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sports
medicine
ACUPUNCTURE
AND SPORTS MEDICINE
A Review of Published Studies
Alec Meleger, MD
Joanne Borg-Stein, MD
ABSTRACT
Acupuncture
is frequently used as a treatment for acute and
chronic sports injury. There is a paucity of large,
randomized controlled trials of efficacy. This article
reviews the available medical literature of acupuncture
treatment in lateral epicondylitis, patellar tendonitis,
plantar fasciitis, frozen shoulder, and osteoarthritis.
Studies of lateral epicondylitis suggest that acupuncture
is superior to placebo. Inadequate data are available
to draw definitive conclusions about the efficacy
of acupuncture in the other diagnoses. There is
a need for larger controlled trials of acupuncture
for most sports medicine musculoskeletal diagnoses.
KEY WORDS
Acupuncture,
Sports Medicine, Tendonitis, Osteoarthritis, Epicondylitis,
Plantar Faschtis, Review
INTRODUCTION
Acupuncture is one
of several disciplines extracted from a complex
heritage of Chinese medicine that also include herbal
medicine, breathing exercises, manipulation, and
stretching. Not until the 1970s did a renewed interest
in Chinese medicine resurface in the United States.
At present, complementary or alternative health
care is very popular and is the focus of substantial
attention by the general public as well as health
care providers. In a national survey of adults,
Eisenberg et al1
found that I in 3 respondents (34%) used at least
1 unconventional therapy in 1990, mostly for common
medical conditions. The total number of visits for
"non-traditional" care was estimated to be 425 million
in 1990, which exceeded the number of visits for
all primary care physicians (388 million).1
Musculoskeletal disorders
are among the most common conditions for which patients
seek help. The same is true when patients turn to
alternative medicine for the relief of pain and
maintenance of their mobility. Various surveys have
shown that musculoskeletal conditions are one of
the most common reasons people present to an alternative
medicine provider.1
- 3
A
number of studies have been published dealing with
the efficacy of acupuncture in treating various
musculoskeletal conditions. The purpose of this
clinical review is to assess the strength of evidence
of acupuncture's effectiveness in the treatment
of diagnoses commonly encountered in sports medicine
and outpatient musculoskeletal practice.
METHODS
To identify previously
published studies, an extensive MEDLINE search
was undertaken covering the period from 1966 to
September 1999. The following key words were used:
acupuncture, orthopedics, athletic injuries,
musculoskeletal, soft tissue injuries, occupational
diseases, cumulative trauma disorders, tendonitis,
bursitis, sprains, strains, sports. The search
was limited to articles featuring human subjects;
all languages and expenmental designs were included.
Published letters, comments, and reviews of treatment
were excluded. A total of 13 studies were identified
for inclusion.
RESULTS
Lateral Epicondylitis
Lateral
epicondylitis, or tennis elbow, is an overuse syndrome
involving the region of the lateral epicondyle.
Most commonly, the origin of extensor carpi radialis
brevis is involved. Patients experience pain and
tenderness, especially with resisted wrist extension,
in the region of the lateral epicondyle. Two randomized
controlled trials, 2 controlled trials, and 1 case
report series were identified.
Randomized Controlled
Trials
Haker and Lundeberg4
examined whether patients with lateral epicondylitis
receiving real acupuncture fared better than patients
receiving sham acupuncture (a procedure designed
to mimic real acupuncture using the same acupuncture
points but with more of a superficial needle insertion).
Eighty-two of the initial 86 patients completed
the study. Range of symptom duration in the intervention
group was 1-60 months (median, 7 months); control
group range was 1-120 months (median, 10 months).
Patients in both groups were similar in sex and
age characteristics. There were 10 treatment sessions
conducted by the same individual. Outcomes were
assessed by a physician blinded to the treatment
schedule. Subjectively, an intergroup comparison
showed that 22 patients (50%) of the 44 in the intervention
group, and 8 (21%) of the 38 in the control group
reported excellent or good results (P<.01). Pain
threshold on gripping was also positively affected
in the intervention group compared with the control
group (P<.05). There was also a greater number
of patients in the control group experiencing pain
when lifting 3 kg (P<.05). None of these differences
were found to be significant at 3-month or I-year
follow-up visits.
