Tennis Elbow Everywhere!
Dr A Breck McKay,* General Practitioner, Carina, Brisbane
Introduction
E
picondylitis, or more correctly
epicondylalgia or tendinop-
athy, frequently presents to
primary care physicians, who either
manage it by evidenced-based meth-
odology or respond as taught, by re-
ferring to rheumatologists or orthopae-
dic surgeons.
The actual cause and pathophysiol-
ogy are still controversial and the treat-
ments are equally varied. 1, 2, 3
The conundrum is compounded by
incorrect terminology, because there
is no inflammation identifiable. It is
considered a localized pain problem,
rather than part of a whole body re-
sponse to injury or potential injury.
How can it be a whole body problem?
Professor Ivan Pavlov identified the
Orienting Response and conditioned
reflexes in 1904-10, when he described
the whole dog responses to combined
internal and external stimuli.4 Dr Edward
de Bono modelled the establishment of
brain patterning as an explanation for
how learning occurred with continu-
ous modification, reinforcement, or
removal of those patterns, as time and
multiple inputs occurred.5 Melzack and
Wall published the Gate Control Theory
of Pain in Science in 1965 and the
elucidation of the mechanisms detail-
ing the neural and chemical pathways
was summarised in The Lancet in
1999.6 McKay and Wall7 linked these
concepts to explain how the whole
human body responded as a single
functional entity at all times and not as
isolated systems, organs, or tissues
which interrogative medicine has de-
fined.
McKay8 then modelled the whole
body learning process as a continuum
from birth to disability/death as parallel
survival-function and pain pathways,
with chaos theory assisting to explain
how the whole body-brain function
occurs and manages the complex in-
puts at conscious and sub-conscious
levels. This allows total management of
all afferents and efferents of the nerv-
ous/endocrine messaging system (Fig-
ure 1) with minimal conscious level
consideration except for the most im-
portant inputs.
Most of these cortical and sub-cor-
November 2005
tical efferents pass via the efferent
vestibulo-autonomic postural control
mechanism and affect not only the
injured tissues (such as tendon attach-
ments), but activate local tissue
perfusion resulting in secondary swell-
ing and further pain perception as
“spreading pain” around the tendon
attachment damage.
Perhaps these efferent autonomic
effects on the peripheral vascular sys-
tems give rise to the neovascular for-
mation and neoneural budding as part
of the body’s self repairing process,
described by Alfredson et al9 and the
referred autonomic controlled, periph-
eral vascular effects to disc injury as
described by Takahashi et al.10, 11
These models might be used to dem-
onstrate epicondylitis as part of a whole
body response, via peripheral sen-
sory-mechanoreceptor afferents, spi-
nal motor reflexes and midbrain
vestibulo-autonomic-postural efferents
causing perceived local swelling, with
changes in the muscular ability to
respond as the negative feedback
counters activity and results in cre-
scendo epicondylar tenderness and
arm/forearm system dysfunction, with-
out inflammation.
Such models may also show how
many other clinical presentations in-
volving muscle, tendon, fascia, or liga-
ment attachments may be better con-
sidered as variations of the described
whole body function/response, and
not the currently perceived series of
localised responses.7
Anatomy and physiology… what
really happens?
The anatomy and physiology of ten-
dons, ligaments, and muscles and their
direct or indirect attachment to bones
at the enthesis, or musculo-tendinous
junction, are well detailed in anatomy
and histology texts. Muscles, tendons,
and ligaments can sustain high length-
wise loadings before they are dam-
aged, but they are less able to tolerate
rotational or cross directional strains.12
An actual tendon may rupture with
little noticeable effect to the whole
body, if supported by adjacent ten-
dons and other tissues, but damage to
the tendon attachment at the enthesis
gives rise to considerable pain, with
reflex whole body and autonomic vas-
cular changes in the damaged attach-
ments, which prevent further injury
and initially facilitate repair. The
mechanoreceptors, thermoreceptors
and the nociceptors are concentrated
in the musculo-tendinous junctions and
in the periosteum at the enthesis.
When muscles tighten under the
influence of A-alpha nerve fibre activ-
ity, the entheses commence feedback
cycles (via the A-delta and C fibres
from mechanoreceptors and noci-
ceptors) to prevent the muscle from
127
Tennis Elbow Everywhere!
pulling out of those attachments or
causing further injury. This feedback
or “wind up” pain6,7,13 acts on the
posterior horn of the spinal cord and
the afferent pathways link to the mid-
brain and higher centres, as well as via
the direct spinal reflex pathway to the
anterior horn motor cells.
This results in conscious awareness
of the pain, and creates autonomic
efferents via the vestibulo-autonomic-
postural pathways (Figure 2). The re-
sultant vascular changes and local
tissue swelling with increased pain
perception at the injury site create an
increasing reflex loss of function from
the activation-feedback mechanisms
described at the affected muscle or
tissues. Ligaments across joint spaces
Figure 3. are similarly affected when over
tensioned and act by feedback to de-
crease any muscle activity that makes
the tension worse (for example, valgus/
varus knees strain the opposite side
knee ligaments, causing pain and dif-
ficulty in standing and walking).
This process results in a whole body
response to “epicondylitis”, which is
really an epicondylalgia or enthesis
dysfunction activating whole body ef-
fects and not merely localized inflam-
matory responses. Management needs
to be directed to the mechanisms of the
whole body functional response and
not merely to the localised perception.7
Treatments consist of injecting local
anesthetic and steroid via multiple nee-
Figure 4.
dling of the painful area, stretching
128 Australasian Musculoskeletal Medicine
exercises, physical therapy, or ultra-
sound. With the injection method, the
clinically separate and combined
mechanism of action of each compo-
nent (needle, steroid, and local
anesthetic solution) has been described
by McKay previously.8
The reduced afferents to the spinal
cord decrease the wind up process in
the posterior horn cell layers, decreas-
ing further afferents via the spinal
pathways to the higher centres. This
reduces activation of the midbrain and
higher centres, and secondary effer-
ent autonomic controls and other ef-
ferent pathway activity decreases,
permitting the previous feed-back lim-
ited muscular function to restore as the
tissues return to the normal state.
Considering all muscle, ligament,and
tendon attachments in a similar light, it
is possible to extrapolate that every
such tender attachment might trigger a
similar wind up problem, resulting in
higher centre efferents which change
the local conditions with swelling and
increased sensitivity. If so, then the
treatment for such tender attachments
might be simple tennis elbow injections
to the identified enthesis or tendon
attachment. These described tender
points are at the entheses and are not
the same as Travell and Simons Trig-
ger Points.1
Clinical observations
From the well-known classical “ten-
nis elbow” injections coupled with the
above whole-body functional analysis,
the author and colleagues identified a
much larger number of similar entheses
and attachments and all have found
that similar needling with local
anesthetic/steroid injections works
well. These injection and stretching
protocols are known to many, and the
following will not be new to some;
however, the whole body explanation
of what happens and why it happens
may be a new concept. It may explain
the whole body response to what at first
appears to be a local problem.
Injection sites resulting in the most
spectacular results have been:
1. The coracoid process (often in con-
junction with rotator cuff injections
to synovial compartments);
2. Lateral processes of the cervical
vertebrae at the origins of the sca-

