Acupuncture of the Knee Thisarticleis based an a lecture given at the BMASSpring Scientilic M-^etinB held in York in May 1991 Summary Kneepain should never be considered in isolation. It must be effectively investigated and accurately diagnosed where possible, to differentiate the variousforms af afthritis,identify causes of inflam matiati and exclude metabolic and otherfactors. Surgical trcatmenL including arthroscopy and joint replacement, is a very ellective option and should naw be cansidered at an earlier stage beforesevere defa nity has accuned. Non-stercidal anti-inflam- matory drugsshouldgenerally be avoided except in topical form. lntra articular steroid injectbtl may oftcn be used after diagnastic aspiation ol the joitlt. AcupunclLtreis very acceptableto patientsbut n)usl be vie\\led as part of an overall treatment plan. 1t is eflective;n acLte and anterior knee pain. ln chrcnic pain il should loB;callybe used where the diagnosis is ktla'"\/n atld where joint aspiratrcn ts not necessary, and it is the treatment af choice t'or advancecl rheumatoid patients who are inade quately controlled on othet therapy 60/" have lastin+benefit. The drawbacl< is that clinics may be overwhelned by the demand for repeated courses of beatment,since the relief is often excellent bul rarely pemanent. TheImportance of Knee Pain The last 10 years have seen a revolution in the availability of newer diaBnostic techniques and lreatment for knee pain and it is irnportant that medicalacupuncturists should be aware ot these advances. Iable / lists five important facts about the knee u,hich demonstrate the predominant nature oi knee pain in our society. Arthritis of the kneeis the commonest causeof disability in those ovef 70 years of age. The problems areparticulafly comrnon in association with many popular sports: to name but a few {ootball, athletics, joggjng and skiing. Many of these problems setthe scene for a lifelong disability with kneepain-HypermobiJity syndrome, described and clarified only within the last 20 years, is very commonly associated with knee pain, partjcularly in the teenaSe period and the early 40's and 50's. Thissyndrome occurs in 107o of the population. Knee replacement js now carried out more commonly than hip arthroplasty in some districts. This is probably because il you get afthritis of the kneeit is likelyto be bilaterai, whereas hip arthritis '- rrry ' omrnoall Lniidrr.rdl. lh. e' e1t Jp.Lr8p In the availability of knee repiacement in this coLrntry is an indicatoroi its comparative success. Our orthopaedic surgeons now regard kneearthroplasty as successfuJ as that done to the hips.Finally, knee painis now the rnost {requent single rheumatolo:lical Key words Acupuncture, Kree Rheumatoid arthritis. pait1, Osteo-arthtitis, Introduction The treatment of knee pain by acupuncture is essentially simple andcouldbe summarised in a few sentences. lt is however vitally important to consider acupuncture lrealmenl of knee pain in perspective and to regard it only as partof a lolal lreaLment of knee problems.The knee has been a much neglected joint with regard to treatmenl, partoi this being due to unavailability of goodtechniques and parl to our initialand very important concentration on hip pain. Hip pain can quickly takepatients off theirfeet and promole severe disability. Knee painin itself,even the Srossest of knee deiorr.ities,seidorn does. KNEE FACTS Athritisoi the knce i5 thc commonest cause of d sability in Knee problems are parti.ularly commoi i|,rssoci.rtion with pop! ar sports: Iootbrll, dlhlel cs, skiine. Hypeftobility syndrome associated most commony with kn-"e pain oc.!rs ii l0'l) ol thepop!lrtion. Kneearth.op astes are now caricd out morc commonlythan hip arthroplasties in some d stricts. Kneepain is now lhe mon lrequer|fhe!nratoloBicil pfoblem enco!ntered n general praclice. Acupun.turein Mc.licine 57 Narenber 19t2 Val 10 No.2 on 27 May 2018 by guest. Protected by copyright. http://aim.bmj.com/ Acupunct Med: first published as 10.1136/aim.10.2.57 on 1 May 1992. Downloaded from
