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Study Shows Acupuncture Helps Tibial Stress Syndrome (Shin Splints)
By Matt Callison, M.S., L.Ac. University of California, San Diego RIMAC Athletic Training Center Translated by Jean Claude Brezillon Corrected by Dalenda Abderahim-LefrancoisAbstact:Forty athletes, ages 18-45 with tibial stress syndrome (shin splints), were analyzed using subjective questioning based on a Likert Pain Scale. They were divided into three treatment groups: Sports Medicine (N=17), Acupuncture (N=12) and a combination group of Sports Medicine and Acupuncture (N=11). The treating practitioners were certified and student athletic trainers at University of California, San Diego RIMAC Athletic Training Center along with acupuncture interns supervised by the author from Pacific College of Oriental Medicine, San Diego. The study took take place over a three-week period, with each participant filling out an initial questionnaire (intake) prior to the first week of treatment. Follow-up questionnaires were utilized at the beginning of each week of treatment for the remaining two weeks (Follow-up 1 and Follow-up 2).Participants answered questions concerning intensity and duration of pain during and between activities, in addition to dosages taken of anti-inflammatory medications (NSAID). Participants in all groups received a minimum of two treatments per week. The three treatment groups were compared to each other: Sports Medicine (S), Acupuncture (A), and Acupuncture and Sports Medicine combination (AS). All athletes reported an increase in effectiveness of treatment from Intake to Follow-up 2, regardless of the treatment group they were in> Athletes in the A and AS groups received the most pain relief, were least hindered by pain during sporting and non-sporting activities, and felt overall that the treatments were more effective than those reporting in the S Group. The perception of pain, pain relief, and effectiveness was not significantly improved for athletes in the S Group. Athletes taking anti-inflammatory medications in the AS and A Treatment Groups took significantly fewer doses during the course of the study than athletes in the S Group. Introducton:From professional to recreational sports, running is a common activity in which tibial stress syndrome becomes a primary complaint of lower leg pain. After treating this syndrome for over 15 years from both a western and eastern view, the author perceived the importance of performing a study on this frequent injury. The research described below was designed to answer the basic question: Over the duration of the study, did athletes who received acupuncture perceive a decrease in shin splint pain and increase in activity level compared to athletes who received standard treatment? Schulman8, described his successful case study on treating tibial shin splint pain with a single acupuncture session. He further noted, that in his reviews on MEDLINE from 1966 to 2000 produced only one article describing a case of a medical acupuncturist creating a needle-induced compartment syndrome7. The patient was diagnosed with anterior lower leg compartment syndrome after the physician's acupuncture treatment. Chronic tibial stress syndromes are noted as associated complications that can lead to compartment syndromes6 although, this article was not relevant to our discussion of tibial stress syndromes. Description of the StudyForty athletes diagnosed with tibial stress syndrome were analyzed using subjective questioning based on a Likert Pain Scale. They were divided into three treatment groups: Sports Medicine (N=17), Acupuncture (N=12) and a combination group of Sports Medicine and Acupuncture (N=11). Treatment group descriptions are as follows. Sports Medicine Group: Using a standard form of treatment, the athletic trainers used modalities such as pulsed ultrasound, stretching, and strengthening exercise in addition to cryotherapy were used to increase circulation and decrease inflammation. Proprioceptive Neuromuscular Facilitation (PNF) stretching and strengthening exercises were primarily used and directed toward the involved lower leg and foot. Other stretching and strengthening exercises were given with the objective to decrease the tension of the affected musculature. Acupuncture Group: The primary treatment was directed at the edge of the tibia where micro- tearing of the affected muscle takes place. The anterior edge was treated when the tibialis anterior was affected with the medial edge treated when the tibialis posterior muscle was involved. Between 10 and 15 #34 or #36 gauge needles were threaded obliquely and subcutaneously along the edge of the tibia between the soft tissue and bone. Motor points of the soleus, gastrocnemius, and tibialis anterior were also used, in addition to two to three palpable ahshi points along the medial arch between SP 3 (Taibai) and K 6 (Zhaohai). Other points were chosen based on the practitioner's prerogative to balance and remove obstruction from the meridians. These additional points included: ST 36 (Zusanli), GB 34 (Yanglingquan), SP 9 (Yanglingquan), SP 8 (Diji), K3 (Taixi), UB 58 (Feiyang), LIV 8 (Ququan) and LIV 3 (Taichong). Five minutes of tui na massage techniques followed the acupuncture treatment. Moxibustion and electric stimulation were not used. Acupuncture and Sports Medicine Group: A combination of both types of treatments was used. Treatment modalities utilized would vary based on time available and a concern of "over treating" the injury. Understandably, not every modality was used during each treatment as the athletic trainer and supervising acupuncturist discussed what techniques would be appropriate. Acupuncture, tui na, and facilitated stretching were the consistent modalities used along with one or two others mentioned above. ParticipantsForty participants were involved in this study with ages ranging from 18-45 years old. Thirty-six attended UCSD and participated on athletic teams which included track and field, cross country, volleyball, basketball, lacrosse, ultimate Frisbee and soccer. Four others were recreational runners and not associated with UCSD. Gender was not recorded. About half (N=23) of the athletes wore orthotics. They were asked to continue using their orthotic corrective devices if they were already wearing them, or not start using them during the duration of the study. Analysis indicated that the use of orthotics was not significant between treatment groups. QuestionnaireThe study took place over a three-week period. Each participant filled out an initial questionnaire (Intake) prior to the first week of treatment. Follow up questionnaires were utilized at the beginning of each treatment week for the remaining two weeks of the study. (Follow-up 1 and Follow-up 2). Participants answered questions concerning intensity and duration of pain during and between activities, in addition to dosages taken of anti-inflammatory medications (NSAID). Participants received a minimum of two treatments per week. The results of the subjective questioning were analyzed using a multivariate analysis of variance (MANOVA). The dependent measurements for this study were the participants' self-report of the items listed below by question number:
