- Email: [email protected]
Bloodletting-cupping for 169 cases of pes anserinus myotenositis
World Journal of Acupuncture – Moxibustion 29 (2019) 231–234
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Report
Bloodletting-cupping for 169 cases of pes anserinus myotenositis Shaoren CAI ()∗, Yong JIN (), Wanyu ZHANG (), Zhongtang LIAO () Department of Disease Prevention, Pingle Hospital of Orthopedics and Traumatology, Shenzhen 518010, Guangdong Province, China ( , 518010, )
a r t i c l e
i n f o
Article history: Available online 19 August 2019 Keywords: Pes anserinus myotenositis Bloodletting Bleeding Cupping
a b s t r a c t Objective: To observe the clinical effect of bloodletting-cupping for pes anserinus myotenositis. Methods: A total of 169 patients of pes anserinus myotenositis were collected. The tapping or bloodletting with plum-blossom needle or the syringe needle was adopted at the local Ashi points to induce bleeding and the cupping was followed. The cup was retained for 10–15 min. The treatment was given once a week and continued till the clinical symptoms disappeared or the patients were unwilling to continue the treatment. The maximal treatment was 10 times. Before and after treatment, the score of visual analogue scale (VAS) and Lysholm knee score, as well as the clinical effects were observed of the patients. Results: Of 169 cases, 137 cases were cured, 20 cases improved and 12 cases failed. The effective rate was 92.89%. Of the 137 cured cases, 10 cases were cured after 1 time of treatment, 5 cases were cured after 10 times of treatment and the rest 122 cases were cured between 2 and 9 times of treatment. VAS score was reduced to be (1.10 ± 0.32) after treatment from (4.35 ± 0.60) before treatment and Lysholm score was increased to be (92.74 ± 5.04) from (65.42 ± 6.38). Conclusion: The bloodletting-cupping alleviates knee pain, or even cure it completely and improves the motor function of knee joints in the 169 patients of pes anserinus myotenositis. The clinical effect is satisfactory. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
Pes anserinus myotenositis, also called pes anserine bursitis, or tibial medial condyle inflammation, is a clinical common seen disease in orthopedics department. It is an aseptic inflammation on the tibial medial condyle of the medial collateral ligament of knee joint, manifested as pain on the medial side of knee when exerting the flexion and extension of joint. Generally, the patient can clearly point out where the pain is located on the eminence of the tibial medial condyle, in a size as the belly side of the pinky, about 1 to 2 cm from the knee joint space [1]. This disease used to be commonly seen in the patients of middle age or the elderly and the incidence was especially high in soldiers. While in recent year, along with the deep awareness on sports and health, the incidence of this disease has been increased in the young people who is keen on mountain climbing and long-distance running [2]. Although pes anserinus myotenositis is a common disorder in clinic, there are few reports on it in literature [3]. At present, the nonsteroid anti-inflammatory agents e.g. voltaren and indometacin, the physiotherapy, e.g. ultrasonic wave, microwave, laser and thermal magnet therapy, as well as relaxation and immobilization method are commonly adopted in the treatment. However, the side effect ∗
Corresponding author. E-mail address: [email protected] (S. CAI).
of medications and the limitation of physiotherapy may affect the therapeutic effect on the disease. By summarizing the clinical experiences in acupuncture, we adopted the bloodletting and cupping in treatment of this disease. The report is as follows. Clinical data General data From June 2016 through to May 2018, 169 outpatients of pes anserinus myotenositis were collected from the Pain Department of Acupuncture and Moxibustion, Shenzhen Pingle Orthopedics and Traumatology Hospital. Of them, there are 116 males and 53 females, aged from 18 to 65 years old, averagely (37.4 ± 8.2) years old, with the duration of disease of 1–10 months, averagely (3.7 ± 1.2) months. Of all of the patients of pes anserinus myotenositis, there were 71 cases on the left knee and 98 cases on the right. Diagnosis criteria The diagnosis criteria on tibial medial condyle inflammation were drafted from Criteria of Diagnosis and Therapeutic Effect of
https://doi.org/10.1016/j.wjam.2019.08.001 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
232
S. CAI, Y. JIN and W. ZHANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 231–234
Fig. 1. Bloodletting with plum-blossom needle and cupping for pes anserinus myotenositis.
