Richard C. Niemtzow: The purpose of this roundtable is to discuss the role of acupuncture as related to common injuries, acute and chronic pain, and the rehabilitation, of athletes as well as the individual with an active lifestyle.
I will have the speakers introduce themselves before we begin.
Matt Callison: My name is Matt Callison. I'm a licensed acupuncturist. I'm the president of AcuSport Education and also the Sports Medicine Acupuncturist Certification (SMAC) Program.
Brian Lau: My name's Brian Lau. I'm an acupuncture physician in Florida, and also an educator with the Sports Medicine Acupuncture Certification Program, and I teach Cadaver Lab dissections with Sports Medicine Acupuncture and AcuSport, but also other venues and for other health professions.
Ben Ingram: My name is Ben Ingram. I'm a physician by background. I'm dual boarded in family medicine and sports medicine. I work for the Army, so most of what I do is sports medicine. My background in acupuncture is related to treatment of athletes. I really look forward to today's talk, and probably learning some things myself. Thank you.
Richard C. Niemtzow: Ian and Hannah, can you introduce yourselves?
Ian Armstrong: Absolutely, thank you Richard. My name is Ian Armstrong and I am an acupuncturist in San Diego, California area. I am certified in Sports Medicine Acupuncture, as well as an instructor in the Sports Medicine Acupuncture Program. I teach the Treatment of Orthopedic Disorders at Pacific College of Health and Science (PCHS) and supervise a shift treating University of California San Diego (UCSD) collegiate and club athletes through PCHS. In my practice, I mainly focus on orthopedics, sports injuries, rehabilitation, and pain.
Hannah Leahy: I'm a physical medicine and rehabilitation doctor, with dual board certification in in sports medicine too. Currently I treat a lot of acute and chronic musculoskeletal and neurologic injuries in the military members stationed here in Bavaria.
I see the full spectrum of acute and chronic pain, and I have a background in working in orthopedic clinic too where I diagnosed and treated acute and chronic injuries and pain conditions. I have been trained now in Battlefield Acupuncture (BFA), and I use a lot of dry needling techniques on a daily basis.
Anthony Von der Muhll: Hello, everyone. I'm a traditionally trained licensed acupuncturist, Certified by the National Board of Acupuncture Orthopedics, which unfortunately went defunct when the generation of founding instructors retired over the last decade. I've devoted myself to building a Certificate Program in Acupuncture Orthopedics to carry on their work, which I now teach mostly in the context of a Doctorate Program in Acupuncture and Oriental Medicine at the Academy of Chinese Culture and Health Sciences in Oakland, California. I also completed Myopain Seminar's myofascial trigger point needling certification program, which I incorporate into my teaching and practice. My particular subspecialty within acupuncture orthopedics and sports medicine is treating joint hypermobility and dysfunctions with dry needling.
Richard C. Niemtzow: I'm going to turn it over to Matt. First topic is, How can acupuncture help an acute trauma with inflammation? For example, a sprained ankle experienced by an athlete.
Matt Callison: Okay. Well, this topic could go on for quite a long time, especially with the panel that we have here. There's going to be a lot of different aspects of it, so I'll try to keep it short and sweet with this. I think over the last decade, maybe 15 years, there's been a lot of research on how acupuncture is helping with decreasing inflammation, like the antihistamine effect, and the downregulation of pro-inflammatory cytokines, neuropeptides, etc. That's been shown and proven.
I think the aspect of reducing inflammation or in Traditional Chinese Medicine (TCM) methodology, to clear Heat, importantly is to not use acupuncture at that site of an active inflammatory process. This is something where TCM explains to never needle into the area that is excessive. Just from my own clinical practice, trying to needle into an area that is pretty hot and inflamed just exacerbates the area.
I think the pros to acupuncture in that case is to needle adjacent points, muscles that'll have stability and integrity for an ankle sprain. For example, the peroneus longus and the tibialis posterior that, in fact, will probably help with the integrity of that ankle. As far as trying to clear the edema and the inflammation, there are many points that we can use. For example, the distal points, the Ting Well points and such, to be able to help drain some of that edema.
Bleeding, cupping and bleeding, and needling distally is another area that we could discuss that helps incredibly in positively changing secondary response inflammation and by-products. In my mind, it's like a pressure valve releasing some of the oncotic pressure, which is a manifestation of the secondary response, when bleeding or needling distally seems to diffuse this inflammatory process.
The takeaway here is not to needle into the actual area of inflammation, because that does aggravate the area, but to use adjacent points to be able to help to clear the edema and the inflammation.
Brian Lau: Sure. Great answer from Matt, and I'll just add to it one aspect that we definitely teach within Sports Medicine Acupuncture, which is also to look at the general balance of the body. An ankle sprain would be a great example as there might be pre-existing imbalances that led to that potential for the ankle sprain. This is very common. There might be muscles crossing the ankle, which are inhibited and aren't supporting the ankle well, thus increasing demand to the ligaments. Those inhibited muscles can be a problem in terms of healing if they fail to support proper movement and stability.
Balancing the structures that are acting on the ankle with points into the various muscles that are inhibited and overactive can help regulate the position of the ankle, and then set a situation for easier and better, more efficient healing.
Richard C. Niemtzow: Thank you, Brian. Ian, do you have a comment?
