Abstract
ABSTRACT
Background:
Musculoskeletal injuries can be debilitatingly painful, with long recovery times and activity-limiting prognoses. While numerous studies and case reports illustrating the benefits of acupuncture in treating various musculoskeletal conditions are available, more studies specific to acute injury are needed.
Case:
A 45-year-old male presents ∼48 hours post a severe injury to his R hamstring while walking in his neighborhood. He has a history of musculoskeletal disorders, which may be due to an undiagnosed hypothyroid condition. A combination of acupuncture, myofascial release techniques, and kinesiology taping (KT) was administered in 7 treatments over 28 days postinjury.
Results:
This patient was back to normal functionality, strength, and ROM within 4 weeks of this injury, more than 5 weeks ahead of his orthopedic physician's estimated recovery time. At 28 days postinjury, after 7 treatments, visual analog scale had decreased from 9/10 to 0/10, Tenderness To Palpation Scale decreased from grade IV to I, and Lower Extremity Functional Scale increased from 0/80 to 74/80.
Conclusion:
Using a combination of acupuncture, myofascial release techniques, and KT may greatly reduce the healing and recovery time in patients with acute musculoskeletal injuries.
CASE PRESENTATION
A 45
Following the usual standard of care for acute muscle injury, he saw an orthopedic specialist MD at a local orthopedic ER walk-in clinic on 10/12/21, ∼14 hours postincident (PI). An X-ray and MRI of the R hip were performed that day. The X-ray was unremarkable, and the MRI was negative for hamstring avulsion at the muscle insertions, which were the primary concern. However, the MRI focused on the R hip and did not extend the entire length of the hamstring muscle group. He was diagnosed with a nonsurgical grade 3 hamstring strain, and Mobic 15 mg daily was prescribed. He was advised to use crutches to be completely nonweight bearing until a follow-up appointment in 6 weeks. He was also advised that he would likely not walk without assistance until at least 12/31/21, which greatly distressed him. Myofascial therapy techniques via physical therapy were recommended, but the patient sought these from his Licensed Acupuncturist, (the author), instead.
At his initial presentation for acupuncture treatment on 10/13/21, the author observed that his R posterior thigh was warm and inflamed, but not discolored. Marked edema was observed in the BL36 and BL37 areas. The patient reported no paresthesia, or sensory deficit in his R leg. He had been taking the prescribed 15 mg Mobic for ∼27 hours. No other internal or topical medications or supplements had been taken for this injury. He graded a IV on the Tenderness to Palpation Scale (TTPS), flinching when his R hamstring was touched, and a 0/80 on the Lower Extremity Functional Scale (LEFS). His pulse was wiry, tight, choppy, and slow. Using the 0–10 visual analog scale pain scale, he reported that the pain in his R hamstrings ranged from 7/10 to 9/10. Standing using crutches with no weight on his R leg, his pain is 7/10. If he engages his R hamstrings, his pain is immediately 9/10. This pain is fixed, sharp, and stabbing. Manual muscle tests (MMT) were not performed during the first 4 appointments due to the pain level and severity of the injury.
PAST MEDICAL HISTORY
The patient was diagnosed with Hashimoto's Thyroiditis in 2020. He is under the care of an endocrinologist and takes 125 mcg of Levothyroxine QD in the morning, 1 hour before any caloric intake. He has a history of musculoskeletal injuries, and it is suspected that he has hypothyroid myopathy. A muscle biopsy is indicated to confirm this diagnosis, but it has not yet been ordered.
INTERVENTIONS
The author treated this patient 7 times, averaging every 4 days, over 28 days. Multiple interventions were used in this case, all chosen to alleviate pain and repair soft tissues as quickly as possible. Kinesiology taping (KT) was used to decrease pain and inflammation. 1 Acupuncture was used to calm shen, clear stagnation, and move qi and blood (Table 1), and both acupuncture and myofascial release techniques were used to facilitate muscle and connective tissue repair.2,3 A combination of manual myofascial winding 4 and the Bladder/Lung (BL/LU) midday/midnight channel correspondence was used beginning with the fourth treatment (10/20/21), to promote healing of the rift in the R hamstring muscle fibers. The positive effects of this combination of methods to reduce estimated healing time in this acute injury were hypothesized by the author, and were based on years of sports and orthopedic training and experience. The goal of this combination of modalities was to decrease the orthopedic physician's previously stated estimated healing time and get the patient back to normal activity levels more quickly than projected.
Points Used with Direction, Depth of Placement, and Intended Actions
Kim. 5
BL/LU, Bladder/Lung.