Molsberger and Hille5
randomized 48 patients to assess whether classic
acupuncture versus sham acupuncture (feigning needle
insertion by stimulating skin area not containing
relevant acupuncture points using a pencil-like
probe) has greater effect on treatment of tennis
elbow. The experimental and control groups had comparable
duration of illness, pain scores, sex, and mean
age. An examiner blinded to the study performed
post-intervention assessment. One acupuncture treatment
was performed on all patients. After treatment,
79% of classic acupuncture patients reported
pain relief of at least 50%, with 25% of patients
in the placebo group reporting the same (P<.01);
average duration of pain relief was 20.2 and 1.4
hours, respectively.
Controlled Trials
Brattberg6
compared the efficacy of acupuncture (n=37) vs steroid
injection (n=26) in the treatment of lateral epicondylitis
Of note, equivalence between the groups was neither
intended nor achieved. There was a longer duration
of symptoms and greater proportion of males in the
acupuncture group; group age characteristics were
not reported. Six acupuncture treatments on average
were administered; there was no mention about the
type of steroid used and the number of injections
given.
Follow-up was by means
of a questionnaire in which the patient indicated
the degree of pain still experienced. Different
patients were followed up for various lengths of
time:
1-3 months, 3-6 months, or 6-2 months. Of the acupuncture
patients, 92% replied. Sixty-two percent stated
that they were much better or had no pain at all,
compared with 31% of patients (P<.005) who received
steroid injection.
Chilton7
assessed the combined efficacy of acupuncture plus
steroid injection (n=16), versus steroid injection
alone (n=19). The 2 groups appeared to be comparable
for average age and sex distribution; no mention
was made of the average duration of symptoms. Patients
were seen at 2-3-week intervals with a maximum of
3 sessions permitted. Tenderness over the lateral
epicondyle was used as an outcome measure. In the
acupuncture-plus-steroid injection group, 81% of
patients required only 2 sessions for resolution
of symptoms; 6% did not achieve relief. The numbers
for the steroid injection-only group were 68% and
16%, respectively. Statistical significance was
not calculated; treatment assessed was not blinded.
Case Reports
He
and Wen8
described 58 patients with tennis elbow. There were
22 men and 36 women, with ages ranging from 27 to
73 years, and symptoms ranging from 1 week to 9
years. Reported were (rounded) 52% considered cured,
with no symptoms for more than 6 months; 40% had
"excellent" outcomes, and 9% experienced no benefit.
Osteoarthritis
Osteoarthritis,
a degenerative disease of the joints with gradual
loss of articular cartilage, can be a long-term
consequence of contact sports. An example is cervical
osteoarthritis in football and soccer players. Patients
complain of pain and tenderness with mobilization
and weight-bearing of the joint involved. The MEDLINE
search produced 4 randomized controlled trials and
I retrospective cohort study.
Randomized Controlled
Trials
Christensen and colleagues9
assessed the effects of acupuncture on pain and
function in individuals with severe knee osteoarthritis.
Thirty-two patients were randomly assigned to 2
groups: a no-treatment control group and a group
that received 20 minutes of acupuncture for a total
of 6 treatments.
Post-randomization group
characteristics were not reported. Sham acupuncture
was not performed on the no-treatment group. Twenty-nine
patients completed baseline and 9-week evaluations.
At week 9, the treatment group reported about a
23% decrease in pain using a visual analog scale
(VAS) compared with the 12% increase in the control
group (P=.03). In the intervention group, median
time to walk 50 m and 20 steps decreased 28% and
30%, respectively, compared with a decrease of 13%
and increase of 9%, respectively, in controls (P<.01).
Subsequent similar treatment (acupuncture) of the
control group resulted in comparable changes as
in the treatment group. A blinded observer performed
the objective assessment.
Gaw and colleagues10
investigated 40 patients with osteoarthriti of the
knee, hip, cervical spine, fingers, or back. Patients
were randomly assigned to 2 groups of 20:1 receiving
classic Chinese acupunctur and 1, sham acupuncture.
Post-randomization groups were similar with regard
to age, sex, duration of illness, treated joint,
occupation pre-treatment medications, and mental
well-being. One patient withdrew secondary to an
unrelated illness. A total of 8 acupuncture treatments
were performed, followed by an assessment by 2 blinded
observers. Outcome measures were tenderness and
subjective report of pain and activity. Both groups
showed a post-treatment reduction in pain; there
was no intergroup statistical difference observed.