Ian Armstrong: Sure, I would definitely agree with everything Matt and Brian have said. Bleeding techniques, whether with cups or bleeding Ting Well points or other strategies, as Matt mentioned, can be very helpful in the acute inflammatory process. It is always important to assess what other structures and tissues away from the acute injury site might have contributed to the acute one in front of you, and how you can set up the body for success moving forward, as Brian discussed about thoughts on improving ankle stability and joint imbalance.
Let me see what I can add, however. In the example, we had an acute ankle sprain, but what if we used the example of, say, a soft tissue strain or tear? In this case to be able to look at the myofascial chain above and below or even next to the injured area, and treat here, is also quite beneficial. If you're thinking about a high hamstring/bicep femoris strain, for instance, you can look at treating the Sacrotuberous ligament that is superior to it, the Peroneus Longus inferior to it, all structures directly connected.
Even needling something like the Quadratus Femoris that connects to the Ischial tuberosity, is next to and will have tensional relationships to the Bicep femoris, I've found to be really helpful. Needling the above, below, and adjacent tensional pieces in that particular myofascial chain can help take unwanted tension off the strained muscle, allowing for faster healing time and more range of motion.
In this same example, to expand on Brian's thought process, I think, if you have a high hamstring strain, what does their pelvis look like? Regulating or balancing this would also be important. Do they have an anterior tilt/Lower Cross syndrome causing the hamstring to be on constant tension? Then treating something like the Psoas here would be beneficial for example. These are aspects that I would always want to assess. Looking to local and global perspectives with posture.
Hannah Leahy: The main point I thought was important to discuss here was that with these, there's some evidence that there's this anti-inflammatory effect, in that there can be inhibition of some of the inflammatory pathways, so used acutely for musculoskeletal injuries like an ankle sprain, for example, there can be downregulation or inhibition of the COX-1 and 2 pathways that we also address through use of medication.
It can really supplement the treatment that way. I completely agree with addressing the other associated muscle groups, because you can definitely have that muscle inhibition or motor inhibition. If you can improve the strength early on, you're going to have a faster recovery. I'm sure, I think somebody I heard say about the tissue perfusion aspect, improving the vasomotor control, and the tissue that's been injured.
There is certainly a huge role for addressing acute trauma with acupuncture, and just downregulating that immediate central nervous system response, trying to modulate that in addition to the local inflammation, to prevent it from turning into a more chronic nociceptive pain problem.
Richard C. Niemtzow: We will have patients coming into our clinic who have had a chronic ankle sprain, and still are experiencing pain.
We end up doing BFA for them with the hopes that over a period of time, the pain will go away. As a rule the ankle pain it gets referred to our clinic when it becomes chronic and the patient is not making any progress.
Matt next topic: “Can acupuncture help with torn cartilage, ligaments, and tendons?”
Matt Callison: Thank you, Richard. That's a great question. Yes, I think that's actually something important to speak about. Since you plugged the BFA, I might as well go ahead and talk about chronic ankle sprains as well the way we do in Sports Medicine Acupuncture.
This is something that we love to treat, because the way that we treat it is really quite significant, and lots of positive results with it, from needling into the ligament, as long as there's not the episode in the inflammatory response and such, but needling into the ligamentous tissue, and trying to stimulate the mechano-transduction and the extracellular matrix, which does seem to help bind the region.
After needling directly into ligaments, it can change orthopedic examinations. If it was the ankle, it can help to increase the integrity of the anterior drawer test. Not just needling locally, of course, that's going to be important, but then also what Ian and Brian were talking about, needling the important muscles of stability. If it was going to be in the ankle, the peroneus longus, the tibialis posterior, the peroneus tertius.
Then as Ian was speaking of earlier, what's happening with the knee, what's happening with the pelvis? Once the acupuncture treatment is completely done, then using myofascial work also to complement that, and then prescribing exercises, the strengthening exercises, or the stretching exercises, or the proprioceptive exercises. Chronic ankle instability is actually a fun thing to treat, especially for that patient that has perpetual ankle sprains all the time. Their function becomes a lot better.
It's a wonderful thing. It's rewarding. As far as the ligaments, yes. I think needling directly into the ligaments is really quite profound with acupuncture, because they are so mechanical, and they have mechanical properties, and simulating the sensory afferents from that, I think, is very, very important. Again, needling the adjacent and distal points with the channels in mind, and also the postural integrity is going to be very important.
Anthony Von der Muhll: Elaborating on what Matt said, all of which I agree with, I often find it quite useful to needle directly into ligamentous tissue. The tightening up of overstretched ligaments and the stabilization of joints can be instantly verified upon needle withdrawal-even by beginners with a half-hour of training in joint-play/end-feel testing. I find that restabilizing a joint typically leads to rapid, sometimes immediate gains in range of motion and transarticular muscle strength, and sometimes even reduced paresthesia if adjacent neural tissues are no longer being compressed by compensatory muscle splinting. Likely this is due to resetting of joint proprioceptors and restored arthrokinetics, though I haven't seen very much research in this area.
Even if there is a lag in range of motion and strength improvements, in my experience, other modalities—myofascial trigger and motor point needling, traditional acupuncture, gua sha, cupping, etc. work faster and better with less regression when the underlying joint or joints are stable and functioning properly. And the effects of needling ligamentous tissue are typically also immediately felt by patients, not so much as immediate pain reduction, although sometimes that's also the case. But what I hear often from patients is things like “it feels more solid, stronger, stable, better control.” Which is exactly what I'm looking for. The pain reduction will follow–or of course can be accelerated by adding ear, distal, electroacupuncture to the local joint needling.
