by Matt Callison, B.S., L.Ac.

The first two articles of this series discussed assessing the various stages of muscle tissue injury according to western and eastern views. From the initial injury to the rehabilitation phase, assessment and treatment protocols vary depending on the severity of the stagnation involved and the patient's strength to heal. In this article, we will describe the treatment of the muscle injury and the patient using various needle techniques, herbal prescriptions and other treatment modalities.

Treatment of Both the Muscle Injury and the Patient
Treatment according to the principles of TCM reflects a wholistic approach and ultimately the balancing of Yin and Yang. Since Yin and Yang indicate the type of condition and overall qualitative aspect of energy, differentiation of this parameter between the patient and the muscle injury is important so that we can bring equilibrium to the whole, which is the primary law of acupuncture. In this next section, we will examine the treatment of the muscle injury and then correlate it to the treatment of the patient who has the muscle injury.

Treatment of the Muscle Injury
The practitioner's treatment protocol and plan depends on what stage the muscle injury is in when the patient arrives. The use of local, adjacent and distal points along with clinical techniques such as cupping, massage and moxibustion is based on assessment of the muscle injury location and severity.

• Local points: These points can be Ah shi points or points located on the meridians. Usually it's best to use local and Ah shi points away from the injury site that has redness and swelling. Determination of where to needle locally is through palpation in which the tear site can be felt for an active inflammatory process. By palpating the local affected meridian(s) and surrounding muscle tissue for pain and soreness, just proximal and distal to the injury site, the practitioner can attempt to remove the stagnation and quell the Yang activity. Just a few local needles placed strategically can be effective without adding to the Excess activity.
  
  
• Adjacent points: It is beneficial to needle adjacent points above and below the affected area with the intention of remaining on the affected meridian(s). If possible, the practitioner should choose points that move Qi and Blood obstructions from the channel. For example, a muscle tear to the triceps muscle will be benefited if SI 9,10, LI16, or SJ10 or 14 are treated.
  
  
• Distal points: Distal points are easier to choose because of the many possible point functions which can benefit the injured site. There are many categories to choose from:
  
  
• Tonification or sedation points are useful depending on what phase the injury is in.
  
  
• Ting-well points are good to needle and/or bleed to drain the excess blood and heat from the meridian.
  
  
• Xi-cleft points can be used in acute cases to open the meridians and rid obstructions.
  
  
• Source and luo combinations are effective. The practitioner should choose the source point of the affect- ed meridian and the luo point of the coupled meridian.
  
  
• Cupping: This is very beneficial in the later stages of the healing phases once the inflammation cycle has diminished. Cupping helps to bring deep Qi and Blood stagnation from the muscle injury to the surface so that it can be easily dispersed. Bleeding with cupping is very useful, especially in cases of intramuscular hematomas. The practitioner first pricks the venous pooling over the injury site and then applies the cup; the pumping type of suction cup works better in these cases to increase the vacuum effect.
  
  
• Moxibustion: At the injury site, the warming and tonifying nature of moxibustion is beneficial to use in the later stages of healing when the Yang inflammation activity is not predominant. It is very effective for muscle spasms in the repair and fibroplasia phases and to activate the Yang Qi during the established healing and rehabilitation phases.
  
  
• Massage: There are a multitude of massage techniques that work very well in all phases of the healing cycle, including methods that help disperse the edema from the inflammatory cycle, release muscle spasms and create flexibility of developing scar tissue. To examine the benefits of massage in the context of treating a muscle injury warrants an entire article in itself. There are many classes and textbooks that the reader can study which specialize in this type of massage therapy.
  
  
• Needling a first and second degree muscle tear defect: This technique is beneficial when inflammation is minimal. The practitioner palpates the injury site for the muscle tissue fibers that have mildly "bunched up." A second degree strain will have a more pronounced defect than a first degree strain. Needling is done in the direction that the muscle fibers run on each side of the defect. The amount of needles used will depend on the size of the defect. The needles will be inserted away from the defect and threaded towards the defect in line with the affected muscle fibers. Two or three needles should be inserted parallel and threaded towards the defect with the needle tip ending at the defect. The same technique is used for needling underneath the defect, starting away and threading towards the "bunched up" tissue. The needles inserted above and below the defect should line up with each other according to the direction of the muscle fibers, and they should also be parallel to each other, side-by-side. This technique is used in the later stages of healing. Using electric stimulation is beneficial with the leads connected above and below the defect to the needles that are in-line with each other.

Needling the Motor Point of the Muscle
A motor point is the point where the motor nerve enters the muscle. On entering the muscle, the nerve branches off into motor units and then onto motor end plates that enervate the many muscle fibers that cause contraction. When a muscle is torn, the electrical activity is disrupted due to trauma of the nerve fibers in the muscle. Nerve tissue regeneration, although slower, is much like muscle tissue repair in that it can be hindered by Qi and Blood stagnation and scar tissue formation, but subsequently benefited through treatment. It is not uncommon for an untreated previously torn muscle to test weak to manual muscle testing even after a year from the initial injury. A muscle injury can inhibit the nerve's action potential on the muscle creating less muscle strength. The muscle's loss of strength is directly proportional to the amount of tissue damage affecting the nerve's action potential and is inversely proportional once treatment has begun.