Dickens and colleagues11
studied the effect of acupuncture vs mock transcutaneous
nerve stimulation (TNS) in patients with tra-pezio-metacarpal
osteoarthritis. Thirteen patients were initially
recruited with 12 completing the trial. Recruited
patients were randomly assigned to either treatment
or control and were similar in mean age, sex, and
duration of symptoms. Each participant received
sessions of either procedure. A blinded observer
assessed post-intervention functional capacity,
pinch grip, joint tenderness, sleep disturbance,
medication intake, pain scores (VAS), and verbal
rating of improvement. No intergroup statistical
significance was observe secondary to the small
sample size, even though the treatment group was
measurably numerically superior.
Takeda
and Wessel12
examined the efficacy of real acupuncture sham acupuncture
in subjects with radiographic evidence of osteoarthritis
of the knee. Forty subjects were randomly assigned
to the experimental and control groups in a double-blinded
manner. The groups appeared similar in mean age,
sex, weight, and body mass index. There appeared
to be significantly more individuals with advanced
osteoarthritis in the real acupuncture group. Symptom
duration was not reported. Outcome measures used
included the Pai Rating Index of the McGill Pain
Questionnaire, the Western Ontario and McMaster
Universities (WOMAC) Osteoarthritis Index, and pain
threshold at 4 sites in the knee. Each subject underwent
a total of 9 treatments. The study demonstrated
that both interventions & creased symptoms in
persons with osteoarthritis of the knee. There was
a tendency for the true acupuncture group to show
a greater response, but this did not achieve statistical
significance.
Retrospective Cohort
Study
Zwolfer and associates13
conducted a retrospective study of 35 patients with
osteoarthritis of the knee who were treated with
"Bachmann Point" acupuncture. There was a 60% questionnaire
responce rate; the average number of acupuncture
sessions was 26. Seventy-one percent of patients
replied that the intervention was helpful. Nineteen
percent were free of pain, and 6 months later, 57%
were still better than before the acupuncture therapy.
(Editor's
Note: "Bachmann Point"
acupuncture is the 5 acupuncture points around the
patella and knee regions which Dr G. Bachmann, Heidelberg,
Germany, wrote about in his 1992 article in the
American Joumal of Chinese Medicine, "Acupuncture
in Gonarthrotic Pain - Bachmann's Knee Program.")
Patellar Tendonitis
Patellar tendonitis
(or jumper's knee) is an inflammation of the patellar
tendon secondary to repetitive trauma. Patients
complain of pain and tenderness over the patellar
tendon or the inferior pole of the patella. The
MEDLINE search revealed 1 randomized controlled
trial.
Wang and colleagues14
randomly assigned 156 patients into 3 groups: acupuncture
and moxibustion, microwave needling, and laser irradiation.
Post-randomization group characteristics were not
reported. Group sizes consisted of 85, 38, and 33
patients, respectively. The same acupuncture points
were needled in all cases; a similar number
of treatments were performed. Outcomes were classified
as absence of symptoms, marked efficacy, improvement,
or no response. All 3 groups showed improvement;
the acupuncture-moxibustion group showed the greatest
improvement. The only intergroup statistical difference
found was in the percentage of patients responding
in the acupuncture-moxibustion group versus the
microwave group.
Plantar Fasciitis
Plantar fasciitis
is 1 of several causes of heel pain secondary to
chronic overuse resulting in inflammation of the
plantar fascia. The literature search revealed 1
published case series on the efficacy of acupuncture
in patients with plantar fasciitis.
Tillu et all15
investigated the effect of acupuncture in the treatment
of heel pain
due to plantar fasciitis in patients without prior
response to conservative
treatment. Eighteen consecutive patients with a
mean age of 49
years (range, 31-70 years), 28% male, with a mean
duration of symptoms 6
of 25 months (range, 12-30 months) received a total
of 4 treatments on the
affected side. Values on a VAS were used as the
outcome measure. After 4
treatments, 7 (39%) of 18 patients reported greater
than 50% pain relief; 7
others reported no relief. The authors reported
a significant difference
(P<.00 1) of post-treatment compared with pre-treatment
VAS scores.
Frozen Shoulder
Frozen shoulder
is a condition in which the shoulder capsule becomes
contracted and thickened with a dramatic decrease
in the shoulder range of motion. Associated conditions
are cervical spondylosis, hypothyroidism, and diabetes
mellitus. The MEDLINE search produced I published
case series on the effect of acupuncture on frozen
shoulder.