Matt Callison: For me, talking about tendons now, needling into tendons when they are injured, exacerbates the condition just in my own opinion. Most injuries in my mind are more about the synovial lining and the extracellular matrix around the region that is becoming irritated. The needle technique that I developed and use is to thread the needle on each side of the tendon, as close as possible to the tendon, but not to insert it into the tendon. Then, of course, the application of heat with that response, in my own clinical experience, better than electric stimulation.
Anthony Von der Muhll: That's very interesting for me to hear, Matt, I too started experimenting with this same technique of needling parallel to tendons after finding that needling directly into tender locations resulted in pain without gain.
Matt Callison: Then, of course, using eccentric exercises after that, and also myofascial techniques to reduce adhesions that are in the area. Tendons and ligaments respond very well to acupuncture. I haven't had the best of luck with cartilage, torn cartilage, which makes a lot of sense. I do not think that acupuncture is going to help with a bucket handle tear of a meniscus or horizontal cleavage tear.
I do think it changes the pain response with it, which can help with muscle guarding and such. As far as the repair, that's going to be more of surgery, in that case. I think it's more palliative care when somebody actually has a cartilage injury. Without speaking any more about it, I think we should probably continue.
Anthony Von der Muhll: I'll just concur with Matt that tears in cartilage such as bucket handles in a meniscus or a large tear in a labrum don't, in my experience, seem to respond in a lasting way to acupuncture. I suspect this poor response has to do with the negligible intrinsic vascularization of these tissues. Sometimes I see modest improvement with small lesions, which I suspect has to do with acupuncture's nonspecific analgesic and anti-inflammatory effects, rather than any significant healing of the underlying tear. I generally think of cartilaginous tissues as about as “inert” and unresponsive as tissue gets in the human body.
Brian Lau: I have a lot of similar thoughts as Matt and Anthony. With tendons, of course, they are fascially continuous with the muscle. Looking at the state of this unit of muscle and fascia is going to be very important for healing. People can get injured for a number of reasons. If enough force goes into the body, an injury can occur even if there's really good balance and strength in that muscle. But, if there are pre-existing problems in the myofascial net, then injury is more likely to occur and it will frequently occur at its weakest point.
An example is the supraspinatus. If it's inhibited and not really working effectively, and other structures, like the lower traps aren't working effectively to create a good scapular movement, that's going to set up a propensity to have a tendon injury such as a tear or tendinitis. So, you would want to look beyond treating just the injured tendon, but you would also treat the structures that are part of efficient movement of that region.
Ligaments are also very interesting, as they have interesting fascial relationships with the muscles. My view on this is very informed by anatomist and researcher, Jaap van der Wal. He has done research on the ligaments and their connection to the myofascia. The classical anatomical view would be that the ligaments are parallel structures deep to the muscles that cross the joint and they are active in stabilization particular at the end range of motion. In van der Wal's research, he dissected the muscle tissue away but kept the epimysium, the fascial surroundings. He showed that the ligaments are deeply integrated with that epimysium of the muscles and their function is also much more integrated with that of the muscle.
A great example of this would be the quadriceps and the ligaments of the hip. Due to these fascia connections, as the quadriceps contract, they tense and communicate with the ligaments through the entire range of motion and, therefore, the ligaments are not just active at the end range.
To me, this speaks to the effectiveness of treating along myofascial planes of tissue and to regulate tone in the channel sinews in addition to treating the local ligament injury.
Ben Ingram: In regard to cartilage, I personally don't enter cartilage. I stay away from that with needles.
Generally, the same is true for ligaments. The one thing I will say about the cartilage and the ligaments, going back to some of the other commenters on ideas like dyskinesia and bad movement patterns, particularly with the shoulder, and I'll even say, a lot of the things we're seeing with hip labral tears, which I think personally is a movement pattern similar to the shoulder. We just don't understand them well yet. Patellofemoral pain in the knees, knee arthritis, and going down in the ankles for chronic ankle instability.
I think there is value there in relieving tension on the ligaments, or relieving tension on the cartilage by returning people to normal movement patterns. I think there is a role for acupuncture, particularly up in the muscular bellies to relieve that tension. On the subject of tendons, I'm a pure sports med trained guy, and so this may be somewhat an anathema to the pure acupuncture community, but if I am entering a tendon with a needle, I had very different results going under ultrasound guidance versus going on land mark based guidance.
I had better results with ultrasound to know I was actually in the lesion, and over time, I could actually see the lesion filling. However, I don't think the tendon is, if we take the Achilles in particular, I don't think the tendon is ever truly the problem. I think the problem was upstream in the gastrocs and the soleus, and maybe even higher than that, going all the way up to the hip, in terms of bad movement patterns and tension in the muscles.
I think there is a huge role for acupuncture along with physical therapy, and relieving those imbalances and then strengthening and making the patient more symmetrical. Over.
Richard C. Niemtzow: Thank you Ben. Ian, do you have anything to add?
Ian Armstrong: Let me see, I too have similar thoughts on this with Brian, Matt, and Anthony. The tendon needling technique that I used for instance, I learned from Matt! I also concur in not having great success needling into tendon or with cartilage injuries (labrum, meniscal tears). We can, however, help with joint balance and ligamentous laxity, as Anthony discussed, that contributes to more minor injuries to this type of tissue. Treating this way can often save or prolong the patient from surgical intervention.
