Ultrasound-Guided Electroacupuncture Treatment for Rotator Cuff Tendinopathy: Proposing an Effective Alternative to Nonoperative Medical Treatments

INTRODUCTION

Rotator cuff (RTC) tendinopathy is a common and painful condition of the shoulder, affecting athletic and nonathletic patient populations, through overuse and overloading patterns in the shoulder that impair function and quality of life. Pain recurrences are also a common problem with RTC tendinopathy. This condition often results in the following changes within the tendon's architecture itself which can be detected by ultrasound imaging: thickening, intrasubstance tearing, partial bursal or articular surface tearing, and calcium deposition. ¹ These architectural changes can be associated with a subacromial bursitis, which can also be seen sonographically. The supraspinatus and infraspinatus tendons are most commonly involved due to their anatomical location in the shoulder predisposing them to repetitive stress and strain with overhead and external rotation movements.

Common medical treatment modalities to date for RTC tendinopathy outside of oral medications and physical therapy include corticosteroid injections, platelet-rich plasma (PRP) injections, extra-corporeal shockwave therapy (ESWT), and various tenotomy procedures (tenex, tenjet, and percutaneous needle tenotomy).

PRP is an autologous mixture of highly concentrated platelets and growth factors produced by centrifugal separation of a patient's whole blood, which when injected into a site of injury can promote cell recruitment, proliferation, and angiogenesis. Multiple studies to date, including meta-analyses, have shown that PRP injections for RTC tendinopathy reduces short- and long-term pain. ² ESWT is also considered to be an effective treatment option for reducing pain, whereby concentrated rapidly delivered acoustic waves (shockwaves) are delivered into targeted tissue to promote regional blood flow and thereby increase growth factors to promote healing and repair. ³ Studies comparing this treatment modality to physical therapy alone have been very promising for long-term outcomes. ⁴ Percutaneous needle tenotomy refers to a needling technique whereby a needle repeatedly fenestrates the affected tendon, thereby encouraging localized bleeding and an immune system cascade with growth factor production to aid healing. ⁵

Sports medicine acupuncture treatments to date for RTC tendinopathy have been pioneered primarily by Matt Callison, LAc and Whitfield Reaves, OMD, LAc. These treatments can include traditional Chinese medicine approaches of bleeding techniques of the tendino-muscle Small Intestine (SI) and San Jiao (SJ) meridians, SI3 and BL65 Shu-Stream Point combination needling, and addressing any underlying Qi and Blood stagnation, Liver blood deficiency, and Wind-Cold or Cold-Damp obstructions.^6,7 Huatuojiaji Points C4–C6 can also be needled to promote a facilitated segment along the RTC innervated spinal segment. ⁶ Muscular/Motor point needling techniques of the supraspinatus muscle occur at SI12, infraspinatus muscle at SI11 and surrounding trigger points, and possible LI14 needling if the deltoid muscle is involved. ⁷ Myotendinous needling techniques occur at LI16 for the supraspinatus and SI10 and/or SI9.75 for the infraspinatus. ⁷ Tendon needling techniques for both the supraspinatus and infraspinatus occur at LI15 and SJ14 and at the extra point daijianzhen for the supraspinatus.^6,7

Electrical stimulation can be effective with orienting the leads to pair either the individual muscles if two needles are placed in those locations or pairing the individual muscle-tendon needles. ⁷ Direct or needle moxa can be utilized, as well as needle rotation to wrap the underlying connective tissue. ⁶ Treatment duration is often two times/week for 3–6 weeks.

This article presents a fusion of western medicine-based techniques and acupuncture. It utilizes ultrasound imaging of the RTC and the acupuncture needles, thereby allowing image-guided needling into symptomatic areas of RTC tendon pathology. Electrical stimulation of the acupuncture needles followed to promote blood flow and therefore growth factor production, resulting in both short- and long-term pain control and healing. ⁸ This offers a shorter treatment duration than the current acupuncture treatments and utilizes a less-invasive approach than the standard of care approaches.

CASE

A 58-year male who enjoyed golfing and P90X for exercise presented for chronic (over 1 year) right shoulder pain that stopped him from doing any overhead motions or lifting. He had been diagnosed with RTC tendinopathy and impingement by a board certified sports medicine physician at ChristianaCare, a large hospital system in Delaware. He had already completed 6 weeks of formalized physical therapy without improvement, after which he had a subacromial bursa corticosteroid injection with ongoing maintenance of a home exercise program for periscapular and RTC strengthening that gave him 4 months of partial pain relief. Oral pain medications like nonsteroidal anti-inflammatories were not helpful and he preferred to not be on daily pain medication.

He presented again to discuss additional options after having a noncontrast shoulder magnetic resonance imaging that showed subcentimeter, partial articular surface tearing of the supraspinatus and infraspinatus tendons that could not be operatively managed, in addition to edema around his subscapularis tendon. He continued to deny any paresthesias and had normal sensation in the C5–T1 dermatome distribution, as well as a negative Spurling's maneuver for radiculopathy. His exam showed normal shoulder range of motion, normal scapular mechanics, and 4/5 strength of the supraspinatus and infraspinatus and pain with impingement testing by Neer's and Hawkin's maneuvers.

Given that multiple RTC tendons were involved, and there was not a single discrete tear, PRP was not initially recommended. Given his level of weakness and discomfort on exam, ultrasound-guided electroacupuncture was discussed as an alternative to ESWT, as it allowed for a broader area to be treated in a less painful manner than ESWT. Tenotomy treatments were not considered, as the patient did not want the required transient reduction in his physical activity. The treatment plan was to significantly lessen his symptoms first with electroacupuncture performed by the sports medicine physician and then determine the need for additional treatment modalities going forward.

