Tui Na in Clinical Practice

by Bob Flaws, Dipl.Ac., CH

The Tuina Treatment of Tennis Elbow

In 1982, I was studying acupuncture at the Shanghai College of Chinese Medicine and working as an intern in the acupuncture department at the Long Hua Chinese Medical Hospital. Sometimes, during the heat of the summer, there were not that many patients to see in the acupuncture ward, so I would wander through the hospital to see what else I might learn. As a graduate of the then-Boulder School of Massage Therapy (BSMT), I had practiced massage for several years prior to studying acupuncture. Thus, I was immediately fascinated by what I saw when I discovered the tuina, or Chinese medical massage, ward.

The movements I witnessed were unlike anything I had learned at BSMT. I was especially enamored of the idea of specific protocols lasting 15-30 minutes for the remedial treatment of specific conditions. Therefore, I arranged to study tuina the following year and to work as a tuina intern at the Yue Yang Chinese Medical Hospital, also in Shanghai. Eighteen years later, I am still as enthusiastic about tuina as I was then.

Below is the tuina protocol I learned for the treatment of tennis elbow. It is based on the rolling school (guan fa pai) of tuina popular in Shanghai founded by my personal teacher, Ding Ji-feng.¹ Dr. Ding had been practicing this method for over 50 years when he taught it to me.

Western Medicine and Tennis Elbow

Lateral epicondylitis, also called tenosynovitis (and more colloquially, tennis elbow), consists of inflammation of the tendons attached to the lateral side of the elbow at the epicondyle of the humerus. Patients with tennis elbow experience pain in the lateral aspect of the elbow, which may radiate into the forearm, and occasionally into the hand. The pain occurs with grasping activities and may be accompanied by a sense of weakness. An achy discomfort may also be present at rest or at night after activity. This inflammation may be caused by a sudden violent injury, repetitive strain or microtrauma. Tennis elbow occurs equally in men and women and is most commonly seen in patients between the ages of 35-50. Tennis elbow is found not only in tennis players, but in baseball players; swimmers; carpenters; plumbers; meat cutters; musicians; or anyone who repeats an arm motion over and over.

The Western medical diagnosis of lateral epicondylitis mainly consists of physical examination of the affected area eliciting abnormal tenderness to palpation over the lateral epicondyle. X-rays may show calcium deposits on the lateral epicondyle but are not typically required to make this diagnosis. Bone spurs only occur in 20% of tennis elbow patients. The Western medical treatment of tennis elbow mainly consists of rest, anti-inflammatory medication and the application of ice. This is supplemented by stretching and strengthening exercises; straps; wrist braces; and cortisone shots. Surgery is indicated in approximately 5% of cases when all of the above measures have failed over a course of several months and pain continues to prevent activity. The success of tennis elbow surgery is generally 85-95% excellent relief of pain.² However, patients typically require 3-6 weeks of recuperation before returning to work, and several months before returning to sports or heavy use of the arm.

Chinese Medicine and Tennis Elbow

Chinese disease categorization: Tennis elbow is called zhou lao (elbow taxation); zhou tong (elbow pain); and shang jin (damaged sinews) in Chinese medicine.

Chinese disease causes: Taxation detriment with possible contraction of wind cold evils.

Chinese disease mechanisms: Overwork taxation causes detriment and damage to the sinews and vessels of the elbow. On the one hand, there is insufficient blood to nourish the sinews; on the other hand, there is blood stasis obstructing the free flow of the vessels. This may be complicated by external contraction of wind cold evils due to defensive qi vacuity.

Treatment principles: Soothe the sinews and free the flow of the network vessels; quicken the blood and transform stasis; regulate the qi in the channels and vessels.

Treatment Method

1. Apply rolling technique from the shoulder down to the elbow for 5-10 minutes.
2. Press and knead the local area of the elbow while performing range of motion passive movement of the elbow joint. Increase pressure gradually on any a shi (i.e., painful) points, paying special attention to qu chi (LI 11) and shou san li (LI 10). Also try to separate any fibrous tissues with the thumb of one's dominant hand.
3. Flex and extend the wrist joint with one hand while holding the elbow in the other.
4. Chafe the lateral side of the elbow with a medicated liniment or ointment until the local area is very warm to the touch and the patient says it feels hot. Because tennis elbow is due to microtrauma, especially in patients whose qi and blood have begun to decline due to aging, and is often complicated by external contraction of wind cold evils, such external liniments are primarily made from acrid, warm, qi-moving, blood-quickening medicilans suitable for wind cold impediment problems.
5. Use the rearranging method on the fingers, and rub, knead and shake the hands.
6. Rub/roll the whole arm from shoulder to hand.
7. Ask the patient to keep the elbow immobile for at least 24 hours.
8. Repeat this treatment every other day until the pain subsides (typically 3-6 treatments).

Other adjunctive measures may include the use of moxibustion locally on the elbow (either indirect, roll moxa or direct, non-scarring, "grain of rice" or thread moxa), or warming with a TDP heat lamp.³ Internal administration of Chinese medicinals based on the patient's individual pattern discrimination is also quite helpful.⁴

To get a satisfactory result with tennis elbow, the patient needs to refrain from all activities, be they work or play, that aggravate the condition. Until or unless the patient is willing to allow the inflammation of their lateral epicondyle to heal, no amount of tuina or Chinese medicinals is going to get a satisfactory effect. If the cause of this inflammation is work-related, the patient should be advised to modify their equipment or work habits. This may mean using a lighter hammer or tennis racket or seeking professional advice from an ergonomic specialist or kinesiologist.

While ice is indicated within Chinese medicine for recent traumatic injuries and acute inflammations with redness, swelling and palpable heat, it is usually contraindicated for tennis elbow. Even though Western medicine defines lateral epicondylitis as a species of inflammation, it does not usually present heat signs and symptoms according to Chinese pattern discrimination. In fact, given the common age range of patients with tennis elbow and its Chinese name, elbow taxation, this condition is usually a vacuity condition complicated by cold and/or blood stasis, all of which may be worsened by the application of cold. This is why the external application of warmth is usually so important for the treatment of this condition.

In my experience, both in China and the U.S., tuina is definitely an effective therapy for the remedial treatment of tennis elbow.

Reference:

1. The rolling method school of tuina developed out of the Yi Zhi Chan Fa Pai (The One Finger Zen School). Dr. Ding had learned yi zhi chan fa from his father. The yi zhi chan technique is a method for treating individual acupoints. Based on similar wrist mechanics, Dr. Ding developed a series of other techniques for treating larger areas of the body. The hallmark of this school is its primary emphasis on guan fa (rolling technique), whereby large areas of the body are treated with the medial-dorsal edge of the hand and wrist using a specific rolling motion. Once properly trained, this technique can be done for hours with little stress, yet it is deeply penetrating, and strongly moves the qi and quickens the blood.
2. McFarland E, Curl LA. Patient Guide to Sports Elbow. Johns Hopkins Sports Medicine, p. 4.
3. TDP lamps are a type of heat lamp manufactured in China and sold by American acupuncture suppliers. These lamps combine radiant heat therapy with electromagnetic radiation. They are very popular with acupuncturists in China and North America.
4. When treating tennis elbow with internally administered Chinese medicinals, the main pattern is qi and blood vacuity with wind cold impediment. For more information, see: Flaws B, Sioneau P. The Treatment of Modern Western Medical Diseases with Chinese Medicine.