Diseases and Syndromes in Traditional Chinese Medicine [4]. These are 1 pain at the attachment of pes anserinus tendon inferior to the tibial tubercle on the anterio-medial aspect of the distal end of tibia; 2 history of sport strains or overstrain of the knee due to long-time walking and standing; 3 tenderness and swelling at the anterior area of the knee joint in physical examination, pain aggravated on passive eversion and extorsion of knee joint, as well as on resistant flexion of knee joint; 4 inability to squat or go downstairs in severe condition; 5 exclusion the disorders of meniscus, ligament and bone of knee joint; 6 exclusion the lumbar nerve root disorder. Inclusion criteria
1 Aged from 18 to 65 years old, either gender. 2 Duration of disease was in the range from 2 weeks to 1 year. 3 Agreed of clinical observation. Exclusion criteria
1 Incomplete skin in local area. 2 Incomplete data or difficulty in cooperation in treatment. 3 Combined with gouty arthritis, tumor and synovial tuberculosis. Therapeutic methods The bloodletting-cupping was adopted. The patient was in supine, with the affected knee flexed and extended slightly and the affected area exposed completely. The routine sterilization was adopted on the area with iodophor. The local Ashi points (pain points) were selected as the stimulated points. The 2 or 3 pain points were detected by the clinical physician on the lesion area and marked by a marker. A disposable sterile plum-blossom needle or a No.5 disposable syringe needle was used and the tapping or rapid pricking was adopted around the marked Ashi points. If the doctor used a plum-blossom needle, the tapping area was as the size of a table tennis ball by taking the Ashi points as the center. Tapping was adopted for about 30 s till slight bleeding (Fig. 1). If the doctor used a syringe needle, the Ashi points were pricked rapidly and repeatedly for 5 to 10 times till slight bleeding. Soon afterwards, the fire cupping or air-suction cupping was used on the bleeding site and the cup was retained for 10 to 15 min. When the cup was removed, the local bleeding area was cleaned with aseptic cotton ball or cotton swab, the puncturing site was re-sterilized with iodophor. Therewith, the band-aid or aseptic dressing was used to cover the wound surface. The patient was advised to keep the wound clean and dry in 24 h so as to avoid infection. The treatment was given once a week and continued till the clinical symp-
toms disappeared or the patients were unwilling to continue the treatment. The maximal treatment was 10 times. Observation of therapeutic effect Observation indexes Visual analogue scale The visual analogue scale (VAS) is commonly adopted to evaluate pain intensity in patients. A ruler with the measurements from 0 cm to 10 cm is selected. According to patients’ subjective responses on pain, the corresponding scale is recorded. The higher the scale is, and the more severe pain is. 0 means no pain, 1–3 means mild pain, 4–7 means moderate pain, 8–10 means severe pain. Lysholm knee scoring sale Lysholm scale is commonly adopted in clinic to evaluate the motor range of knee joint, composed of 8 items [pain (0–25 points), instability (0–25 points), locking (0–15 points), swelling (0–10 points), limp (0–5 points), stair climbing (0–10 points), squatting (0–5 points), support (0–5 points)]. The Lysholm score is in the range from 0 to 100 points. The lower the score is, the poorer the skin joint condition is. Standard of the therapeutic effect The therapeutic effect was evaluated according to Criteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine [4]. Cured: disappearance of pain on the medial side of knee joint, negative response to the tenderness of pes anserinus tendon on the medial side of tibia, no pain on passive eversion and extorsion of knee joint, and no pain on the resistant flexion of knee joint with normal kneeling-down or squatting function. Improved: obvious alleviation of pain on the medial side of knee joint, disappearance or alleviation of swelling or tenderness of pes anserinus, mild pain on passive eversion and extorsion of knee joint, and remarkable improvements of kneeling-down or squatting function. No effect: all of the symptoms and physical signs being the same as the conditions before the treatment. Statistical analysis SPSS 18.0 software was adopted in the statistical analysis on the data. Mean ± standard deviation (Mean ± SD) was used to express the measurement data. The pared-samples t-test was used before and after treatment. P < 0.05 indicates the significant difference in statistics.
S. CAI, Y. JIN and W. ZHANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 231–234 Table 1 Comparison of VAS and Lysholm scores before and after treatment in the patients of pes anserinus myotenositis. Time point
Cases
VAS score
Lysholm score
Before treatment After treatment
169 169
4.35 ± 0.60 1.10 ± 0.32a
65.42 ± 6.38 92.74 ± 5.04a
a
Compared with the score before treatment, P < 0.05.
