Ankle Pain

Sharon G., Reseda, California. 2007  Achilles tendon injury.

Sharon, a 62 years old educator, had injured her left ankle in 2005 and her right ankle in 2006. Had been Physical therapy and medication seems not effective reversed her ankle condition.  Walking and standing were hard due to pain. She also suffered fibromyalgia and hypothyroidism. Markedly tenderness over both Achilles tendon and big nodule in the middle of the tendon were detected. Flexion, extension and rotation of the ankle joints were limited due to pain. Electro Acupuncture started to apply on 3/20/2007. After 6 treatments had provided, the nodules in the Achilles tendon were dissolved. Pain was progressively diminished with range of joint motion increased. Total 14 treatments had been given and she was dismissed on 7/27/07 in a good walking and painless condition.        

Structure of the ankle joint

Ankle joint is a weight bearing joint for the body during walking. It is formed by the conjunction of three bones. The end of the tibia (main long bone of the leg) and a thinner long bone fibula (stay on the outer side of the tibia) meet a large bone in the foot called talus to form the ankle. The protrusions of each side of the ankle called malleoli. These provide stability to the ankle joint making it as a hinged joint capable of moving in two directions, flexion and extension.

The ankle joint is enclosed by a fibrous joint capsule. Two ligaments are tightly strapping the outside of the ankle with the lateral malleolus (lateral collateral ligament) and the inside of the ankle with the medial malleolus (medial collateral ligament) to provide the stability of the joint. Several tendons attack the large muscles of the leg to the foot wrap around the ankle from the front and behind. There are large tendons in the back such as Achilles tendon of the calf muscle attaches to the heel, posterior tibial tendon passes behind the medial malleolus, and the peroneal tendon passes behind the lateral malleolus to attach into the foot.

There are powerful muscles located in the front and back portion of the leg contact and relax during walking that move the ankle. Normally the ankle has the ability of approximately 20 degrees of dorsiflexion (toward to the body) and 45 degrees of plantar flexion (away from the body).

Causes of ankle pain

1. Sprains. Ankle sprains are one of the most common musculoskeletal injuries, and happen when there is a preexisting muscle weakness or previous injuries of the ankle joint. The typical injury occurs when the ankle is twisted in a sport activity or by stepping off an uneven surface. Injury caused ligament to be tore partially or completely, either on one side or both sides of the ankle. Partial tears retain some ankle stability whereas complete tears lose the normal joint function. Broken or chipping of bone might also accompanied. Severe pain with swelling over the injured area usually immediately occurred.
2. Tendinitis. Tendinitis of the ankle represents inflammation of the tendons which can be caused by trauma, infection, or inflammatory arthritis.
3. Tarsal tunnel syndrome. This is a result of nerve compression at the ankle as the nerve passes under the normal supportive band surrounding the ankle called the flexor retinaculum. This syndrome is similar to Carpal tunnel syndrome of the hand. It can be caused by injury, overuse or even varicose veins. Other pain, it is manifested by tingling or numbness at the inner heel arch or toes.
4. Plantar fasciitis. Plantar fasciitis most often seen in athletes, obsess people, and person whose daily life require a considerable amount of walking or standing. Plantar fasciitis is one of the most common causes of heel pain results from inflammation of the plantar fascia. Plantar fascia is a broad, ligament-like structure that extends from the calcaneus (heel bone) to the base of the toes. Repetitive stress or excessive weight can cause small tears in the fascia, leading to various degrees of pain many times that can take a long time to resolve.

The role of acupuncture in the treatment of Ankle pain

Sprains. The standard treatment of acute injury to the ankle is the same as those apply to the musculoskeletal trauma, that is RICE—raise, ice compression, compression and elevation. One thing has to make sure is there is no fracture of bones exited. Many times a small chip of bone may not need any further added treatment.

Acupuncture in sprains can do at least three things. First of all, it increases the local micro-circulation which relieves the swelling that enhance the healing process and alleviate pain on the same time. Secondary, acupuncture decreases pain by increasing subject’s tolerance and stimulation of endorphins. Thirdly, function can be improved by less local edematous and milder pain suffering.

Plantar Fasciitis. Acupuncture treatments for Plantar Fasciitis (PF) is one of the many choices of treatment and has been shown its great improving effect. The basic reactions of acupuncture treatment are to increase the local microcirculation, relieve congestion and swelling, and promote the healing process. The treatment most of the time will be combined with electric stimulation to promote the reliving of pain, swelling, and inflammation by stimulating the mid brain to increase the concentration of endorphins and enkephalins.

Demography of ankle pain patient and treatment results of our clinic

Study data draw from 2003 to 2007. Age: 45 to 80, average 63. Gender: F: M=3:1

Diagnosis	% of total pain patients	% of Improvement	% of marked improvement	Average treatment
Ankle Pain	2.42	92.8	86.9	7

Be noted that the result of treatment relate closely with many factors include age, gender, length of sickness, severity of sickness, treatment that have used and current combined therapy. Unfortunately, in United Stated many choose acupuncture treatment as tier last resource.

Literature Review

Robert Perez-Millan. Low-Frequency electroacupuncture in the management of refractory plantar fasciitis: A case series. Medical Acupuncture Vol. 13; No. 1

Eleven patients diagnosed with plantar fasciitis referred for a trial of acupuncture after failing other conservative methods of treatment. Mean age of the patients was 40, 27% male with a mean duration of symptoms of 39 months. Acupuncture with traditional points and trigger points were used with application of low frequency electric stimulation, 1 treatment weekly for 6 sessions. 82% of the treated patients reported greatly improvement in pain reduction and of them 36% were completed healed.

Karagounis P, et al. Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols. Foot Ankle Spec. 2011 Aug;4(4):226-34. doi: 10.1177/1938640011407320.

Plantar fasciitis (PF) commonly causes inferior heel pain and occurs in up to 10% of the US population. Treatment protocols in most studies include the use of ice therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and stretching and strengthening protocols. The aim of the current study was to examine the effectiveness of 2 different therapeutic approaches on the treatment of PF in recreational athletes using the Pain and Disability Scale for the evaluation. A total of 38 participants with PF were randomly allocated to 2 different groups of 19 male participants in each group. Group 1 was treated with ice, non-steroidal anti-inflammatory medication, and a stretching and a strengthening program. Group 2 received the same therapeutic procedures as group 1, reinforced by acupuncture treatment. The primary outcomes, nominated a priori, were pain description and mobility-function at 1 and 2 months. Outcomes were measured with the pain scale for PF. The mean total score of the acupuncture group at the third measurement was statistically minor compared with the mean total score of the first group. Acupuncture should be considered as a major therapeutic instrument for the decrease of heel pain, combined with traditional medical approaches.

Zhang SP et al. Acupuncture treatment for plantar fasciitis: a randomized controlled trial with six months follow-up. Evid Based Complement Alternat Med. 2011;2011:154108. doi: 10.1093/ecam/nep186. Epub 2011 Feb 15.

The aim of this study was to determine the efficacy and specificity of acupuncture treatment for plantar fasciitis. Subjects were randomly assigned to the treatment group (n = 28) or control group (n = 25). The treatment group received needling at the acupoint PC 7, and the control group received needling at the acupoint LI 4. Treatment was administered five times a week for 2 weeks, with an identical method of manual needling applied to the two acupoints. Significant differences in reduction in pain scores, favoring the treatment group, were seen at one month for morning pain, overall pain and pressure pain threshold. No serious adverse event was observed in either group. The results indicate that acupuncture can provide pain relief to patient with plantar fasciitis, and that PC 7 is a relatively specific acupoint for heel pain