I guess where I can also add my two cents here is in emphasizing the importance overall in treating the ligaments and tendons in this way. Going back to the ankle sprain example, now in chronic or postacute phase, and as Matt was saying, it is important to actually needle into those ligaments and stimulate these joint receptors, and really help the injury from becoming more chronic. Ankle sprains are something that, one, are so common, and two are brushed over and undertreated, under rehabilitated. Especially in younger athletes.
In the facility where I practice, we have a good amount of serious teen athletes that train there. Screening these athletes in first visits you hear about a ton of ankle sprains, for instance, that happen in their respective sports. They're not the only ones who get them, of course, but they are a great example of what the postinjury process for an ankle sprain typically looks like for people without us. They will rest it, maybe splint or wrap it, even put a boot on it if it's pretty severe, but there's not much rehab that's done. This can lead to a whole host of problems later.
For example, my experience when treating people with noncontact anterior cruciate ligament tears, or any kind of noncontact knee injury commonly have had previous ankle injuries that we're not treated or rehabbed well. I don't know what the percentage would be, but I would guess over 90% in my experience.
Needling these ligaments help full stability of the ankle and are extremely important to treat. Having a proper ankle position and stability and movement (especially dorsiflexion) helps with alignment of the Tibia and femur, with less shearing forces on the meniscus, and even less strain on the medial collateral ligament and lateral collateral ligament, how much a flat foot can lead to valgus knee position, even pelvic position… standing or moving, and running or something like that.
How well can they push off on the big toe? How active is that arch able to stop the natural pronation of a rocking of a foot? All these aspects are important to assess, not only for, again, rehabbing the ankle, but as well as for the knee. Needling these ligaments is a very important part of the treatment strategy.
Ben was mentioning treating upstream for the Achilles tendon, of course, is super important, I would add making sure that that foot position is really solid is also imperative. For example, a flat foot will contribute to a bowing of the Achilles (Helbing sign), and that's going to lead to more irritation of that Achilles tendon as well. That would be my thought process on it. So going back to the local and global postural assessment.
Hannah Leahy: Yeah, so where can I jump and add in anything? I think everyone covered so much. One of the themes I heard emerging that I agree with is that a lot of times, when we're looking at the diagnosis, and seeing evidence of torn cartilage or ligaments or tendons, there's a tendency in medicine at least, to just look at that structure if you see it on imaging, and hyper-focus on that, rather than stepping back and looking at the whole picture.
I like to look at the other factors as well, such as the myofascial trigger points. I find it fascinating how much overlap there is between the myofascial trigger points and the traditional acupuncture points. Some studies have reported it's 70 up to 90% overlap. (Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain. 1977 Feb;3(1):3–23. doi: 10.1016/0304-3959(77)90032-X. PMID: 69288. Dorsher P.T., Fleckenstein J.: Trigger Points and Classical Acupuncture Points, Part 1: Qualitative and Quantitative Anatomic Correspondences. German Journal of Acupuncture and Related Techniques 2008; 51: pp. 15–24.)
There are some good studies now supporting its use in patellofemoral pain. (Zarei H, Bervis S, Piroozi S, Motealleh A. Added Value of Gluteus Medius and Quadratus Lumborum Dry Needling in Improving Knee Pain and Function in Female Athletes With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. Arch Phys Med Rehabil. 2020 Feb;101(2):265–274. doi: 10.1016/j.apmr.2019.07.009. Epub 2019 Aug 26. PMID: 31465756.) I use a protocol where I dry needle the gluteus medius, and the quadratus lumborum in patients with patellofemoral pain, which I see a lot of, and that can really help as one of the earlier treatments for that. That kind of hits on addressing the dyskinesia piece, but it's also that we make sure we're looking for these myofascial trigger points.
I think the other thing I wanted to add was that in tendon pathology and ligament pathology, there's just a wide spectrum. You see the old injuries, the new injuries, and then the ongoing injuries. They all look very different. As Ben alluded to, under ultrasound, you really can get a good look at these structures, and you see the difference in how they look, and whether there's signs of neovascularization. That can really change the behavior of a tendon in terms of how it's going to respond to needling procedures via acupuncture, or things like percutaneous needle tenotomies, or platelet-rich plasma, or things like that.
You have to factor that into the treatment plan, what stage of healing or injury the tendon is in.
Anthony Von der Muhll: This is all very interesting to me. What I'll add to the discussion from my own experience is that my go-to modalities for chronic tendinopathies do not involve needles. Number one for me is gua sha, which originated in the Far East and has now been taken up by Western Chiropractors as Graston Technique, or Physical Therapists call Instrument-Assisted Soft-Tissue Mobilization. Whatever one calls it, the method is to apply a lubricant to the skin and then take a blunt edge of a handheld tool–I prefer a porcelain wonton soup spoon–and scrape or even grind along or across the tendon–usually distal-to-proximal along the fiber orientation, although I use cross-fiber at the rotator cuff distal tendon attachments and sometimes other locations. Sounds uncomfortable, but by adapting the pressure to the patients' tolerance, I generally find it has the best risk:discomfort:benefit ratios for tendons of the physical interventions in my toolbox.
The other technique I find useful is to apply suction cups over tendons or aponeuroses that are large and flat enough for them to adhere, such as the thoracolumbar fascia and gluteal tendons, and the patellar tendon, and then guide the patient through active range of motion with the cups in place for a few minutes.
There's a lot more that could be talked about here regarding the use of gua sha tools and suction cups in treating tendon and myofascial injuries generally that I won't go into here, as our focus is on acupuncture. But I'd be remiss in not adding that these other traditional East Asian modalities, in my experience, play a much more important role in healing tendinous injuries than local acupuncture.
