CLINICAL APPLICATION OF ACUPUNCTURE IN COMMON SPORTS INJURY

1. CLINICAL APPLICATION OF ACUPUNCTURE IN COMMON SPORTS INJURY

2. SPORTS INJURY • In Broad Terms • Injuries caused by participation of sporting activities • May include different systems of the body • For the purpose of this seminar • Limit to that of the Musculoskeletal System • Especially that of soft tissues

3. Falls within the subject of Traumatology in Chinese Medicine (中醫傷科學) • Classified as Jin injuries (傷筋 / 筋傷)

4. Jin 筋 • Jin in Chinese Medicine represents virtually all soft tissues of the musculoskeletal system • It encompasses everything from fascia, tendons, ligaments, muscles; to subcutaneous tissues, joint capsules, fibrocartilages, etc.

5. Etiology of Jin Injury • Endogenous Factors (內因) • Age 年齡 • Physique 體質 • Anatomical structure 局部解剖結構 • Occupation 職業

6. Mechanism of Jin injuries • Qi and Blood 氣血 • Acute Jin injury  dysfunction of the flow of Qi and blood急性筋傷 – 急驟的暴力可致氣血運行失常 • Chronic Jin injury – inadequacy in Qi and Blood cannot resist exogenous factors and violence慢性筋傷 – 氣血虛弱, 筋肉失養, 失養則虛, 虛則不耐疲勞

7. Mechanism of Jin injuries • Jin Yi (Nourishing fluid) 津液 • Acute Jin injury – wasting of Jin Yi dysfunction of Jin Yi metabolism急性筋傷 – 津液虧耗, 津液代謝失調 • Chronic Jin injury – Jin Yi inadequacy  poor joint mobility, stagnation of fluid movement and metabolism  stagnation and swelling津液虛少, 不能濡潤關節, 屈伸不利; 勞損引起津液代謝失調, 積聚腫脹

8. Mechanism of Jin injuries • Meridians 經絡 • Jin injuries  damage Meridians“若因傷折, 內動經絡, 血行之道不得宣通, 瘀不散, 則為腫為痛” • Meridian stagnation and blockage  Jin weakness  Jin Injury經絡為病, 血瘀阻不通, 導致筋肉失養而發生筋傷疾患

9. Mechanism of Jin injuries • Meridians 經絡 • Jin injuries  damage Meridians“若因傷折, 內動經絡, 血行之道不得宣通, 瘀不散, 則為腫為痛” • Meridian stagnation and blockage  Jin weakness  Jin Injury經絡為病, 血瘀阻不通, 導致筋肉失養而發生筋傷疾患

10. Common Physiotherapy Treatments of Soft Tissue Sports Injuries • Manual Therapy • Deep Tissue Massage • Mobilization and Manipulation • Myofascial Release, etc. • Electrophysical Agents • Acupuncture • Exercise Therapy • Taping and Orthotics

11. Acupuncture • Acute Stage • Ah Shi Points 阿是穴 • Points in the vicinity 近部取穴 • She (demoting) techniques 瀉法 • Leave the needles for 5 – 10 minutes or do not leave the needles留針5 – 10 分鐘或不留針

12. Acupuncture • Sub-acute & Chronic Stages • TriggerPoints 以痛為腧 • Points along the meridian 循經取穴 • Bu (promoting) techniques 補法為主 • May combine with Moxibustion (especially when wind, coldness and dampness factors are present in meridians)可配合艾灸 (尤其是風寒濕邪阻痹經絡時)

13. Effects of acupuncture • Pain relief • Reduction of swelling • Release of Jin (soft tissues) 舒筋 • Promotion of flow in Meridians 通經活絡 • Improve circulation • Reduce muscle spasm

14. Mechanisms of Acupuncture • Pain-gate mechanism • Counter-irritant effect • Endogenous Opiate release • Axon reflex of inflammation

15. Mechanisms of Acupuncture • Effects on Meridians (unknown mechanism) • Improvement of Qi and Blood flow • Correction of Zang Fu functions • Meridians flowing through the area have healing effects on the area 經脈所過, 主治所在

16. Mechanisms of Acupuncture • Information Hypothesis 信息學說 • Signal of “injury” • Eliciting natural mechanism of repair • General body balancing • Chaos Theory

17. Special considerations • Aseptic technique on the field • Vigorous cleaning of the skin • Cleaning of the operator’s hands • DO NOT touch the body of the needle • Use gloves if need to hold body of needle (e.g. using long needles) • Shelter the client with good posturing • Explanation to the client

19. China • Some of the best Olympic athletes are incorporating acupuncture into their wellness programs. • China's most popular sportsman, the 7 foot 6 inch China basketball center, Yao Ming, used acupuncture and Oriental medicine to help him recover after undergoing surgery on his ankle in April, 2007. • Outside china • Getting more and more popular china • Getting more and more popular • Outside china • Getting more and more popular

20. How acupuncture can help? • One systematic review found strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain (Trinh 2004). This updated an earlier review on the same subject where there was insufficient evidence to either support or refute the use of acupuncture (Green 2002). The only other systematic review on sports injuries found that, based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with patellofemoral pain syndrome were acupuncture, quadriceps strengthening, and the use of a resistive brace (Bizzini 2003). There is also positive evidence from individual randomised controlled trials, showing that: • acupuncture reduced pain in patients with plantar fasciitis (Zhang 2001); • electroacupuncture had better therapeutic effects than medication, both in the short and long term, in patients with acute lumbar strain (Yao-chi 2007); • acupuncture plus warmed needle relieved the pain of chondromalacia patella (Qui 2006); • acupuncture reduced NSAID intake and relieved pain in patients with shin splints (Callison 2002); • acupuncture reduced the pain of patellofemoral pain syndromes (Jensen 1999); • acupuncture was effective for soft tissue disease (Yuan 1989).

