Browsing articles tagged with " Ankle pain"

68. An Ancient “New Way” to use Acupuncture to treat Cervical Dystonia

Mar 7, 2017   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 8 (1), March, 2017, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878, Tel: (203) 637-7720

Cervical Dystonia




Lisa L. is an 18-year-old female, who had been complaining of neck pain for the past six years.  The patient reports that, six years ago, when she woke up, she suddenly realized that her neck jerked to the left. The jerk happened very often; her neck would jerk two or three times every 5-10 minutes.  The jerk was involuntary and occurred more frequently especially when she was tired or under stress. However, if she had a good night’s rest, felt energized, and focused on something (e.g. her favorite sports), she would not experience the sudden, involuntary neck movements. Only when she sat still, did her neck start to jerk.

Lisa’s neck muscle always feels very tight, and the tightness can be very painful. She has been to many doctors and has tried everything, such as physical therapy and multiple medications, without any improvement. She therefore came to me for evaluation and treatment. Upon physical examination, I noted that the left side of the patient’s sternocleidomastoid muscle had hypertrophied. It felt like a thick rope on the left side of her neck. I also noted that other muscles had undergone hypertrophy: the levator scapular and splenius capitis at the cervicals. Throughout the entire physical examination, there was no jerk or involuntary contraction on the left side of the patient’s neck.

What Lisa is suffering from is called cervical dystonia, which is the most common form of focal dystonia.  Cervical dystonia is characterized by abnormal and spasmodic squeezing of the muscle that leads to muscle contractions in the head and neck area. The movements are involuntary and are sometimes very painful, causing the neck to twist repetitively, resulting in abnormal posture.  Overall, this may affect a single muscle, a group of muscles, such as those in the arms, neck, and legs, or even the entire body.  Patients with dystonia often have normal intelligence and no associated psychiatric disorders.

The causes of cervical dystonia are currently unknown.  There are two types of cervical dystonia:

Primary cervical dystonia: This type of cervical dystonia is not related
to any identifiable, acquired disorders affecting the brain or spinal cord such
as stroke, infection, tumor, or trauma. In some cases, primary cervical dystonia
is genetic, caused by abnormal genes such as dystonia DYT1. However,
because not all carriers of the DYT1 gene develop cervical dystonia, it
is likely that other genes or environmental factors may play a role in the
development of cervical dystonia.

Secondary cervical dystonia: Unlike primary cervical dystonia, secondary
cervical dystonia has obvious causes such as stroke, tumor, infection in the
brain or spinal cord, traumatic brain injury, toxins, birth defect, etc.  There
may be a period of months between the injury and the onset of the dystonia.

Tests and diagnosis:

The first step when diagnosing cervical dystonia is to determine if any of the causes that may lead to secondary dystonia are evident.  The following tests may be used to screen and/or diagnose for secondary cervical dystonia:

1.Toxins and infections screening: blood or urine samples will confirm the presence of toxins and infections.

2.Tumor screening: an MRI will identify and visualize tumors of the brain or spinal
cord.

3.Genetic testing: can be used to identify DYT1, which is critical to the diagnosis
of primary cervical dystonia.

4.Electromyography (EMG) testing: measures electrical activity of muscles.  An EMG can help diagnose muscle or nerve disorders.

Medications:

Many different medications have been used to treat cervical dystonia but most are not effective:

1.Cogentin and Kemadrin are examples of drugs that decrease the level of acetylcholine. These have helped some patients but have sedating side effects.

2.Valium, Ativan, Klonopin, etc., regulate the neurotransmitter GABA.

3.Sinemet, Laridopa, etc. either increase or decrease dopamine levels.

4.Carbamazepine is an anticonvulsant.

Botox injections:

Botox injections can usually stop the muscle spasms by blocking acetylcholine, relieving the symptoms for approximately three months. Very experienced doctors should administer the Botox injections. If Botox is used for more than a one-year period, it will gradually become less effective because the patient’s body will begin producing auto-antibodies against it.

Other treatments:

In some severe cases, surgery may be an option.  Surgery is the last resort and is used to selectively denervate the nerve supplying the muscle.