Results Comparison of VAS and Lysholm scores before and after treatment in the patients of pes anserinus myotenositis After treatment, the symptoms were all relieved in all of the patients. VAS score was lower than that before treatment and Lyshom score was higher than that before treatment, indicating the significant differences. See Table 1 for details. Clinical effect in the patients of pes anserinus myotenositis A total of 169 patients participated in this study and no case was dropped out. After treatment, 137 cases were cured, 20 cases improved and 12 cases failed. The curative rate was 81.07% and the effective rate was 92.90%. Of 137 cured cases, 10 cases were cured after 1 time of treatment, 5 cases were cured after 10 times of treatment and the rest 122 cases were cured between 2 and 9 times of treatment. Typical case A male patient, 37 years old, visiting the clinic of the Department of Pain with Acupuncture and Moxibustion in our hospital on June 18, 2017. Chief complaint: feeling pain on the medial side of the right knee joint after playing basketball 2 months ago, since then, pain was often presented, aggravated after exercise and slightly alleviated after resting. Physical examination: tenderness (+) on the tibial tubercle of the medial side of the right knee, aggravated pain on passive eversion and extorsion of the right knee. Diagnosis: pes anserinus myotenositis. The patient narrated that the therapeutic effect was not so satisfactory after the external use of voltaren and impulse wave treatment and still felt pain on the medial side of knee. The patient received bloodletting-cupping at Ashi points in our department. The pain points were detected and marked on the medial side of knee joint. The disposable No.5 sterile syringe needle was used to prick the affected area rapidly, for about 30 s, till the slight bleeding. The stimulating area was as a size as a table tennis ball by taking the Ashi points as the center. Afterward, the fire cupping was adopted on the bleeding site and the cup was retained for about 10 min. When the cup was removed, the local bleeding area was cleaned and the puncturing site was re-sterilized. Therewith, the band-aid was used to cover the wound surface. The patient was advised to keep the wound clean and dry in 24 h and avoid spicy and greasy food. After the first treatment, pain on the medial side of knee was relieved obviously. The second treatment was given in the next week with the same method. After two times of treatment, pain disappeared completely and the motor function of knee joint was recovered. The patient was advised to have the physical training of the muscle strength of the lower limbs without loading and avoid strenuous exercise and wind-cold invasion. No recurrence happened in 3-month follow-up. Discussion Pes anserinus is a confluence of tendinous structures on the medial side of tibia, being constituted by the tendons of three
233
anatomical structures, namely, sartorius, gracilis, and semitendinous muscles on the inferomedial aspect of the tuberosity of the tibia, at the medial proximal tibia, similar in an appearance of goose foot [5]. Pes anserinus mainly functions at maintaining the stability of knee joint, exerting the pronation and flexion of knee joint and avoiding over-rotation and eversion of the joint [3]. The tendons or ligaments of pes anserinus are inter-inserted, closely structured in anatomy. The strenuous activity or long-term repeated movement of knee joint is apt to induce chronic strain, bleeding and scarring, and thus, aseptic inflammation is caused, resulting in local adhesion, swelling and pain in the knee joint. The physical therapy or blocking injection is commonly adopted in western medicine for such disease. It will take a long time to achieve the effect with physical therapy and the duration of such treatment is relatively long. The effect of blocking injection is definite, but many patients are worried about its side effect and thus unwilling to accept it. Therefore, more and more patients seek the treatment of traditional Chinese medicine. Pes anserinus myotenositis is not denominated in the classics of traditional Chinese medicine (TCM). According to its clinical symptoms, such disease should be classified into the category of bi syndrome. TCM holds "where is obstruction, where is pain". Pain of pes anserinus myotenositis is caused by the obstruction at the meeting site of the muscle regions of the three yin meridians of foot at pes anserinus. It is recorded in Língshu¯ ( , The Spiritual Pivot) that the muscle regions of foot-taiyin, foot-shaoyin and foot-jueyin meridians are knotted at the medial condyle of tibia at knee joint and the disorder of these meridians at this region refers to the pain at the apophysis between the medial condyles of femur and tibia. It is seen that the ancient scholars had been recognized that pes anserinus myotenositis was a kind of common disorder early. Regarding the treating method, the