Chris Mallac looks at the anatomy and biomechanics of the FHL the pathogenesis of possible injury, and provides detailed rehabilitation suggestions. The flexor hallucis longs (FHL) has been referred to as the ‘Achilles of the foot’ due to its unique role controlling mid foot pronation and supination. Its physiological and mechanical properties allow it to act... MORE
Acupuncture for sports injuries?
When conventional rehabilitation methods are just not enough, what else can facilitate return to sport? Tracy Ward looks at the evidence for and against acupuncture.
The use of acupuncture has been documented for centuries and it is regularly used in traditional Chinese medicine (TCM). Acupuncture involves the use of small, disposable, single use, sterilised needles to pierce the skin’s surface to a specific depth. The location and depth of needle insertion depends on the injury and the desired treatment effects. Needle location often follows meridians; which are the channels or pathways in the body based on TCM.
TCM is an ancient form of medicine that dates back to 1000BC. It is a holistic approach that the Chinese used to (and still do) treat anything and everything including systemic conditions, long-term illness, and emotional stresses such as depression and irritable bowel syndrome. TCM aims to restore balance within the body for optimal health, just as our body’s normal functions require homeostasis for cell regulation. The philosophy of TCM is to provide the correct stimulus to trigger natural healing mechanisms. This philosophy has influenced the Western approach, where the principles remain similar, but where the use of acupuncture is heavily reliant upon clinical findings and scientific evidence.
Acupuncture can provide a number of benefits, including:
- Pain relief – Acupuncture needles can be placed where the injury occurred in the muscle or tissue, and also the surrounding areas. Their insertion provides a minor trauma to the skin, which stimulates the production of pain relieving chemicals both locally at the trauma site, and at the brain and spinal cord level. Chemicals such as endorphins and opioids are released and pain feedback channels from the pain source to the brain are blocked so that the level of pain perceived by the brain is reduced1.
- Inflammation reduction – The microtrauma of needle insertion also stimulates an natural anti-inflammatory response by releasing chemicals that cause vasodilation (blood vessel dilation) and vascular permeability (this allows greater flow of chemicals through the vessels)2. These physiological responses allow the removal of inflammatory mediators from the injury site, and the enhancement of healing mediators to the area.
- Trigger point release – In addition to promoting anti-inflammatory and pain relieving mechanisms, acupuncture can also be used to resolve regions of tightened muscle called trigger points. Trigger points (also known as muscle knots) occur when there is the over-contraction of a small number of muscle fibres in one region3. Needling directly in to the trigger points simply causes mechanical disruption of the contracted muscle fibres to encourage relaxation. It also stimulates blood flow and the delivery of oxygen and nutrients through vasodilation, and reduces the elevated electrical activity in the muscle, allowing them to relax4.
Figure 1: Bladder points in the lower limb. Hamstring trigger points are located within the muscle bellies at the source of pain – ie between the regions of BL 36 and BL 38.
Acupuncture in rehab – acute intervention
Given the potential benefits, acupuncture treatment may help accelerate the return to rehabilitation and training for athletes. With pain modulating and inflammatory reduction effects the athlete is then better placed to begin loading their body and the injury safely. An example is trigger point release.
Trigger points can often develop after repetitive activity, eccentric and concentric exercises, and in association with pain5. The acute onset of pain from a muscle contraction or spasm is usually the result of overloading the muscle, over stretching it, or increased activity without adequate warm up or preparation. The trigger point development will produce nociceptive pain, reduce the range of movement, and may alter gait patterns, giving an overall loss of function.
One case study describes the acute onset of hamstring muscle pain in a football player whilst warming up prior to a game6. Serious injury including a muscle tear was ruled out and the player was considered essential to the game so immediate intervention was required. During these match situations there is not time for prolonged rehabilitation methods and often manual treatment can provoke further pain and disability.
The sudden onset of pain with loss of limb movement suggested both an inflammatory and mechanical component to his injury. The player received acupuncture needling in to the trigger points within his hamstring muscles, and also needling along the ‘bladder meridian’ (see figure 1). This is the meridian that promotes the pain relieving and anti-inflammatory effects for the lower limb. Treatment time was only 4 minutes long because the match was due to begin. However following his treatment session his pain levels reduced dramatically and he regained full function. He managed to play the full match with no adverse effects. This case study demonstrated immediate intervention, which facilitated rapid return to play with no adverse effects. Trigger point acupuncture can also be used after games or training when acute muscle spasms occur and the muscle needs further stimulus to relax. This is often a more gentle approach to the acute situation, where too much massage or manipulation can provoke further pain and muscle contraction.
|The appealing benefits to athletes|
|Unlike prescription medications, herbal supplements, and other methods of pain relief, acupuncture produces very little in the way of side effects. This is especially beneficial to athletes where any drug side effects can affect training and performance, and where doping regulations have become increasingly strict on what can legally be consumed. However, minor side effects have been reported in 1.2 per 1000 persons treated(13).