Another treatment option is deep brain stimulation.  This involves implanting an electrode in the brain connected to a stimulated device in the chest that generates an electrical pulse.  These electrodes will temporarily disable nerve activities by damaging
small areas of the brain.

Chinese medicine:

According to traditional Chinese medicine, cervical dystonia is caused by excessive liver wind. The liver controls the movement of all tendons, muscles and joints in the human body. Excessive liver wind overstimulates the tendons, muscles and joints, constantly activating the muscles. We use the following methods to treat our cervical dystonia patients.

  1. Acupuncture

The principle acupuncture treatment used to treat cervical dystonia reduces the excessive liver wind and thereby decreases the activities of the tendons, muscles and joints. The acupuncture points are along the meridians of the liver and gall bladder, such as the Feng Chi and Tai Chong points.

In addition, because patients with cervical dystonia have abnormal head and neck movements, acupuncture must also be used along the Du meridian, which controls head movement. The Du meridian supplies the entire brain. If the energy of the Du meridian is excessive, the entire head will move abnormally. Therefore, the acupuncture treatment should also include the Da Zhui and Hou Ding points from the Du meridian.  These points will adjust and regulate the Du meridian, the yang, activate the tendon function, and balance the input and output of the energy of the Du meridian.

The acupuncture treatment should also include the Xin Shu, a direct outlet acupuncture point from the heart and the Shen Shu, a connecting point from the kidney. Sheng MenTai Xi and the points listed above are involved in the circuitry of the heart and kidney, and will decrease the fire surrounding these organs, keeping the yin and yang in harmonious balance. Some local points in the neck and head such as Tian ChuangTian RongTian Ding, and Fu Tu, should also be used for their localized calming functions.

This combination of local and distal acupuncture points will greatly decrease the symptoms associated with cervical dystonia.

  1. Moxibustion:

Moxa is a Chinese herb similar to cigarette to warm certain points in the human body. We suggest to use the following device to moxa the neck sternocleidomastoid muscle for 30 minutes. Patients should learn how to use it before you use for yourself.

  1. Guasha (Scrape) :

Following  the length of  sternocleidomastoid muscle, use the Guasha plate to scrape down 30 times then up 30 times, 5 sessions per day.
The patient was treated with acupuncture at the above points for approximately two months, three times a week. After the last treatment, the number of neck contractions had significantly decreased. Now, she only experiences mild neck jerks and contractions, allowing her to perform her daily activities in a normal manner.

Tips for acupuncturists:

  1. Acupuncture cannot treat all forms of cervical dystonia. The milder the disease, the better the treatment results. Physicians should find the cause if the patient is suffering secondary cervical dystonia.
  2. Using heating pads and massages after the acupuncture treatment increases its effectiveness.

Tips for patients:

1.The earlier the treatment, the better the treatment results.

  1. Help yourself with Guasha, Moxa, massage and heating pad.

 

67. Dr. Jun Xu’s calling from West Africa

Mar 5, 2017   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

Dr. Jun Xu went to Leprosy village in 2013, 2014 and 2016, soon he will go to the leprosy village on March 31, 2017.

In 2013, there was no a single room being used for treatment in the leprosy village, Dr. Xu and his team had to use a tent. The temperature was around 125 Fahrenheit degrees.

The leprosy patients were waiting for their turn to be attended. Dr. Jun Xu saw about 200 patients a day.

Typical leprosy patient:
Early Stages
Spots of hypopigmented skin- discolored spots which develop on the skin
Anaesthesia(loss of sensation) in hypthese opigmented spots can occur as well as hair loss
“Skin lesions that do not heal within several weeks of and injury are a typical sign of leprosy.” (Sehgal 24)

Progression of disease

“Enlarged peripheral nerves, usually near joints, such as the wrist, elbow and knees.”(Sehgal 24)
Nerves in the body can be affected causing numbess and muscle paralysis
Claw hand- the curling of the fingers and thumb caused by muscle paralysis
Blinking reflex lost due to leprosy’s affect on one’s facial nerves; loss of blinking reflex can eventually lead to dryness, ulceration, and blindness
“Bacilli entering the mucous lining of the nose can lead to internal damage and scarring that, in time, causes the nose to collapse.”(Sehgal 27)
“Muscles get weaker, resulting in signs such as foot drop (the toe drags when the foot is lifted to take a step)”(Sehgal 27)