fire needling technique is used at the pain site with strong and quick puncture. It is a kind of reducing technique of acupuncture and its basic theory is same as bloodletting therapy. In bloodletting-cupping therapy, the skin of the affected area is sterilized, and then the pricking or the tapping is adopted with the three-edged needle or the cutaneous needle respectively to cause bleeding. Afterwards, the fire cupping is adopted at the pricked site to intensify the effect of bleeding [6]. The medical silk book excavated from the Mawangdui tomb of Han Dynasty has included the relevant record on the bloodletting-cupping method and such method has been extensively used in surgical disorders and traumatic injury of TCM [7]. At present, this method is commonly adopted in the treatment of acne, herpes zoster and arthritis in clinic, but it is seldom used in the treatment of pes anserinus myotenositis. In clinical practice, we discovered that the bloodlettingcupping method of acupuncture at local Ashi points have achieved the satisfactory effect on the disease, which avoids the side reactions of western medication and the equipment requirement in physical therapy and it shortens the duration of treatment compared with the common needling technique of acupuncture. The bloodletting therapy acts on promoting qi and blood circulation in the local obstructive site so that swelling and pain can be relieved [8]. The bloodletting and cupping adopted at the site of swelling and pain effectively improve the microcirculation of the affected area, relieve vascular spasm and reduce inflammatory exudation in either acute or chronic case so as to remove swelling and stop pain. In this study, the bloodletting-cupping was adopted for 169 patients of pes anserinus myotenositis. After treatment, knee pain was alleviated or even disappeared completely and the motor function of knee joint was improved. The clinical effect was satisfactory. In future, a control group should be set up so that the effect of bloodletting-cupping can be objectively evaluated in this disease.
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References [1] Zhang LT, Wang CL, Tian PJ. Medial tibial condylitis. Acta Chin Med Pharmac 1980;7(3):36–8. [2] Guan QL, Pan ZX, Wang TT, Wang XH. Long-term effect of radiating extracorporeal shock wave in the treatment of pes anserinus myotenositis. People’s Mil Surg 2015;58(01):56–7. [3] Zhang XZ, Zhang DZ. Experiences in diagnosis and treatment of pes anserinus myotenositis. J Jinzhou Med Univ 2005;26(02):89. [4] State Administration of Traditional Chinese Medicine. Criteria of diagnosis and therapeutic effect of diseases and syndromes in traditional Chinese medicine. Nanjing: Nanjing University Press; 1994.
[5] Ai P. Research progress of pes anserinus myotenositis. Diet Health Care 2018;5(22):298–9. [6] Shi XM. Science of acupuncture-moxibustion. Beijing: China Press of Traditional Chinese Medicine; 2007. [7] Wu MY, Liang C, Hu Y. Clinical application of pricking blood and cupping in Chinese medicine surgery. J Chin Prescript Drug 2018;16(07):27–8. [8] Chen XH. Bloodletting therapy. Beijing: The People’s Medical Publishing House; 2009.
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Report
Bloodletting-cupping for 169 cases of pes anserinus myotenositis Shaoren CAI ()∗, Yong JIN (), Wanyu ZHANG (), Zhongtang LIAO () Department of Disease Prevention, Pingle Hospital of Orthopedics and Traumatology, Shenzhen 518010, Guangdong Province, China ( , 518010, )
a r t i c l e
i n f o
Article history: Available online 19 August 2019 Keywords: Pes anserinus myotenositis Bloodletting Bleeding Cupping
a b s t r a c t Objective: To observe the clinical effect of bloodletting-cupping for pes anserinus myotenositis. Methods: A total of 169 patients of pes anserinus myotenositis were collected. The tapping or bloodletting with plum-blossom needle or the syringe needle was adopted at the local Ashi points to induce bleeding and the cupping was followed. The cup was retained for 10–15 min. The treatment was given once a week and continued till the clinical symptoms disappeared or the patients were unwilling to continue the treatment. The maximal treatment was 10 times. Before and after treatment, the score of visual analogue scale (VAS) and Lysholm knee score, as well as the clinical effects were observed of the patients. Results: Of 169 cases, 137 cases were cured, 20 cases improved and 12 cases failed. The effective rate was 92.89%. Of the 137 cured cases, 10 cases were cured after 1 time of treatment, 5 cases were cured after 10 times of treatment and the rest 122 cases were cured between 2 and 9 times of treatment. VAS score was reduced to be (1.10 ± 0.32) after treatment from (4.35 ± 0.60) before treatment and Lysholm score was increased to be (92.74 ± 5.04) from (65.42 ± 6.38). Conclusion: The bloodletting-cupping alleviates knee pain, or even cure it completely and improves the motor function of knee joints in the 169 patients of pes anserinus myotenositis. The clinical effect is satisfactory. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