Richard C. Niemtzow: All right, thank you. Listening to this is extremely interesting, and I think our readers will appreciate your views on these various subjects.
Matt, next topic is does acupuncture help with recurrent sports injuries not healing?
Matt Callison: Thanks, Richard. I think, gosh, to answer that question, it really seems like we already have answered that, the entire panel, with just sizing this up, looking at dysfunctional movement patterns, looking at posture, looking at muscle imbalances, looking at the stage of injury. That's just from the external aspect of it. I think the beauty of TCM, also naturopathy, is to look at what's happening at the internal environment.
Why is this person not healing? Is it going to be diet related? Is it sleep related? Is it something that's going on in their life as far as the stress? It's important to look at the internal environment and the external environment for these chronic injuries. Also, just on a side note with this, sitting back and listening to everybody's comments, my undergraduate work is from San Diego State University in athletic training and sports medicine. That was my first targeted area, and then I became a licensed acupuncturist, licensed 30 years ago. There was no conversation of this happening 30 years ago at all. I'm sitting back and listening to this, and just watching how much acupuncture, TCM, and dry needling, and medical acupuncture has really excelled, especially over these last 15 years. Like I said, this wasn't happening 25 years ago.
This kind of conversation is really quite stimulating, to see where we have gone and where we're going in the future with this. I hope that helps. Brian, do you want to take it away?
Brian Lau: Sure. That's a big topic. Let's take off the table things that wouldn't be expected to heal. Obviously, if somebody had an Achilles tendon rupture, you wouldn't be surprised if this was not healing well without intervention. It would be unrealistic to expect that to heal on its own.
Let's focus on things that should be healing, that have a good prognosis to heal for the conversation. In this case, if something's not healing, I agree with Matt, looking at the internal environment, diet and other things that we can address from either Western or a TCM standpoint, would be very important.
Also, treating things that are less objective can open possibilities when a painful condition persists. When working with musculoskeletal problems, you have to use both objective information such as those found in imaging along with subjective findings from things like palpation and orthopedic tests. Many clinicians rely too heavily on things like imaging. But, the pain can be more complex than just the finding from imaging and there can be other influences that we can't see, but need to still find and treat. Trigger points are a really important thing that gets overlooked in many clinical settings. These take time and skill to palpate and locate and there is a degree of subjectivity to this process since we can't see them on imaging, at least in imaging use in a clinical setting. But trigger points are present in many pain conditions. I have seen mention of 80% of painful conditions have some degree of trigger point involvement, and this matches what I see in clinic.
If clinicians don't take the time to look for trigger points when treating musculoskeletal pain and injury, they are missing a large component of the problem and the patient may not improve as expected if all you are considering is the findings from imaging. I think that's where doing things like acupuncture can be very valuable as we have the tools to treat trigger points and this allows us to look beyond what we might be able to see with imaging and we can expand the treatments to help get people out of pain and dysfunction.
Richard C. Niemtzow: All right, thank you Brian and Ben for your comments.
Ben Ingram: Again, this is just amazing discussion, and I'm even myself learning from my colleagues as we talk about this. As I think through the first commenter's discussion on how in the last 15 years, this has really entered the discussion, I know when I was training in family medicine, the only way we really had to heal things was shoot an x-ray, which is always normal, do a magnetic resonance imaging (MRI), which is probably normal, and then give them therapy through the gut via pills. That never really seemed to work. That's part of what sent me the direction of sports medicine.
I think that's where there's a great deal of potential value, I think even in our graduate medical education pipeline, and going into medical schools, especially your traditional MD schools, of understanding the whole person better, of understanding the fundamental complexity, the mechanics of human motion, and going to the earlier comments of one person had one exam, one person have another exam, reached different conclusions, and they'd probably both be right. The end goal is to get the patient feeling better and returning to function.
Going back to Richard, your earlier comment on the role of BFA, I think that is a good tool that is an introduction to the world of acupuncture for physicians who are otherwise unintroduced. It's fairly easy to teach, fairly easy to maintain as a skillset, but when you see the utility of it, it begins to open doors for people to re-examine the way they're taught, where you needed to put medicines to the gut to bring healing over.
Ian Armstrong: I also wanted to say what a pleasure it has been to hear everyone's answers to these questions. I am so happy and honored I could be a part of this!
Wow, yes big topic as Brian said, and I would agree with Matt that we have been answering this one all throughout this discussion. By taking in all factors previously stated by other in the panel, acupuncture clearly can help with recurrent injuries not healing. If I could add another factor that has not been touched upon yet, it would be one we discuss quite a bit in the SMAC program. The aging athlete. What is their age?
With aging and natural degenerative changes, that is, spondylosis, acupuncture can have such a strong positive effect on helping the nourishment, and combat these aging factors that can contribute so strongly to recurrent stubborn injuries. Something to always think about is how well the injured area is being nourished, not only from a biochemical perspective, systemically in the body, as discussed earlier (internal environment) but also from a nerve perspective. Making sure the nerve to the injured area is uninhibited as possible to do its job, whether it is at a common nerve entrapment site in the periphery, or at the nerve root. Having that disruption at the nerve root is so much more common as we age, even if that occlusion is asymptomatic at that spinal segment. Just a reminder here to look at the age, how something like spondylosis could be contributing to the stubbornness of the injury not healing, and to treat accordingly.