Long-term Effects
“If left untreated, leprosy can cause deformity, crippling, and blindness. Because the bacteria attack nerve ending, the terminal body parts (hands and feet) lose all sensations and cannot feel heat, touch, or pain, and can be easily injured…. Left unattended, these wounds can then get further infected and cause tissue damage.” (Sehgal 27)
As a result to the tissue damage, “fingers and toes can become shortened, as the cartilage is absorbed into the body…Contrary to popular belief, the disease does not cause body parts to ‘fall off’.” (Sehgal 27)

Every year, Dr. Jun Xu and his team bring around $300,000 worth of medicine donated from his team members and Americares in Stamford, CT to treat the leprosy and other patients in Senegal and Guinea Bissau. http://www.americares.org/, in 2017, his team also received medicine donation from Direct Relief in California, https://www.directrelief.org/.
Dr. Jun Xu and his team finally established a clinic in the leprosy village, one building for the clinic, and another building for the living of doctors and nurses.

Leprosy village people were celebrating the opening of the clinic.

There are 8 wards, which could hospitalize the patients if it is medically necessary.

Dr. Jun Xu’s team usually stay in Senegal for 10 to 14 days, these are the foods his team brought from US in order to keep them health and safe. They do not dare to eat street food.

The above are the coolants contained food Dr. Jun Xu’s team brought from US

Dr. Jun Xu and his team from US in 2006.
If you are interested in joining Dr. Jun Xu’s team or donating to his work in Senegal, please address your check payable to AGWV, and send to
Jun Xu, MD, 1171 E Putnam Avenue, Riverside, CT 06878, USA.
Dr. Xu promises that all your donation 100% will go to Senegal and his team will nerve use a penny from your donation. You will receive the tax deductible receipt. Any amount is a great help for Africa patients.
For more info, please visit our websites at
http://www.drxuacupuncture.co/ and http://www.africacriesout.org/

52. Acupuncture and Rheumatoid Arthritis

Apr 29, 2013   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 5 (4), April, 2013, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Fax: (203)637-2693

 

Acupuncture and Rheumatoid Arthritis

 

Fig. 1 Hang RA http://www.fsb555.com

Sandy, a 45 year-old woman, complained of bilateral hand and wrist pain on-and-off for many years. Recently for a month now, she felt both hands had constant pain and were tender, warm and swollen.  She woke up with morning stiffness that may last for hours and felt firm bumps of tissue under her both forearm accompanied with fatigue, mild fever and gradually weight loss. She visited her PCP and was given naproxen to reduce her inflammation and pain, however, she felt no improvement. She was referred to a rheumatologist, who ordered x-ray images and rheumatoid factor test.  Both were positive for Rheumatoid Arthritis, therefore, the diagnosis was confirmed. The patient was given methotrexate and felt better for morning stiffness and swelling, however, she had many side effects, such as, nausea, vomiting, hair loss, etc. Because of above complaints, she came to me for evaluation and treatment.

 

Rheumatoid Arthritis (RA) is a chronic, long-term disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs. As the disease progresses, symptoms often spread to the knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.

The stiffness seen in active RA is most often worst in the morning. It may last one to two hours (or even the whole day). Stiffness for a long time in the morning is a clue that you may have RA, since few other arthritic diseases behave this way. For instance, osteoarthritis most often does not cause prolonged morning stiffness.

Other signs and symptoms that can occur in RA include:

Loss of energy

Low grade fever

Loss of appetite

Dry eyes and mouth from a related health problem, Sjogren’s syndrome, etc

Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands

Fig .2 Synovium  http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp

The normal joint structure appears on the above left. On the right is the joint with rheumatoid arthritis. RA causes synovitis, pain and swelling of the synovium (the tissue that lines the joint). This can make cartilage (the tissue that cushions between joints) and bone erode, or wear away.

