INTRODUCTION

Acupuncture has been a part of sports medicine since the dawn of Chinese civilization. The concept of Qi is the essence of Chinese martial arts as well as of acupuncture, and historically the masters of Chinese martial arts were also experts in traditional Chinese medicine (TCM). They used acupuncture to treat acute and chronic martial arts injuries, and also to “tonify Qi,” meaning to activate the healing mechanism of the body to prevent injuries and improve performance.

Today the use of acupuncture in sports medicine is becoming more and more recognized. The continuing growth in popularity of recreational sports and fitness activities creates more injuries like strains, sprains, and broken bones. Now that we better understand the benefits of acupuncture we know that it can be very effective not only for martial arts injuries but also for preventing and treating all kinds of sports injuries for both professional and amateur athletes.

The most common sports injuries are musculoskeletal disorders such as damage to muscles, bursae, ligaments, capsules, and bones. In this chapter we focus on injuries caused by repetitive overuse of muscles, joints, and bones.

Any movement of the human body is a complicated biomechanical process that requires the coordination of many muscles and different parts of the body. When a muscle is weak or injured, it becomes tight, fatigued, inflamed, undernourished, or hypoxic. This injured muscle will disturb the normally synchronous and harmonious coordination between it and other muscles and the result will be pain or injury. This is why muscle injury can spread easily if not treated early. For example, if a group of injured muscles are left untreated, it can result in a stress fracture of the bone. Acupuncture can accelerate the healing of injured muscles and/or injured soft tissues, thus preventing the injury from spreading further. Treating injured muscles also indirectly helps to accelerate the recovery of injured bones because the healed muscles and the soft tissues allow for an increased blood supply, which is needed for regeneration of bone tissue.

When sport accidents cause severe injuries that affect the bones, orthopedic specialists should be consulted immediately. In these cases, acupuncture can still be used to promote rehabilitation and accelerate recovery after surgery.

Most sports injury pain is of an acute nature resulting from strain and/or sprain. If the acute pain symptoms are neglected (e.g., when some athletes try to perform while ignoring their pain), the acute pain may became chronic and lead to changes in the histological structure of the tissues. The chronic problem will eventually permanently deprive the soft tissues of their functional ability, such as, for example, the full range of contraction of the muscle.

THE DIFFERENCE BETWEEN TREATING PROFESSIONAL AND AMATEUR ATHLETES

There are two basic differences between patients who are professional athletes and those who are amateur athletes. First, professional athletes have a greater risk that a minor injury will become a severe or even disabling condition because their tight schedules do not give them sufficient time to recover. Amateur athletes usually have enough time to adequately treat their acute injuries. Second, the purpose of treating a sports injury in a professional athlete is not pain relief but functional recovery, whereas for nonprofessional athletes, pain relief is the primary purpose.

When a professional athlete is injured, the tight schedules of training and competition usually prevent the dedication of sufficient time to achieve proper healing, even in the case of a minor injury. Because of this some professional athletes start to perform again before they are fully recovered. The athletes and their coaches try to find a quick fix such as painkillers or steroid injections. But there is no such quick fix. As a result, minor injuries become chronic, and the damage can spread to other tissues. Consequently, many professional athletes have to live with chronic pain or, in some cases, they become disabled, threatening their entire athletic career.

Athletes and coaches should understand that in most cases pain does not appear suddenly but develops as a result of cumulative stress or injury in neuromusculoskeletal tissues, often accompanied by inflammation and swelling. This pathological process, if not completely reversed, gradually reduces the function and structure of the injured tissue to a critical level where the body starts to “cry” for help and protection. Pain means that the injured tissue has been deprived of a sufficient supply of blood, nutrition, and oxygen for some period of time. Acupuncture needling relaxes the stressed tissue and revives the normal supply of nutrients and oxygen. After treatment, the pain will disappear but the process of proper recovery of affected tissues—the replacement of damaged cells by healthy ones and the recovery of normal function and strength—still needs time.