lene muscle (C 3, 4, 5, 6, 7) (Figure
3);
3. Levator scapulae insertions into the
superomedial aspects of the supe-
rior angle and tip of the scapula(e)
(Figure 4);
4. Attachments of the gluteus medius/
minimus to the top of the greater
trochanter;
5. Medial and lateral, proximal, and
distal ligaments of the knee, often on
both sides (medially for valgus and
laterally for varus deformity) (Fig-
ure 5);
6. Insertions of the hamstrings, both
laterally and medially on the tibia,
and also specifically the gracilis,
sartorius and semitendinosus distal
attachments to the medial aspect of
the body of the tibia at the pes
anserinus;
7. Ligament and tendon insertions
around the ankle joints (for example,
Achilles tendon, deltoid ligament,
anterior talofibular, anterior inferior
tibiofibular, and calcaneofibular liga-
ments);
8. Interspinous ligaments (ISLs) above
and below the spine of any crush
fracture in a vertebral body, such as
occurs in osteoporosis. (The pain is
not due totally to the crushed verte-
bral body as currently described,
but is due mainly to the increased
tension on the ISLs, as the spines
are distracted above and below the
spine of the affected vertebra. This
may also explain why vertebral body
cement reduces the pain of spinous
distraction of the ISL).
Rather than pretending to remember
the anatomy, McKay examines Grant’s
Atlas of Anatomy (open at the relevant
pictures) with the patient to describe
the injections and also to review the
detailed anatomy required to be accu-
rate with such injections.
The most difficult entheses to inject
are the lateral processes of the cervi-
cal spines (Figure 3), but with careful
digital tip palpation lying square in the
lateral position and using 25 G x 30mm
needles and small volume injections
(such as 0.2-0.3 ml of 0.5% lignocaine
3ml/Celestone Chronodose 1 ml), very
accurate bony placement is possible.
The results are most spectacular. Side
effects may include a feeling of being
woozy/off balance (but not vertigo per
November 2005
Figure 5.
se) for perhaps 10-30 minutes after
injection and occasional peripheral
anesthesia along cervical dermatomes.
This is uncommon with the use of small
volumes of dilute injectant and reposi-
tioning the needle tip if paresthesia is
elicited.
Conclusions
Injecting “tennis elbow” or “golfer’s
elbow” (epicondylalgia) is a common
general practice/primary care physi-
cian management. By understanding
the anatomy, physiology, and whole
body functional response7, 8 plus the
mechanism of pain production and
wind up,13 it is possible to use the same
simple intervention at other body sites
where similar “-algia” events occur.
Many patients who have suffered
severe musculoskeletal neck pain and
migrainous headaches are often to-
tally free after very few injections to the
identified tender lateral processes and/
or the posterolateral muscle attach-
ments of the cervical vertebra. The
injections produce surprising and spec-
tacular results. The author can attest to
the simplicity and the subjective effect/
benefit having had his bilateral cervical
(C4, 5, 6) vertebrae injected in Octo-
ber 2004.
Just as any injury/nociceptive input
has to be relayed through the midbrain
to the cortical areas for conscious
recognition, so must any resultant
efferents pass through the midbrain
areas and back to the periphery before
any response can occur. This local-
izes the vestibulo-autonomic- postural
mechanism at the centre of any total
Tennis Elbow Everywhere!
body response (afferent and efferent)
to any external or internal body threat,
and responses rarely occur only at
spinal reflex level.
Ivan Pavlov identified the Orienting/
Focusing Response (1910) and the
formation of conditioned reflexes in
1904, but it was the Reflex of Purpose
(1916) that linked this all together. It
was not until Edward de Bono de-
scribed the pattern formation of brain
function5 that a neuro-physiological
explanation of conscious versus sub-
conscious function was expressed fully.
The advent of the fMRI and magneto-
encephalogram are permitting the defi-
nition of the higher centre pathways,
but the midbrain centres are too small
and complex to yet be examined in
such a manner.
Tennis elbow or any similar strain to
an enthesis or musculo-tendinous at-
tachment can be viewed as a similar
whole body response and the mecha-
nism then becomes simplified and
understood.
Just as Yelland et al14 carried out
double blind controlled trials of prolo-
therapy similar studies are needed to
confirm the above observations and
explanations using the Bogduk and
Masters Matrix.15
Perhaps there are many other medi-
cal presentations which might be bet-
ter understood and managed when
considered as a whole body response,
using similar simple and easier to ap-
ply protocols.
Modern interrogative medicine might
be missing the whole body function in
many clinical presentations by con-
129
Tennis Elbow Everywhere!