RA is an autoimmune disease. This means that certain cells of the immune system attack healthy tissues — the joints in RA, cause the inflammation in the synovium, the tissue that lines the joint. Immune cells release inflammation-causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone.

Rheumatoid arthritis affects the wrist and the small joints of the hand, including the knuckles and the middle joints of the fingers.

 

Fig. 3 RA Hand Deformity  www.eastlady.cn

Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.

Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. Telltale signs include:

Anemia (a low red blood cell count)

Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)

Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70% of patients with RA)

Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

X-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.

 

Fig. 4 Normal Hand X-ray http://gb.123rf.com/photo_751289_hands-on-x-ray-film.html

Fig 5.  RA hand x-ray

There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.

There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime. The treatment must start as earlier as  possible.

A goal of physical therapy is to help make the muscles stronger and the improve the motion of the joints.  Warming up painful joints is very important in managing pain and priming the body for more exercise.  This can be accomplished with moist heating pads, a whirlpool or warm shower.  Following the warm-up, aerobic exercise such as a stationary bike, elliptical, or even arm bike will continue to work the body.  Other arthritis friendly options are aquatic exercises, tai chi or yoga routines.

 

Fig. 6 http://www.tospt.com/aquaticTherapy

It is important to be flexible with the workout routine, as if after the warm-up and aerobic exercise the joints are still very sore, change to strengthen a body part with less discomfort.  However, do not get in a habit of skipping the warm-up and light aerobic exercise if a joint is tender, as often just these two steps will greatly improve how the joint is feeling.  Below are a few range of motion and light strengthening exercises to help the hand that can be performed daily.

Fig. 7 http://morphopedics.wikidot.com/physical-therapy-management-of-rheumatoid-arthritis

West Medicine Treatment:

Good control of RA requires early diagnosis and, at times, aggressive treatment. Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever. DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA.

Common DMARDs include methotrexate (brand names include Rheumatrex® and Folex®), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Older DMARDs include gold, given as a pill — auranofin (Ridaura) — or more often as an injection into a muscle (such as Myochrysine). The antibiotic minocycline (e.g., Minocin, Dynacin and Vectrin) also is a DMARD, as are the immune suppressants azathioprine (Imuran) and cyclosporine (Sandimmune and Neoral). These three drugs and gold are rarely prescribed for RA these days because other drugs work better or have fewer side effects.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. These medications are also DMARDs. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.

The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care requires the expertise of a team of providers, including rheumatologists, primary care physicians, physiatrist and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.

Living with rheumatoid arthritis

 

It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.

 

When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.

 

Acupuncture Treatment:

 

Acupuncture is an excellent alternative way to treat your symptoms. It has no side effects and can be combined with traditional western medicine to relieve your symptoms. The choice of acupuncture treatment of RA  is as following,

Fig 8. Common used acupuncture  points on hands for RA patients

1.         Common used body points: Du20 Bai Hui,  GB8 Shuai Gu, UB9 Yu Zhen, Ht7 Shen Men, GB20 Feng Chi, UB15 Xin Shu, UB20 Pi Shu, UB18 Gan Shu, UB23 Shen Shu, St6 Zu San Li, Sp6 San Yin Jiao, Lv3 Tai Cong, UB2 Zan Zhu, Kid3 Tia Xi.

2.         Arthritis: Shoulder: LI 15 Jian Yu, SI 9 Jian Zhen, SJ 14 Jian Liao, SI 10 Nao Shu, SI 11 Tian Zhong, LI 16 Ju Gu  Wrist: LI5 Yang Xi and SJ 4 Yang Chi.  Hand: L11 Shao Shang, L10 Yu Ji, LI 1 Shang Yang, LI 2 Er Jian, Ht 9 Shao Chong, Ht 8 Shao Fu, SI Shao Ze, SI 2 Qian Gu, SI 3 Hou Xi, SI 4 Wan Gu, PC 9 Zhong Chong, PC 8 Lao Gong.   Knee: LI 4 He Gu, LI 11 Qu Chi, St 35 Du Bi, Nei Xi Yan, Sp 10 Xue Hai, St 34 Liang Qiu, He Ding, UB 40 Wei Zhong. Feet: St 45 Li Dui, St 44 Neiting, Sp 1 Yin Bai, Sp 2 Da Du Sp3 Tai Bai, Sp 4 Gong SunUB 66 Zu Tong Gu, UB 65 Zhi Yin, UB 65 Shu Gu.