Hannah Leahy: Yeah, so I think when we're looking at these patients who aren't healing, one of the things that I also hear from my colleagues on this conversation is that a lot of times, maybe they've been seen by multiple providers, and just validating the musculoskeletal pain, that it doesn't necessarily need to follow a certain pattern, or be seen on certain imaging. That can be very powerful in the process of healing for patients, and then offering them something.
Often, they're very frustrated with their injury. If it's not healing right, it's limiting their ability to function throughout the day, it's limiting their sleep. I see the stimulation of these anatomic neuroactive points in the body, either through dry needling, or manual therapies, or through injections as a relatively safe treatment option. I think it's amazing to me how many people have told me they've been in pain for 10 years, and it has never been offered to them.
I think again, relative to, like I said, I worked in an orthopedic clinic, all my colleagues were orthopedic surgeons. A lot of people would go step quickly into surgery to do exploratory arthroscopy, just to see if they can find a source, and without trying any of these other things. I think just in terms of a risk benefit perspective, if somebody's in this category of recurrent or chronic not healing injury, that's important to make sure the patient's been offered this.
I think we can do a better job just advocating for these treatments for patients through the medical professions, and making sure there's access and ongoing training for medical professionals.
Anthony Von der Muhll: This is a really useful and interesting discussion. That's really the big question, isn't it? Why do some athletes or patient's courses fail to follow the normal prognoses and seem refractory to treatment? I think one of the great contributions that Chinese Medicine has to offer is to look beyond the local, immediate, and obvious, and I mean here in terms of orthopedics and kinesiology, not just at internal medicine, psychoemotional, and factors from other body systems.
When examining, for example, a postacute ankle sprain using joint end-feel testing, I often find ligamentous laxity at sites beyond what is indicated by the patient's history or MRIs. In addition to the well-known and frequently injured anterior talofibular and calcaneofibular ligaments, there may be laxity at the posterior talofibular, deltoid, and spring ligaments, and the calcaneocuboid, talonavicular, Lisfranc, or cuboid—5th metatarsal joints—which may be asymptomatic! Old sprains may be silent and yet very hypermobile, at the root of or a major factor in chronic pain and disability. Patients may not even remember whether and when they sprained their ankle, and yet the ankle dysfunction is causing arthrokinematic and myofascial disturbances not only up and down the leg but also crossing over the contralateral leg in a compensatory pattern, a factor in dysfunction in the pelvic girdle and spine, and trigger point formation and motor point abnormalities along those myofascial tracts.
So another way that classical Chinese Medicine also adds significantly to a precision-oriented cross-sectional orthopedic focus on particular joints and ligaments can be found in how Nei Jing described 2,500 years ago an extraordinarily sophisticated understanding of the longitudinal organization of tissues into myofascial and neurovascular tracts, often translated, mistranslated, I believe as “meridians.” Matt and Brian have done a great job of comparing classical texts with cadaver studies here, as have some other translators and researchers over the last 20 years. The takeaway: Chinese view guides clinicians to look distally and proximally from symptomatic regions and injury up and down these kinematic chains, and also to consider anterior–posterior, medial–lateral, and crossover relationships.
That sounds like it takes a lot of time, but the remarkable and rewarding thing about dry-needling ligaments is how quickly these tissues respond, in my experience. Once the target ligament and joints are identified through end-feel testing and palpation for tenderness (supplemented with reviewing any available imaging), typically a minute or so of probing around into any given target tissue with a needle to elicit a referred pain pattern will be sufficient. No retention needed, withdraw the needle and reassess joint stability and tracking, and typically it's improved; if results are insufficient, repeat until stability is restored, or patient's limits of tolerance are reached, or, rarely, one runs out of time. But it's rare that more than 5 minutes with a few needle insertions and probing is needed for significant improvements in or restoration of stability—if there's no response, it suggests to me either complete or near-complete rupture of the ligament, or practitioner error, the results are that predictable.
Those with training in prolotherapy or other regenerative injection modalities can probably explain better than me why that increased stability often lasts after a few or sometimes a single session, and continues to build over the next six months or so. This probably involves release of tissue growth factors, improved vascularization, and deposition of collagen fibers that restore structural integrity to the joints, and a virtuous cycle of reduced nociception and increased proprioception. I've hardly been able to find any studies of this ancient technique done with a dry needle, but the results are in general quite predictable and verifiable objectively.
I realize I'm belaboring this point about acupuncture restoring structural integrity to joints. But that's because I think acupuncture's ability to affect structure is often underestimated in mainstream medical thinking in both the East and West. Acupuncture's benefits for functional disturbances in inflammation, pain, dysfunctional neural patterning, anxiety, etc. appropriately grab our attention, but we can also affect structural lesions with this minimally invasive technique.
Richard C. Niemtzow: Thank you all very much. For our last question, Matt, I think there will be people who will be interested in how an acupuncturist can get additional training to treat sport injuries?
Matt Callison: In TCM schools, there are a few classes, depending on the college or the university that is teaching, about sports injuries, but definitely not to the depth that a postgraduate education has. In our program, the Sports Medicine Acupuncture Certification Program, I'm happy to say, we're starting our 16th program coming up in September here in San Diego, and also New Jersey, that Brian and Ian and myself teach in, with also the cadaver dissection as part of the educational program.
