Sport injuries are common with both hobby and professional sports enthusiasts. The worst case scenario is that they will prevent a career in sports. To ensure a fast recovery without much suffering of pain or loss of athletic performance is therefore the highest priority.
Acute knee and ankle injuries (Fig. 1) are most common and frequent especially amongst athletes in tennis, soccer, basketball and dancing. Here, fast sprints, sudden turns, stopping and restarting or physical contact with an adversary take place.
Figure 1: Sprained ankle with or without fibula fracture, a frequent sports injury (© iStockphoto)
CONVENTIONAL THERAPY VERSUS INTEGRATIVE TCM TREATMENTS
First aid measures in conventional therapy is RICE (rest, ice, compression, elevation) and protection through immobilization to decrease pain intensity. Further in the course of rehabilitation, physiotherapy and a range of other physical treatments are applied to help maintain a proper and complete functioning as well as early mobilization of the injured joint.
On the other hand, therapeutic principles of Traditional Chinese Medicine (TCM) are based on dissipating Qi stagnation and blood stasis caused by the initial traumatic impact. A combination of TCM methods, such as acupuncture and herbal medicines together with Tui Na massage, have successfully been applied. Based on the concept of Qi and the idea that the whole organism, including anatomical structures like bones, ligaments and tendons, is a vibrating system with self-regulating healing power, the approach of immobilization and mobilization changes: Movement is not only interpreted by bio-mechanical analyses, but can also be seen as necessary means to circulate Qi in the meridians and to help to recover physical function.
This concept, common also to Qi Gong theory, leads to a reduced immobilization time, individually adapted rehabilitation program, which actually already begins at the moment of injury. An obsolete strategy is a strict and rigid classification in different stages with immobilization in the acute and reconstruction stage and movement only in the rehabilitation stage.
As far as the widespread practice of using ice therapy for acute injuries is concerned, from an energetic point of view it is superfluously or even counterproductive: In short term, it may help soothing pain and reduce swelling caused by injury, but the longer it is applied, decelerates the energy and blood flow, which already are stagnant due to the trauma. TCM instead offers excellent and effective options (Fig. 2) to handle acute injury conditions without using ice:
An acute and reconstruction stage treatment includes case specific herbal formulas and a combination of acupuncture and Tui Na massage techniques. Core benefits of applying TCM concepts and treatments is: quick pain relief, reabsorption of edema and hematoma and the improvement of energy and blood circulation to accelerate the healing process. It also signifies a quick come back to sports and daily activities.
Figure 2: Examples of therapeutic methods of TCM: materia medica and acupuncture(© iStockphoto)
CASE HISTORY: WEBER B FRACTURE OF A PROFESSIONAL SOCCER PLAYER
During an indoor tournament and a direct clash with an opponent, a professional soccer player was injured. It was diagnosed as a fibula fracture near the syndesmosis area (type Weber B).
Based on clinical symptoms and radiological evaluation, the fracture was considered sufficiently stable to avoid immobilization in a plaster cast, as well as surgical procedures. From various previous experience the soccer club expected a 3 month minimum downtime of the player. Chinese medicine treatment was applied instead of RICE (Rest, ice, compression, elevation), details see below. Surprisingly for both, team and soccer club, and thanks to the integration of TCM treatment the injured soccer player was able to return to a competitive match after 6 weeks already. This is half of the time expected for rehabilitation.
The treatment and rehabilitation protocol may be summarized as in table 1:
- Regular daily applications of specific TCM herbal tinctures and herbal pastes together with Tui Na or sport massage especially during acute and reconstruction stage.