3.         Neurological Symptoms: Fatigue, Depression and Poor Sleep: Major points: St 36 Zu San Li, PC6 Nei Guan,  LI4 He Gu, Ht7 Shen Meng, Sp6 San Yin Jiao, GB20 Feng Chi, Du20 Bai Hui, EX-HN1 Si Shen Cong, assistant points: Du14 Da zhui, Ren12 Zhong Wan, Ren14  Ju Que, Ren6 Qi Hai, Ren4 Guang Yuan, UB21 Wei Shu and UB23 Shen Shu.

4.         Heart Palpitation: PC6 Nei Guan, Ht7 Shen Men, UB15 Xin Shu, Ren14 Ju Que, UB14 Jue Yin Shu

5.         Dizziness: Si Shen Chong, Du20 Bai Hui, Du12 Shen Zhu, UB12 Feng Men, UB43 Gao Huang, Sp6 San Yin Jiao, St36 Zhu San Li, LI11 Qu Chi.

Sandy’s Treatment:

Sandy was treated with me for 2 x per week for 8 weeks. I first try to decrease her pain at the joints and body with the points of group 1 and 2 , then, I used the group 3 and 4 points to help her to improve her fatigue and depression, after about 2 month’s treatment, Sandy was put on maintenance treatment program once a week for 4 weeks, and she  felt much improved. Her pain scale decreased from 7/10 to 2/10. Her swelling at both hands is much relieved.

Tips for Patients:

1. Multiple Therapies are the best way to treat RA with combination of medicine, PT and Acupuncture.

2. Newer treatments are effective. RA drugs have greatly improved outcomes for patients. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.

3. Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. A physiatrist who is an expert in RA also can design a customized treatment plan that is best suited for you. Therefore, the rheumatologist, working with the primary care physician and other health care providers, should supervise the treatment of the patient with RA.

4. Start treatment early. Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

Tips for Acupuncturists:

1. Treat your patients as a whole person and long-term treatment is necessary. You should encourage your patient perform exercise, which will keep your patients’ mobility of hands and other joints.

2. Encourage your patients to have at least 8 weeks treatment. It is very important to have a long-term treatment to achieve the best results.

 

33. Acupuncture and Lateral Ankle Sprain

Sep 20, 2011   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  1 Comment

 

News Letter, Vol. 3 (9), September, 2011, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

 

Lateral Ankle Sprain

Fig 9.1

Douglas is a 26 year-old male football player who has been experiencing right lateral ankle pain after a month of strenuous exercise.  He was training for the 100-meter dash when he felt a pain in his right ankle that caused him to fall.  He was immediately taken to a sports medicine doctor who found his right ankle to be moderately swollen, though because of the severe pain Douglas felt, the doctor immediately sent him for an MRI without contrast of the right ankle.  The MRI showed no fracture, no ankle bone dislocation, though showed there was a ligament sprain of the right ankle.

 

The patient was given preventative treatment known as RICE, which stands for:  R is rest; the patient was ordered to stay off the right ankle.  I is ice for ice packs to be held to the affected area to decrease both the inflammation and the swelling.  C is for compression: the patient was given an elastic sock to wear on his right ankle and E is elevation, so the patient was instructed to elevate his leg to decrease the edema and the swelling.

 

The patient gradually felt better, however he still felt pain in the right lateral ankle after a month, so he came to me for further treatment and evaluation.

 

I noted the ankle was still slightly swollen and the lateral right side of it was very tender.  The range of motion of the right ankle dorsiflexion, i.e. his right foot bend up to his nose was 0-30 degrees and the plantarflexion, i.e. his foot bend down to the ground, 0-20 degrees, though with pain.