Transcript
Acupuncture of the Knee
This article is based an a lecture given at the BMAS Spring Scientilic M-^etinBheld in York in May 1991
SummaryKnee pain should never be considered in isolation.It must be effectively investigated and accuratelydiagnosed where possible, to differentiate thevarious forms af afthritis, identify causes of inflammatiati and exclude metabolic and other factors.Surgical trcatmenL including arthroscopy and joint
replacement, is a very ellective option and shouldnaw be cansidered at an earlier stage before severedefa nity has accuned. Non-stercidal anti-inflam-matory drugs should generally be avoided except intopical form. lntra articular steroid injectbtl mayoftcn be used after diagnastic aspiation ol the joitlt.AcupunclLtre is very acceptable to patients but
n)usl be vie\\led as part of an overall treatment plan.1t is eflective;n acLte and anterior knee pain. lnchrcnic pain il should loB;cally be used where thediagnosis is ktla'"\/n atld where joint aspiratrcn ts notnecessary, and it is the treatment af choice t'oradvancecl rheumatoid patients who are inadequately controlled on othet therapy 60/" havelastin+ benefit. The drawbacl< is that clinics may beoverwhelned by the demand for repeated coursesof beatment, since the relief is often excellent bulrarely pemanent.
The Importance of Knee PainThe last 10 years have seen a revolution in theavailabi l i ty of newer diaBnostic techniques andlreatment for knee pain and it is irnportant thatmedical acupuncturists should be aware ot theseadvances. Iable / l ists f ive important facts about theknee u,hich demonstrate the predominant nature oiknee pain in our society. Arthrit is of the knee is thecommonest cause of disabil i ty in those ovef 70years of age. The problems are part iculafly comrnonin association with many popular sports: to namebut a few {ootball , athletics, joggjng and ski ing.Many of these problems set the scene for a l i felongdisabil i ty with knee pain- HypermobiJity syndrome,described and clarif ied only within the last 20 years,is very commonly associated with knee pain,part jcularly in the teenaSe period and the early40's and 50's. This syndrome occurs in 107o of thepopulation.
Knee replacement js now carried out morecommonly than hip arthroplasty in some distr icts.This is probably because i l you get afthri t is of theknee it is l ikely to be bi laterai, whereas hip arthrit is'-
rrry ' omrnoall Lni idrr.rdl. lh. e' e1t Jp.Lr8p Inthe availabi l i ty of knee repiacement in this coLrntryis an indicator oi i ts comparative success. Ourorthopaedic surgeons now regard knee arthroplastyas successfuJ as that done to the hips. Finally, kneepain is now the rnost {requent single rheumatolo:l ical
Key wordsAcupuncture, KreeRheumatoid arthritis.
pait1, Osteo-arthtitis,
IntroductionThe treatment of knee pain by acupuncture isessential ly simple and could be summarised in a fewsentences. l t is however vital ly important to consideracupuncture lrealmenl of knee pain in perspectiveand to regard it only as part of a lolal lreaLment ofknee problems. The knee has been a muchneglected joint with regard to treatmenl, part oi thisbeing due to unavailabi l i ty of good techniques andparl to our init ial and very important concentrationon hip pain. Hip pain can quickly take patients offtheir feet and promole severe disabil i ty. Knee pain initself, even the Srossest of knee deiorr.ities, seidorndoes.
KNEE FACTS
Athr i t is o i the knce i5 thc commonest cause of d sabi l i ty in
Knee problems are par t i .u lar ly commoi i | , rssoci . r t ion wi thpop! ar spor ts : Iootbr l l , d lh le l cs, sk i ine.
Hypeftobility syndrome associated most common y withkn-"e pain oc. ! rs i i l0 ' l ) o l the pop! l r t ion.
Knee arth.op ast es are now caricd out morc commonly thanhip ar throplast ies in some d st r ic ts .