- Apart from initial taping almost no immobilization
- Start with vertical maximum load (walking) after 3 days
- Resume running training after 10 days
- Continuous increase of physical exercise load and return to team training after 4 weeks
- Comeback after 6 weeks
|Diagnosis/examination/ symptoms||Therapy||Chronology||Immobilization/ physical activity|
|acute injury||slight massage with blood (Xue) stasis breaking and blood moving herbal tincture.No ice therapy!||first aid||compression|
|physical examination: suspected ankle bone fracture||application of blood (Xue) stasis breaking and blood moving herbal paste (over night)||after 30 minutes||taping|
|radiologically: stabile distal fibula fracture of type Weber B||slight classic sports massage once a day applying acute phase herbal tincture and overnight herbal paste||1. day||no immobilization!|
|free of pain, ø pressure pain or rest pain||– classic sports massage once a day applying acute phase herbal tincture and overnight herbal paste every second day for 14 days.- twice a day magnetic field therapy||3. day||vertical maximum load, no longer need to be careful with gait!|
|start rehabilitation program: bicycle||7. day||start rehabilitation|
|subjectively: trauma is overcome!||rehabilitation program: running||10. day||The injured player: „let´s get back to soccer playing” (but still not allowed)|
|physically fully recovered||from 4 weeks on||return to team training and soccer playing|
|ready for competition||41. day (6 weeks)||Comeback for 65 minutes in a competitive game|
Table 1: Chronological treatment- and rehabilitation procedures after ankle sprain with fibula fracture
Despite the initial prognoses both healing and rehabilitation time could be reduced by 50% due to combined and effective TCM trauma treatment.
JUST A LUCKY COINCIDENCE? – POSSIBLE EXPLANATORY MODELS AND CURRENT RESEARCH RESULTS
The harmonious interaction and self-regulation of the body forces play an important role to adjust healing processes. From an TCM point of view therapeutic strategies aim at optimizing the body´s own healing mechanism and regulatory process. Healing mechanisms which are triggered by the injury itself are to be sustained and regulated by TCM treatment strategies. They must be adapted to individual conditions and to the three healing stages: acute or absorption stage, reconstruction stage and rehabilitation stage. A pathophysiological subdivision in 3 healing stages gives theoretical guidance, but in reality the three stages exist contemporarily and are influenced by each other. The self-regulating healing potential of the body, as a result of free flow of Qi, is the key to reconstruct affected structures from the very first moment on. During each of the three stages the free flow of Qi and blood may be successfully stimulated by TCM according to the following principles:
ACUTE- OR ABSORPTION STAGE – REDUCTION OF EDEMA AND PAIN, ACCELERATED HEMATOMA ABSORPTION
Acute hematoma and swelling after trauma can be eliminated most effectively by using TCM methods such as slight Tui Na massage and application of liniments and herbal pastes (see as an example table 2 and table 3).
|Zi Jin Jiu – “Precious purple medicated wine“||Quantity|
|Draconis Resina (Xue Jie)||6g|
|Carthami Flos (Hong Hua)||6g|
|Camphora (Zhang Nao)||3g|
|Alpiniae Officinari Rhizoma (Gao Liang Jiang)||12g|
|Piperis Longi Fructus (Bi Bo)||9g|
|Asari Herba (Xi Xin)||6g|
|Sinapis Albae Semen (Bai Jie Zi)||6g|
|Borneolum (Bing Pian)||3g|
|Rehmanniae Radix (Sheng Di Huang)||6g|
|Centipedae Herba (E Bu Shi Cao)||9g|
|Olibani Resina (Ru Xiang)||4,5g|
|Myrrha (Mo Yao)||4,5g|
|in 50% Alcohol||500g|
Table 2: Example of a TCM herbal tincture used for injury in acute and sub-acute stage
|Jie Gu Gao – „Bone Knitting Paste”||Quantity|
|Acanthopanacis Cortex (Wu Jia Pi)||2 parts|
|Lumbricus (Di Long)||2 parts|
|Olibani Resina (Ru Xiang)||1 part|
|Myrrha (Mo Yao)||1 part|
|Eupolyphaga seu Steleophaga (Tu Bie Chong)||1 part|
|Drynariae Rhizoma (Gu Sui Bu)||1 part|
|Bletillae Rhizoma (Bai Ji)||1 part|
|Mel||is required to achieve a homogenous paste|
Table 3: Example of a TCM herbal paste used for injury in acute and sub-acute stage
Acupuncture however offers an additional Qi (blood) moving method to relief pain and to increase blood flow to accelerate absorption processes in the acute stage. According to TCM theory (Yin and Yang relation) by improving the flow of Qi it is possible to increase blood circulation. A Japanese study titled “Changes in Blood Circulation of the Contralateral Achilles Tendon During and After Acupuncture and Heating” (1) investigated the effects of acupuncture and heating (application of hot pack) treatments on blood circulation in the ipsilateral and contralateral Achilles tendon. Measurements of blood circulation during and after treatment were made by using a red laser lights (BOM-L1TRSF, Omega Wave).