 

The patient had suffered a lateral ankle sprain, the most common form of ankle sprains, which accounts for 80% of this type injury.  There are three small ligaments in the ankle which are very easy to sprain.

  1. Anterior talofibular ligament (ATFL):  This is the most common ligament injury
  2. Calcaneofibular ligament (CLF): This is the second most common and
  3. Posterior talofibular ligament (PTFL):  This is the last to be injured.

http://www.webmd.com/hw-popup/ankle-sprain Fig 9.2

All of these three ligaments function to stabilize the ankle during inversion, so when the ankle experiences inversion on the plantarflexed foot, this is the most vulnerable position.

 

http://www.midwestsportsfans.com Fig 9.3

Ankle Sprain Causes

The ankle pain is most often caused by injury to the ligaments, not bone. Ankle ligaments, especially as mentioned above are injured most commonly when the foot is turned inward or inverted by a force greater than the ankle ligaments can sustain. This kind of injury can happen in the following ways:

  • Sports: such as football, basketball, tennis, when the athlete landed with the plantar foot inverted and the downward force. A common example is a basketball player who goes up for a rebound and comes down on top of another player’s foot. This can cause the rebounder’s foot to roll inward.)
  • Fall while stepping on an irregular surface, such as stepping in a hole.
  • The most common ankle sprains are Inversion injuries, in which the foot rolls inward, are more common than eversion injuries (also referred to as a high ankle sprain), in which the foot twists outward.

There are three grades of lateral ankle sprains:

  1. Grade 1 is mild, which includes partial tear of the ATFL and intact CFL and PTFL.  There is no instability, mild swelling and point tenderness at the lateral aspect of the ankle.
  2. Grade 2 is moderate.  There is a complete tear of the ATLF and partial tear of the CLF.  The patient’s ankle is very unsteady and exhibits diffuse swelling and ecchymosis.
  3. Grade 3, severe. This is the complete tear of the ATFL and CFL.  The patient in this case is extremely unsteady.

 

Western medicine treatment.

  1. During the acute stage the ankle is treated with RICE, as detailed above.
  2. Nonsurgical treatment only can treat grade 1 and possibly part of grade 2; grade 3 requires surgery.
  3. Physical Therapy:

 

A rocker boot helps to promote a more natural gait while providing stability for severe ankle sprains, fractures of the foot and for post-operative use.  There are many types of rocker boots, but most feature adjustable air cells to ensure a custom snug fit to accommodate any foot.

 

Ensuring optimal pain free motion is needed to help with recovery.  Starting with Active Range of Motion perform up to 30 pain free reps of the 4-Way Ankle Movements before moving on to resistance with strengthening.  Strengthening the muscles of the ankle and lower leg is important to prevent imbalances and future weakness in the ankle.

 

1: Dorsiflexion – foot is pulled back towards the body against resistance

2: Plantarflexion – foot is pushed down away from the body against resistance

3: Inversion – foot is turned down and in against the resistance

4: Eversion – foot is turned up and out against the resistance

Fig 9.4

 

 

Fig 9.5

 

 

 

Fig 9.6

 

 

Fig 9.7

 

 

 

To continue to strengthen the stabilizing muscles of the ankle and improve proprioception work on standing balance on the ground.  After, continue to progress to balance with a foam pad for 2 sets of 30 seconds.

Fig 9.8

 

 

 

This will assist in strengthening the stabilizing muscles of the ankle and help to regain balance in circumstances where the ankle may be injured again such as in basketball when going up for rebound and coming down on another players ankle.  The wobble board once balance is achieved in standing on a flat surface and on the foam pad can be used again, this time in a standing position.

 

Traditional Chinese medicine treatment:

 

Many patients tried everything before they came to me. They usually had different treatments for years. However, they still feel pain with difficulty standing, and walking. They have extreme pain by walking a long distance, such as during vacation. Acupuncture might be their last resort.

