Female Athletes and ACL Reconstruction: Rehabilitation Integrating Acupuncture and Medical Herbology
By Ronda Wimmer, PhD, MS, LAc, ATC, CSCS, CSMS, SPS

Acupuncture Today
August, 2004, Vol. 05, Issue 08

Female athletes and their participation in sports events have increased dramatically over the past 20 years. ACL injuries in female athletes also are on the rise. As motor skill level, physical musculature and speed increase, so, too, do the injuries.

The anterior cruciate ligament (ACL) is the most common injury site in women’s sports. Women athletes at greatest risk are those who are involved in sports that require pivoting, cutting, jumping and twisting movements. Noncontact ACL injuries are far more common in women than men, and sports in which ACL injuries occur most frequently include gymnastics, soccer, basketball, field hockey, volleyball, lacrosse, softball, rugby and martial arts. Integrating Oriental medicine within the ranks of the sports medicine team can provide valuable modalities in the rehabilitation of ACL injuries.

Injury Mechanism (Western)

ACL injuries in noncontact sports include: hyperextended knee with a one-stop landing; twisting/deceleration force upon the knee in cutting or pivoting maneuvers; and landing from a jump in which the knee is internally rotated and hyperextended. Internal (intrinsic) risk factors include hormones, joint laxity, muscle strength, ligament size, neuromuscular strength, lower limb alignment, and intercondylar notch width. External (extrinsic) factors include type of shoe, training/conditioning level, shoe surface interface friction, and equipment used. The most common ACL injuries result from a forceful twisting motion (knee flexed and foot planted, causing external rotation of the tibia on the femur).

The above stated injuries include risk factors such as Q-angle and hamstring/quadriceps ratio. The Q-angle (the angle formed by a line from the ASIS [anterior superior iliac spine] to the center of the patella and then a line from the center of the patella to the tibial tuberosity) represents the direction force of the quads during directional force exerted upon the patella during lower-leg extension. Usually, females have greater Q-angles than males, and reflect less-developed vastus medialis oblique muscles and weak hamstrings, which contribute to noncontact ACL injuries. Normal ranges for Q-angle measurements are from 15o- 17o. Usually, if the measurement is greater than 20o, this is considered abnormal.

The hamstring/quad ratio reflects the female athlete’s tendencies to have weaker hamstring strength, as the hams are ACL agonists working synergistically with the ACL to prevent anterior translation of the tibia. The quads act as antagonists to the ACL, creating force that creates anterior tibial translation. When balanced, these opposing forces assist in protecting the knee. Female athletes tend to have greater quad muscle strength over the hamstrings, thus predisposing female athletes to ACL injuries.

Injury Mechanism (Eastern Perspective)

Female athletes in general, as with all athletes (due to training schedules in conjunction with work and school schedules), create pre-existing conditions upon their lifestyles. Common pre-existing deficiencies related specifically to the knee represent Kidney qi deficiency and/or Kidney yang deficiency. Over time, this gives rise to external invasion of bi syndrome, specifically wind, cold and damp, that can invade the channels of the Kidney/Urinary Bladder.

Muscles need nourishment, and the Spleen qi provides and supports that nourishment, along with the Liver blood supporting and nourishing the tendons. The Kidney essence/jing supports and nourishes the bones and marrow according to the Five-Element correspondence.

Bi Syndromes Related to the Knee

Typical physiological manifestations for diagnosis include two specific types of excess and deficiency categories. Excess conditions create obstructions within the channels, whereas the deficient condition represents pre-existing conditions of zang/fu organ deficiency. These excess conditions ultimately lead to blood and qi stagnation, creating pain, whereas deficiency conditions are created from an internal zang/fu organ pre-existing deficiency within qi/blood/yin/yang, which is unable to support or nourish the joints and muscles due to lifestyle.
Wandering Bi Painful Bi Fixed Bi
Wind presents as a yang pathogenic factor

Wandering pain

Constantly changing movement

Dispersion and upward movement Cold presents as stagnation

Contraction with severe pain

Pain alleviated by warmth Damp presents as yin pathogenic factor

Damp accumulation and stagnation

Flowing downward

Heaviness
Acupuncture can assist with mild to severe cases, and should focus on ah shi points. However, if it is too painful, use the contralateral point instead. This will counterbalance any local stagnation in the area. Local points to be used include UB40 and xiyan. Other points used are LV8 (he sea point LV), ST34 (xi cleft point ST), ST35 (lateral xi yan point), and SP10 (regulates, nourishes and sedates the blood). Added points specific to bi syndromes include wandering bi LV3 and GB34 sedating. For painful bi, add ST42 and SJ4 (moxa). For fixed bi, add SP6, SP9, SJ6 and UB20.

During the rehabilitation phase, tieh ta can be used among many other medical herbal formulas that move qi and blood stagnation. Within the second week of rehabilitation, blood palace can be used for invigorating the blood. Within the third to fourth week, use du hou ji sheng tang to release external pathogens, tonify Liver/Kidney qi and tonify the blood, in order to prevent chronic wind/cold/damp invasion. There are many patent remedies available for use. The concept is not to use protocol treatments, but to think through, using the Oriental medicine philosophy.

Another factor is patient follow-through when implementing therapeutic exercises with ACL reconstructions with physical therapists and/or chiropractors, athletic trainers and kinesiotherapists. One can integrate acupuncture within the process to assist in patient range of motion, pain, and keeping the qi moving, preventing stagnation for a more specific, successful and enhanced recovery.

