Volume 4, Number 3 | Fall 2009

Clinical Report 1 (Japan)
Acupuncture Treatment for Chronic Plantar Pain –One Case Report
Tomoyuki Nabeta
Health Faculty, Dept. of Acupuncture & Mosibustion
Morinomiya University of Medical Sciences

1. Introduction
Pain associated with numbness of the extremities isindicative of constriction of central nerves or nerveroots and diagnostic imaging is often performed in
medical facilities for the lumbar and cervical regions.
However, frequently any clear organic diseases areabsent and causes remain unknown, so that local
symptomatic treatment is performed. Many of thepatients receiving acupuncture treatment in Japan
underwent treatment in medical facilities but
without resulting in any improvement and came ourclinic in the hope for some relief. This article
presents one case report, where acupuncture
treatment was markedly effective.
2. First visit
Born in July 1936, aged 74 years, female, housewife
First visit: November 1, 2010 (Monday)
Chief complaint: plantar pain1) Anamnesis
Three months earlier without any causes the patient
can think of the left heel became swollen upon risingin the morning, subsequently developing severe painand resulting in the disability to walk. An
orthopedist took an x-ray picture of the foot but
could not identify any anomalies and therefore gave
the patient cold compresses. Yet, the pain was notalleviated and starting one month ago she ceased
seeing the orthopedist and started instead to visit anosteopathic clinic. The treatment there resulted insome improvement of the symptoms, but she still
had to walk on the toes because of the pain during
walking. The pain was of a tingling nature and grewworse when walking. During rest she felt somediscomfort, but not strong pain. As concurrent
symptoms she complained about marked shoulder
10

stiffness and occasional headaches. The headacheoccurred frequently in the right parietal area andwas a continuously squeezing pain. She was easily
susceptible to stress and irritation during daily life.
2) Acupuncture treatment experienceShe had no previous acupuncture treatment
experience and since this was her first visit, she felt
somewhat frightened. A friend of hers wascommuting to this clinic and because this friend took
the patient by car, she could visit our clinic, although
she lived rather faraway.
3) Past history
Surgery for varices near the 4th digit of the left foot.
Surgery of the left eye, resulting in a recovery of left
visual acuity to 1.2. (right: 0.3)
The timing of the surgeries for both symptoms isunclear.
4) Examination findings(1) Observation upon entering the room
The upper half of the body leaned forward and apainful gait protecting the left foot could beobserved.
(2) Observing the patient in a sitting position
I Static observation
I instructed the patient to sit at rest in the most
comfortable position with eyes closed, facing straightforward and observed this posture. This showed thatthe right shoulder was elevated, the neck tilted to
the right and slightly rotated to the left.
II Dynamic observation
I instructed the patient to bend the neck for-,backward, sideways and rotate it. Retroflexion of theneck caused a sensation of dull pain extending fromthe cervical to the back region, while upon
anteflexion the patient reported a feeling of tractionin the posterior region of the neck, bending to the leftcaused a feeling of traction in the right shoulder
region, while rotation to the right was restricted.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 4, Number 3 | Fall 2009(4) Observation in face-down position
I Observation
Protuberances on both sides of the erector spinae
muscle region between Th4 and Th7 could beobserved.
II Palpation
I observed a very strong tension from the cervicalregion towards both shoulders, in particular within
the right trapezius muscle in the vicinity of GB 21(Kensei, Jianjing) a string-like induration andtenderness was observed. In the same locationpressure induced ischemia triggered in the rightposterior cervical region a dull pain, so that I
considered this area to be a trigger point.
The triceps surae muscles were overall very tense
and a slight swelling and reddening of the heel
region could be observed. Lightly touching the same
region or compression causes the patient to complainof a numbening pain.
(4) Observation in face-up position
II Palpation
On the outside of both lower legs an increased
tension of the long peroneal muscle and theperoneus brevis muscle was observed andparticularly marked on the left. Moreover, on the
medial side of the left lower leg, the muscle along themedial marginal region of the tibial bone was flaccid.
Passive movement of the ankle joint showed that therestriction of the mobility (resistance) was moremarked on the left side. A mild degree of edema wasalso noted for the left lower leg, so that pressure
against the tibia left a finger impression. In thecenter of the right sternocleidomastoid muscle belly
a strong tension could be observed and the patientcomplained about tenderness of the same site andparietal discomfort upon compression, so that thissite too was identified as a trigger point.
5) Comprehension of the pathologic condition
Excessive tone of the muscle groups stabilizing theankle joint could conceivably be a factor for therestricted joint movement. Since the patient could
not recall any contusion of the left heel possibly
responsible for the symptoms, the condition wasprobably not caused by a trauma. For some reason
circulatory problems in the left heel region developed
and the resulting swelling caused a local
compression neuropathy, so that during walking thecompression conceivably led to the manifestation ofpain.
The author thought, that the excessive tension of themuscle groups located around the ankle joint andthe tension of the erector spinae muscles caused by
the patient's stooped posture were related to themuscle tone of the neck and shoulder region andthus possibly contributed to the headache. Because
the disturbance of the trunk balance shifted thecenter of gravity and thus put an increased stress on
the antigravity muscles, the patient shifted hercenter of gravity forward, so that the muscle tension
in the posterior crural muscles increased and thetone of the triceps surae muscles responsible forplantar flexion of the ankle joint led to a tensing of
the long peroneal muscle, peroneus brevis muscle,posterior tibial muscle and this in the end probably
led the development of an increased tonus of theflexor hallucis longus muscle. While these muscle
groups caused a shortening of the ankle joint andthus a limitation of the mobility, at the same timethey probably also adversely affected the flexibilityof the plantar arch. Accordingly, the increased
muscle tension in the lower legs conceivably
developed in this patient because of the abnormal
posture assumed during daily living, resulting in anabnormal center of gravity.
6) Treatment plan
Purpose of the treatment was to achieve relaxationof the structural muscles of the ankle joint topromote mobility of the ankle joint and relaxation ofneck and shoulder region muscles. Tension of thelumbar and back muscles too should have beenadjusted to improve the posture, but because thisThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 4, Number 3 | Fall 2009