Figure 3: The time course changes in oxyhemoglobin (Oxy; a ), deoxyhemoglobin (Deoxy; b ), total hemoglobin (THb; c ), and oxygen saturation (StO 2 ; d ) of the treated tendon (open spots) and non-treated tendon (closed spots) during and after different acupuncture techniques (Acu-1, Acu-2, Acu-3). * significantly different from the resting level (* p < 0.05, * * p < 0.01, * * * p < 0.001) (Kubu K. et al, 2011, S. 809) 
Figure 3 presents the time course changes of Oxyhaemoglobin (Oxy: a) , Deoxyhaemoglobin (Deoxy: b) , Total haemoglobin (THb: c) and oxygen saturation (StO2: d) of the treated (open spots) and the non-treated (closed spots) tendons, expressing blood circulation and metabolism of the Achilles tendon during and after acupuncture treatment. Various acupuncture techniques were applied, however, only after using the up and down manipulation (Acu-2) the blood volume and oxygen saturation increased significantly on the treated tendon although the measured variables for the non-treated side still did not change. An interesting finding in this study was that the values of the contralateral side changed gradually not during acupuncture but only after removal of the needle. During the second half of recovery period (measuring interval was 40 minutes), the increase in THb and metabolism activity of the contralateral side was significantly correlated to that of the ipsilateral tendon. Both tendons showed signs of higher blood circulation after ipsilateral acupuncture and after the removal of acupuncture needles. Something that was not found applying a hot pack to heat the ipsilateral tendon.
These results provide clear indications, that the healing of the injured tendon, through better blood circulation, may be stimulated by applying acupuncture not only ipsilateral (affected meridians), but also to the contralateral healthy limb. This circumstance offers an additional treatment option when treatment of the affected tissue becomes impossible due to immobilization measures. In this case herbal pastes maybe applied to injured area (beneath the cast) and acupuncture and Tui Na massage maybe applied, amongst other treatments, to the contralateral side.
Conclusion: Acupuncture and herbal treatment during the acute and absorption phase are indicated to improve Qi (and blood) circulation and absorption and elimination of accumulated blood, liquids and cells. This is the basic condition to reduce the acute stage and have an earlier transition to the reconstruction stage. If the body is able to start with the reconstruction of tissues earlier, a significantly reduced healing time is obtained and the risk of posttraumatic symptoms, like persistent pain, is reduced.
RECONSTRUCTION STAGE – HOW TO STIMULATE HEALING PROCESS OF INJURED TISSUES
A combination of herbal applications and Tui Na as well as acupuncture are recommended to accelerate the healing process and to achieve an improvement of the cellular structures. As far as acupuncture treatment to improve tissue healing is concerned, a study revealed an interesting finding, the effect of acupuncture therapy on the healing process of calcaneal tendon of dogs was examined after tendon splitting (2). The dogs where randomly divided into two groups from the third day after surgery, whereas only one group received acupuncture therapy for 10 min/day (GB 30, BL 40, ST 36) during two weeks. Macroscopic changes showed that the dogs with acupuncture treatment had less peritendinous adhesions than those without. Histological fewer inflammatory cells and a more regular and parallel arrangement of collagenous fiber bundles, as well as the normal thickness of the epitenon a peritenon were observed (Fig. 4). This animal experiment study postulated that using acupuncture causes cells to differentiate, leading to the formation and organization of collagen fibers, and preventing soft tissue bonding.