Needling the muscle's motor point activates the action potential and "jump starts" the muscle. A weak muscle upon manual muscle testing can be immediately strengthened once the motor point has been needled. For best results, the practitioner should look or feel for the muscle to actually jump when needling the motor point. This technique can be used at any stage of muscle injury healing with the consideration that the motor point's location is not at the site of injury when the inflammatory process is present.

For location of motor points, John Warfel's book, The Extremities-Muscles and Motor points (Philadelphia: Lea & Febiger, 1993.) is an excellent reference.

Treatment of the Patient
It is important to consider the amount of energy the patient with the muscle injury possesses and whether the patient presents certain factors that will inhibit maximum healing. Consider whether a Zang-Fu disharmony that has impaired the production and circulation of Qi and Blood in the affected muscle's jing-luo exists. In addition, attention to the pulse, observation of the tongue and general inquiry and assessment of the Eight Principles will give the practitioner the needed information to develop a treatment protocol.

When examining the Eight Principles, the most important of these principles is Yin and Yang, since the three other pairs can be classified within the previous pair:

• Yang: Excess, Hot, External
• Yin: Deficient, Cold, Internal

Since no one is 100 percent Yin or Yang; it is necessary to consider which of the two principles predominates. This is possible by observing what is going on with the Yin and Yang Qi of the body. Does the person walk into the office robustly or timidly? Is his/her voice soft or loud? Is there a deficiency of Yin creating a relative preponderance of Yang or vice versa?

Once the Yin and Yang of the patient has been established, this is compared to what phase of healing the injury is in, with the goal being restoration to the whole.

Treating A Yang Muscle Injury in a Predominately Yang Person
A high school football player tears his vastus lateralis quadricep muscle and seeks treatment the day after the accident. The practitioner assesses that the injury is in the phagocytosis phase and that it is a second-degree muscle strain from a compressional impact. Palpation to the tissues indicates that the site of impact and most of the stagnation is just above ST33 and is about 3 inches in diameter. Observation of the tissue shows a intramuscular hematoma at the site of impact with an intermuscular spread along the anterior and lateral thigh. Differential diagnosis shows a predominately Yang person, meaning that there is an overall presence of Yang Excess. The treatment protocol is to:

• Disperse the Yang of the whole body with points such as DU14, SJ5, REN12, 4 and ST36.
• Disperse the Qi and Blood stagnation in the jing-luo using local, adjacent and distal points. Some possible points to treat the injury are: ST30, 31 and/or 34, GB36, 34. Bleed ST45 and GB44.
• Perform cryotherapy on the injury site.
• Needle the motor point of the vastus lateralis muscle.

Possible herbal remedies during this phase of treatment include:

• Musk and Catechu
• Chin Koo Tie Shang Wan
• Yunnan Pai Yao
• Die Da Wan

Treating A Yang Muscle Injury in a Predominately Yin Person
A middle-aged, blond male with a fair complexion speaks softly and timidly as he describes the water skiing accident that tore his hamstring three days ago. Palpation to the injured tissues indicates that the principles are Yang, Excess and Hot. The tear is a severe second-degree distraction tear with a moderate defect located in the muscle belly of the semimembranosus. Muscle function is not completely lost and there is no severe "bunching up" of muscle fibers along the muscle resembling a tumor, ruling out a third-degree tear. There is severe blood stagnation from intra- and inter-muscular damage. The differential diagnosis tells you that the patient's overall Yang Qi is deficient with a preponderance of Yin. The treatment protocol is to:

• Strengthen the Yang and bring it up from the lower part of the body with points like DU20, SJ5, REN12, 4 and disperse the Yang in the lower part of the body close to where the injury is located, ST36.
• Clear heat and resolve Qi and Blood stagnation from the meridians: using cyrotherapy if preferred by the practitioner. Possible points to use include UB40, 57, 36, 60, 67, K2,3 and/or 7.
• Bleed the ting-well points.
• Needle the motor point of the semi-membranosus.

In prescribing herbal remedies during this phase of treatment, the practitioner should be aware of the patient's Yang deficiency and combine the following list with tonic formulas such as:

Kidney Tonics:

• Ta Huo Lo Tan
• Kang Gu Zeng Sheng
• Ge Jie Ta Bu Wan

Blood vitalizing formulas

• Musk and Catechu
• Pian Yunnan Pai Yao
• Chin Koo Tieh Shang Wan
• Die Da Wan

Treating A Yin Muscle Injury in a Predominately Yin Person

A quiet, overweight female office worker was walking around the corner approaching her desk when she ran into an opened desk drawer, hitting her tibias anterior muscle. She seeks treatment 20 days after the injury, and the practitioner's inquiry revealed that her shin was swollen and painful for the week following the initial injury. She treated the injury with ice off-and-on for the initial three days and continued with cryotherapy after work each day. Upon observation, the practitioner sees that the swelling and bruising has diminished, but the patient still complains that walking upstairs and inclines continues to cause her pain. The treatment protocol is to:

• Tonify the Yang to balance the Yin with points such as SJ5, REN 12,4 and ST36. This is appropriate since the patient is predominately Yin and the nature of Yang is more mobile than Yin.
• Warm the muscle and disperse the Qi and Blood stagnation. Some possible techniques could be to needle and moxa the local and Ah shi points and possibly cupping and/or massage to disperse the stagnation.
• Needle the motor point of the tibias anterior muscle.