WHAT TO DO WHEN A SPORTS INJURY OCCURS

When pain or injury occurs during sport activities, the athlete should stop and immediately seek a medical evaluation. Acupuncture treatments will be effective to reduce pain, swelling, and inflammation, and the athlete should avoid deep massage or stretching, which may further damage the tissues. An ice pack can be used for the first day or two, to reduce inflammation, and a heat pack should be used to promote blood circulation after the inflammation has been reduced. A few days away from training are essential. Although mild exercise is beneficial for recovery, no physical stress should be placed on the damaged tissues. After recovery is achieved, the athlete still needs to be careful to monitor the amount and intensity of the training, to keep it within a level that is acceptable for the injured tissue, gradually increasing back to a normal level. This may result in a few extra days before the athlete is able to resume training or competition but it will protect the body from permanent injury and minimize the threat to the athlete’s professional career.

There is a general agreement among pain specialists that 3 months are needed for natural healing of soft tissues. If pain from a sports injury continues after 3 months, it is regarded as chronic pain. Our clinical experience shows that in cases of minor and moderate acute pain from a sports injury, proper acupuncture treatment can relieve pain in less than 2 weeks. Without proper treatment, the initially treatable acute pain may become a chronic disorder.

Generally, athletes are healthy and physically active, with a high healing potential. Thus, most of their acute pain symptoms can be treated effectively by acupuncture within a range of a few hours to a few days. The painful tissue is usually physically damaged, energetically starving, physiologically abnormal, functionally disabled, and affected by an abnormal accumulation of metabolic toxins. Acupuncture needling can relieve pain in a very short period of time by desensitizing the nerve endings and reducing swelling and inflammation.

Pain pills, which block the perception of pain in the athlete’s brain, also work very well because a healthy body responds better to pain medication than does an unhealthy one.

It is clear that both acupuncture needling and pain pills can stop sports-injury pain in a very short time, but repairing the damaged tissue and restoring function take much more time. Athletes have to be aware that pain relief does not equal functional relief, and to achieve the latter, the normally intense schedule has to be relaxed. It is important to note the difference between acupuncture therapy and pharmaceutical therapy. Acupuncture works on the peripheral level (the local injured tissue), the spinal cord level (gate control in the spinal cord to block pain signals), and the brain level (pain modulation in brain centers). It starts by fixing the damage first, and as the damaged tissue starts to heal, the pain subsides. In contrast, pain medication blocks the pain signal at the spinal cord level or in brain centers and quickly takes away the sensation of pain, but the tissue damage is still waiting for the supply of nutrition and oxygen that is needed for healing. When athletes use pain medication or steroid injections to suppress pain and immediately resume training and competition, the tissue damage becomes more severe.

NO QUICK FIX FOR SPORTS INJURIES

It is understandable that patients want to be healed quickly. Our experience of working with athletes, both professional and amateur, shows that even with the high level of health that they enjoy, healing of injury and pain cannot be accelerated beyond the body’s natural rate without the risk of aggravating the injury and leading to disability in the future.

Muscle has an important physiologic character: it has a memory of its injury. After an injured or sick muscle is properly treated and recovers, the pain disappears and the flexibility of the muscle fibers is restored, but the memory of the injury will stay for a much longer time, depending on the severity of the injury. As long as the healed muscle retains the memory of its injury, it becomes fatigued and weaker faster and is liable to produce pain and injury again if exposed to the same repetitive overuse. It takes time and a conscious effort toward restraint to erase a muscle’s memory of its injury. Athletes with acute muscle pain should not ignore the memory factor, which is an important part of muscle rehabilitation.

PAIN PILLS SHOULD BE USED WITH CAUTION FOR ACUTE SPORTS PAIN

In sports activities, pain appears as a result of cumulative stress or damage to the tissues. The pain is a warning signal intended to protect the damaged or exhausted tissues and to demand additional nutrition, oxygen, relief from the stressful activity, and time to repair and regenerate the tissues. If the demand is ignored, as when pain is numbed by pills or steroid injections, which suppress pain but retard the process of healing, it can result in a future disaster for the injured athlete.

In the context of athletic activity by healthy people, pain is a warning signal, part of the protective wisdom of the body. Chronic pain, however, is a disease in and of itself. For athletes, this difference is important, and different strategies should be used to treat different kinds of pain.

Pain pills are not a solution for restoring the function of injured soft tissue. Athletes should focus on functional restoration as being more important than suppression of acute pain.

