Acupuncture case report and evaluation of literature: Acute inflammation of an underlying chronic Achilles tendinopathy.
Submission Deadline: June 1st 2012
Word Count: 2,495
Submitted for MSC level marking. Examination comments highlighted in red.
This case study documents the use of acupuncture for the treatment of an acute inflammation of peritendinous structures, a common problem that presents in physiotherapy clinics. The author explores the current available research and how acupuncture fits into traditional physiotherapy basing treatment on underlying physiological mechanisms. A 37-year-old man with a two year history of chronic posterior ankle pain with a recent exacerbation following a 10km running race was treatment with acupuncture, eccentric loading, ultrasound and manual therapy. After 22 days an 80% reduction in visual analog scale (VAS) was noted and the patient had begun to complete short treadmill runs as tolerated. In this case acupuncture as an adjunct to physiotherapy improved both function and reduced pain scores.
Introduction to condition
Achilles tendinopathy is the most frequently occurring tendnous lesion in the sports setting (Maffulli et al, 1998) and is characterised by pain in the tendon, generally at the start and end of exercise (Vega et al, 2008). The pathogenesis of tendinopathies remains unclear (Abate et al 2009) however is thought to occur in three stages (Fu el al, 2010) as demonstrated in figure one. Tendinopathies are predominatly described as tendinosis, which presents as disorientation of collagen, focal necrosis, and increased prominence of vascular spaces (Khan et al, 1999). This can often be palpated as thickening or nodules within the tendon (Vaga et al, 2007). Acute inflammatory changes in the tendon sheath have also been documented and terms such as tenosynovitis, para- tenonitis, and peritendinitis have been used (Woo et al, 2007).
Figure 1: Stages of tendinopathies
(Unable to show picture due to copyright)
Where was this taken from a as this is copyright so you should cite the origins
Overuse, repetitive strain or mechanical overload to tendons are considered as primary trigger of symptomatic tendinopathy in various regions however pathology is noted in both athletic and non athletic populations (Fu et al, 2010; Almekinders and Temple, 1998;Rolf and Movin, 1997; Astrom, 1998). To review the literature surrounding the authors treatment searches were conducted on AMED, CINAHL and MEDLINE using the key words tendinopathy, acupuncture, achilles, objective measures and eccentric loading. You have not discussed the pathophysiology, aetiology or best practice which was asked for in this section.
The subject was a 37 year old male runner who presented with a two day history of right ankle pain, loss of ROM and tendo-achilles thickening following a 10k running race. He completed the race and had applied ice and had taken Ibruprofen, which he felt had improved symptoms. He felt his symptoms had worsened over the two days, particularly in the morning and he described that putting his heel to the floor reproduced sharp pain (VAS 8/10).
- Six month history of mild discomfort in his right posterior ankle
- Aggravated with running, walking up hill and eased with heat and rest.
- No specific trauma
- Able to weight bear throughout
- No pins and needles were reported and red flags were ruled out.
On initial examination he reported that the pain had reduced to an intermittent dull pain (VAS 5/10) on the posterior aspect of his ankle, which radiated up into his medial right calf. He reported intermittent sharp pain with walking particularly after prolonged sitting. This gentleman has a sedentary role, runs four x 10km weekly and competes twice a month.
Observation: Mild external rotation of right foot with thickening of bilateral Achilles tendons (Right>Left). Moderate reduced weight bearing on right.
Gait: Antalgic on right, pain on toe off for initial seven strides before easing. Stride length short throughout assessment.
Table 1 Range of movement of the ankle joints
|Range of Movement||Right ankle:||Left ankle:|
Muscle Length Tests:
Gastrocnemius; in subtalar neutral (passive): Right = 12° Left = 150
Weight bearing dorsiflexion (knee-wall): Right: 3cm
- Thomas test: Negative Left and Right.
- Heel raise (Bilateral): Reduced weight bearing on right. Able to achieve five repetitions before significant pain ++ and fatigue. Poor control with excessive inversion of right ankle. Single heel raise not tested due to pain.
The Arc sign: Positive right and left.
There was marked tenderness and thickening of both TA (Left = 3.5cm and Right= 4cm- measured 7cm proximal to insertion). Trigger points within right gastrocnemius particularly within the medial head.