Pes anserinus myotenositis, also called pes anserine bursitis, or tibial medial condyle inflammation, is a clinical common seen disease in orthopedics department. It is an aseptic inflammation on the tibial medial condyle of the medial collateral ligament of knee joint, manifested as pain on the medial side of knee when exerting the flexion and extension of joint. Generally, the patient can clearly point out where the pain is located on the eminence of the tibial medial condyle, in a size as the belly side of the pinky, about 1 to 2 cm from the knee joint space [1]. This disease used to be commonly seen in the patients of middle age or the elderly and the incidence was especially high in soldiers. While in recent year, along with the deep awareness on sports and health, the incidence of this disease has been increased in the young people who is keen on mountain climbing and long-distance running [2]. Although pes anserinus myotenositis is a common disorder in clinic, there are few reports on it in literature [3]. At present, the nonsteroid anti-inflammatory agents e.g. voltaren and indometacin, the physiotherapy, e.g. ultrasonic wave, microwave, laser and thermal magnet therapy, as well as relaxation and immobilization method are commonly adopted in the treatment. However, the side effect ∗
Corresponding author. E-mail address: [email protected] (S. CAI).
of medications and the limitation of physiotherapy may affect the therapeutic effect on the disease. By summarizing the clinical experiences in acupuncture, we adopted the bloodletting and cupping in treatment of this disease. The report is as follows. Clinical data General data From June 2016 through to May 2018, 169 outpatients of pes anserinus myotenositis were collected from the Pain Department of Acupuncture and Moxibustion, Shenzhen Pingle Orthopedics and Traumatology Hospital. Of them, there are 116 males and 53 females, aged from 18 to 65 years old, averagely (37.4 ± 8.2) years old, with the duration of disease of 1–10 months, averagely (3.7 ± 1.2) months. Of all of the patients of pes anserinus myotenositis, there were 71 cases on the left knee and 98 cases on the right. Diagnosis criteria The diagnosis criteria on tibial medial condyle inflammation were drafted from Criteria of Diagnosis and Therapeutic Effect of
https://doi.org/10.1016/j.wjam.2019.08.001 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
232
S. CAI, Y. JIN and W. ZHANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 231–234
Fig. 1. Bloodletting with plum-blossom needle and cupping for pes anserinus myotenositis.
Diseases and Syndromes in Traditional Chinese Medicine [4]. These are 1 pain at the attachment of pes anserinus tendon inferior to the tibial tubercle on the anterio-medial aspect of the distal end of tibia; 2 history of sport strains or overstrain of the knee due to long-time walking and standing; 3 tenderness and swelling at the anterior area of the knee joint in physical examination, pain aggravated on passive eversion and extorsion of knee joint, as well as on resistant flexion of knee joint; 4 inability to squat or go downstairs in severe condition; 5 exclusion the disorders of meniscus, ligament and bone of knee joint; 6 exclusion the lumbar nerve root disorder. Inclusion criteria
1 Aged from 18 to 65 years old, either gender. 2 Duration of disease was in the range from 2 weeks to 1 year. 3 Agreed of clinical observation. Exclusion criteria
1 Incomplete skin in local area. 2 Incomplete data or difficulty in cooperation in treatment. 3 Combined with gouty arthritis, tumor and synovial tuberculosis. Therapeutic methods The bloodletting-cupping was adopted. The patient was in supine, with the affected knee flexed and extended slightly and the affected area exposed completely. The routine sterilization was adopted on the area with iodophor. The local Ashi points (pain points) were selected as the stimulated points. The 2 or 3 pain points were detected by the clinical physician on the lesion area and marked by a marker. A disposable sterile plum-blossom needle or a No.5 disposable syringe needle was used and the tapping or rapid pricking was adopted around the marked Ashi points. If the doctor used a plum-blossom needle, the tapping area was as the size of a table tennis ball by taking the Ashi points as the center. Tapping was adopted for about 30 s till slight bleeding (Fig. 1). If the doctor used a syringe needle, the Ashi points were pricked rapidly and repeatedly for 5 to 10 times till slight bleeding. Soon afterwards, the fire cupping or air-suction cupping was used on the bleeding site and the cup was retained for 10 to 15 min. When the cup was removed, the local bleeding area was cleaned with aseptic cotton ball or cotton swab, the puncturing site was re-sterilized with iodophor. Therewith, the band-aid or aseptic dressing was used to cover the wound surface. The patient was advised to keep the wound clean and dry in 24 h so as to avoid infection. The treatment was given once a week and continued till the clinical symp-