Knee pain is now lhe mon lrequer|fhe!nratoloBicil pfoblemenco!ntered n general praclice.
Acupun.ture in Mc.licine 57 Narenber 19t2 Val 10 No.2
problem encountered in Beneral practice. Fromthis l ist i t can be seen how impodant i t is that we al lhave some understanding of the variet ies ()1treatment available ior knee pain and the types ofproblems I ikely lCJ be encountefed. l t is seldom thatwe can get ah,ay with treating one knee joint inisolation, or indeed with using a single treatmentsuch as acupuncture.
Classification of Knee PrcblemsThe classif ication introduced here lTable 2) isintended to be a functional one. l t endores ddia8nosis to be made accordin:l to age and f indingswithin the knee, and also assists when lookinB at thedifferent treatments avaiiable.
The n osi impoftant adolescent problerns in theknee are anterior knee pain and Osgood'Schlattersdisease. OsBood-Schlatters disease (osteochondrit isof the t ibial tubercle) is comparatively rdre, oLLursgenerally in the early teenage period andfortunately, i f treated adequatel, heals completelyleaving only a sl ight bump. l t is however painful andit does put chi ldren off sports at a formative age.Anterior knee pain is far more diff icult to treat.Sometimes calied chondfomalacia patelJae, i t is abenign but extremely troublesome condit ion thatoccupies a lot of the t irne of rheumatologists, physiothefapists and orthopaedic surSeons. In somepatients it appears to be completely unlreatabJe. h issornetimes associated wirh hypermobil i ty syndromeor obesity and can go on for many years. Numerousdit'erent treatments have been tried, some of themextremely invasive, but none has reaily provedefrective. When we see a teena8er apparentlymaking a great fuss about knee pain, we shouldremember work done by rheumatological paediatr i-cians which has shown that adolescents have a verydifferent perception oi what is BoinB on in theirbodies than us. They {ind i t considerably rnorediff icult to cope with chronic pain problems thanyounget chi ldren or older people.The second group o{ knee problems is the soft
Novembet 1992 Vol 10 No.2
t issue lesions including sports injuries. Thefe arevarious forms of bursit is around the knee joint, ofwhich prepatel lar bursit is is undoubtedly thecommonest, and different types of strained tendons.Althou8h benign they can be very persistent anddiff icult to treat. They can be part of a general isedarthrit ic problern such as ankylosing spondyli t is,gout of rheumatoid arthrit is. Prepatel lar bursit is hasa part icuiar tendency to get infected and this alwaysmakes me cautious about using penetratinginlections.
l l _e ro . r rone . r t l po o l I neo p roben . -en i nfheumatological cl inics, apart from osaeoarthrit is, isa monarthrit is. This can pfesenl at any age. Inchildhood it may be the early symptoms of juvenilechfonic arthrit is and may go on in adult l i fe to bepart of psoriat ic arthrit is or ankylosing spondyli t is.In adults i t rnay well be traumatic, but this is morefrequently undiagnosable and diff icult to treat longterm. Intense inf lammation or haemarthrosis canlead rapidJy to joint destrucl ion- These patients mayhave other diseases such as leukaemia,haemophil ia, Ehlers Danlos syndrome or infection.Monarthrit is demands ful l investigation with astraightforward X ray of the knee, aspiration of thejoint and analysis of joint f luid, simple biochemicalscreen including serur. uric acid, and ahaemogJobin and ESR-The frequency oi osteoarthrit is of the knee is welJ
known. Pain in osteoafthrit is arises from a numberof different factors and it can be useful in treatingthe knee to be able to differentiate these. Crowin8osteophytes can produce localised pain mainly overthe medial aspect of the knee, although sometir.esthe lateral, and can also produce l igamentous strain.Local treatment of these tender spots is moreeffective for this type of knee pain than treatrnent ofthe joint i tself. Patel lo-femoral pain should alwaysbe differentiated from femoro-ribial pain. TiBhtnessof the capsule and stiffness may be one of theearl iest symploms ol osteoarthrit is and these arebest treated by topical injection, gels and simplephysiotherapy. Knee joint osteo-arthfi t js is verycommonly unicompartmental and this can lead toinslabil i ty of the knee. Examination for this isimportant in assessing futufe treatment anclquadriceps function is vital to maintain mobil i ty andstrenBth of the knee.All forms of inf lammatory arthrit is can attack the
knee another reason for always aspirating a kneejoint i f there is f luid present. Sero negative arthrit iscommonly pfesents with knee problems, as doesrheumatoid arthrit is. Unti l i ts later stages, howevetinf lammatory arthrit is of the knee rs seldomextremely painful. The only exception to this is inReiter 's syndrorne, reactive arthrit is, where the jointcan be extremely painful and so can aspiration.