21. Ankle Injuries

22. Ankle injury is the most common injurys among all the joint injurys all over the body ,and I think most of us have suffered from it.So today let’s studay it together .this is an image taken from xi'an ,and I think that she is also suffering from ankle injury. Really slight pain?

24. Anatomy: Ankle Mortise

25. Bony Anatomy(28 piece) Fibula tibia talar calcaneus lateral malleolus Posterior Process of talus Lateral tubercle calcaneuslateral process of the talus Anterior process of the calcaneus Talar dome

26. Phalanges Metatarsal bones Cuboid bone Calcaneus Lateral process of the talus Calcaneus Posterior process of the talus: medial tubercle groove for flexor hallucis longus tendon Lateral tubercle Articular surface of the talar dome Navicular bone Cuneiform bones

27. Lateral Ligament Complex The most important ligament anterior talofibular ligament calcaneofibular ligament posterior talofibular ligament

28. Medial Ligament Complex Medial ligament : Posterior tibiotalar ligament Tibiocalcaneal ligament Anterior tibiotalar ligament Tibionavicular ligament

29. Why the ankle joint always to be hurted? The speciality of ankle • The movement of the ankle is a complex movement including 6 directions : Plantar bending/ dorsiflexion Inversion(内翻）/eversion Intortion /extorsion • The ankle assume Large amount of motion with heavy weight-bearing sometimes the ankle bears 5 times of body weight while you doing some exercise (high jump) • Obviously there is no strong muscle around it

30. Ankle Sprains overview • Ankle Sprains is the most common joint injurys all over the body • Most common sports related ligament injury • About 90% ankle injury shows lateral ligament complex injury • Most common injurys related Inversion（内翻） mechanism • Terrible is “ High rate of recurrence” • mostly due to incorrectmanagement and Inadequate rehabilitation • Some Drs just only give the patient painkiller and tell them “have a rest,its will be OK after afew days.

31. Lateral Ankle Sprain • anterior talofibular ligament • calcaneofibular ligament • posterior talofibular ligament When you sprain the ankle in Inversion-Plantar position ,it will hurted the LLC Lead to Anyone or all ligs be torn

32. When you see your Dr,the Dr will need complete history Including: • Previous injury about ankle and foot • Mechanism of injury (The exactly position of the ankle extemporaneous ) • The ambulation immediately that you can do after injury • Physical examination Precise location of tenderness point, Rom…and so on • X-ray examination to be sure that there is fracture or not

33. Physical examination Items: • Inspection • ROM (range of movement) • Strength • Special Tests • Tenderness point of Palpation

34. Inspection • the hurted ankle maybe showsSwelling AND Subcutaneous hemorrhage • sometimes, It keeps in Varus position

35. ROM the normal range of the ankle movement • Plantar (0 ～30degrees) dorsiflexion(0 ～50degrees) • Inversion(内翻）/eversion (0 ～30degrees) • Heel cord flexibility If the range of the ankle movenent beyond the normal, Maybe some of your ligaments have been torn.

36. Special Tests • Anterior drawer test and Suction sign • Integrity of ATFL • Talar tilt test • Integrity of CFL • Squeeze test and External rotation test • Syndesmotic injury (tib-fib ligaments) Maybe It would cause sharp pain,but No correct examination no correct diagnosis and also no correct trratment,so you should give your dr your cooperation

37. Anterior Drawer

38. Squeeze/ External Rotation Test

39. Palpation • BE SPECIFIC! If you hurted your lateral ligament complex,there will be an obvious tenderness point

40. Grading Severity • Grade 1 - stretch injury • Grade 2 - partial tear • Grade 3 - complete tear

41. Tear: ATFL torn Normal This MRI image show the anterior talofibular ligament torn

42. Treatment: Acute • The treatment about Acute can be abbreviated asRICE ,and it should be done during first 24-72 hours,)AND it is only suitable for GRIDE-1 ankle injury Rest Ice Compression Elevation • Painkiller for 3-7 days • Protect from further injury • Functional weight bearing • Early ROM If the injury is more serious the most important treatment is effective Fixation especially for grade 2or3(such as plaster spint fixation) The other treatment such as:

43. Ice: during the first 24 hours ,you should do cold-compress with ice bag, 20一30 minutes every time。 After 24 hours you should do hot compress ,that will be better for your ankle blood circulation and reduce swelling. The ankle should not be massaged within First 24 Hours，because that will lead to more bleeding.

44. Compression for 2 days to stop bleeding

45. Keep the ankle elevation It will help your ankle blood circulation to get better and to reduce swelling

46. Treatment: Subacute • The Goals is to restore full Range Of Motion, muscle strength, heel cord flexibility, and proprioception • Return to play - sports specific drills • Protect! a boot which can surround the ankle will be better for you ASO ankle stabilizing orthosis

47. Ankle Rehabilitation After ankle injury,the ankle rehabilitation will help your ankle recover in short time .it is including muscle exercise in every directions ,like the below images show Step by step To strengthen the posterior muscle of Shank

48. To strengthen the lateral muscle of shank To strengthen the stability of the ankle

49. How long will you can Return to Play after ankle injury • Grade 1 stretch injury : 1-2 wks • Grade 2 partial tear : 2-4 wks • Grade 3 complete tear : 4-8 wks • “High ankle sprain”: 6-12 wks

50. Preventive measure Ⅰ Warm-up is important before heavy exercise Ⅱ Cruris muscle power training The measure is the same to ankle Rehabilitation Ⅲ the most important is toDo Balance training the most effective and the most simple measure is to stand with single leg for more than 5 minutes ereryday.