Achilles Tendon Palpation test (Maffulli et al, 2003) : Right = VAS 8/10, Left = VAS 1/10.
Patients perception : Calf strain following run.
Goals: To decrease pain when walking and be able to complete short runs within six weeks.
Severity: Moderate Irritability: Moderate Nature: Primary hyperalgesia
Clinical Impression: Acute inflammation of tissues surrounding a chronic Achilles tendon disrepair with associated delayed onset muscle soreness(DOMS) in soleus and gastroc. Also noted was asymptomatic thickening in the left TA’
Clinical reasoning and underlying mechanisms
Morning stiffness/pain, a palpable nodule and pain on tendon loading are suggested clinical markers for tendinopathies (Cook and Purdam, 2008). A history of overload and repetitive strain of the Achilles tendon also fits the diagnosis of an Achilles tendinopathy. Furthermore a positive arc sign and palpation test, which demonstrate high specificity (0.83), also support this diagnosis. The thickening of the tendon suggests pathological changes in the tendon, which can be categorised into Stage 3 (Figure 1), which is indicative of increased nociception.
As this case discusses an acute inflammation of an underlying chronic tendinopathy There is no evidence of inflammation on the pathophysiology of tendon injury ( Khan; Alfredson; Cook) the pain mechanism in question is nociception, which has been described as a ‘…painful stimulus to peripheral tissues, creating a stimulus response relationship between pain provocation and pain experience’ (Bradnam, 2007). Both an inflammatory and mechanical component should be considered and an appropriate rehabilitation enforced to reduce sensitization of the dorsal horn neurons within the spinal cord (Bradnam, 2007). In accordance with the Bradnam (2003) clinical reasoning paradigm points were chosen based on the pain mechanism involved and the clinician hoped to access peripheral, segmental and supraspinal benefits of acupuncture (Bradnam, 2007) at relevant points throughout rehabilitation.
Preliminary evidence of tendonopathies have attributed noiceptive inflammatory pain to unidentified bio- chemical noxious compounds such as glutamate, substanceP , orcalcitoningene-relatedpeptide (CGRP)(Ackermann, 2003; Alfredson, 2002; Danielson et al. 2006). Neural factors such as sensory neuropeptides show that tendinous tissues are supplied with a complex network of neuronal mediators involved in the regulation of nociception, vasoactivity and inflammation (Ackermann et al, 2003).
For this reason local points in the right lower limb were avoided initially to avoid peripheral neuropeptide release, which may have a detrimental, overloading effect leading to increased pain (Longbottom, 2006). Previous research has also shown an increase in blood volume in the Achilles during acupuncture needling (Kubo et al, 2010). Whereas this may be beneficial to treat the DOMS within the gastrocnemius it may increase the prominence of vascular space, which is a characteristic of tendonopathies (Khan et al, 1999). Furthermore one proposed theory of the effectiveness of eccentric loading is the reverse of neovascularisation (Ohberg and Alfredson, 2004). Thus the author prioritised that global pain relief alongside tendon re-organisation though the use of traditional physiotherapy modalities was needed initially.
Previous research has found acupuncture beneficial in the reduction of perceived pain arising from exercise induced muscle soreness (Robertshawe, 2009). This evidence may be useful when considering the treatment of DOMS where ischemia is the main pain mechanism involved however may be limited in validity for treating an Achilles tendinopathy. This study inserted needles unilaterally at gallbladder 34, lung 3 and 5, large intenstine 11, spleen 10 and at tender points that were identified using palpation at 24 hours and 48 hours. With suspected local inflammation of the peritendinous structures over stimulation of local tissue was avoided to reduce further sensitisation of the dorsal horn. Although this study’s external validity is limited due to its small sample size it showed significant differences and acupuncture was superior in reducing perceived pain to both sham acupuncture and control group.
Stimulation of the three gates why not 4 this is not in the segment? (Bilateral LI 4 and left LIV 3) was used to encourage supraspinal effects such as diffuse noxious inhibitory controls (DNIC), beta endorphin mediated descending pain inhibitory pathways (Sterner-Victorin et al, 2002) and increase blood flow to the hypothalamus and the dPAG (Lewith et al, 2005) which are important regions for acupuncture analgesia (Zhao, 2008). Further evidence using fMRI studies have shown activation of these regions through stimulation of LI 4 (Wu et al, 1999), which can be enhanced through longer periods of stimulation.