Neurological problems of the lower l imbs wil lfrequently lead to knee pain. One sees this mostpan i u ln r l l i r - r J l l p je ' l a ro . i . . whe e r r r y , asepain is frequentiy a feature because of autonomicdisturbance, but also in strokes. The main problem
CLASSIFICATION OF KNEE PROBTEMS
A. Adolesceny'conScnital: ant€rior knee pa n, genu valgum,Osgood Schlatter's discasc.
B. Sof t t iss!e ln j ! ry l in f ammat ion.
D. Traunra: ha€marthrosis, cartilage tear, ligament tear,
E. In f lamnratory ar thr i l ls .
C. Nelro logl .a prob ems.
H. Metabo ic disease: Pa8efs, Eou! rickcts, ost€onralacia,naenracnrcmators, pseudo SouL
appears to be hyperextension of the knee and thetendency lor the knee joint to col lapse on weightbearing. Forccd f lcxion of the knee can produceintractible pain which wil l last for a long t ime.When a serious neurological lesion js present in thelower l irrbs lhe knee joint should bc protected bysplints when the patient is walking-Melabolic disease can attacl< the knees, the
commonesl LJeing Paget's diseasc and gout. WherePagels disease affects the bone at a joint margin,pain and quite ranrpant ostcoarthrit is wil i develop.This is more commonJy seen in the hip, but I havealso seen i l in the knee \a, 'here cithcr the femur orlhe t ibia has been attackcd and the bone enclsexpanded. Such arthrit is is vcry intractible as regardspain. Surgeons are often reluctant to feplace jointsaitected by Pagel 's disease because of thc unpredictabJe nature of Lhe bone status. Rickets hasalmost disappeared in this country, but both r icketsand osteomalacia have been seen in the Asianpopulation, parl icularly amongsl women, bccauseof the inadequate amounls oi vi iamin D in the dietand lack oi sunshine- Finally in the classif ication ofknee problems never forget infection. Mosl virusesthat lead to arthrit is afled the knees, these includcparvo-virus, chicken pox, rubella, coxsackie andmany others. Similarly bacterial infections' o^ munl) , f ' - , I thp ( r pts \ a hd\p .ee1 ' rFr l r8o-
coccus, €:onnocaccus, st/eptococcus andstaphylocaccus most commonly in our distr ict.a)nce again the impodance of aspiration of the kneefor diagnostic purposes cannot be over-emphasised.
lnvestigationsMost basic investjgai ions for knee pain are availablein distr ict general hospitals. These inclLrde plainradiographs, which should include skyl ine ' . , iewsof patel la and weiSht bearing views, simplehrr, F"mr, a and l^opn"a oloi l , . ' . ' . t joi ' l laspiral ion for cel ls, crystals and cultufe, arthrography, ult lasound and arthroscopy. In early kneepain X-rays are useless. Baselinc investigationswould bc haemoglobin, ESR and joint aspiration i ff luid is avai able. l f these investiBations do not yielcla clear diagnosis, and knee swell ing and painpersist, i t is probably besL Io seek a special istopinion. There afe fow quile a wide rangc otspecial ist scanning techniques availablc whichpromise increasing diagnostic sophist ication tor the{uture, but at prescnt are mainly of research interest.These includc heat technetium and gall iLrmscanning, and the use of magnetic resonance orspectroscopic resonant techniques for lookinB at soflt issues.ln summary, knee pain and swell ing should never
be considered in isolation and knee effusions shouldalways be investiBated by aspiration of the joint andblood tests done, even in single joint arthrit is, toestablish the presence of inf lammation or othefsystenric disease.
