A Virtual Roundtable Discussion: The Role of Acupuncture in Sports Injuries and Best Practices

Medical AcupunctureVol. 35, No. 5 Roundtable DiscussionFree AccessA Virtual Roundtable Discussion: The Role of Acupuncture in Sports Injuries and Best PracticesModerator: Richard C. Niemtzow, Participants: Matt Callison, Brian Lau, Benjamin Ingram, Ian Armstrong, Hannah Leahy, and Anthony Von der MuhllModerator: Richard C. NiemtzowUS Air Force Acupuncture and Integrative Medicine Center Joint Base Andrews, MD, USA.Search for more papers by this author, Participants: Matt CallisonAcuSport Seminar Series, Inc. dba AcuSport Education, Sports Medicine Acupuncture Certification Program, San Diego, CA, USA.Search for more papers by this author, Brian LauSports Medicine Acupuncture Certification, Ideal Balance: Center for Sports Medicine. Acupuncture, Tampa, FL, USA.Search for more papers by this author, Benjamin IngramUnited Stated Army, Mons, Belgium.Search for more papers by this author, Ian ArmstrongFunktion Acupuncture, San Diego, CA, USA.Search for more papers by this author, Hannah LeahyDefense Health Agency, US Army Medical Department Activity Bavaria, Germany.Search for more papers by this author, and Anthony Von der MuhllSports Acupuncture Clinic, Charlottesville, VA, USA.Search for more papers by this authorPublished Online:17 Oct 2023https://doi.org/10.1089/acu.2023.29241.rtlAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Richard C. Niemtzow: The purpose of this roundtable is to discuss the role of acupuncture as related to common injuries, acute and chronic pain, and the rehabilitation, of athletes as well as the individual with an active lifestyle.I will have the speakers introduce themselves before we begin.Matt Callison: My name is Matt Callison. I'm a licensed acupuncturist. I'm the president of AcuSport Education and also the Sports Medicine Acupuncturist Certification (SMAC) Program.Brian Lau: My name's Brian Lau. I'm an acupuncture physician in Florida, and also an educator with the Sports Medicine Acupuncture Certification Program, and I teach Cadaver Lab dissections with Sports Medicine Acupuncture and AcuSport, but also other venues and for other health professions.Ben Ingram: My name is Ben Ingram. I'm a physician by background. I'm dual boarded in family medicine and sports medicine. I work for the Army, so most of what I do is sports medicine. My background in acupuncture is related to treatment of athletes. I really look forward to today's talk, and probably learning some things myself. Thank you.Richard C. Niemtzow: Ian and Hannah, can you introduce yourselves?Ian Armstrong: Absolutely, thank you Richard. My name is Ian Armstrong and I am an acupuncturist in San Diego, California area. I am certified in Sports Medicine Acupuncture, as well as an instructor in the Sports Medicine Acupuncture Program. I teach the Treatment of Orthopedic Disorders at Pacific College of Health and Science (PCHS) and supervise a shift treating University of California San Diego (UCSD) collegiate and club athletes through PCHS. In my practice, I mainly focus on orthopedics, sports injuries, rehabilitation, and pain.Hannah Leahy: I'm a physical medicine and rehabilitation doctor, with dual board certification in in sports medicine too. Currently I treat a lot of acute and chronic musculoskeletal and neurologic injuries in the military members stationed here in Bavaria.I see the full spectrum of acute and chronic pain, and I have a background in working in orthopedic clinic too where I diagnosed and treated acute and chronic injuries and pain conditions. I have been trained now in Battlefield Acupuncture (BFA), and I use a lot of dry needling techniques on a daily basis.Anthony Von der Muhll: Hello, everyone. I'm a traditionally trained licensed acupuncturist, Certified by the National Board of Acupuncture Orthopedics, which unfortunately went defunct when the generation of founding instructors retired over the last decade. I've devoted myself to building a Certificate Program in Acupuncture Orthopedics to carry on their work, which I now teach mostly in the context of a Doctorate Program in Acupuncture and Oriental Medicine at the Academy of Chinese Culture and Health Sciences in Oakland, California. I also completed Myopain Seminar's myofascial trigger point needling certification program, which I incorporate into my teaching and practice. My particular subspecialty within acupuncture orthopedics and sports medicine is treating joint hypermobility and dysfunctions with dry needling.Richard C. Niemtzow: I'm going to turn it over to Matt. First topic is, How can acupuncture help an acute trauma with inflammation? For example, a sprained ankle experienced by an athlete.Matt Callison: Okay. Well, this topic could go on for quite a long time, especially with the panel