Ene and Odi16
published a case series on the efficacy of acupuncture
in treating various neurologic and musculoskeletal
disorders. This study included 4 cases of mild to
severe frozen shoulder as based on the range of
motion; the duration of symptoms was not reported.
Each patient received 6 treatments. Post-treatment
pain response to mobilization was absent in the
3 mild-to-moderate cases; the range of motion improved
from 45' to 90' and 70' to 180' in abduction and
elevation, respectively. In I case of severe frozen
shoulder, post-treatment pain response was mild
with abduction improved from 0' to 50' and elevation
from 10' to 140'. Length of post-treatment follow-up
was not reported.
CONCLUSION
We have summarized
the published evidence regarding the efficacy of
acupuncture in the treatment of lateral epicondylitis,
osteoarthritis, patellar tendonitis, plantar fasciitis,
and frozen shoulder.
For the treatment
of lateral epicondylitis, 2 randomized controlled
trials show a statistically significant positive
result with acupuncture treatment when compared
with placebo. One of the non-randomized controlled
trials also shows acupuncture's statistically significant
efficacy compared with steroid injection. In a non-randomized
controlled trial, Chilton' reported a higher success
rate with acupuncture and steroids versus steroid-only
treatment, but the samples were too small to reach
any intergroup statistical significance. While the
number of high-quality trials is small, the evidence
does suggest that acupuncture can be effective in
the treatment of tennis elbow.
We
found 4 randomized controlled trials of acupuncture
in osteoarthritis. Only the study by Christensen
et al9
showed statistical improvement compared with no
treatment in patients with osteoarthritis. Three
other studies compared acupuncture with sham acupuncture
and reported no statistically significant benefit
to acupuncture. This suggests that acupuncture is
not superior to sham needling in reducing pain of
osteoarthritis; both alleviate symptoms to approximately
the same degree.
One
randomized controlled study reported the treatment
of patellar tendonitis. The post-randomization group
characteristics were not reported.
Acupuncture and moxibustion were evaluated as a
combined treatment instead of evaluating acupuncture
alone. The only statistically significant improvement
was found when the intervention group was compared
with acupuncture that used exactly the same areas
of stimulation with subsequent microwave needle
stimulation. There is inadequate data to formulate
a definitive conclusion for acupuncture treatment
of patellar tendonitis. Similarly, there are inadequate
data to determine acupuncture's efficacy in the
treatment of plantar fasciitis and frozen shoulder.
However, case report evidence does suggest the possibility
of efficacy.
Further
single-blind, randomized controlled trials are needed
to assess the efficacy of acupuncture in a variety
of common sports medicine diagnoses. Standardization
of the acupuncture points used, depth of insertion,
and appropriate control treatments are needed to
reach definite conclusions regarding efficacy.
REFERENCES
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DM, Kessler RC, Foster C. Unconventional medicine
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He LP, Wen XA. Treatment on tennis elbow with heat
needling: a clin ical summary of 58 cases. J Tradif
Chin Med. 1988;8:129-130.
9.
Christensen BV, Iuhl IU Vilbek H. Acupuncture treatment
of severe knee osteoarthrosis: a long-term study.
Acta Anaesthesiol Scand. 1992; 36:519-525.
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Gaw AC, Chang LW, Shaw L-C. Efficacy of acupuncture
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Dickens W, et a]. A single-blind, controlled and
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Takeda W, Wessel J. Acupuncture for the treatment
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Zwolfer W, Grubhofer G, Cartellieri M, Spacek A.
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Wang LQ, Wang AM, Zhang SD. Clinical analysis and
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Tillu A, et a]. Effect of acupuncture treatment
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AUTHORS' INFORMATION
Dr
Alec Meleger is a senior Resident in the Harvard
Medical School Physical Medicine and Rehabilitation
program, Cambridge, Massachusetts.
Alec
Meleger, MD
Resident, Physical Medicine and Rehabilitation
Harvard Medical School
Spaulding Rehabilitation Hospital
125 Nashua Street Boston, MA 02114
Dr
Joanne Borg-Stein is an Assistant Professor at the
Tufts Medical School Physical Medicine and Rehabilitation
department, Boston, Massachusetts.
Joanne
Borg-Stein, MD
Medical Director, Spaulding-Wellesley Rehabilitation
Center
65 Walnut Street
Wellesley, MA 02481
Phone:     781-431-9144
- Fax: 781-431-9152 E-mail: md.borj@nwh.org
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