These effects include nausea, fainting, dizziness and bruising. Serious adverse effects have been reported to be extremely rare, with figures showing only 0.0002% of patients affected(14). Furthermore, the adverse effects of acupuncture are reversed upon removal of the needles, and a study of over 3 million cases showed that those who did suffer adverse events made a full recovery(15). No drugs, no side effects, and no lasting adverse events all combine to make acupuncture an appealing option in rehabilitation.
Acupuncture in rehab — chronic facilitation
Chronic injuries such as tendinopathies account for 30-50% of all sports injuries and can be debilitating for up to 32 months7. Tendinitis is the inflammatory stage of a tendon injury. Tendinopathies are the result of failed healing and initial response to treatment. As the injury prevails, it becomes chronic with degeneration of the tendon tissue and repeated microtrauma; this is a tendinopathy8.
Tendinopathies can prevent athletes from training due to the on-going pain they experience, and the uncertainty of the safety limits with exercise so as not to further damage the tendon. This pain can often dissuade athletes from performing eccentric loading – often regarded as an effective treatment method for all tendinopathies. Acupuncture can help in these situations by reducing pain and enabling athletes to begin rehab involving eccentric loading of the tendon.
For example, patellar tendinopathy can keep athletes away from sport for long periods of time. One acupuncture study highlighted a semi-professional rugby player who had significant quadriceps muscle wastage, shortening and pain upon any activity that involved the quadriceps so he was unable to train in any capacity9. The aim of his acupuncture treatment was to reduce pain levels enough to facilitate a gradual return to training. After six sessions of acupuncture his pain reduced by more than 50% and pain occurred less frequently. This intervention then allowed him to start gentle aerobic exercises and move on to eccentric training and rugbyspecific drills.
Another example is Achilles tendinopathy, which accounts for 11% of all running injuries and continues to be a problematic injury to treat. Achilles tendinopathy often leads to impaired gait and significant limping when pain persists. A case study involving a marathon runner with an acute onset of achilles tendinopathy received acupuncture treatment over four weeks10. While simple rest would have played a role in the recovery process, these results provide some evidence that the acupuncture treatment helped to promote healing effects within the tendon, enabling long-term maintenance in the form of eccentric loading to then be implemented.
Although much less researched, the use of acupuncture has also recently been applied to chronic ankle pain, and specifically ligament sprains. Despite being a different tissue from tendons and muscles, there is no reason as to why a ligament injury would not benefit from acupuncture. The treatment has been shown to reduce pain levels significantly and allow restoration of joint range of movement with six treatments, after a nine month history of chronic ankle ligament sprain11. This demonstrates that despite the specific injury diagnosis, the beneficial effects of acupuncture can still occur when the symptoms are of mechanical, inflammatory and/or nociceptive origin.
Working better together
With all injury-management strategies, a holistic and combined approach can often provide the most rapid recovery. One study provides an example of the use of acupuncture and other treatment methods in patellar tendinopathy12.
|Week No.||Acupuncture use||Other treatment methods||Outcomes|
|1||Local to the injury (surrounding the patellar tendon).||Home stretching of the quadriceps, hamstrings and hip flexor muscles. To begin gentle eccentric exercise.||Pain increased from 6/10 to 7/10 with squats and single leg stand|
|2||Around the patellar tendon.||Deep-tissue massage of the quadriceps and to increase the repetitions of the eccentric exercises.||Pain reduced from 6/10 to 4/10|
the knee and
down the leg.
|Deep transverse frictions to the patellar tendon. Passive stretching to the quadriceps and further increase in repetitions of the eccentric exercises.||Pain remained at 4/10 and there was no pain noted on static quadriceps contractions.|
|4||Trigger point locations within the quadriceps.||Weights were added to the eccentric exercises. Stretches were deepened.||Pain reduced to 3/10 overall. There was now no pain with active quadriceps contractions as well as with static contractions. Muscle length had increased.|
In week one, the athlete’s pain levels increased following the introduction of eccentric exercises. However with further acupuncture treatment the pain score reduced and further manual treatment was possible, as well as progression of the exercises. By week four, the athlete was able to add weights to his eccentric exercises, and he then
returned to rugby drills.
Acupuncture offers an additional adjunct to rehabilitation, pain-relieving and antiinflammatory benefits, which are stimulated via the needling to the skin and the activation of receptors. Acute conditions such as the acute onset of pain or trigger points can be treated effectively with acupuncture when time is limited. Chronic conditions such as tendinopathy may also benefit, as acupuncture reduces pain levels, allowing participation in other rehabilitation methods such as eccentric loading, weight training and sportsspecific exercises. Another benefit is that acupuncture is virtually without major side effects and detrimental effect to training, making it the ideal addition to athlete rehabilitation.
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