that we have here. There's going to be a lot of different aspects of it, so I'll try to keep it short and sweet with this. I think over the last decade, maybe 15 years, there's been a lot of research on how acupuncture is helping with decreasing inflammation, like the antihistamine effect, and the downregulation of pro-inflammatory cytokines, neuropeptides, etc. That's been shown and proven.I think the aspect of reducing inflammation or in Traditional Chinese Medicine (TCM) methodology, to clear Heat, importantly is to not use acupuncture at that site of an active inflammatory process. This is something where TCM explains to never needle into the area that is excessive. Just from my own clinical practice, trying to needle into an area that is pretty hot and inflamed just exacerbates the area.I think the pros to acupuncture in that case is to needle adjacent points, muscles that'll have stability and integrity for an ankle sprain. For example, the peroneus longus and the tibialis posterior that, in fact, will probably help with the integrity of that ankle. As far as trying to clear the edema and the inflammation, there are many points that we can use. For example, the distal points, the Ting Well points and such, to be able to help drain some of that edema.Bleeding, cupping and bleeding, and needling distally is another area that we could discuss that helps incredibly in positively changing secondary response inflammation and by-products. In my mind, it's like a pressure valve releasing some of the oncotic pressure, which is a manifestation of the secondary response, when bleeding or needling distally seems to diffuse this inflammatory process.The takeaway here is not to needle into the actual area of inflammation, because that does aggravate the area, but to use adjacent points to be able to help to clear the edema and the inflammation.Brian Lau: Sure. Great answer from Matt, and I'll just add to it one aspect that we definitely teach within Sports Medicine Acupuncture, which is also to look at the general balance of the body. An ankle sprain would be a great example as there might be pre-existing imbalances that led to that potential for the ankle sprain. This is very common. There might be muscles crossing the ankle, which are inhibited and aren't supporting the ankle well, thus increasing demand to the ligaments. Those inhibited muscles can be a problem in terms of healing if they fail to support proper movement and stability.Balancing the structures that are acting on the ankle with points into the various muscles that are inhibited and overactive can help regulate the position of the ankle, and then set a situation for easier and better, more efficient healing.Richard C. Niemtzow: Thank you, Brian. Ian, do you have a comment?Ian Armstrong: Sure, I would definitely agree with everything Matt and Brian have said. Bleeding techniques, whether with cups or bleeding Ting Well points or other strategies, as Matt mentioned, can be very helpful in the acute inflammatory process. It is always important to assess what other structures and tissues away from the acute injury site might have contributed to the acute one in front of you, and how you can set up the body for success moving forward, as Brian discussed about thoughts on improving ankle stability and joint imbalance.Let me see what I can add, however. In the example, we had an acute ankle sprain, but what if we used the example of, say, a soft tissue strain or tear? In this case to be able to look at the myofascial chain above and below or even next to the injured area, and treat here, is also quite beneficial. If you're thinking about a high hamstring/bicep femoris strain, for instance, you can look at treating the Sacrotuberous ligament that is superior to it, the Peroneus Longus inferior to it, all structures directly connected.Even needling something like the Quadratus Femoris that connects to the Ischial tuberosity, is next to and will have tensional relationships to the Bicep femoris, I've found to be really helpful. Needling the above, below, and adjacent tensional pieces in that particular myofascial chain can help take unwanted tension off the strained muscle, allowing for faster healing time and more range of motion.In this same example, to expand on Brian's thought process, I think, if you have a high hamstring strain, what does their pelvis look like? Regulating or balancing this would also be important. Do they have an anterior tilt/Lower Cross syndrome causing the hamstring to be on constant tension? Then treating something like the Psoas here would be beneficial for example. These are aspects that I would always want to assess. Looking to local and global perspectives with posture.Hannah Leahy: The main point I thought was important to discuss here was that with these, there's some evidence