Acupuncture to Treat Osteoarthritic Knee Pain

Approximately 60% of elderly males and 70% of elderly females in the United States have from osteoarthritis (OA) of the knee. Acupuncture may help reduce pain (iStock).

Knee Osteoarthritis and Conventional Treatments

Knee osteoarthritis is one of the most common types of chronic arthritis¹ and can cause articular cartilage damage, joint, and para-knee articular soft tissue degeneration.² Although the damage cannot be reversed, the symptoms can be manageable.

Approximately 60% of elderly males and 70% of elderly females in the United States have from osteoarthritis (OA) of the knee and related difficulties. Decreased quality of life occurs in activities of daily living, with lessened functional mobility in the community, home, and workplace environments due to the symptoms of joint pain, swelling, and deformity.²˒³

The American College of Rheumatology (ACR) guidelines for treating knee OA offer several approaches to alleviate pain, including surgery and prescribed medications.⁴ NSAIDs are the most common drugs used for alleviating pain from knee OA but have the possible side effect of gastrointestinal (GI) bleeding.⁵ Further, geriatric-aged adults often have comorbidities that can quickly increase the side effects due to drug interactions.¹

Acupuncture is an ancient Chinese medical modality that can effectively treat various diseases and relieve symptoms and discomfort.⁶ A systematic review conducted by the Osteoarthritis Research Society International indicated that patients with knee OA may benefit from acupuncture treatment to reduce pain symptoms.⁷

In the following case report, we share how acupuncture helped an elderly female reduce knee OA pain and improve function.

Patient Presentation: Knee Osteoarthritis, Shoulder Pain

A 77-year-old female presented to the authors’ practice in 2021 to receive acupuncture for bilateral knee osteoarthritis that had been diagnosed in 2013. She reported living with this pain for many years, noting that it had become more pronounced over the past 5 years. She requires the assistance of a cane to walk, and whether she is at rest or being active, she shares that the pain affects her daily life. (She does not like to wear a brace on her knee as that exacerbates the pain.) Sleeping is difficult for her as well because of the constant pain, and cold and rainy days tend to increase her knee pain.

In addition to this chief complaint, the patient reports right shoulder pain with a limited range of motion (ROM) in flexion. Upon physical exam, ROM in the right shoulder was 90° to 100°. Previous medical history includes fibroids in her 30s and a complete hysterectomy at the age of 36.

This patient currently takes losartan for high blood pressure, levothyroxine for hypothyroidism, and albuterol for asthma. She also takes a daily multivitamin, fish oil, and turmeric.

Her reported pain level at the first visit was 9/10on the visual analog scale. She was awaiting knee replacement surgery, which had been delayed due to the COVID-19 pandemic.

Assessment of Osteoarthritis Knee Pain

Imaging Results (Western medicine approach)

MRIs of the patient’s knees show that the right knee had:

• moderate medial tibiofemoral and patellofemoral arthrosis demonstrated by joint space narrowing, marginal osteophytes, and associated varus alignment

• mid-lateral compartment osteoarthritis

• small superior patellar enthesophyte

• small knee effusion

• no fracture or dislocation

The left knee MRI showed:

• moderate to severe tricompartmental medial tibiofemoral and patellofemoral arthrosis demonstrated by joint space narrowing, marginal osteophytes, and associated varus alignment.

• mid-lateral compartment osteoarthritis

• small superior patellar enthesophyte

• no knee joint effusion

• no fracture or dislocation

Evaluation Points using Traditional Chinese Medicine

Traditional Chinese Medicine practices four pillars for evaluating one’s overall condition:

• observing

• listening

• palpating

• asking

The patient was assessed using all pillars for complete evaluation and proper treatment. The patient had an aversion to cold, disliking cold weather in winter months as it exacerbated the pain in her knees, thus affecting her quality of life. She stated she has no sweating and regular bowel movements with no straining or loose stools. Her urination is normal with no pain, dribbling, or incontinence, but she frequently wakes (3 to 4 times nightly) to urinate. The pain in her knees is alleviated by warmth and resting; however, she still suffers from pain even during resting. She suffers from some eye dryness, but her auditory senses are normal. Her energy is usually a steady 6/10, and she does not suffer from excessive or external stress.