Figure 4: Longitudinal section of the Achilles tendon of a control dog (out of group 1) (left), of a treated dog (out of group 2) (middle) 60 days after splitting and a longitudinal normal section of the Achilles tendon on day 0 (right) (Sharifi, D. et al, 2009; S. 183)
Concerning the external application of Chinese herbs, another animal experiment study aimed to determine the effectiveness of a herbal paste (see Table 4) in the promotion of fracture healing and the formation of callus of an artificially induced standard midshaft fracture of the rabbit tibia (3).
|Sambucus Williamsii Ramulus (Jie Gu Mu)||30g|
|Dipsaci Radix (Xu Duan)||15g|
|Notoginseng Radix et Rhizoma (San Qi)||9g|
|Carthami Flos (Hong Hua)||9g|
|Rhei Radix et Rhizoma (Da Huang)||30g|
|Gardeniae Fructus (Zhi Zi)||9g|
Table 4: Herbal formula used topically for bone fracture treatment; aqueous and ethanolic extracts mixed up to a paste
In vitro, this TCM formulation (Table 4) was able to increase the cell proliferation rate in osteoplastic UMR-106 and human endothelium HUVEC cells significantly. In vivo, the bone healing stimulating effect could be proven by radiological findings of an increment of callus size at weeks 2-5 in the treatment group.
Conclusion: Both studies show interesting scientific results about the effectiveness of Chinese herbal applications and acupuncture treatment to speed up the healing process in body tissues during the reconstruction phase.
REHABILITATION/ MOBILIZATION STAGE – ESTABLISHING FUNCTIONAL INTEGRITY
The aim of rehabilitation is to gain mobility without pain and to restore physiological and functional movements. Specific physical exercises (physiotherapy) stimulates through pressure and tensile forces, directing proliferation of fibers and tissue and helps to build up the functional integrity. So physiotherapy is a fundamental part of the rehabilitation treatment protocol at this stage.
In „western“ thinking, the injury quite often is considered as cured, as soon as the damaged structures have gained stability and daily work is manageable or returning to sportive activities is possible again. Minor ailments and restrictions of motion, pain caused by load or sensitiveness to climate and climate changes are often tolerated or seen as inevitable. Very different from the idea of TCM: The symptoms as mentioned above, are an expression of a still remaining latent, persistent Qi stagnation and Blood stasis and blocked meridians. If left untreated this condition causes movement-induced pain and, in long term, can lead to arthrosis. Therefore it is essential in TCM clinical practice, to provide continuous and consequent treatment also in stage 3, the rehabilitation stage of trauma. Fortunately we have very efficient options available: Additional to and in combination with moxibustion, there are a variety of specific herbal formulas to warm and open meridians and move blood and Qi and for “steaming” injured body areas in the late stage (Table 5).
|Gu Shang Wai Xi Yi Fang – “No. 1 tincture for bone injury”||Quantity|
|Cissi Caulis (Kuan Jin Teng)||30g|
|Uncariae Ramulus cum Uncis (Gou Teng)||30g|
|Lonicerae Caulis (Jen Tong Teng)||30g|
|Vaccariae Semen (Wang Bu Liu Xing)||30g|
|Artemisiae anomalae Herba (Liu Ji Nu)||15g|
|Ledebouriellae Radix (Fang Feng)||15g|
|Rhei Radix et Rhizoma (Da Huang)||15g|
|Schizonepetae Herba (Jing Jie)||10g|
|decoct in water for bathing and steaming|
Table 5: Gu Shang Wai Xi Yi Fang. Washing and steaming the injured area in stage 3
Combining those warming methods (moxibustion and liniments) with Tui Na techniques to soften tissue and to open meridians helps to overcome rigidity and pain syndromes in the late stage trauma.
Acupuncture also offers, aside from pain relief, interesting additional options: The authors of a study titled “Improvement in training Quadriceps muscles after ACL-reconstruction with acupuncture” (4) believe that a long lasting rehabilitation phase, as well as chronic secondary injuries, are mainly the consequences of disordered proprioception and reduced capability to recruit neuromuscular structures. The goal of this study was to examine the use of acupuncture in rehabilitative strength training and to improve excitability of quadriceps muscle after anterior cruciate ligament plastic. It was ascertained that acupuncture increases motoric excitability and supports the neuromuscular system. Higher levels of muscular strength were reported due to a better recruitment of neuromuscular structures. After stimulating two acupuncture points (St 32 and St 36) the M. quadriceps femoris showed a highly significant increase in EMG-amplitudes, strength values and median frequencies and ensured a full utilization of the whole neuromuscular potential.