was the patient’s first acupuncture treatment, thiswas omitted in order to reduce the stimulus dose.
Further, from a point of view of meridians thecondition was considered to be a lesser yang disease,
where an increased tension was observed along thegallbladder meridian, while on the medial side of thelower leg along the reverting yin liver meridian someedema could be noted, allowing the conclusion thatthe greater yin spleen meridian is weakened andthus relevant therapeutic points were selected on
the various muscles. For the acupuncture treatment
40 mm No.18 needles manufactured by Seirin wereused. Since the patient underwent acupuncture
treatment for the first time, obtaining de qi waseither not necessary or kept to a mild degree.
7) Treatment
I Treatment for the heel pain
Left GB34
Purpose: Reduction of the long peroneal muscle
tension, stimulation of the common fibular nerve,
adjustment of the lesser yang gallbladder meridian.
Method: Perpendicular insertion, 1 cm insertion
depth, obtaining de qi is not necessary afterthrusting and lifting with little stroke.
Left BL60Purpose: Stimulation of the fibular nerve,
adjustment of the greater yang bladder meridian.
Method: BL60 was needled perpendicularly in a
fashion of "penetrating insertion" towards KI3,
where the movement of the tip of the needle could befelt underneath the skin, meaning that the needle
had passed beneath the Achilles tendon. Obtaining
de qi is not necessary.
BL57 (bilateral)
Purpose: Reduction of the triceps surae muscle
tension, adjustment of the greater yang bladdermeridian.
Method: Perpendicular insertion in the region ofmuscle-tendon
transferregion
fromthe12

gastrocnemius to the Achilles tendon, insertion todepth of more than 2 cm until the needle reached thetransitional region of the soleus muscle. Otaining deqi is not necessary.
Left SP6
Purpose: Relaxation of the posterior tibial muscle
and freeing the three leg yin meridians.
Method: Perpendicular insertion, insertion for morethan 2 cm. Otaining de qi is not necessary.
LR3 (bilateral）
Purpose: Relaxation of plantar muscles, adjustmentof the liver meridian.
Method: Slightly oblique insertion towards the baseof the first and second metatarsal bones. Insertion toa depth of more than 1 cm and obtaining de qi.
II Treatment of the neck and shoulder region
symptoms
Induration in the center of the rightsternocleidomastoid muscle belly.
Purpose: Calming the trigger point
Method: Presence of strong tenderness, bycompressing the area of blood deficiency for 5
seconds a perpendicular vertical insertion was madein the area of the discomfort reported in the parietal
region, and after thrusting and lifting several times
de qi was obtained.
GB20 (bilateral）
Purpose: Relaxation of the semispinal muscle of thehead and the greater posterior rectus capitis muscle,
freeing of the lesser yang gallbladder meridian.
Method: Markedly oblique insertion toward theoccipital bone, after confirmation that the needle tip
touched the bone the needle was slightly retracted
and thrusting and lifting performed. Obtain only amild degree of de qi.
Hyakuro (bilateral)
Purpose: Reduction of the tension of the erector