INTEGRATIVE NEUROMUSCULAR ACUPOINT SYSTEM FOR SPORTS TRAUMA

The 24 homeostatic acupoints (HAs) of the Integrative Neuromuscular Acupoint System (INMAS) are a map of the most important points for restoring the physiologic function of muscles. Most of the INMAS acupoints are situated in the major muscles that ensure the body’s movement and coordination, and all HAs are supplied with major peripheral nerves. Needling INMAS acupoints improves the function and coordination of major muscles and joints. A local injury is always associated with one or more HAs, and stimulation of the local HAs improves the blood circulation and energy metabolism of the injured area.

When pain or injury occurs, the local HAs and SAs should be needled first, and then the distant HAs should be needled to treat possible referred pain, to reduce stress, and to activate homeostatic restoration.

MECHANISMS OF ACUPUNCTURE THERAPY USED IN SPORTS MEDICINE

Acupuncture is effective in sports medicine because, through the healing mechanisms discussed above, it can accelerate the healing of existing trauma, prevent future athletic injuries, and improve athletic performance.

USING ACUPUNCTURE FOR INJURY PREVENTION AND IMPROVEMENT OF PHYSICAL PERFORMANCE

All repetitive strain or overuse injuries from sports activities are caused by physiologically sick muscles. The muscles become injured gradually, without initial warning signals, and the majority of athletes are not aware when a muscle starts to become sick. They may feel some pain or some tightness in the muscle during or after sports activities, but since the pain is not evident during less stressful activities such as walking they believe that there is nothing wrong with the muscle; they believe that massage or a hot bath will take care of the situation. When palpating such affected muscles, however, tender, sore, and even painful spots are felt, and these are symptoms of the sick muscles.

Most of these sensitive spots will not disappear on their own, because, in fact, they are signs of structural abnormality. After repetitive strain or overuse, some muscle cells (fibers) shrink and form contracture spots or bands. Most sensitive spots or bands, if not properly dissolved, can become permanent structures in the muscle. If a muscle harbors these sensitive spots, physiologically the muscle becomes more easily and quickly fatigued; functionally it becomes less flexible and resistant to whole-range stretching and more slow to recover after exercise.

These injured muscles are the weakest muscles in an athlete’s body. They disturb the coordination of synchronous muscle movements and cause misalignment of the joints. If the injured muscles are continuously forced to move, they will share the injury with neighboring muscles and tendons in order to protect themselves. As a result, muscle activities are handicapped and even a minor activity can then create a physical injury.

Acupuncture needling is the most effective modality for tight muscles because it physically breaks and dissolves the contracture in a precise way without side effects and thereby accelerates the healing and recovery of the dysfunctional muscles. A healthy, pain- and contracture-free muscle is more flexible and less prone to injury. It works better and longer, and recovers faster from contraction, so it can sustain and adapt to the most vigorous training. This is why acupuncture needling can prevent muscle and soft tissue injury and improve an athlete’s physical performance.

TENDINITIS FROM REPETITIVE STRAIN OR OVERUSE IN SPORTS

Tendinitis is a common repetitive strain/overuse disorder in sports medicine. It usually occurs in the tendons of the major muscles associated with the shoulder, elbow, wrist, and knee joints, and in some muscle attachments such as the calcaneal (Achilles’) tendon or that between the hamstring muscle and the ischium.

We have seen both professional and amateur athletes with various kinds of tendinitis who came to us because they failed to obtain relief or suffered worse pain after undergoing conventional treatment including surgery, steroid injections, pain medication, physical therapy, and massage. We found that most of these conventional modalities focused on pain and inflammation of the injured tendons but ignored the root of the tendinitis problem: the sick muscle(s).

The muscles are built for contraction and consist of the most dynamic, flexible, and contractible muscle cells (fibers) in the body. The tendons consist of connective tissues that connect the muscles to the bones, and are functionally much less contractible so that they can effectively transfer the muscle’s contraction to the motions of the joints and bones. So in the muscle-tendon-tendon attachment structure (tendons attach to the bones, to other tendons, or to dense connective tissues), the muscle creates a contraction, the tendon transfers the contraction to the bones or other tendons, and the bone moves. This is normal functioning.

After repetitive strain or overuse, the mechanism of self-protection is activated and the muscle becomes sick. It is then less contractible (tight) or may even produce tender contracture inside it that resists further contraction. When the sick, noncontractible muscle is still forced to contract, it tries to force the noncontractible tendon to stretch, which leads to inflammation or physical rupture of the tendon. Similar to the process that occurs inside the muscle, a contracture of the connective tissues is also formed inside the tendon to resist any forced stretch(ing). This type of physical force and physiologic stress is the cause of most of the tendinitis injuries that are found in sports.

