are above the elbow, therefore if we believe that there is an involvement of the supinator, as commonly is the case, then we must go to the track of the radial nerve approximately, or to the supinator muscle directly here on the lateral aspect of the elbow distal to lateral epicondyle. The supinator has a double origin. The supinator at the ulnar crease - supinator crease of ulnar at the lateral epicondyle and at the radial humeral - radial ligament.
And from there it goes over the radius to attach on the other of the radial so it’s able to pull the bone and roll in it, and producing that supination. It’s a very particular arrangement of the fibres of the supinator. It’s relatively simple then to reach it, so we can use the ulnar as a landmark. We can go from the ulnar towards the radius, and before we reach the radius, or as we reach the radius there, we should be on the motor point of the supinator. It’s a shallow insertion, there it is.
And there it is. I felt the muscle jumping. We had a twitch response. That is the best possible corroboration of what we’re doing.
I will very briefly put a very gentle electrical stimulation just to feel the muscle jumping. I feel it under my finger and that’s enough to confirm that I’m where I need to be. We can do these needle one by one with the monopolar stimulator or, since we need a fair amount of stimulation, as it’s trying to achieve changes in a chronic condition, then we will be better off using the regular stimulators. And here we can connect distal points with some of the promixal points. As discussed elsewhere, the connections just represent an intention and a polarity. So the intention is to pass electricity through the affected area. The polarity of the human body is negative more distally than proximally.
I would to cross the joints. I would like to have something above the joint for that connection, and then I would like to connect this area with something that radial nerve tranc proximal, and that way we are crossing the area twice, at least with the cables. In actuality, electrons are going to be deployed from each of the insertion sites. So I will insert a needle on the traditional acupuncture point at small intestine 9 along the triceps - the long head of the triceps. That’s ...
our model is a little sensitive but she has some pathology in the area so there is a degree of sensitization that needs to be expected in any patient with any chronic condition. Therefore it’s a good example of a real live situation and we need to accommodate the technique to the situation.
As stated above it would good to go here just - let’s say the area is quite sensitive, which is the case. We don’t want to go in this case directly to the radial humeral joint, which we could in another situation. Instead, we are going to just try to intercept that the tranc of the radial nerve as the radial nerve goes from posterior to anterior, pierces the septum. And then I have something for my distal needle, and then I can use the other circuit as a bridge between these two ... and the tranc of the radial nerve. That’s too tight?
Okay, so we can select one of the two there and then we can add more electricity if we need to do so, but this represents what we’re trying to accomplish. We are passing electricity along radial nerve territory. We’re passing electricity along the physical location of the most common [estrecal], the mention of the problem, which is the lateral epicondyle, the common extensor
tendon, and we are involved in the radial nerve from the posterial aspect of the shoulder. We could - we’ll leave this here as the example. We’ll use our model here. We could equally try to reach the joints by going to the anterior aspect of the radiohumeral joint, traditional insertion side along 5, which is located along the medial border here of the brachioradialis at the level of the antecubital fossa, is the trajectory of the - both the musculocutaneous nerve, the terminal branch, the lateral antebrachial cutaneous nerve, and deeper, the radial nerve. So it’s simultaneously - it’s
tendon, and we are involved in the radial nerve from the posterial aspect of the shoulder. We could - we’ll leave this here as the example. We’ll use our model here. We could equally try to reach the joints by going to the anterior aspect of the radiohumeral joint, traditional insertion side along 5, which is located along the medial border here of the brachioradialis at the level of the antecubital fossa, is the trajectory of the - both the musculocutaneous nerve, the terminal branch, the lateral antebrachial cutaneous nerve, and deeper, the radial nerve. So it’s simultaneously - it’s