#1: 10/13/21 (∼45 hours PI): pain 7/10 constantly, 9/10 if R hamstring is touched or R knee flexion is attempted. Palpation is barely tolerated, TTPS is grade IV, LEFS is 0/80. Passive knee flexion is tolerated.
○ KT with 2″ RockTape® in inverted Y formation, split at ∼BL37.5, covering the muscle attachments at the ischial tuberosity down to the fibular head laterally at about 30% stretch and wrapping around the tibial head medially at about 40% stretch. X pattern over the area of most intense inflammation: ∼BL37.5.
○ DBC™ .20 × 30 spring 10 acupuncture needles were inserted perpendicularly into acupoints GV20 and GV21 and bilateral ST8 to calm shen, bilateral points: SP10 to move qi and blood, LI4 to clear stagnation, ashi ∼LU4 utilizing the BL/LU midday/midnight channel correspondence to alleviate pain, GB34 to benefit the sinews, ST36 to calm shen and alleviate pain, and KD3 to tonify yin and promote circulation. DBC .20 × 15 spring 10 acupuncture needles were inserted perpendicularly into bilateral shen men. Deqi sensation was obtained, and all needles were retained for ∼25 minutes.
○ At the end of treatment, Seirin® Pyonex .20 × .90 (green) press needle tacks were placed on bilateral SP10 to continue to move blood and qi, and ashi ∼LU4 to continue pain relief.
#2: 10/15/21 (∼93 hours PI): pain 4/10 constantly, 8/10 if R hamstring is touched or R knee flexion is attempted. Palpation is still barely tolerated, TTPS grade is IV, LEFS is 7/80. There is a marked reduction in inflammation where the kinesiology tape has been. No bruising is visible anywhere on the R leg.
○ Same acupuncture treatment as #1: 10/13/21.
○ Reapplied the KT in the same pattern, except that inflammation has moved inferiorly, and the X is now at BL37.
#3: 10/18/21 (7 days PI): pain 3/10 constantly, 5/10 if R hamstring is touched, 7/10 if R knee flexion is attempted. Palpation is more easily tolerated, TTPS grade is III, LEFS is 12/80. Inflammation has been further reduced, and a distinct divot in the muscle can now be felt in the area near BL37. No bruising is visible. He now uses a walker instead of crutches at home ∼50% of the time.
○ Same treatment as #2: 10/15/21.
○ Gentle myofascial release of the entire R hamstring group using guasha in the direction of the muscle fibers with a stainless-steel scraping tool and a combination of equal parts Blue Poppy Sports Massage Oil and Blue Poppy Dr. Bob's Medicated Oil, 7-minute duration. While this was initially uncomfortable for the patient, within 2 minutes, he relaxed, and the treatment was easily tolerated.
#4: 10/20/21 (9 days PI): pain 2/10 constantly, 5/10 if R hamstring is touched, or R knee flexion is attempted. Palpation is easily tolerated, TTPS grade is III, and LEFS is 19/80. Inflammation has been further reduced, and a space between the muscle fibers between the biceps femoris long head and the semitendinosus at the level of BL37 can be felt and seen. There is a rift in the connective fascia at BL37 ∼ 1.0″ in width.
○ Same acupuncture treatment as #3: 10/18/21, plus manual myofascial winding and traction technique at 2 ashi points in the myofascial division between biceps brachii short and long head at ∼LU4. This combined myofascial winding with the BL/LU midday/midnight correspondence to encourage the repair of connective tissues in the R hamstrings. Bilateral needles were wound clockwise and retained with traction held for 30 seconds on and 30 seconds off for 5 minutes. While he said it was “weird,” the patient tolerated this well.
○ Reapplied KT in the same pattern, X at BL37.
#5: 10/25/21 (14 days PI): pain 0/10 constantly, 2/10 if R hamstring is touched, or R knee flexion is attempted. There is minimal inflammation on the R hamstring and no bruising on the R leg. The rift in the fascia at the level of BL37 appears to have narrowed. Palpation is easily tolerated, TTPS is grade II, LEFS is 39/80. MMT of the R hamstrings group showed an Oxford Muscle Testing Scale (OMTS) grade of Poor– pretreatment, while the R hamstrings tested Poor+ posttreatment, the posttreatment testing did produce 5/10 pain. He is using his R leg with the walker but is being very careful.
○ Same acupuncture treatment as #4: 10/20/21.