Segmental effects were utilized by inserting needles onto the contra lateral limb. The bladder, gall bladder and stomach meridans all lie in close proximity to the affected tissue therefore these were targeted. Traditional Chinese acupuncture suggests tendon problems are linked to liver Bi and advises the use of GB 34 and BL18 (Hopwood and Donnellan, 2010) to support local points in this region. Previous rat models have reported strong analgesic effects which may be linked to an increased density of mast cells at these points and one theory suggests that degranulation at these points could be linked to their analgesic effects (Zhang et al, 2008). Adequate sample sizes and the comparison to a control group help to increase reliability of results however a major limitation of this study is the assumption that rat tissue mimics that of humans.
BL 27 was chosen as a segmental points because it lies in the same dermatome as the affected tissue which is? . Acupuncture has previously been effective for the modulation of pain via the pain gate mechanism (Carlsson, 2002) which involves stimulation of A-beta nerves that communicate with the dorsal horn of the spinal cord, brain stem and PAG, triggering descending inhibitory pathways in the shape of endogenous opioid mechanisms (Kaptchuck, 2002; Longbottom, 2010)
Gastrocnemius trigger points were directly needled using a dry needling technique.
Hong (2000) proposed that local tenderness and taut bands (trigger points) are caused by a sustained contraction of the sacromere. Limited perfusion appears to result in decreased O2 concentration within the trigger point (Brukle, 1990), which in turn affects the efficiency of the calcium pumps. This results in a sustained increased in intercellular calcium levels and it is thought that a shortage of ATP, which serves to allow release of the myosin cross bridges, causes continuous activation of actin and myosin.
A further theory discusses that an abnormality of the motor end plates causing excessive acetylcholine levels may also cause of excessive intracellular calcium levels. The purpose of the needling is therefore to increase circulation and decrease acetylcholine levels to normalize the physiological function of the motor end plate and sarcomere. Insertion of needle appears to cause a localized stretch and may have an effect on straightening collagen fibres (Langevin, 2001). A pistoning action was used until the muscles relaxed and then the needle was removed.
Table 1.2: Treatment choice and acupuncture point rationale.
|Day||Treatment Aim||Rationale||Points||Needle diameter||Additional treatment|
|1||Screen patient for contraindications of acupuncture and physiotherapy modalities: Nil noted.Global analgesiaStimulation of parasympathetic nervous system.||Stimulation of dPAG to influence opiod mediated analgesia.||Bilateral LI 4Left LIV 3.BL 62 Left
(20 mins in situ)
|30mm40mm||Gastrocnemius and soleus stretches.Effleurage and ischemic myofascial trigger point release.Ice advised for posterior ankle.Heat and gentle self massage advised for medial head gastrocnemius.
Medial arch supports provided.
|4||Provide analgesia through the pain gate mechanism.Increase ROM and tissue length of the gatrocnemius.Encourage reorganization of the tendon.||Stimulation of segmental benefits of acupuncture used proximally (BL 27/L5) and distally on the opposite side to stimulate the dorsal horn and provide gate modulation of pain.Opioid mediated analgesia through 3 gates.||Bilateral LI 4 and left LIV 3Bilateral BL 27.BL 62 Left
(20 mins in situ)
|Soft tissue massageMyofascial trigger point release.Contact relax to right calf.Soft tissue release.
Deep transverse frictions x 3 to right TA.
|8||Provide analgesiaImprove function of motor end plate regulation.Begin layering||Dorsal horn inhibition, stimulation of dPAG through simultaneous joint mobilizations and acupuncture.Influences on descending inhibitory pain pathways through DNIC.||Bilateral LI 4 and left LIV 3Bilateral BL 27BL62 Left GB 34 LeftBL 57 Bi-lat
Dry needling into mtrp within the medial gastrocnemuis
(20 mins in situ)
|Contract relax muscle energy techniques to right calf.Soft tissue release and massage to increase blood flow and reduce sensitivity.Begin 12 week eccentric loading program.