TreatmentIable - l sLrmmarises the sorts of treatments that areavailable for knee pain. Most of these are freelyavailable to Seneral practi t ioners, some ar-aorthopaedic or rheumatoloBical but should beavailable in any distr ict. Systemic drugs play l i t t lepart in the treatrnent oi knee pain unless this pain ispart of a Seneralised condit ion. This is important inthe elderly where anti inf anlmator,v drLrgs areprescribcd far too often for osteo arthrit is, withdisastrous results. l t is best to be nihi l ist ic about nonstcroidal anti inf lammatory drugs and the evidencethat new and vefy expensive preparations, such asntisoprostol, do prcvcnt gastro intestinal side effectsis awailed. Simple anal€tesics undoubtedly play ap l r r l i . r p i p l . $ \ e ' e l ^ \ ^ . \ e . " l r e p l ^ i n i r
the only joint ai lected, consideration shoulr l beBivef to topical drlrgs which penetrale well and canbe very useiul. l t has takef a very long l ime foranti- ini lanrmntory drugs to be produced ior topjcapfepafation, but we now have diclofe,ac,ketoprofen, piroxicam, ibuprofen and varioussalicylate type prepafations in 8el form which arevery acceptable to the patients, penetrate well andcan be effective fof <nee pain.
Physiothefapists no\/ tend to diagnose, and tfeataccording to their own diagnosis. They tend tospecial ise with outpatient physiotherapists havingtwo special i t ics, one being pain rel ief and thesecond rnobil isation and treatment of various spinalproblcrns. For knee problems physiotherapists tenclto concentrate on education as regards muscle careand joinl protection, assessment for walking aids,orlhotics and pain rel ief. Part icularly in iashron atpresenL are lasers, different forms of magnetisrn andinterferential. Partnership between thc occupationallherapist and physiotherapjst is closc with regard toknee pain. ( lccupational therapists can be helpful inadvisinB palients or] the height of bed and chairs andon the best types of chair available, and inassessTnent for ihe provision of different types ofonhotics, and in assessment of mobil i ty arouncl thehome. The use of stair l i f ts, for instance, or moving 11rground f loor accommodation can be a very helpfulalternative to the struggle of cl imbing the stairs, lhusdiminishing the pain level quite considerably.