ResultsThe independent variable was Treatment Group (S=Sports Medicine, A=Acupuncture, or AS=Combined). Each of the dependent measures were assessed three times (Intake, Follow-up 1, & Follow-up 2). Multiple comparisons were made at each time interval (Intake, Follow-up 1, & Follow-up 2) to evaluate intra-group differences. The following is the results reported by question. 1. Frequency of primary sport. There were no differences between Treatment Groups or over the three time intervals for Sport Frequency. This indicates that athletes in each group participated in their sport at approximately the same level of activity. 2. Pain level during sporting activity this past week. During the course of the study, athletes in the Acupuncture (A) and Acupuncture/Sports Medicine (AS) treatment groups reported significantly lower pain levels during sporting activity compared to athletes in the Sports Medicine (S) group [F(2,36)=15.7, p<.05]. Athletes in the A group reported lower pain levels than athletes in the AS group, but the difference between the groups was not significant. 3. Pain level during non-sporting activities this past week. Pain level during non-sporting activities significantly decreased for athletes in the AS and A Treatment Groups [F(2,35)=4.5, p<.05] over the course of the study. Athletes in the S group reported no significant change. 4. Pain level now. The current level of pain significantly decreased for athletes in the SA and A Treatment Groups [F(2,37)=31.5, p<.05] over the course of the study, compared to athletes in the S group 5. Affect of pain on sport activity performance. There were significant differences in the amount of pain that affected activity performance reported by the groups during the course of the study [F(2,37)=7.1, p<.05]. Specifically, the S and AS groups were significantly more affected by pain than the a group; p=.002 for S, and p=.004 for SA. Significantly more pain affected all groups from Intake to Follow-up 1, as reported at Follow-up 2 [F(2,72)=3.5, p<.05]. However, in both the AS and A groups, the affect of pain on activity performance decreased from Follow-up 1 to Follow-up 2, compared to athletes in the S group. In addition, the A group reported at Follow-up 2 slightly less affect of pain on activity performance (1.58) than initially reported at Intake (1.67). 6. Hindered by pain after sport activity. The level of pain one to eight hours after the sports activity significantly decreased over the course of the study [F(2,74)=6.0, p<.05] for all athletes, mainly due to the decrease form Follow-up 1 to Follow-up 2 [F(1,37)=17.4, p<.05]. Athletes in the Acupuncture Group reported the least hindrance by pain, but there was no statistically significant difference between the Treatment Groups. 7. Effectiveness of treatment on pain. All athletes reported an increase in effectiveness of the treatment from Follow-up 1 to Follow-up 2, regardless of the Treatment Group they were in [F(1,37)=10.6, p<.05]. However, athletes in the Acupuncture Group reported significantly more improvement than those in the S Group (p<.05). While athletes in the A group reported the highest levels of effectiveness, there was no statistical difference between the S and the AS groups. 8. Dosage of anti-inflammatory medication (milligrams per tablet & amount taken per day). Medications reported by all treatment groups included Ibuprofen, Advil, Naproxen, Aleve, and Others. Over the course of the study, athletes in the AS and A Treatment Groups took significantly fewer tablets than did athletes in the S Group [F(2,17)=11.8, p<.05]. The number of tablets taken by athletes in the AS and A Groups declined over time while the amount taken by participants in the S Group remained the same [F(2,17)=4.8, p<.05]. DiscussionAcupuncture appears to be an effective modality for relieving pain associated with shin splints and for reducing reliance on anti-inflammatory medication. Athletes in the Acupuncture and Combined Groups received the most pain relief, were least hindered by pain during sporting and non-sporting activities, and felt that the treatments were effective. The perception of pain, pain relief, and effectiveness was generally unchanged for athletes in the traditional Sports Medicine Group. Anti-inflammatory medication use decreased over the duration of the study in the Acupuncture and Combined Treatment groups. Due to the small population involved in this study, the results show only preliminary tendencies. A larger pool of people would need to be analyzed in order to conclude validity. The use of Sports Medicine modalities alone have successfully cured thousands of athletes with this syndrome and is used as a primary treatment source. This study does indicate enough statistically significant evidence to view the use of acupuncture as a viable treatment modality. FOOTNOTES:1. Hamil, J., Knutzen, KM. Biomechanical Basis of Human Movement. Baltimore: Williams & Wilkins, 1995. 262. 2. Contemporary Chinese acupuncture is nowadays influenced by the materialistic and mechanistic Western way of thinking. So it has somehow left behind some more "subtle" data. It would certainly gain by recovering its own sources in some fields, but it still remains a very useful and performing therapeutic that has proved its efficiency worldwide 3. Brukner P., Bennell K. Stress fractures in female athletes: diagnosis, management and rehabilitation. Sports Med. 1997; 24:419-429. 4. Mulligan ME. The "gray cortex": an early sign of stress fracture. Skeletal Radiol. 1995; 24:201-203. 5. Anderson, M., Hall, S. Sports Injury Management Baltimore: Williams & Wilkins, 1995. 250. 6. Styf JR, Korner LM. Chronic anterior-compartment syndrome of the leg: results of treatment by fasciotomy. J Bone Joint Surg Am. 1986;68: 1338-1347. 7. Smith DL, Walczyk MH, Campbell S. Acupuncture-needle-induced compartment syndrome. West J Med. 1986;144: 478-479. 8. Schulman RA. Tibial shin splint treated with a single acupuncture session: case report and review of the literature. J. Med. Acu. 2001; 13#1
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