toms disappeared or the patients were unwilling to continue the treatment. The maximal treatment was 10 times. Observation of therapeutic effect Observation indexes Visual analogue scale The visual analogue scale (VAS) is commonly adopted to evaluate pain intensity in patients. A ruler with the measurements from 0 cm to 10 cm is selected. According to patients’ subjective responses on pain, the corresponding scale is recorded. The higher the scale is, and the more severe pain is. 0 means no pain, 1–3 means mild pain, 4–7 means moderate pain, 8–10 means severe pain. Lysholm knee scoring sale Lysholm scale is commonly adopted in clinic to evaluate the motor range of knee joint, composed of 8 items [pain (0–25 points), instability (0–25 points), locking (0–15 points), swelling (0–10 points), limp (0–5 points), stair climbing (0–10 points), squatting (0–5 points), support (0–5 points)]. The Lysholm score is in the range from 0 to 100 points. The lower the score is, the poorer the skin joint condition is. Standard of the therapeutic effect The therapeutic effect was evaluated according to Criteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine [4]. Cured: disappearance of pain on the medial side of knee joint, negative response to the tenderness of pes anserinus tendon on the medial side of tibia, no pain on passive eversion and extorsion of knee joint, and no pain on the resistant flexion of knee joint with normal kneeling-down or squatting function. Improved: obvious alleviation of pain on the medial side of knee joint, disappearance or alleviation of swelling or tenderness of pes anserinus, mild pain on passive eversion and extorsion of knee joint, and remarkable improvements of kneeling-down or squatting function. No effect: all of the symptoms and physical signs being the same as the conditions before the treatment. Statistical analysis SPSS 18.0 software was adopted in the statistical analysis on the data. Mean ± standard deviation (Mean ± SD) was used to express the measurement data. The pared-samples t-test was used before and after treatment. P < 0.05 indicates the significant difference in statistics.
S. CAI, Y. JIN and W. ZHANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 231–234 Table 1 Comparison of VAS and Lysholm scores before and after treatment in the patients of pes anserinus myotenositis. Time point
Cases
VAS score
Lysholm score
Before treatment After treatment
169 169
4.35 ± 0.60 1.10 ± 0.32a
65.42 ± 6.38 92.74 ± 5.04a
a
Compared with the score before treatment, P < 0.05.
Results Comparison of VAS and Lysholm scores before and after treatment in the patients of pes anserinus myotenositis After treatment, the symptoms were all relieved in all of the patients. VAS score was lower than that before treatment and Lyshom score was higher than that before treatment, indicating the significant differences. See Table 1 for details. Clinical effect in the patients of pes anserinus myotenositis A total of 169 patients participated in this study and no case was dropped out. After treatment, 137 cases were cured, 20 cases improved and 12 cases failed. The curative rate was 81.07% and the effective rate was 92.90%. Of 137 cured cases, 10 cases were cured after 1 time of treatment, 5 cases were cured after 10 times of treatment and the rest 122 cases were cured between 2 and 9 times of treatment. Typical case A male patient, 37 years old, visiting the clinic of the Department of Pain with Acupuncture and Moxibustion in our hospital on June 18, 2017. Chief complaint: feeling pain on the medial side of the right knee joint after playing basketball 2 months ago, since then, pain was often presented, aggravated after exercise and slightly alleviated after resting. Physical examination: tenderness (+) on the tibial tubercle of the medial side of the right knee, aggravated pain on passive eversion and extorsion of the right knee. Diagnosis: pes anserinus myotenositis. The patient narrated that the therapeutic effect was not so satisfactory after the external use of voltaren and impulse wave treatment and still felt pain on the medial side of knee. The patient received bloodletting-cupping at Ashi points in our department. The pain points were detected and marked on the medial side of knee joint. The disposable No.5 sterile syringe needle was used to prick the affected area rapidly, for about 30 s, till the slight bleeding. The stimulating area was as a size as a table tennis ball by taking the Ashi points as the center. Afterward, the fire cupping was adopted on the bleeding site and the cup was retained for about 10 min. When the cup was removed, the local bleeding area was cleaned and the puncturing site was re-sterilized. Therewith, the band-aid was used to cover the wound surface. The patient was advised to keep the wound clean and dry in 24 h and avoid spicy and greasy food. After the first treatment, pain on the medial side of knee was relieved obviously. The second treatment was given in the next week with the same method. After two times of treatment, pain disappeared completely and the motor function of knee joint was recovered. The patient was advised to have the physical training of the muscle strength of the lower limbs without loading and avoid strenuous exercise and wind-cold invasion. No recurrence happened in 3-month follow-up. Discussion Pes anserinus is a confluence of tendinous structures on the medial side of tibia, being constituted by the tendons of three