TREATMENT FOR KNET PAIN
A. NON-SURCICALL DUBs: sydenl . and top. : r l .2 ntra artic!lar and soft tissue corticoste old iniection.
.+. Occutationrl therapy
8. SURCICAL
2. L Banrent replncemert .
A.upuncture in Me.licine 59 Novenbet 1992 Val lO Na.:l
lntra-afticular and intra lesional hydrocortisone oltriamcinolone injections remain the mainstay oftreatnrent for a number of condit ions, aJthoughacupuncture has been found to be a very satisfactory substitute in others. Inflammatory arthritis canbe effectively Itealed by hydrocortisone ot triamci-nolone, and aspiration of the joint for diagnosis andfor comfort can be combined with this so easily thatthere seems l i t t le point in substitut ing acupuncturefor this condit ion.The real revolution in treatment of the r<rree rras
been sur8ical and has happened in the last l0-15years. The introduction of the arthroscope, downwhich minor operations can be done and throughwhich biopsies can be taken, means that arthrotornyhas disappeared as an orthopaedic operation. Afterarthroscopy fhe patient is in hospital for less than 24hours and can be back to work within 2 days. Theanaesthetic is I ight, the scaf minute and post-operative recovery very quick. Arthroscopy hasreplaced open surgery for the treatment of almost ai linternal derangerients of the knee and for diagnosis,including synovial biopsy. Arthroscopy is also usedas a treatment for arthrit is of the knee. The knee isarthroscoped, tr immed and washed out of ai l i tsdeb r , . a f o rn o l . p r i nB , l ea r i nB pe rhap ' e re r ) . i rmonths. ln our department we have not found thispart icularly effective long term and don't real ly l ikesubjecting patients, especial ly the elderly, to suchffequent anaesthetics although in Canada this isalmost a routine treatment for arthrit is of the knee.Carbon and other f ibres to replace torn cruciatel iSarnents, or medial of lateral l igaments of the knee,have also given a new l ight to the treatrnent oftraumatic instabil i ty of the knee. It is known to beinevitable that osteo arthrit is of the knee wil ldevelop within 10-20 years of such a traumaticlesion if the knee is lelt unstable. The use of art i f iciall igaments has not been without i ts snags and sideeffects and this form of treatrnent is still in itsinfancy. Neveftheless it can be very effective.Knee joint replacement has been through many
headaches and come out on the other side more orless tr iumphant. Knee arthroplasty is now assuccessful as the hip and appears to last about aslong. The feats about losing a leg or having a shortleg are no longer reasonable with modern types ofarthroplasty. The newer types which al low forrotation as well as f lexion and which leave most ofthe soft t issues intact seem to be the most successrur.The difference between knee and hip arthroplasty isin the recovery period and in the amount of painsuffered. Knee arthroplasty is more painful to thepatient than hip arthroplasty and recovery ofmovement is slower. A patient with a hipreplacernent can confidently expect, i f i t 'ssuccessful, to be walking reasonably and normallyand driving within six weeks- Whilst this may be sofor a knee, full recovery of range of movement andsprightl iness of the leg is seldom achieved in undersix months after knee arthroplasty. The mainproblem now with Joint repjacement is to decide
when it should be done. A grossly unstable valgusor varus knee seldom does well with a kneerepJacement because a surBeon has to use aconstrained arthroplasty and this does not stand verymuch strain. l t is now my pfactice once lsee adeveloping valgus or varus deformity with arthrit isto refer straight away to an onhopaedic surgeon.With the increasing success of knee arthroplastyour orthopaedic surgeons are now much moreenthusiastic about doinS knee joint replacement insuch patients. This does inevitably mean that we areoperating on younger patients, but we wil l have toawait the passaSe of iime to see whether we areriSht to do this.
AcupuncturcHaving looked at the type of problems that occur inthe knee and the types of treatment that areavailable, where does acupuncture f i t in to this?Acupuncture is not a lasi resort treatment for kneepain but may often be the f irst. There are two mainproblems with this in NHS practice. The f irst is thatthe wait ing l ist for treatment is long and it is easierand quicker to treat by injections. The second is thatonce it has been proved that acupuncture iseflective for treatment in a case o{ establishedarthfi t is, then the patient is l ikely to continue askinSfor i t . Knee acupuncture accounts for perhaps 10%ot our acupuncture practice in Wycombe. We arenow giving something l ike 1600 acupuncturetreatments a year, representing 400 patients. Patients
Usefr acupuncture poinE for the treatnent af knee pain.