Ultrasound to right TA (subacute due to recent inflammatory of peritendinous tissue): 3mhz, 1:4. 7mins, 0.2w/cm2
|15||Provide segmental analgesia and continue to treat trigger points locally, improving normal muscle regulation and length.||Dorsal horn inhibition, accessing the pain gate regulation of pain.Stimulate local blood flow within the right calf to reduce myofascial pain caused by ischemia.Prolonged length of needling to stimulate supraspinal effects.
|Bilateral LI 4 and left LIV 3Bilateral BL 18Bilateral BL 27
BL 57 Bi-lat
Dry needling into mtrp as required.
(30 mins in situ)
|Ultrasound to right achilles tendon to encourage regulation of collagen orientation:3mhz, 1:4, 0.25 w/cm2 for 7 minutes.Continue eccentric loading program
Soft tissue massage.
|22||Same as treatment on day 15|
The rationale for treating this patient with acupuncture was to allow supraspinal pain relief, reduce inflammation in combination with traditionally modalities, which aimed to effect collagen alignment to prevent reoccurence. The patient was also referred to a podiatrist to address foot biomechanics, which may be a causative factor.
It is important that a correct diagnosis is formed to enable appropriate treatment in accordance to pathology. Two Achilles tendinopathy diagnostic measures were consistently used. The Achilles palpation test, which involves compression of the tendon between the second and fourth digit, has been shown to demonstrate good inter rata reliability with a sensitivity of .58 and specificity of .84 (Mafulli et al, 2003). The Arc Sign, which involves active plantar flexion and dorsiflexion whilst observing the TA and noting if swelling remains static (absence of tendinopathy) or moves (presence of tendinopathy), also has a high specificity (.83), which helps to support that the correct clinical impression was concluded (Mafulli et al, 2003).
The patient reported a 50% improvement in VAS scores after the first session. This could be attributed to stimulation of the three gates and it links with DINC as discussed above. The gentleman continued to make good progress throughout the following three sessions. A layering approach was employed as described by Bradnam (2007) which suggested that by increasing the number of needles, leaving the needles in situ for longer or applying greater intensity of stimulation were suitable progressions of treatment.
When the patient progressed into the sub acute phase (Session 3) and significant reduction in pain was observed local points were utilized. Local points aimed to stimulate A-delta and C fibres to encourage the release of substance P and neurokinin and calcitonin gene related peptides (Weidner et al, 2000). Sensory neuropeptides modulate an immune response therefore will assist in tissue healing (Brain, 1997) in addition to local inflammation prompting the release of endorphins (Carlsson, 2002).
At this point the patient reported minimal pain (VAS 2/10) and was keen to begin sport again and therefore he was advised to start short treadmill runs as tolerated. Western evidence suggests that acupuncture causes a local increase in endorphins, which has been shown to provide 2-3 days of pain relief (Bessen, 1999). The patient was then advised to utilize these two days to continue their home exercises program, which included calf stretches and eccentric loading which stimulate mechanoreceptors. It has been suggested that stimulation of mechanoreceptors (to produce hyopalgesia) and sympathoexcitation (through choice of acupuncture points) could stimulate the dPAG, which is a primary anatomical pathway mediating opioid-based analgesia (Loyd and Murphy, 2009; Vicenzino et al. 1995; Vicenzino et al. 1998), thus influencing supraspinal modulation of pain. These findings are based on animal models, which may not be representative of the human population.
Although the primary aim was to treat acute inflammation ???? its underlying cause must be addressed to prevent future reoccurrence. Research suggests that conservative management of chronic Achilles tendinopathy should be pursued for 3-6 months before surgery is considered (Vega et al, 2007). Taping, laser, MWM, stretches, ultrasound and conditioned management are a few techniques employed by physiotherapists currently to treat tendinopathies. However evidence is controversial and although physiotherapy appears to be superior to cortisone injections and control at six weeks no differences were seen between the groups at 52 weeks (Bisset et al, 2005). In agreement with previous research (Herrington and Mcullock et al, 2007) concluded that a 12-week eccentric exercise program combined with a conventional treatment of ultrasound and deep transverse frictions is more effective in treating Achilles tendinopathy than conventional treatment alone.