In acupuncture school, there is no cadaver training, this is something that we at AcuSport Education bring to the field. This is really important for us to have a lot of anatomical knowledge, especially knowing the underlying anatomy of where the acupuncture needle is going, and what depth that you really want to stimulate. Our program is starting in September. It's just over a year. It's about 270 hours where we look at postural assessment, dysfunctions, muscle imbalances, how to treat the myofascial sinew channels that all communicate with one another, which is really quite amazing when you look at the different channels that were taught 3,000 years ago. And, how effective they are today, and observing what's happening and what the teachings in the Ling Shu, what points to be able to treat.
There's over 75 pages in the classics, talking about needle technique. Therefore, the founding fathers of TCM found it imperative to use proper needle technique to establish a certain goal.
This is what we do in the Sports Medicine Acupuncture Certification Program, and then prescribe exercises as well with it. It's a pretty in-depth educational program that we're all pretty darn proud of. Thanks very much for the opportunity, Richard. Appreciate that.
Brian Lau: I'm going to echo what Matt said. Anatomy is really of prime importance. I co-teach the cadaver dissection labs with AcuSport Education. I also do dissection and lead a five-day dissection with the University of Tampa physician assistant program. A lot of people think that's kind of unique as an acupuncturist, I guess, that not many acupuncturists would be leading a dissection lab like that. It's unfortunately true.
I would like to see that as being just sort of a normal thing. Who is better to know anatomy than somebody who's inserting a needle and having to know what depth that needle reaches, what tissue is being reached by that needle, and what structures it's passing through, and also what structures to avoid where you are? I think the acupuncture field, especially the non-MD-based, medical acupuncturists tend to not currently have very good anatomy understanding, but this does seem to be changing.
The straight acupuncture field needs to really up its game and get a lot better with anatomy, but especially if you're going into sports orthopedic-based acupuncture. The second component, of course, I would say, which ties hand in hand with that is palpation skills. This needs to be very refined, if you're going to be doing very anatomical-based needling.
Ben Ingram: Great question. I'm going to answer this mostly from a military standpoint. The military had for a while been investing in acupuncture training for its physicians. To the best of my knowledge, a lot of that has died off. I think a lot of that was because they were not getting a very good return on investment.
My personal opinion is that the physicians being trained did not have enough sports medicine training or sports anatomy, going back to this theme of anatomy that keeps coming up, to really take the skills they were being taught and use them in the population they had. The military population is an athletic population, just by nature of what they do for a living.
I think, Hannah, whom I know where she's working, because I just came from that station myself, is mostly dealing with acute, chronic, and subacute musculoskeletal issues. The data from the military bear out, that's a lot of their injuries that they see. I think improving the anatomy, improving the training of the people that are being trained from military perspective, and where the money's being put to increase that return on investment, and increase the timeline to return to full military duty, and the percentage of people return to full military duty.
Ian Armstrong: So, not to repeat what everyone was saying, but I would agree with that 150%. It's really about first diving into leveling up your anatomical knowledge, and being able to continue to refine what you visualize under the skin in terms of directly what's there, what's linked superior and inferior, what is superficial and deep. So, not just understanding what you are palpating under your finger, but how it connects or correlates to other structures around it, from head to foot. For me this is where the real fun begins, and is what takes years of continuous study.
I can't say enough about the importance of possibly getting into a cadaver lab, as was also mentioned, and how well that can increase someone's anatomical knowledge in just a five-day program. What a gift to see firsthand the different tissues and the depths. Being a teacher at PCHS, where students studying to become acupuncturists, they're used to finding points by using these little dots on skin before my class. Then they get into Treatment of Ortho class where I'm teaching to actually needle into different tissues, and they can often get pretty apprehensive and tenuous. That feeling to me is often directly correlated with their lack of musculoskeletal anatomy. All this is highly emphasized in the SMAC program. But anatomy is not something that you just study for a term or even a year. It continues. Layers of the onion continue to unwind as you continue to study. It's always something that you're learning. To me it is part of the fun. You must continue to study refine and practice.
The other aspect would be learning your postural and Ortho Neuro assessments. These types of practices in clinic have become more and more of a lost art/science. There is so much information to glean from performing these assessments, and they all take practice and repetition just like anything else. And patients really appreciate the time and explanation, for they often just don't get that anymore.
Richard C. Niemtzow: Yes, Thank you very much. Hannah do you have anything to add?
Hannah Leahy: Yeah, I agree with everything that's been said. Yeah, the anatomy, 100%. I still, I've been doing this for a long time learning anatomy, and I still feel like I learn or have new understanding of anatomy that helps me be a better clinician. I'm still looking up things from time to time, and I think it's fun and critical to understand anatomy to be able to treat these sort of injuries.
Then yeah, what Ben was saying about the military in particular, we have a lot of physicians I work directly with over here who are in primary care usually, and they have a lot of interest in acupuncture, but not a lot of comfort with it because it's not used routinely. If it's not an ongoing skill that they're utilizing, a lot of physicians will not continue with it and primary care in particular is being pulled in so many different directions with their time. This ongoing education and appropriate reimbursement or allotted time for health care professionals to offer these treatments to patients is an important piece to acknowledge to improve the access patients have to these treatments.
One other thing I wanted to mention, I know there are some people on this panel who have an athletic training background and that was one of my first jobs in college. I worked in a training room, which first got me interested in the musculoskeletal system. For those that are interested in learning, that's the place to go to see sports injuries. You'll see a high number of them, you'll see the acute and chronic ones. Any university or even a small college, just if you can get in the training room and volunteer or help out, you'll see a lot.