centrating on the currently interro- 11. Takahashi Y et al. Neural connection

gated detail or “wood chips” and miss-
ing the whole tree.
After all, health is defined as normal.
One should then ask: How is this clini-
cal presentation different from nor-
mal? Then follow with: How can we
restore health or the normal state?
* mckayabATbigpond.net.au
between the ventral portion of the lumbar
intervertebral disc and the groin skin. J
Neurosurg 1996; 85(2): 323-28.
12. Wall PD, Melzack R. Ligaments and
Tendons. In Textbook of Pain. 4th ed.
Churchill Livingstone, 1999. Pp. 530-31.
13. The Pathophysiology of Pain. North
Ryde NSW: Astra-Zeneca Pharmaceuti-
cals Pty Ltd.

References 14. Yelland MJ, Glasziou PP, Bogduk N et

al. Prolotherapy injections, saline and exer-
1. Travell JG, Simons DG. Myofascial Pain
cises for chronic low-back pain: a
and Dysfunction: The Trigger Point Manual.
randomized trial. Australas Musculoskel-
Part One Chapter 3: 45-102 and Part Three
etal Med 2004; 9(2): 80-87 (first published
Chapter 33: 478. Williams & Wilkins Balti-
in Spine 2004:29(1): 9-16 ).
more, 1992.
15. Bogduk N, Masters S. Musculoskeletal
2. Wall PD, Melzack R. Tennis Elbow or
Medicine tip: The Matrix. Australas Muscu-
Epicondylitis. In Textbook of Pain. 4th ed.
loskeletal Med 2003; 8(2): 118.
Churchill Livingstone, 1999. Pp. 573, 13-92.

3. Hong QN, Durand MJ, Loisel P. Treat-

ment of lateral epicondylitis: where is the
evidence? Joint Bone Spine 2004; 71(5):
369-73.

4. Pavlov IP. Orienting or Focusing Re-

sponse. Lectures on Conditioned Reflexes,
Volume 1, Chapter XI. New York: Interna-
tional Publishers, 1928. Pp.133-35.

5. de Bono E. The Past Organises the

Present: The Jelly Model, Short Term and
Long Term Memory. The Mechanism of
Mind. Simon and Schuster, 1969. Pp. 93-
97, 111-16.

6. The Pain Series. The Lancet 1999; 353.

7. McKay AB, Wall D. The Orienting Re-

sponse and the Functional Whole Human
Body. Australas Musculoskeletal Med
2003; 8(2): 86-99.

8. McKay AB. Pain and Chronic Low Back

Pain: A New Model Part 1 & 2. Australas
Musculoskeletal Med 2004 9(1): 14-25.

9. Alfredson H, Ohberg L, Forsgren S. Is

vasculo-neural ingrowth the cause of pain
in chronic Achilles tendinosis? An investi-
gation using ultrasonography and colour
Doppler, immunohistochemistry, and di-
agnostic injections. Knee Surg Sports
Traumatol Arthrosc 2003; 11(5): 334-38.

10. Takahashi Y, Hirayama J, Nakajima Y

et al. Electrical stimulation of the rat lumbar
spine induces reflex action potentials in the
nerves to the lower abdomen. Spine 2000,
25(4): 411-17.

130 Australasian Musculoskeletal Medicine