The patient’s tongue is slightly purple with a thin white coat and a center crack. Her pulse on both right and left hands was weak in the cun position, choppy in the guan position, and deep in the chi position.

We concluded that the patient has painful obstruction syndrome which indicates pain, soreness or stiffness and pain due toblood stagnation, which can present as distending pain with occasional sharp and shooting pain.

Treatment Plan for Knee Osteoarthritis

Fluid and Tension Relief

Based on the patient’s diagnosis, we planned to move lymphatic fluid, release myofascial tension, and decrease blood stagnation to alleviate her pain and improve her quality in the interim while awaiting knee replacement surgery. According to point specificity, the acupuncture points were selected, needling the right when the symptoms were on the left and needling the opposite end of the channel from where the symptoms were located.

Acupuncture Points

The patient was scheduled to come once a week for a 15-week term. Acupuncture and Master Tung points were inserted (as described below) on the patient before she was positioned on the treatment table. Master Tung needling was done to test her mobility and see if there would be an improvement.

The following points were primarily used to tonify and move her Qi and blood, eliminate stagnation, and reduce pain. Many of these acupuncturepoints were also used for their anatomical location, doubling as local points along the affected channel of the knee (see Figure 1):

• ST 34 Liangqiu

• ST 35 Dúbí

• ST 36 Zúsānlî

• ST 37 Shàngjùxū – Point of Sea of Blood

• ST 40 Fēnglóng – transforms phlegm

• SP 9 Yīnlígquán – resolves damp, benefits the knee locally

• M-LE-27 Hèdîng

• MN-LE-16 Xiyan

The following acupuncture points were selected to help calm the patient’s Shen and to reduce pain:

• LI 4 Hégû

• DU 20 Bâihuì

• M-HN-3 Yìntáng

The following acupuncture points were selected to help tonify the kidneys based on traditional Chinese medicine theory that states that as one begins to age their life, essence (held in the kidneys) depletes, leading to deficiency of Qi and blood:

• KID 3 Tàixī

• KID 6 Zhàohâi

Master Tung points are arranged topographically by an anatomical zonal concept; each zone functions as a reflexive microsystem and has points that affect the entire body (see Figure 2):

• 11.01 Da Jian, big distance – on the index finger, .3 cun from the center of the finger, on the proximal section of the finger

• 11.05 Zhong Jian, center distance – in the center of the proximal section of the palmar side of the index finger

• 11.09 Xin Xi, heart knee – located on both sides of the middle segment of the middle finger on the dorsal side, in the center between the second and third finger creases

• 11.16 Huo Xi, fire knee – on the little finger, .2 cun lateral to the edge of the fingernail

The following acupuncture points were selected based on anatomical location and based on meridian theory, which connects lower to upper for the reduction in shoulder pain:

• ST 38 Tiáokôu

• SJ 14 Jiānliáo

• LI 15 jiānyú

• M-UE-48 Jiānqián

An even needle technique was used. This acupuncture technique is characterized as lifting, thrusting, rotating of the needle clockwise and counterclockwise, evenly, in both directions.

Patient Outcome

Upon insertion of needles at the patient’s first visit, she reported significant improvement in the reduction of pain. She was able to move around more freely with Master Tung points inserted. Once removed, she could position herself safely and comfortably on the treatment table. Master Tung points were then inserted again during treatment with other body points to address the knees and shoulders. After laying supine for 30 minutes, all needles were removed.

Once safely seated in a chair, the Master Tung points were inserted again for a third and final time. The patient was asked to move and walk to evaluate her pain. She reported that her pain had gone from a 9 out of 10 upon entering the clinic to a 2 out of 10 during the acupuncture treatment.

During her three subsequent visits, the same protocol was administered, with the addition of Yin Tang, DU 20, KID 3, and KID 6 on her fourth visit. As noted, the patient’s first visit pain level report was 9 out of 10. Each time the patient came, she reported her pain was diminishing. Each time she returned, she stated that her pain came back slowly during the week, and she lasted longer each week with less pain.