Conclusion: The use of all TCM therapies such as moxibustion, acupuncture, Tui Na massage and (external) herbal treatment during the late stage of trauma is absolutely indicated and useful to prevent from persisting Qi stagnation and blood stasis and to prevent complications like chronic pain syndromes and post-traumatic arthrosis after soft tissue injuries and fractures.
Traditional Chinese traumatology, exists as part of traditional Chinese medicine since ancient times. It is based on the principles of Chinese medicine and includes not only acupuncture and Tui Na massage, but also external and internal use of Chinese herbs. Many current research results confirm traditional concepts and authors long time and very positive experiences in applying TCM treatment methods in case of sports injuries. Shortened healing- and rehabilitation phases, minimized risk for long-term complications, such as post traumatic arthrosis or chronic pain syndromes through TCM treatments are the result and of course this is highly welcomed by patients and athletes and should be considered more by public healthcare system and society for a considerable cost reduction.
 Kubu K et al, Changes in blood circulation of the contralateral Achilles tendon during
and after acupuncture and heating, International journal Sports Medicine, 32 (10): 807-813, 2011
 Sharifi, D. et al, The effect of acupuncture therapy on the repair of the calcaneal tendon (tendo calcaneus communis) in dogs, Turkish Journal of Veterinary & Animal Sciences, 33(3): 181-184, 2009
 Li Hua Peng et al, In vitro & in vivo assessment of a herbal formula used topically for bone fracture treatment, Journal of Ethnopharmacology, 131: 282-289, 2010
 Ludwig, M., Verbesserung der Trainierbarkeit der Quadrizepsmuskulatur nach vorderer Kreuzbandplastik durch Akupunktur, Deutsche Zeitschrift für Sportmedizin, 52 (3): 100-103, 2001
Authors: Dr. med. Karl Zippelius , B.Sc. Angela Schwarzinger
About the authors:
Dr. med. Karl Zippelius
– Specialization in trad. chinese orthopedics and traumatology (PR China)
– Head of the centre of “TCM in sports“ at the „austrian institute for sports medicine“ (ÖISM) (Austria)
Teaching and research:
– Since 2002 researcher at „Tianpeng Longevity & Orthopedics Research Institute“ Chengdu/China
– Lecturer at „Universitá degli Studi di Firenze“ (Master in TCM)
– „Leitfaden Chinesische Medizin“; Focks, Claudia (Hrsg.), Karl Zippelius (Coauthor), ì6. Aufl. 2010, Elsevier
– „Die spontane Achillessehnenruptur – ein vorhersehbares Ereignis? Erklärungsmodelle, Präventivmaßnahmen und Therapievorschläge“, Karl. Zippelius Sport- und Präventivmedizin, Volume 40, Number 2, 19-26, Springer
– „The effectiveness of external application of Chinese herbs to promote fracture union and soft-tissue healing“, Karl Zippelius, European Journal of Integrative Medicine Volume 4, Supplement 1, 119 – Elsevier, 2012
– „Sportverletzungen – verkürzter Heilungsverlauf durch integrative TCM Therapie“, Karl Zippelius, Angela Schwarzinger, Sport- und Präventivmedizin, Volume 44, Number 1 2014, Verlagshaus der Ärzte/Wien
B.Sc. Angela Schwarzinger
– Sport science, University Vienna (Austria)
– Tuina Anmo Practitioner Manus Institute Vienna
– TCM Nutrition, Claude & Ina Dialosa (Shambhala, Vienna)
– China Beijing International Acupuncture Training Centre (CBIATC)
The content of this publication is ©2015, all rights reserved. This publication is protected by copyright held exclusively by Karl Zippelius. Any reproduction or utilization in whole or part is explicitly subject to prior approval by Karl Zippelius. The authors made every effort to ensure the accuracy and completeness of all the information (the “Content”) contained in this publication. The authors do not assume any responsibility for the accuracy and completeness of the information provided by the publication. Therefore, we exclude any claims against the authors for the damage caused by use of any kind of the information provided herein, whether incorrect or incomplete.