Anterior Posterior
sT.33 _ "
SP,1O
. . _ 8 1 . 4 0
SP9ST,36
8L,57
Novenber 1992 Vol 1O Na.2 60 Acupunclurc in MediciDe
with knee pain which is chronic, and where thediagnosis is clear and the toint does not requireaspirating, are preferential ly treated by acupunctureraiher than dfuSs or injection where it is possible todo so.Caution sti l l needs to be displayed about using
acupuncture in rheumatoid arthrit is and otherinf lammatory disorders. The f irst reason for this isthat systemic treatment for inflammatory arthritis isnow being used very much earl ier than previously.The second is that al l patients with an inf lammatoryarthrit is, and part icularly fheumatoid, do have anincreased tendency for infection and the fewerneedles that are used on them the better. The thirdreason is that i t is easy to f lare rheumatoid arthrit iswith acupuncture however gently the patient istreated. ln more advanced rheumatoid arthriticpatients in whom other treatments have fai led, or inthose who cannot or do not wish to tolerate drugs,acuplncture may be a treatment of choice. Theresults compare very much with the resultr for othertreatments. The success for knee acupuncture issomewhere in betrveen the success rate for the neckand the lower back- A lasting benefit can beobtained in about 60% of patients, meaning thatperhaps one or two courses a year are al l that isnecessary. The response is much the same as withother treatments, that is immediate pain rel ief withthe use of suitable local needles with a build up ofrel ief only after 3 or 4 treatments. As with al l formsof acupuncture, individualised treatment courses arerequired which, as already emphasised, can meanIhe demand i . i n l i n i re . { , upun ( l u re i \ a \ e }acceptable treatment in the lower limbs, tar more soto patients than drugs. However, it is not generallyacceptable to teenaSers. They hate needles, iheirconcept of what is going on in their body can Sivethem nightmares, and vasovagal attacks arecommon. Such patients should always be treatedvery gently, should be al lowed to l ie clown anclshould be given a very adequate explanation ofwhat is BoinS on before treatment is started.
be added the presence or absence of swell ing orstiffness. Acute pain or stiffness can be treated bythe conventional recipe type o{ treatment; the use ofeither electr ical or manual st imulation wil l producea very immediate pain rel ief. This is the type oftreatment used fot knee sutgery in China and wil lalso increase the range of movement quite dramati-cal ly and make the patient feel immediately befter-This type of approach for acute pain seldom lastsmore than a short t ime, bLrt can be buil t on over aperiod of weeks.For more chronic pain i t is again sug8ested that the
classical Chinese recipe points should be used inaddition to the tender spots around the knee. If thepatient has an enthesopathy, that is inf lammation ofthe tendon end, or an expanding osteophyte whichis pull ing on the periosteum, the use of tender spotswith some periosteal pecking can be veryeff icacious albeit extremely painful. In usinB theextra points "Xiyan", the eyes of the knee, thecapsule should be penetrated since this is where thenerve endings l ie.Anterior knee pain can be effectively treated by
acupuncture. The use of tender spots and periostealtappinS can be helpful, to8ether with the use ofneedle fanning around the tendon end.
AnatomyIable 5 summarises the anatomy of the nerve supplyto the knee. Knowledge of the course oi thesenerves provides addil ional acupuncture points bothproximally and distal ly to the knee joint and also anexplanation for the effects of many of the commonacupuncture points used. Both the front and back ofthe knee afe r ichly supplied with cutaneous nervesand the knee cap has a huge plexus of thesupeficial nerves, which probably accounts for thefrequency of anterior knee pain.
DiscussionAcupuncture can be used as a treatment tor mosttypes of knee pain at different stages in theirprogression. Acupuncture can also be used success-ful ly after knee surgery part iculafly for the anteriorknee pain which often fol lows knee jointreplacement.
the type of approach toused in our cl inics. This is
chronic pain and to this may
Iable 4 summarisesacupuncture treatmentclassif ied into acute or
Acupu nctu re i n Med ic i ne
ANATOMY OF THE KNTE - NERVE SUPPTY
1. CUTANEOUSFront - via femoral nerve: cutaneous nerves, patellarp lex!s (1.2,3,4)Medial Side medial cutaneous nerve and saphenousnerue (1.2,1,4)Back - posterlor cutaneous nerve (S.1,2,3)LateralSide Lateral cltaneous nerve ofthigh (1.2,3)
2. KNEI 'OINIFront - femoral nerue, saphenous nerueLateral - Anteriortibial neNe or lateral popliteal nervePostero lateral Lateral pop iteal(1.4,5, S.1,2)Por"ro nedrdl \ ,e lL l pnpl i led l . l .4 . r
' . ' .