Specifically, on her fourth visit, pain on arrival for the appointment was at 6 out of 10. She shared that this pain subsided after she left her acupuncture treatment from a 6 out of 10 to a 1 or 2 out of 10 and then gradually increased during the week until she came for her next appointment.

Although the patient was scheduled for 15 weeks of treatment, she fell ill and was unable to return for treatment after Week 4.

Discussion

This patient case integrates the use of Traditional Chinese Medicine and Master Tung acupuncture to treat bilateral knee osteoarthritis. According to Traditional Chinese Medicine theory, this patient’s pain was brought on by Qi, blood stagnation and a constitutional essence deficiency related to aging. This stagnation or blockage is relieved by using different acupuncture needling techniques by enhancing the flow of Qi and moving blood in the meridians and musculoskeletal system.

Master Tung Theory and Acupuncture Points

Master Tung theory uses many points not found in the traditional systems of Chinese medicine. The distribution of the points includes the entire body. However, it is arranged topographically by an anatomical zonal concept where each zone functions as a microsystem and has points that affect the entire body.⁸ Tung's system practical point selection is based on three types of correspondence:⁹

• image correspondence, or the diseased body area

• channel correspondence or the diseased channel

• tissue correspondence, being the diseased tissue

Acupuncture as an Alternative Treatment for Musculoskeletal Pain

There has been an increased interest in acupuncture as an alternative to traditional treatment methods for musculoskeletal pain, including the symptoms related to osteoarthritis, and research into the mechanisms of how it works has been undertaken. The analgesic properties of acupuncture stimulation have now been speculated to at least be correlated with ERK (extracellular signal-regulated kinase) phosphorylation following acupuncture needling¹⁰ and, therefore, could explain why patients report a decrease in their pain symptoms. In addition, improved microcirculation coupled with analgesic effects of needle stimulation¹¹ could bring about long-term improvements.

See also, cold laser therapy for knee OA pain.

Studies have shown the anatomical presence of tiny myelinated and unmyelinated nerve fibers, arterioles, venules, and lymphatics at acupuncture points.¹² According to Thomas Myers’ study on myofascial lines, myofascial meridians are postulated to occur along body paths where connective tissues (including myofascial, tendons, and ligaments) not only have anatomical continuity but also exhibit only a gradual change in tissue orientation along the entire pathway. This anatomical configuration conceptually allows the strain to be transmitted across the structures in a given myofascial meridian. Further, this concept may explain why a distal acupuncture point, such as on the leg, can affect the shoulder or vice versa, as well as why points on the upper body can affect myofascia in the lower body (see also, Anatomy Trains by Thomas W. Myers).¹³

As shown in a previous case report,¹⁴ which illustrated the use of fascial needle manipulation and acupuncture to treat low back pain, fascial manipulation affects these myofascial lines and is described as follows. A 3 cun needle is inserted one-quarter inch to one-half inch into the superficial fascia overlying a taut and/or tender band of muscle tissue. The needle is then gently “bowed” and the handle twirled until a mild sensation, warmth, or vibration is achieved and radiates distally away from the point of insertion. This stagnation or blockage is relieved through the use of different acupuncture needling techniques by enhancing the circulation of qi and blood throughout the myofascial system.

Conclusion

Given the reported improvement from the presented case, acupuncture could be a viable option in controlling the pain while she awaits her knee replacement surgery. However, the patient was only able to receive four complete and effective treatments before she became ill.

Had the patient continued her treatments, we surmise she would continue to see improvement in her knee pain while awaiting her knee replacement surgery, her ROM would continue to increase, activities of daily living would improve, and her pain would be tolerable. Treatment adherence is important for these types of cases for both the practitioner to modify the points in the treatment and how the patient reacts to these changes.

The reduction in pain reported by the patient, the combination of myofascial needle manipulation, Master Tung points, and Traditional Chinese Medicine acupuncture proves the efficacy of managing pain; it is an option worth offering to mitigate symptoms for those with knee osteoarthritis awaiting surgery.