Possible herbal remedies during this phase of treatment include:

• Clematis and Stephania
• Yi Yi Ren Tang
• Du Huo Ji Sheng Tang

Combining these with Kidney Yang tonics may be a consideration.

Treating A Yin Muscle Injury in a Predominately Yang Person

A young active female triathlete injures her deltoid muscle while training for her next competition, and, two weeks later feels a sharp pain around the LI14 area while lifting her bicycle onto the racks of her car. While she says that it feels much better now, it still hurts her in the morning upon waking and the pain seems to change location during the day. Upon observation, there aren't any signs of residual hematoma, and palpation to the muscle indicates a muscle spasm that is sore to the touch, but the patient reports that massage makes it feel better. The tear is in the Yin phase of healing, and the rest of the body is predominately Yang. The treatment protocol is to:

• Tonify Yin in the other parts of the body with points such as K6, SP6 and P6.
• Remove the obstruction from the meridian with points such as LI16 and 11.
• Remove obstruction through cupping and/or massage.
• Warm the Yang Qi and activate healing with moxa application to the injury site.
• Needle the motor point of the posterior deltoid muscle.

Possible herbal remedies during this phase of treatment include:

• Chiang Huo and Tumeric
• Chin Koo Tieh Shang Wan

Consider using appropriate tonics in combination with the above formulas:

• Si Wu Tang
• Tang Kuei and Peony
• Ba Zheng Tang
• Tang Kuei and Rehmannia

As aforementioned, it is important to address the Zang-Fu pathology that may be creating disharmony to the patient while also considering the organs responsible for the soft tissue health, namely the Spleen Qi and Liver Blood.

In conclusion, there is often a tendency to direct treatment primarily at the site of the injury with the expectation that resolving the pathological process and balancing the local meridians will return the patient to a healthy state. There are many potential fallacies to this approach that make it unsuitable as a reliable treatment mode, and poor management of an injury can contribute to delayed healing or an unstable and weakened body area. To assume that treatment to the muscle injury alone will be in the best interests of the patient is not a wholistic approach. It is important to bear in mind the patterns of disharmony the patient with the muscle injury presents. Chinese Medicine's basis for diagnosis, the Eight Principles, gives the practitioner an all-encompassing understanding of the patient as well as the muscle injury in order to develop a treatment protocol to restore equilibrium to the whole.

For practitioners, it is important to understand the basic fundamentals of wound repair and scar formation in order to gain optimum treatment results and ensure the full recovery of the injured patient. This is initially accomplished through reducing the effects of the initial injury or trauma. Bleeding and swelling must be controlled as quickly as possible to minimize the magnitude of the Blood stagnation and hematoma. Limiting the stagnation of blood allows the healing process to commence earlier, thereby reducing the length of inactivity caused by the injury. Rehabilitation treatment procedures using exercise and acupuncture in conjunction with various methods of hot and cold applications are designed to optimally rehabilitate the injured patient in a minimal period of time. It is not the intent of this article to discuss the many various modalities and treatment procedures which would involve volumes of information. The intent of this article is to give the reader only a fundamental understanding and to inspire that one seek out new information in this area and continue to improve and refine the treatment of injury using the combination of Western and Chinese Medicine.

The Author
Matt Callison began his career as an athletic trainer receiving his bachelor of Science Degree in Sports Medicine from San Diego State University in 1985. In 1991, he received his Masters Degree in Traditional Oriental Medicine from Pacific College of Oriental Medicine, where he is currently on the teaching staff. Mr. Callison began his studies in Applied Kinesiology in late 1991, and has continued his education in this area and Chinese Medicine in order to synthesize these two disciplines. In 1996, he completed a 240 page workbook, that he uses to effectively teach the combination of Applied Kinesiology, Sports Medicine and Chinese Medicine in his seminars around the United States entitled the Energetics of Structural Balance.

References
American Academy of Orthopaedic Surgeons. Athletic Training and Sports Medicine. Rosemount: Academy of Orthopaedic Surgeons, 1991.

Booher, James M. and Gary A. Thibodeau. Athletic Injury Assessment. St. Louis: Times Mirror/Mosby College Pub., 1986

Dharmnanda, Subhuti. Chinese Herbology. Portland: Institute of Traditional Medicine and Preventative Health Care, 1989.

Peterson, Lars and Per Renstrom. Sports Injuries. St. Louis: Mosby Year Book, 1986.

Warfel, John H. The Extremities-Muscles and Motor Points. 6th Edition. Philadelphia: Lea & Febiger, 1993.

Wodden, Michael J. Orthopaedic Physical Therapy. New York: Churchill and Living stone, 1994.