Given the fact the there is still significant deniability within the wider medical community regarding the existence of myofascial trigger points (MTrP), I am always interested to learn of further physical evidence to back up our clinical assessment findings.

Although the ability to image MTrP and taut band on ultrasound is not new, recently I was fortunate to view not only a still frame but a video clip of a needle penetrating a taut band an eliciting the local twitch response. The vigorous response from the muscle when the MTrP was targeted directly would suggest a level of reactive dysfunction within that particular portion of muscle which would be difficult to dispute, especially if the patients familiar pain was reproduced at the same time. Further ultrasound findings have included hypoechogenicity, alterations on local muscle tension and muscle entropy (Shah et al, 2008).

Introduction

Patellofemoral pain syndrome (PFPS) is the single most common condition seen by sports medicine practitioners.1 There is extensive literature investigating the efficacy of physical interventions for this condition,2 however there is relatively little considering the role of Acupuncture. This would be in contrast to knee osteoarthrosis which has been well investigated over recent years.3 In this case study an Acupuncture based approach was used to treat PFPS. What has been highlighted are the limitations of Acupuncture treatment if perpetuating factors are not adequately considered and addressed.

Presenting complaint

M complained of regular intermittent knee pain which was localised to the right supero-lateral aspect of the patella. He reported a VAS of 5 on the day of assessment. He also reported the same area as being tender to local pressure. Aggravating factors would be walking for 10 minutes or longer, climbing stairs, sitting with the knee flexed greater than approximately 80 degrees and any attempt to run. Rest and maintaining the knee in extension would ease the knee. Occasionally at night, if he were to roll onto the right knee, pain would wake him. Morning stiffness would be common. He noticed mild swelling around the lateral patella which would worsen towards the end of the day depending on how active he had been.

When using Medical Acupuncture in the treatment of musculoskeletal pain, I find myself in the main selecting either segmental points or trigger points if present, sometimes both.

Segmental points are basically those where tissue, preferably muscle, which shares the same segmental innervation as the structure likely to be responsible for nociceptive input, is stimulated. Trigger points must meet with the relevant diagnostic criteria and when using Medical Acupuncture to deactivate may be referred to as dry needling. These terms are often used interchangeably however, at least in Europe.

One of the conditions for which I find segmental Acupuncture particularly useful is that of knee osteoarthrosis and associated pain symptoms. The evidence would generally support using more local to the knee joint (White, 2007) and I would select points within muscles which act on the knee joint as well as sharing the same segental innervation. That said, so called sham Acupuncture can also be beneficial in providing pain relief and often extra-segmental points, those outside the segment, are used to augment the effects of segmental points.

Frozen shoulder, otherwise known as adhesive capsulitis, is one of those tricky conditions which I have found respond well to treatment, but patience is required. I am a physiotherapist who likes to see quick results, either objectively or subjectively, ideally both!

However as we all know, the pathophysiology of the frozen shoulder often does not lend itself to such expectations and at the outset and it is important to make the patient aware of this fact.

That said, if the correct treatment approach is applied in the correct manner at the correct stage, the speed at a which a frozen shoulder may resolve (compared to no treatment or ‘wait and see’) can be increased significantly.

Conventional wisdom and anecdotal evidence would suggest a frozen shoulder left alone may burn itself out and resolve spontaneously in 12-24 months. With an integrated physiotherapy approach, in most cases my clients have returned to full pain free function after 3-4 months of treatment, weekly at first and then staggered sessions after about 4-6 sessions.

The placebo response is a psychobiological phenomenon we should use to good effect.

Like it or not, everything we do as physiotherapists has a placebo effect or exerts what may be referred to as ‘non specific effects’.

Whether it is manual therapy, exercise, electrotherapy or dry needling there always has been and always will be a portion of the therapeutic effect which is not necessarily specifically related to the technique itself and which relies on context, expectation, the quality of the therapeutic relationship and so on.