Conclusion

By adding an Eastern diagnostic perspective within the sports medicine team, acupuncturists can be very effective within rehabilitation, and focus on preventative measures that take into account zang/fu organ deficiency and other patterns of differentiation, according to TCM. The acupuncturist can identify and counterbalance TCM patterns, and collaborate with sports rehabilitation specialists as to the modified exercises that balance hams/quads balance and Q-angle differences, by anticipating weaknesses in order to strengthen beforehand during the “off” season. This is a huge component that is currently absent from the physical therapy/rehabilitation; strength and conditioning; athletic training; and performance specialization components. It takes collaboration of all components, in order to see the athlete as a whole. That collaboration should include an acupuncturist as an asset within all of these specializations.

References

¦Arendt EA. Common musculoskeletal injuries in women. Phys Sportsmed 1996;24(7):39-47.
¦Bonci CM. Assessment and evaluation of predisposing factors to anterior cruciate ligament injury. J. Athletic Training 1999 (2):155-164.
¦Goris JE, Graf BK. Risk factors for ACL injury. Wis Med J 1996;95(6):367-369.
¦Kaptchuk, Ted. The Web That Has No Weaver. Ontario: Congdon & Weed, 1983.
¦Loudon JK, Jenkins W, Loudon KL. The relationship between static posture and ACL injury in female athletes. J Sports Phys Ther 1996;24(2):91-97.
¦Giovanni M. Foundations of Chinese Medicine. New York: Churchill Livingstone, 1989.
¦Mao-Liang Q. Chinese Acupuncture and Moxabustion. New York: Churchill Livingstone, 1993.
¦Moeller JL, Lamb MM. Anterior cruciate ligament injuries: Why are women more susceptible? Phys Sportmed 1997;25(4):31-48.
¦Wiseman N, Ellis A. Fundamentals of Chinese Medicine. Brookline: Paradigm, 1985.
¦Xinnong C (chief editor). Chinese Acupuncture and Moxibustion. Beijing: Foreign Languages

***Article 2

Patella Chondromalacia

Direct Electric Acupuncture for Patella Chondromalacia: A Preliminary Report of a Clinical Study
By Hua Gu

Acupuncture Today
October, 2001, Vol. 02, Issue 10

Chondromalacia of the patella is common among athletes and people over 40. It is caused by direct trauma or chronic injury to the knee joint. Although it is often referred to and treated as a discernible ailment, chondromalacia patellae is best thought of as a symptom.
The patella contains the thickest layer of cartilage in the body. It has five facets or ridges: superior; inferior; lateral; medial; and odd. The “odd” facet is most frequently the first part of the patella to be affected in chondromalacia patellae. Chondromalacia patellae is the softening and subsequent roughening of the patella’s hyaline cartilage. This malady presents itself as grinding beneath the patella and may cause related swelling and pain. A definitive diagnosis is made through visual inspection during arthroscopy. Chondromalacia patellae is most often, if not always, the result of biomechanical changes affecting the lower extremity. As such, it may be treated symptomatically by acupuncture.

Acupuncture

A course of treatment is three times a week for three weeks.

Results

The results are based on clinical findings, x-ray and MRI tests.

Excellent: No pain; no signs and symptoms; no discomfort when squatting or kneeling down; no pain when walking up or downstairs. Followup for six months without recurrence.

Good: Pain, symptoms and signs significantly decreased; mild discomfort when squatting or kneeling down. Followup six months with mild discomfort.

Fair: Pain, symptoms and signs decreased; some difficulty when squatting or kneeling down. Followup six months with slight to moderate discomfort.

Poor: No effect or worse.

Thirty-two cases were treated between 9-30 times by the same acupuncturist. Among the 32 cases, 10 were judged as “excellent” (31.1%); 12 “good” (38%); 3 “fair” (9.4%) and 7 “poor” (22%).

Discussion

Direct electric acupuncture is the key for this group of patients. The cartilage in chondromalacia patellae is damaged by many different causes. Physical examinations such as Clark’s sign, the McConnell test, the passive patellar test and Zohler’s sign can help make the diagnosis. X-rays with skyline or sunrise view and knee joint MRI show clear images of the cartilage shape and damage. From the TCM point of view, the diagnosis is the same as bi syndrome, no matter what the cause. After a series of electric acupuncture treatments, most patient knee joint swelling and pain subsided, and range of motion improved.

Electric acupuncture may have the following effects on treatment for chondromalacia of the patella:

1.Direct stimulation by electric current in conjunction with the needles applied to the impaired area may help the regeneration of cartilage.
2.Acupuncture needles inside the joint capsule may relieve synovitis, which will decrease the secretions of the synovial membrane and reduce pain.
3.Most cases in the poor group had moderate to severe misalignment, such as genus varus or valgus, or abnormal Q-angle. These conditions can induce unequal pressure and stress distribition in the femoropatellar joint and cause necrosis of cartilage and cyst formation under the cartilage. Electric acupuncture is a good method to relieve the symptoms of chondromalacia.
4.Perhaps it is the electric current directly working on the joint surface, or the needles’ direct contact with the cartilage, that reduces the pressure inside the joint and relieves the symptoms.
5.Another possibility is that electric stimulation changes the viscosity and pH of the joint’s synovial fluid to alter the irritation to the synovial membrane.
Further study is necessary to assess what happens inside the joint. Arthroscopic exploration is needed to confirm the changes pre- and post-electric acupuncture treatment.

References

1.Gu H. Clinical Traditional Chinese Medicine, Orthopedic Volume. Chinese Medical Science Publisher, 1st ed., 1989.
2.Fulherson JP. Evaluation of the peripatellar soft tissues and retinaculum in patients with patellofemoral pain. Clin Sports Med 1989;8:197.
3.Goodfellow J, Hungerford DS. Patellofemoral joint mechanics and pathology: chondromalacia patellae. J Bone Joint Surg 1976;58B:291.
4.Pickett JC. Chondromalacia of the Patella. Baltimore: Williams and Wilkins, 1983.

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