At the final session the patient reported an occasional dull pain VAS 2/10 in the morning. He was happy that he could tolerate his pain and that it eased once completing his home exercise program. Soleus and gastrocnemius length was equal bilaterally and the Achilles palpation test had a reduced pain score (VAS 4/10). Palpation of the right calf was no longer painful and the patient was back to 3km jogs with nil increase in his symptoms. The arc sign was still present however the nodule on the right TA had reduced in size.
Limitations of single case study
Critique of research into Acupuncture and tendinopathy patella tendon, common exxtensor tendon, Achilles tendon
All missing in your final submission
This study has found that acupuncture alongside traditional physiotherapy modalities effective in the treatment of DOMs and an acute inflammation of peritendinous structures. The author believes there to be strong evidence for the use of acupuncture and its analgesic qualities however appreciates that there is limited evidence which specifically look at its role in achilles tendinopathy which is the likely cause of the recent exacerbation of pain. The author recognises that its single case nature and multi-factoral approach makes attributing the improved function and reduced VAS to one modality is difficult however clinically this is often an approach adopted. Further research is needed with a larger sample sizes to confirm the validity of this study to a wider population and a follow up to review longer-term effects of these techniques on the underlying tendinopathy.
This is not Harvard referencing and there should be no numbers in the referencing
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MARKING Postgraduate Assessment and Grading Criteria for Coursework
Little or nothing of merit
|Knowledge and Application||Demonstrates an outstanding in depth understanding of specialised /applied knowledge||Demonstrates an excellent understanding of specialised /applied knowledge||Demonstrates a very good understanding of specialised /applied knowledge||Demonstrates good-satisfactory understanding of specialised /applied knowledge||Demonstrates limited understanding of specialised /applied knowledge||Demonstrates very limited understanding of specialised /applied knowledge||Demonstrates very poor /no understanding of specialised /applied knowledge|
|Clarity and progression of argument/discussion||Outstanding, logical progression of argument/ discussion with outstanding clarity||Excellent, logical progression of argument/ discussion with excellent clarity||Very good logical progression of argument/discussion with very good clarity||Good-satisfactory progression of argument/discussion with good-satisfactory clarity||Limited progression of argument/discussion with limited clarity||Very limited progression of argument/discussion with very limited clarity||Very poor /no progression of argument/discussion with very poor/no clarity|
|Integration, synthesis and depth of referencing/ information||Demonstrates an outstanding level of integration and synthesis of relevant and appropriate evidence,drawing upon an outstanding range of evidence/ examples||Demonstrates an excellent level of integration and synthesis of relevant and appropriate evidence drawing upon an excellent range of evidence/examples||Demonstrates a very good level of integration and synthesis of relevant and appropriate evidence drawing upon a very good range of evidence/ examples||Demonstrates a good-satisfactory level of integration and synthesis of relevant and appropriate evidence drawing on a good-satisfactory range of evidence/examples||Demonstrates limited integration and synthesis of relevant and appropriate evidence and draws upon limited evidence/ examples||Demonstrates very limited integration and synthesis of relevant and appropriate evidence and draws upon very limited evidence/ examples||Demonstrates very poor/no integration and synthesis of relevant and appropriate evidence and draws upon very poor/no evidence/ examples|
|Critical appraisal, critical thinking/ clinical reasoning||Demonstrates outstanding evidence of critical appraisal/critical thinking/ clinical reasoning||Demonstrates excellent evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates very good evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates good-satisfactory evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates limited evidence of critical appraisal/ critical thinking||Demonstrates very limited evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates very poor/no evidence of critical appraisal/ critical thinking/clinical reasoning|
|Structure, level of written English and Referencing||Demonstrates outstanding structure, outstanding level of written English and completely accurate referencing||Demonstrates excellent structure, excellent level of written English and almost completely accurate referencing||Demonstrates very good structure, very good level of written English and occasional referencing errors||Demonstrates good-satisfactory structure, good-satisfactory level of written English and a few referencing errors||Demonstrates limited structure, weak level of written English and several referencing errors||Demonstrates a very limited structure, very weak level of written English and many referencing errors||Demonstrates a very poor /no structure, very poor level of written English and completely inaccurate /no referencing|