○ Myofascial release of the entire R hamstring group via moving, cupping, using medium-light suction, in the direction of the muscle fibers using large and medium silicone accordion cups and a combination of equal parts Blue Poppy Sports Massage Oil and Blue Poppy Dr. Bob's Medicated Oil, 5-minute duration. The patient tolerated this well and fell asleep during the treatment.
○ Reapplied KT in the same pattern, X at BL37.
#6: 10/29/21 (18 days PI): pain 0/10 with palpation or R knee flexion, unless he moves too quickly, then 5/10. There is no inflammation visible on the R hamstring and no visible bruising on the R leg. The rift in the fascia at the level of BL37 has narrowed to ∼3/8″. Palpation is easily tolerated, TTPS is grade II, LEFS is 58/80. MMT of the R hamstrings group showed OMTS grade of Fair– pretreatment, and while the R hamstrings tested Fair+ posttreatment, the posttreatment testing did produce 3/10 pain.
○ Same treatment as #5: 10/25/21.
#7: 11/8/21 (28 days PI): pain 0/10 at all times. The patient reports that he can now walk slowly unassisted, is fully weight-bearing, and is managing the stairs at home without assistance. TTPS is now grade I, LEFS is 74/80, and MMT of the R hamstrings group showed OMTS grade Good− pretreatment, Good+ posttreatment, and the posttreatment testing did not produce pain.
○ Same treatment as #5: 10/25/21.
DISCUSSION
This case report describes the successful treatment of a severe acute hamstring injury patient and illustrates many key points applicable to clinical practice. During initial treatments, the KT kept the inflammation down and helped create space in the tissues to facilitate tissue repair. The KT also helped reestablish neuromuscular communication to help encourage correct movement patterns and prevent lasting injury to the tissue. At the same time, the cupping was integral to moving blood and bringing fluid in to help repair the tissues. The acupuncture combination of midday/midnight channel correspondence paired with the myofascial winding needle technique first used in treatment #4 was key to helping to reknit the fibers.
Between treatments #4 and #5, LEFS increased 20 points, from 19/80 to 39/80. Subsequent treatments using this combination resulted in LEFS continuing to significantly increase between treatments: from 39/80 at treatment #5 to 58/80 at #6 and 74/80 at #7 (Table 2). The patient's only reservation after 7 treatments was running. All treatments were tolerated well, and the patient reported that he particularly enjoyed the cupping and felt it offered great pain relief.
Treatment Progress Measurements
LEFS, Lower Extremity Functional Scale; OMTS, Oxford Muscle Testing Scale; TTPS, Tenderness To Palpation Scale; VAS, visual analog scale.
Analyzing a single case study can be limited due to its observational nature and the single-participant sample size; however, in this case, the single-participant size also allowed for an in-depth, detailed analysis of the response to the treatment of a specific complex injury over time. The treatment frequency in this case allowed for the results to be tracked almost daily, giving real-time information relative to treatment and recovery progression, which could be clinically relevant in similar future cases. Although the results of this case are clinically relevant to sports medicine and orthopedic acupuncture practices, the circumstances may be difficult to reproduce exactly due to the immediacy with which this patient sought acupuncture treatment after this traumatic injury. These are limiting factors, but it should not be overlooked that a potential new treatment method could be derived from the combined modalities and techniques used in this case. The treatments used were partially limited by the author not having a complete MRI of the injured muscle group. Had that been obtained, more targeted tissue needling and E-stim treatments may have been utilized.
This patient's R hamstrings were back to his normal functionality, strength, and range of motion within 4 weeks of this injury, grading a I on the TTPS only when his R hamstrings were deeply palpated, and a 74/80 on the LEFS. The R hamstrings group continued to Oxford Muscle Testing Scale grade Good or higher with MMT, and the testing did not produce pain (Table 2). He was diligent with rehabilitation exercises and stretching and was careful at the gym and when hiking. At his orthopedic clinic follow-up on 11/22/21, his physician was amazed at his progress and released him from care. Subsequent acupuncture treatments focused on balancing his pelvis, shoulders, and neck from using crutches and a walker. He continues regular acupuncture treatment for Hashimoto's and hamstring tune-ups PRN.
CONCLUSION
The findings in this case suggest that combining acupuncture, myofascial release techniques, and KT might shorten the expected recovery time in an otherwise healthy patient with an acute hamstring strain. While this case had a positive outcome, more research is needed on combining the modalities used in treating acute musculoskeletal injuries.
Footnotes
AUTHOR DISCLOSURE STATEMENT
No competing financial interests exist.
FUNDING INFORMATION
No funding was received for this article.