ACUPUNCTURE TREATMENT Of THE KNEE
A. ACUTE PAIN/STIfFNESS5P9,10, 81.40,57, ST.33,36, Extra Points Xiyan (Eyes of
Elecrrical or manual stimulation.
8, CHRONIC PAINsPg,1 0, B1.40,57, 1R.3,9, ST.33,36, Ah Shi poi i ts .r \ t r d p o i r : \ y d n ' l i P . o l h F k n P F p . - r r r ' . ) n o r r - n
Ear points can be added.
C. ANTERIOR KNEE PAINAdd - periosteal stimulation of patell margins, tannedstimulation of patellar attachment, SP6.
Acupuncture should never be used on its own as atreatment for knee pain. The patients must beinstructed in quadriceps exercises, in correctstanding, walking and sitt ing, and in avordance oikneeling and squatt inS. They should always becounselled about general treatment for theircondit ion and that pain rel ief does not prevent thearthrit is gett ing worse, nor the development of kneedeformit ies which may mil i tate against successfulorthopaedic surgery. Acupuncture treatment shouldalways be preceded by an attempt to diagnose theproblem accurately and ensure that al i forms oftreatment are available to that patient.The diagnosis and treatment of knee pain has
changed considerably in the Jast l0 years. Weshould always attempt to diagnose and treatcondit ions early to prevent future problems,however a large number of cases are notdiagnosable or treatable by modern techniques.Such patients and those in whorn other treatrnent isineffective or incomplete can be successful ly treatedby acupuncture-
Dt A v Camp BSc MB ChR FRCPCon su lta t1t Rheu matologi st
Amercham Ceneral HospitalAmershan, Bucks. HP7 0lD
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Th€ BRlTlSHMEDICALACUPUNCTURESOCIEry h a
medical lyquali{ied doctors
it- The society hasexpanded to inclLrde
sections for dentists andvetennary sur9eons.
The ajrns ofth€ society are to promote the scientificunders'landing and practice of acupuncture as part o{the normal practice of medicine.
The administrative officer will deal with any enquiriesin.luding those regarding membership, courses oftu;tion, text books, scientiJic fieelings and the Journalof the Britkh MedicalAcupuncture Society.
NOMA SuPer Four: A mu ri-purposeiouroutpui electri@l stimulalor lor eleclro acupuncru.e, TENS or auricular lherapy. A dlqilal dispaytacilitates preclse f requency selection.
M!G.QLE\|S: on"*generation of miniature transcutaneoosnerve stimulatorsforthe management andtreatment of chronic oracute pain conditions.Simple to operate, even lor arthritic patients.
Available with either continuous or low fre'quency "burst" outputs. Both models have
asymmetric biphasic modified square wave torm.(Recently leatured in lhe "General Practitionef').
ENERGY POINTSSTIMUTATOR: A roo-sr. randes'e nsrrlmenl lor the easy location and stimulaiion ofaclpuncture poinls wilholl needles. Simple, pain'less saie and ellective. ComDlete wilh a!cxJeter
We alsa 6try a conprc hensive nnee ol ac u p u nctuteneedles and assocraled equipnent, including asele.ion al apptoved acupuncturc text books
P.f,.TEDIGII.16 Blrch Cose, New Haw, Weybrdge, SotreyTelephoner Weybf dge (0932)845495
ACUPHOTON:A sale low-outpul HeNe laser foracce eratedwo!nd healing and thetreahent ol most skin d sorders.(Has had notableslccess n heai ngstubborn varicose ulce6). canaLsobe used lo replace needles ln acu_puncture treatment oi children or
Novenber 1992 Val l0 Na.2 62 AcupDn.tjte in Med i.ine
