A 54 year old male hill walker develops medial forefoot pain while walking downhill and decides to tighten the boot laces to give extra support to the foot. Afterwards, the pain persists and continues over the next 12 months resulting in gait disturbances and reduced walking distances.

Multiple examinations and investigations by orthopods ruled out the usual suspects such as stress fracture of the first or second metatarsal, plantar fasciitis, metatarsalgia, hallux valgus and neuropathies. He was told to go and stretch his calf muscles and all would be well.

Well, not quite...

A recent case report published in Acupuncture in Medicine by Tagami et al (2012) reminds us to be vigilant in our practice when it comes to the potential risk of pneumothorax.

It describes the case of a 69 year old large bodied man who was diagnosed with a rare case of bilateral pneumothorax at a Tokyo hospital's emergency department. He presented with chest pressure, cold sweats and shortness of breath. Immediately after the pneumothorax was confirmed on X Ray, his cardiopulmonary status deteriorated and bilateral tension pneumothorax was diagnosed - an emergency. He was treated successfully with the insertion of drainage chest tubes and he made a full recovery.

It was only after treatment that is was discovered he had received acupuncture 8 hours previously and with no risk factors for spontaneous pneumothorax it was determined that the acupuncture must have been the cause (Remember that pneumothorax can develop up to 48 hours post treatment).

An interesting study by (Huang et al, 2013) has found that myofascial trigger points (MTrP) are significantly more likely to develop in muscle tissue subjected to repetitive eccentric loading and blunt trauma. The muscle tissue showed characteristic increases in myoelectrical potential activity as well as changes in the shape of the myofibrils which became large and round in cross section and enlarged tapering shapes in longitudinal section.

The study was performed on rats, however we can certainly hypothesise that a similar causative mechanism may apply in humans who play regular sports. In particular contact sports such as rugby, American football as well as other sports where acceleration results in high levels of eccentric muscle loading combined with direct blows by various parts of the opponents anatomy.

So what we have here is a working model which may be another way to explain the development of muscle pain in sports. The difference is the pain may be arising from trigger points and not necessarily torn or 'strained' muscle.

As clinicians we all know how tricky tendon pathology can be to treat, especially the grumbly degenerative tendons which are prone to reactive flare ups from time to time (Cook, 2009). I am sure you are all familiar with the evidence for graded exercise in the management of tendinopathies, as well as soft tissue therapy and various offload techniques that can be applied.

There is also clinical evidence for triple therapy medication (ibuprofen, doxycycline and ECGC) to help settle the nasty reactive tendon. However despite best efforts, these tendons can prove stubborn and sometime resistant to conservative treatment.

We may get better results by incorporating acupuncture into the course of treatment? I would routinely needle any trigger points found in the calf muscles, but what about needling the tendon itself?

The results of a recent study (Coombes, 2013) are very interesting when it comes to clinical decision making in the treatment of lateral epicondylalgia (tennis elbow). This was a large RCT looking at those with clinical signs and symptoms of LE, without evidence of cervical/ neural involvement. The participants were randomised into four groups and received either cortisone injection only, cortisone with physiotherapy, placebo injection only, and placebo injection with physiotherapy. I have summarised the results as follows.

Those who had cortisone injections achieved some short term pain relief but at 12 months they are less likely to have recovered completely or be much improved, there is also a high recurrence rate at 24 month follow up. This did not change when physiotherapy was added.