233
anatomical structures, namely, sartorius, gracilis, and semitendinous muscles on the inferomedial aspect of the tuberosity of the tibia, at the medial proximal tibia, similar in an appearance of goose foot [5]. Pes anserinus mainly functions at maintaining the stability of knee joint, exerting the pronation and flexion of knee joint and avoiding over-rotation and eversion of the joint [3]. The tendons or ligaments of pes anserinus are inter-inserted, closely structured in anatomy. The strenuous activity or long-term repeated movement of knee joint is apt to induce chronic strain, bleeding and scarring, and thus, aseptic inflammation is caused, resulting in local adhesion, swelling and pain in the knee joint. The physical therapy or blocking injection is commonly adopted in western medicine for such disease. It will take a long time to achieve the effect with physical therapy and the duration of such treatment is relatively long. The effect of blocking injection is definite, but many patients are worried about its side effect and thus unwilling to accept it. Therefore, more and more patients seek the treatment of traditional Chinese medicine. Pes anserinus myotenositis is not denominated in the classics of traditional Chinese medicine (TCM). According to its clinical symptoms, such disease should be classified into the category of bi syndrome. TCM holds "where is obstruction, where is pain". Pain of pes anserinus myotenositis is caused by the obstruction at the meeting site of the muscle regions of the three yin meridians of foot at pes anserinus. It is recorded in Língshu¯ ( , The Spiritual Pivot) that the muscle regions of foot-taiyin, foot-shaoyin and foot-jueyin meridians are knotted at the medial condyle of tibia at knee joint and the disorder of these meridians at this region refers to the pain at the apophysis between the medial condyles of femur and tibia. It is seen that the ancient scholars had been recognized that pes anserinus myotenositis was a kind of common disorder early. Regarding the treating method, the fire needling technique is used at the pain site with strong and quick puncture. It is a kind of reducing technique of acupuncture and its basic theory is same as bloodletting therapy. In bloodletting-cupping therapy, the skin of the affected area is sterilized, and then the pricking or the tapping is adopted with the three-edged needle or the cutaneous needle respectively to cause bleeding. Afterwards, the fire cupping is adopted at the pricked site to intensify the effect of bleeding [6]. The medical silk book excavated from the Mawangdui tomb of Han Dynasty has included the relevant record on the bloodletting-cupping method and such method has been extensively used in surgical disorders and traumatic injury of TCM [7]. At present, this method is commonly adopted in the treatment of acne, herpes zoster and arthritis in clinic, but it is seldom used in the treatment of pes anserinus myotenositis. In clinical practice, we discovered that the bloodlettingcupping method of acupuncture at local Ashi points have achieved the satisfactory effect on the disease, which avoids the side reactions of western medication and the equipment requirement in physical therapy and it shortens the duration of treatment compared with the common needling technique of acupuncture. The bloodletting therapy acts on promoting qi and blood circulation in the local obstructive site so that swelling and pain can be relieved [8]. The bloodletting and cupping adopted at the site of swelling and pain effectively improve the microcirculation of the affected area, relieve vascular spasm and reduce inflammatory exudation in either acute or chronic case so as to remove swelling and stop pain. In this study, the bloodletting-cupping was adopted for 169 patients of pes anserinus myotenositis. After treatment, knee pain was alleviated or even disappeared completely and the motor function of knee joint was improved. The clinical effect was satisfactory. In future, a control group should be set up so that the effect of bloodletting-cupping can be objectively evaluated in this disease.
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S. CAI, Y. JIN and W. ZHANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 231–234
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