that there's this anti-inflammatory effect, in that there can be inhibition of some of the inflammatory pathways, so used acutely for musculoskeletal injuries like an ankle sprain, for example, there can be downregulation or inhibition of the COX-1 and 2 pathways that we also address through use of medication.It can really supplement the treatment that way. I completely agree with addressing the other associated muscle groups, because you can definitely have that muscle inhibition or motor inhibition. If you can improve the strength early on, you're going to have a faster recovery. I'm sure, I think somebody I heard say about the tissue perfusion aspect, improving the vasomotor control, and the tissue that's been injured.There is certainly a huge role for addressing acute trauma with acupuncture, and just downregulating that immediate central nervous system response, trying to modulate that in addition to the local inflammation, to prevent it from turning into a more chronic nociceptive pain problem.Richard C. Niemtzow: We will have patients coming into our clinic who have had a chronic ankle sprain, and still are experiencing pain.We end up doing BFA for them with the hopes that over a period of time, the pain will go away. As a rule the ankle pain it gets referred to our clinic when it becomes chronic and the patient is not making any progress.Matt next topic: “Can acupuncture help with torn cartilage, ligaments, and tendons?”Matt Callison: Thank you, Richard. That's a great question. Yes, I think that's actually something important to speak about. Since you plugged the BFA, I might as well go ahead and talk about chronic ankle sprains as well the way we do in Sports Medicine Acupuncture.This is something that we love to treat, because the way that we treat it is really quite significant, and lots of positive results with it, from needling into the ligament, as long as there's not the episode in the inflammatory response and such, but needling into the ligamentous tissue, and trying to stimulate the mechano-transduction and the extracellular matrix, which does seem to help bind the region.After needling directly into ligaments, it can change orthopedic examinations. If it was the ankle, it can help to increase the integrity of the anterior drawer test. Not just needling locally, of course, that's going to be important, but then also what Ian and Brian were talking about, needling the important muscles of stability. If it was going to be in the ankle, the peroneus longus, the tibialis posterior, the peroneus tertius.Then as Ian was speaking of earlier, what's happening with the knee, what's happening with the pelvis? Once the acupuncture treatment is completely done, then using myofascial work also to complement that, and then prescribing exercises, the strengthening exercises, or the stretching exercises, or the proprioceptive exercises. Chronic ankle instability is actually a fun thing to treat, especially for that patient that has perpetual ankle sprains all the time. Their function becomes a lot better.It's a wonderful thing. It's rewarding. As far as the ligaments, yes. I think needling directly into the ligaments is really quite profound with acupuncture, because they are so mechanical, and they have mechanical properties, and simulating the sensory afferents from that, I think, is very, very important. Again, needling the adjacent and distal points with the channels in mind, and also the postural integrity is going to be very important.Anthony Von der Muhll: Elaborating on what Matt said, all of which I agree with, I often find it quite useful to needle directly into ligamentous tissue. The tightening up of overstretched ligaments and the stabilization of joints can be instantly verified upon needle withdrawal-even by beginners with a half-hour of training in joint-play/end-feel testing. I find that restabilizing a joint typically leads to rapid, sometimes immediate gains in range of motion and transarticular muscle strength, and sometimes even reduced paresthesia if adjacent neural tissues are no longer being compressed by compensatory muscle splinting. Likely this is due to resetting of joint proprioceptors and restored arthrokinetics, though I haven't seen very much research in this area.Even if there is a lag in range of motion and strength improvements, in my experience, other modalities—myofascial trigger and motor point needling, traditional acupuncture, gua sha, cupping, etc. work faster and better with less regression when the underlying joint or joints are stable and functioning properly. And the effects of needling ligamentous tissue are typically also immediately felt by patients, not so much as immediate pain reduction, although sometimes that's also the case. But what I hear often from patients is things like “it feels more