 

My personal experience is that we first have to make a clear diagnosis by palpating the tender points to differentiate injuries of the three ligaments: the most common injured ligament is ATFL, the second most common injured ligaments are ATFL and CFL. You will see rarely the PTFL injury. After palpation, you can clearly understand the source of the problems. Then you can treat the injury accordingly.

 

The following acupuncture points are usually selected: Sp 6 San Ying Jiao, UB 62 Sheng Mai, GB 40 Qiu Xu, UB 60 Kun Lun,  PC 6 Nei Guan, and St 36 Zu San Li.

Sp 6 is the crossing points for three Ying Meridians, therefore, it can adjust all three meridians energy, and smooth the blood and qi. UB62 is located at the ATFL, therefore, it is very important to use for the ATFL injury. GB41 coincident at CFL, it will help UB62, both UB 62 and GB 41 will bring blood flow to the injured ATFL and CFL ligaments to facilitate healing. PC 6 and St 36 helps adjust the entire energy flow in the body.

Points Meridian/No. Location Function/Indication
1 San Yin Jiao Sp 6 3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibiaFigure 24.22 Abdominal pain, distension, diarrhea, dysmenorrheal, irregular menstruation, uterine bleeding, morbid leucorrhea, prolapse of the  uterus, sterility, delayed labor, night bed wet, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and leg pain, headache, dizziness and vertigo, insomnia
2 Shen Mai UB 62 In the depression directly below the external malleolus Epilepsy, mania, headache, dizziness, insomnia, backache, aching of the leg
3 Qiu Xu GB 40 Anterior and inferior to the external malleolus, in the depression on the lateral side of the tendon of extensor digitorum longus Pain in the neck, swelling in the axillary region, pain in the hypochondriac region, vomiting, acid regurgitation, muscular atrophy of the lower limbs, pain and swelling of the external malleolus, malaria.
4 Kun Lun UB 60 In the depression between the external malleolus and archillus tendon Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and heel pain, difficult labor, epilepsy
5 Nei Guan PC 6 2 inch above the transverse crease of the wrist, between the tendons of m. palmaris longus and m. flexor radialis. Cardiac pain, palpitation, stuffy chest, pain in the hypochondriac region, stomachache, nausea, vomiting, hiccup, mental disorders, epilepsy, insomnia, febrile diseases, irritability, malaria, contracture and pain of the elbow and arm.
6 Zu San Li St 36 3 inch below St. 35 Du Bi, one finger below the anterior crest of the tibia, in the muscle of tibialis anterior Gastric pain, vomiting hiccup, abdominal distension, borborygmus, diarrhea, dysentery, constipation, mastitis, enteritis, aching of the knee joint and leg, beriberi, edema, cough, asthma, emaciation due to general deficiency, indigestion, apoplexy, hemiplegia, dizziness, insomnia,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig 9.9

 

 

 

 

Treatment course for Douglas:

Douglas underwent my treatment 2-3 x per week for about 5 weeks, besides acupuncture treatment, he also was guided to have strengthening exercise for his right ankle.  I realized that acupuncture treatment only might take a longer time to recover, however, if we combine acupuncture with physical therapy and ankle brace, the patient will have much less pain and resume their regular walk sooner. After 5 weeks treatment, Douglas started his regular walk with mild tenderness; he can sustain much longer ambulation without pain.

 

Tips for Acupuncturist:

 

    1. Acupuncture and physical therapy can treat only the grade 1 ankle sprain.  If grade 2 or 3 is concerned, you should encourage the patient to consult an orthopedic physician.
    2. Acupuncture is a good treatment for long-term ankle pain, you may need to treat the patient for a few months in order to get better results.
    3. You should encourage your patients to use ankle brace to protect ankle joint.
    4. Electrical stimulation with UB 60, UB 62 and GB40 for 30 min are very important.

 

Tips for Patients:

 

  1. For grade 3 sprain, you may consider surgery for reparation. However, if you have grade 1 or 2, be very cautious to have surgery. I have patients who went through many surgeries, have had long term pain for many years.
  2. You should always massage the three points, UB 60, UB 62 and GB40 5-10 min in the morning and evening everyday. If you have anti-inflammatory cream for massage, you will get better results.

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