Thus tendinitis is usually a secondary injury that is caused by the primary injury—muscle sickness. In some cases, the tendons are damaged first, but very soon the injured tendons cause the muscle to become tight or to manifest tender or painful areas in order to protect themselves. It is clear that all tendinitis is associated with sick muscles, regardless of whether the muscles are the primary or the secondary cause.

Therefore, tendinitis should be treated together with the muscles because a sick muscle always places mechanical stress on the tendon. Fortunately, acupuncture can easily handle both muscles and tendons simultaneously. When treating tendinitis a practitioner should carefully examine both the tendon and the muscle to locate the tender spots in both regions, and needle all of these spots. After the treatments, patients should rest or do only very mild exercise so that the healing process can run its course in both the tendon and the muscle.

We have achieved very good results treating tendinitis, especially when patients come to us immediately after it is suspected. We also have helped patients who had previously tried unsuccessfully to obtain healing from other modalities such as medication, steroid injections, or physical therapy, although more treatments and a longer rehabilitation period were needed because these patients have usually suffered more damage if these other modalities were not beneficial.

It is more difficult to treat tendinitis after unsuccessful surgery because (1) surgery, if not well done, may shorten the muscle and create permanent stress in the muscle and tendon, and (2) surgery usually changes some natural structure, and acupuncture works best with natural pathways.

TREATING SOFT TISSUE DISORDERS IN SPORTS MEDICINE

There are many patients who are suffering from the side effects of drugs (such as long-term use of steroid medication) or the consequences of unnecessary surgery, who could have benefited from acupuncture. Many of the side effects of conventional medical intervention can be avoided or reduced when acupuncture is used alone or in combination with other procedures.

Dr. Alec Meleger of the Harvard Medical School Physical Medicine and Rehabilitation program and Dr. Joanne Borg-Stein of the Tufts Medical School Physical Medicine and Rehabilitation department conducted an in-depth review of published studies on using acupuncture in sports medicine. The review paper by Drs. Meleger and Borg-Stein¹ provided objective data to support the clinical value of using acupuncture for soft tissue disorders in sports medicine.

Acupuncture needling (dry needles) and steroid injections (wet needles) have similar therapeutic efficacy as suggested by Dr. David G. Simons.² “Dry needling is as effective as injection of an anesthetic for relief of trigger point symptoms” as long as the dry needling can precisely target the trigger point.

In other research, Dr. Chilton³ reported a higher success rate with acupuncture and steroids versus steroid-only treatment. We believe, too, that a combination of acupuncture needling and steroid injections provides better results than injections alone because acupuncture can be used for breaking all the tender points detected during a treatment whereas one can make only a limited number of steroid injections in any one treatment. Acupuncture stimulates the natural antiinflammatory process in the body and can be used repeatedly to deactivate muscle and fascia contracture. Thus, acupuncture needling can continue to be used during follow-up treatments without any side effects.

These research conclusions about the use of acupuncture for sports-related injuries completely match the understanding and interpretation of the acupuncture mechanism and its clinical features that are presented in INMAS, which among its other merits helps to explain the nonpharmaceutical self-healing mechanism of acupuncture and the different approaches for treating athletic and nonathletic patients.

We should mention one general misconception about acupuncture, which is to treat it like pharmaceutical therapy and thus try to figure out which problems acupuncture can and cannot effectively treat. However, the efficacy of acupuncture depends on how much healing potential is maintained in the body (which is predictable) and the healability of the injury. The same injury may be effectively healable at the acute stage but unhealable in an advanced chronic stage.

SUMMARY

Scientific studies, clinical evidence, and the history of using acupuncture to treat martial arts injuries all indicate that acupuncture has a special value in treating most soft tissue injuries from sports activities, as well as preventing these injuries and improving physical performance.

When pain or soft tissue injury occurs, immediate acupuncture needling will reduce pain and swelling, limit the extent of the inflamed tissues, and accelerate healing. Acupuncture needling can effectively remove muscle and tendon stress and increase the flexibility of the muscles and tendons by dissolving the contracture that reduces blood circulation and causes muscle pain. INMAS provides an indispensable tool for practitioners to locate the most important acupoints for effectively treating sports-related injuries, preventing future injuries, and improving athletic performance by improving local muscle function and bodily coordination.