solid, stronger, stable, better control.” Which is exactly what I'm looking for. The pain reduction will follow–or of course can be accelerated by adding ear, distal, electroacupuncture to the local joint needling.Matt Callison: For me, talking about tendons now, needling into tendons when they are injured, exacerbates the condition just in my own opinion. Most injuries in my mind are more about the synovial lining and the extracellular matrix around the region that is becoming irritated. The needle technique that I developed and use is to thread the needle on each side of the tendon, as close as possible to the tendon, but not to insert it into the tendon. Then, of course, the application of heat with that response, in my own clinical experience, better than electric stimulation.Anthony Von der Muhll: That's very interesting for me to hear, Matt, I too started experimenting with this same technique of needling parallel to tendons after finding that needling directly into tender locations resulted in pain without gain.Matt Callison: Then, of course, using eccentric exercises after that, and also myofascial techniques to reduce adhesions that are in the area. Tendons and ligaments respond very well to acupuncture. I haven't had the best of luck with cartilage, torn cartilage, which makes a lot of sense. I do not think that acupuncture is going to help with a bucket handle tear of a meniscus or horizontal cleavage tear.I do think it changes the pain response with it, which can help with muscle guarding and such. As far as the repair, that's going to be more of surgery, in that case. I think it's more palliative care when somebody actually has a cartilage injury. Without speaking any more about it, I think we should probably continue.Anthony Von der Muhll: I'll just concur with Matt that tears in cartilage such as bucket handles in a meniscus or a large tear in a labrum don't, in my experience, seem to respond in a lasting way to acupuncture. I suspect this poor response has to do with the negligible intrinsic vascularization of these tissues. Sometimes I see modest improvement with small lesions, which I suspect has to do with acupuncture's nonspecific analgesic and anti-inflammatory effects, rather than any significant healing of the underlying tear. I generally think of cartilaginous tissues as about as “inert” and unresponsive as tissue gets in the human body.Brian Lau: I have a lot of similar thoughts as Matt and Anthony. With tendons, of course, they are fascially continuous with the muscle. Looking at the state of this unit of muscle and fascia is going to be very important for healing. People can get injured for a of If into the an injury can even if there's really balance and strength in that muscle. if there are pre-existing in the myofascial then injury is more to and it will at example is the If it's inhibited and not really working and other like the aren't working to a that's going to set up a to have a injury such as a tear or you would want to look treating just the injured tendon, but you would also treat the structures that are of efficient movement of that are also very as they have interesting relationships with the My on this is very by and der has research on the ligaments and their to the The would be that the ligaments are parallel structures to the muscles that the joint and they are active in stabilization particular at the end range of In der the muscle tissue away but the the that the ligaments are with that of the muscles and their function is also much more with that of the great example of this would be the and the ligaments of the to these fascia as the they and with the ligaments through the range of motion the ligaments are not just active at the end me, this to the of treating myofascial of tissue and to regulate in the in addition to treating the local ligament Ingram: In to cartilage, I I away from that with the same is for ligaments. The one thing I will say about the cartilage and the ligaments, going to some of the other on like and movement with the and I'll even say, a lot of the things with which I think is a movement similar to the We just them well pain in the and going in the for chronic ankle think there is there in tension on the ligaments, or tension on the cartilage by to movement I think there is a role for acupuncture, up in the to that the of tendons, I'm a sports trained and so this be an to the acupuncture but if I am a with a I had very different results going going on had better results with to I was actually in the and over time, I could actually see the I think the is, if we take the in I think the is the I think the problem was in the and the and maybe even than that, going all the way up to the in terms of movement and tension in the think there is a huge role for acupuncture with physical and imbalances and then