Four weekly treatments in total were performed with the patient in a seated position. He was given a home exercise program to progressively strengthen the periscapular muscles and RTC that he started the day after his first treatment. The needles used were of 0.25 mm diameter and 40 mm long (Hua-Xia, Suzhou, China) or 0.25 mm diameter and 50 mm long (Seirin, Shizuoka, Japan) depending upon the depth of the RTC tendon target.

The needles were placed under ultrasound guidance into the following areas: subacromial bursa around LI15; posterior supraspinatus tears and infraspinatus tears around LI15 and SJ14; and infraspinatus tendon sheath threading around SJ14 (Figs. 1–3). Needles were also inserted into the infraspinatus and supraspinatus motor points, SI11 and SI12, respectively. Electro-acupuncture (Model AWQ-104L, Tens Plus Industrial Company, Kwun Tong, Hong Kong) was then performed for 15 minutes at 3 Hz. Needles were paired for electrical stimulation based on similar location: subacromial bursa needles were paired; supraspinatus tears were paired; infraspinatus tears and infraspinatus tendon sheaths were paired; and motor points of the same RTC muscle were paired.

OPEN IN VIEWER

FIG. 1.

(a) RTC Tendon in longitudinal/long-axis with an acupuncture needle inserted in longitudinal/long axis into a small articular surface calcium deposit. (b) Four obliquely oriented arrows depicting the needle traversing the tissue in longitudinal/long-axis. Oval depicting the calcium deposit. The humerus and RTC tendon (white arrow) are labeled. Even when needle visualization is good, it is often incomplete relative to larger hollow bore needles utilized for injections. RTC, rotator cuff.

OPEN IN VIEWER

FIG. 2.

(a) Unlabeled subacromial bursitis and supraspinatus thickening with acupuncture needling of the subacromial bursa under ultrasound. (b) Labeled sonographic anatomy with arrow delineating a subacromial bursitis. (c) Labeled acupuncture needling in longitudinal/long-axis. The needle tip is circled, and the incompletely visualized needle shaft is delineated in arrows. Visualization even when the needle is longitudinal (due to small needle size, depth of needling, and individual patient difference in image quality) is sometimes reliant on the motion of the needle, which is best captured during ultrasound guidance placement or with cine-loops on ultrasound.

OPEN IN VIEWER

FIG. 3.

(a) Infraspinatus tendon in long axis with an articular surface tear delineated by the cortical disruption in the humeral head. Arrows indicating acupuncture needling in short-axis directed toward the cortical tear. (b) Labeled anatomical images with the small arrow indicating the cortical disruption. (c) Acupuncture needling in short-axis is highly reliant on needle motion visualization during scanning. Sometimes serial images from a cine loop will capture the subtle change in echogenic appearance of the needle with motion (arrows pointing to the needle appearing as a more hypoechoic line in 3a to more hyperechoic line of the needle in 3b/c).

RESULTS

Between all treatments the patient's pain progressively decreased and he was able to sleep on his affected shoulder again after two treatments, with restoration of 5/5 strength of his RTC and negative impingement testing maneuvers. His subacromial bursitis resolved by ultrasound examination after two treatments. He was able to progress in his home exercise program for RTC restrengthening between treatments. Two months after starting electroacupuncture, he reported being 85% improved. The patient is now 1 year and 2 months out from treatment and reports only “minimal” discomfort when he crosses his arm over the other shoulder to stretch. He is also back to all desired exercise routines and without impaired function.

DISCUSSION

Acupuncture needles targeting areas of RTC injury offers a minimally invasive and very well tolerated treatment strategy for RTC tendinopathy. There is often less pain experienced during and after the electrical stimulation treatments compared to PRP, ESWT, and tenotomy procedures. This treatment strategy, similar to ESWT, also offers minimal to no down time in the patient's level of activity, which is generally preferred by the patient.

The limitations in this treatment methodology lies within the needle visualization abilities by ultrasound. A structure is always best visualized sonographically when the transmitted ultrasound waves from the probe are perpendicular to the targeted structure. ⁹ For round structures like the RTC tendons, combined with a deeper/steeper needling technique, it can often be difficult staying perpendicular to the entire length of the needle as it traverses tissue. Furthermore, acupuncture needles are often about half the diameter of the smallest 25-gauge hollow bore needle (0.5 mm) that can be used for ultrasound-guided procedural injections, when often even larger needles are utilized instead (e.g., a 22-gauge needle is 0.7 mm and an 18-gauge needle is 1.0 mm). These small diameters make ultrasound visualization of the needles more technically challenging and needle motion visualization by ultrasound is therefore frequently required to ensure proper needle placement into the target tissue. Ultrasound is also very user dependent and therefore needle visualization strategies and techniques improve with ongoing experience.

One can debate whether this type of treatment is acupuncture versus dry needling versus a modified percutaneous tenotomy.^5,10,11 While that discussion is important as we are considering and being sensitive to how western medicine-based sports medicine practitioners like myself could be altering a craft that is thousands of years old, we can also remain open to discovering the benefits of combining these two worlds.

CONCLUSIONS

This case report presents a novel acupuncture treatment for the commonly debilitating and refractory condition of RTC tendinopathy. It fuses treatment strategies within the worlds of sports medicine and sports medicine acupuncture. This fusion appears to be a highly effective treatment strategy, both with respect to significantly reducing the overall number of acupuncture treatments required to treat this condition and with respect to long-term (over 1 year) symptom relief and return of normal function. More cases and formalized research on this methodology needs to transpire to test the hypothesis that image-guided needling techniques can shorten acupuncture treatment duration and improve treatment success for tendinopathies. In the meantime, it sets a promising groundwork for the future of electroacupuncture treatment strategies for RTC tendinopathies.