That's a good way, once you see the injuries, you're going to naturally look up the anatomy. If anyone has access to that, I'd encourage that as a great resource that I've taken advantage of. All through residency and fellowship, I spent a lot of time in training rooms, and learning from the athletic trainers, and from the athletes themselves. I think that's all I had to add, though. Thank you.
Matt Callison: If you don't mind, I'd like to comment if that's okay?
Hi, Matt Callison commenting. Hannah, thank you so much for really saying that. I think all of us can agree, we're all continual students of anatomy and all of the discoveries that are still happening today. It wasn't very long ago that the collateral branch of the lateral collateral ligament, the new branch, I think they call it the anterior lateral collateral ligament was discovered, or the iliocapsularis muscle, which is that very thin ribbon-like muscle that's right next to the iliopsoas going over the anterior hip capsule.
That was discovered I think within the last decade. It just continues and continues, which really makes it exciting. To go back to the sports injuries, this is something that Ian, Brian, and I treat quite a bit of, from chronic to acute. I started an externship, where Pacific College of Oriental Medicine, or it's Health Sciences now, I started this about 15 years ago, where we treat the UCSD athletes.
We work hand in hand with the trainers out there, which is really quite an excellent model to have a triage, where an injury would be coming in, and we triage that with the athletic trainers, discussing “Let's try the acupuncture first, or let's do the acupuncture after the sports medicine techniques.”
We're trying our best to educate acupuncturists in the TCM field about sports injuries and such. You guys, thank you very much for all of this. I really, really appreciate this. This has been a real wonderful experience.
Anthony Von der Muhll: Richard, Matt, and everyone, I feel very honored to be asked these questions and to have the opportunity to participate in this discussion among such a varied group of highly experienced clinicians and educators. I have learned a lot from it myself, and roundtables like this I believe really sharpen and broaden our thinking and get us out of our own clinical ruts which are easy to get stuck in. So, thank you!
Regarding further education and training in sports acupuncture, there are now far more options for clinicians of all license types than there were 30 years ago, thanks to the enthusiasm, open-mindedness, and hard work of those in this panel and many others who have put patient care at the forefront of their attention. I echo everyone's comments above about the value of continuing to study the supposedly mature sciences of anatomy and kinesiology where new discoveries and advancements continue to be made, as well as cross-training with other professions and modalities. The years I spent before and during acupuncture school as a lowly aide and assistant in a physical therapy and athletic training clinic were invaluable, as have been years of working as an acupuncturist alongside osteopaths, physiatrists, and pain medicine physicians in integrative clinics. And studying physical exam with Chiropractors and Osteopaths, myofascial trigger point needling with physical therapists, and ligamentous, joint, and distal needling for orthopedics with other acupuncturists skilled in these techniques, and Chinese medical theory with classicists.
My own 250-hour Certification in Acupuncture Orthopedics program, which I began teaching in 2015 weaves all these various threads together with applications to the general population of chronic pain patients as well as athletes. Much of my formative experience was working in or on a referral basis with clinics where I was seeing many patients suffering from complex and chronic orthopedic problems complicated with neural hypersensitization, deep psychosocial and emotional dysfunctions, and maladaptive responses to pain that exacerbated their disabilities—and often a lot of disagreement or lack of clarity regarding tissue-based diagnosis. Workers comp, litigation, veterans, opioid-dependent patients, chronic depression-anxiety and insomnia, complex regional pain syndrome, etc.
What this experience has taught me is, in my classes, to place a strong emphasis on physical exam skills, joint range of motion and end-feel testing, manual muscle testing, inspection, palpation, observation, and various specialized exams, etc. as not only useful diagnostically and guiding acupuncture, but as a way to gain perspective on patients often misleading or incomplete histories and imaging studies, and as powerful tools for demonstrating to a patient their actual functional capacity and then showing them, with numbers when possible, their improvement over time–or sometimes the lack thereof, and the need for re-evaluation or changing course with treatment.
I now consider physical exam as one of my most powerful treatment tools for moving the patient beyond backward-looking pain histories and refocusing them on regaining functional capacity. Of course this must be done by meeting them where they're at and validating their experiences of suffering—and then gently supporting and guiding them where they want to and need to go. There's as much art if not more than science to this kind of rapport-building and communication, but I attempt to impart through my classes as much as I can about what I've learned about how best to and how not to communicate with patients about injury, pain, and disability. It wasn't emphasized in my basic training as an acupuncturist, I learned mostly through trial and error, but it's a major factor in outcomes, even with highly motivated and goal-oriented athletes, and needs to be addressed in continuing education.
Richard C. Niemtzow: Well, thank you. Does anyone have any final comments? As a non-sports physician, I found this conversation really incredible. I think there will be many, many people whose career will be influenced by all of you. I certainly learned a lot, and appreciate even more about sports medicine, the application of acupuncture.
I would like to thank Yael BenPorat, our managing editor, because she does so much to get the journal out there, and I'm sure each and every one of you will be interacting with her. Yael, do you want to say a few words?
Yael BenPorat: I would like to thank everyone for attending the roundtable discussion today. So much incredible information has been shared. We really appreciate all your views and comments on this very interesting topic in our field. This has been very informative, and I think our readers will find the discussion stimulating and educational.
Richard C. Niemtzow: I want to thank Hannah and Ben from overseas for coming in here at the end of their day almost evening and to the rest of you for your kind participation and for getting up so early in the morning—a big thank you from the publisher—Mary Ann Liebert and myself.