strengthening and making the patient more C. Niemtzow: Thank you Ian, do you have to Armstrong: me I too have similar thoughts on this with Matt, and Anthony. The needling technique that I used for instance, I from I also concur in not great success needling into or with cartilage injuries We help with joint balance and ligamentous as Anthony that to more injuries to this of tissue. this way can often or the patient from where I can also add my here is in the in treating the ligaments and tendons in this way. to the ankle sprain example, now in chronic or and as Matt was it is important to actually needle into ligaments and stimulate these joint and really help the injury from becoming more sprains are something that, are so and are over and in the where I practice, we have a of athletes that these athletes in you hear about a of ankle for instance, that in their not the who get of course, but they are a great example of what the for an ankle sprain typically like for without will it, maybe or it, even a on it if it's pretty but there's not much that's This can to a of example, my when treating with anterior ligament or any of injury have had ankle injuries that not treated or I what the would but I would over in my these ligaments help full stability of the ankle and are important to a proper ankle position and stability and movement helps with of the and with less on the and even less strain on the ligament and ligament, how much a can to even or and or something like well can they off on the How active is that able to the of a of a these aspects are important to not the ankle, but as well as for the Needling these ligaments is a very important of the treatment was treating for the tendon, of course, is important, I would add making that that position is really is also For example, a will to a of the and that's going to to more of that as would be my thought on going to the local and global postural Leahy: so where can I and add in I think so of the I heard that I agree with is that a lot of when looking at the and evidence of torn cartilage or ligaments or tendons, there's a in medicine at to just look at that if you see it on and on that, rather than and looking at the like to look at the other as well, such as the myofascial trigger I find it how much there is the myofascial trigger points and the traditional acupuncture have it's up to points and acupuncture points for and and Acupuncture and of Acupuncture and are some now supporting use in of and Quadratus Needling in and in With I use a where I dry needle the and the in patients with pain, which I see a lot of, and that can really help as one of the for of on addressing the but it's also that we looking for these myofascial trigger think the other thing I to add was that in and ligament there's just a see the injuries, the injuries, and then the all look very As Ben you really can get a look at these and you see the in how they and whether there's of can really change the of a in terms of how it's going to respond to needling acupuncture, or things like needle or or things like have to that into the treatment what of healing or injury the is Von der Muhll: This is all very interesting to I'll add to the from my own is that my for chronic do not one for me is gua sha, which in the and has now been up by as or one it, the is to a to the and then take a of a a or even or the the although I use at the distal and sometimes other but by the pressure to the I generally find it has the best for tendons of the physical in my other technique I find useful is to cups over tendons or that are large and for them to such as the fascia and tendons, and the tendon, and then the patient through active range of motion with the cups in for a a lot more that could be about here the use of gua and cups in treating and myofascial injuries generally that I go into here, as our focus is on acupuncture. But be in not adding that these other traditional in my experience, a much more important role in healing injuries than local C. Niemtzow: thank to this is and I think our will on these various next topic is does acupuncture help with sports injuries not Callison: Richard. I think, to answer that it really seems like we have that, the with just this looking at movement looking at looking at muscle looking at the of injury. That's just from the aspect of I think the of also is to look at what's happening at the is this not it going to be it it something that's going on in their as far as the It's important to look at the and the for these chronic just on a side with and to my work is from San Diego University in training and sports medicine. was my area, and then I a licensed acupuncturist, licensed There was no of this happening at I'm and to and just how much acupuncture, and dry needling, and acupuncture has really especially over