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 4, Number 3 | Fall 2009spinae muscles in the center of the border between
the semispinal muscle of neck and the semispinal
muscle of thorax to alleviate the dull pain triggeredby retroflexion of the neck.
Method: Perpendicular insertion, insertion for morethan 2 cm until resistance is felt.
GB21 (bilateral）
Purpose: Relaxation of the trapezius muscle,
calming the trigger point and freeing of the lesser
yang gallbladder meridian.
Method: Grip the trapezius muscle as thinly as
possible and twist it forward, after confirmation of astrong pain and referred pain extending towards theocciput, directly prepare the pressing hand andinsert the needle. Obtain a mild degree of de qi.
III Stretch exercises and joint mobilization
techniques
Mobilization techniques for the ankle joint
Passive performance of dorsal flexion, plantarflexion, plantar flexion and inversion, plantar flexionand eversion. At this time the techniques areperformed consciously imagining the sliding
direction of the joint. Finally perform traction
towards the heel in a dorsiflexed position.
Mobilization techniques for the neck and shoulder
regionThe head and neck were bend to the left, while thejaw was moved in three directions to the right, frontand left side, the muscle groups of the neck werestretched in general, on the sides and in the back.
After performing the same procedure for the rightside, a passive traction of the cervical vertebrae isperformed.
IV Other
The patient was instructed to rotate both ankles athome and assume a proper erect posture.
8) Immediate effects

The stiffness of the neck and shoulder region wasmarkedly alleviated and movement of head and neckeasier. The patient felt the pain in the left heel while
walking, but she reported it being less than whenshe visited the clinic. I told the patient: "Since themuscles stabilizing the ankle joint are now softer,
the overall circulation has improved and if theswelling decreases with time, I think the pain will godown too." and instructed her to go home andobserve the course.
3. Second treatment session
Day of visit: November 8, 2010, 1 week after the firstvisit
1) Course
The pain of the foot had disappeared completely by
the day following the treatment. It has not recurred
until now. The condition of the neck and shoulder
regions too is good.
2) Examination
Swelling and reddening of the left heel haddisappeared. Tension of lower leg muscle groups haddecreased. The tension of the right trapezius muscle
had decreased too. In the neck and shoulder region
on the left side externally from C7 a dull pain
remained, that grew worse upon rotating the neck.
Treatment
The pathologic condition anticipated during the firstvisit was thought to have improved, but the patient
treated to alleviate the remaining mild degree ofmuscle tension and free the meridians. I added somemore acupoints for the purpose of systemic
regulation.
Points removed from the first visit regimen.
GB20, Hyakuro, BL57
Newly added treatment points
SP9, induration at BL20, induration at BL21, left
BL10
4. Subsequent course
Since the patient lived at a considerable distance

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 4, Number 3 | Fall 2009

from the clinic another patient commuting to ourclinic suggested giving the patient a ride, but for
certain reasons that other patient stopped visiting
our clinic, so that the appointment made for 2 weeks
later was canceled. At that point I inquired bytelephone and was told that there were norecurrences and she felt fine. I instructed the patient
to visit my clinic again, if the symptoms should recuror other symptoms develop and initiated myfollow-up.
5. Discussion
This patient had consulted medical facilities over a
period of 3 months without experiencing anyimprovements, while the pain was markedlyrelieved by a single acupuncture treatment, whichclearly shows the effectiveness of the acupuncturetreatment. I discussed that the treatment included
meridian therapeutic elements, but it wasconsidered mainly as an attempt at correcting thebody's balance anomalies thought to cause local
stress and thus led to the development of thesymptoms. While the patient presented with thechief complaint of left heel pain during walking, theauthor considered the usually poor posture and theunbalanced tension of the antigravity muscles as the
etiologic factors. These caused heavy strain on one
leg, where the muscles groups stabilizing the ankle
joint developed an abnormally high tone, so that theshock absorbing properties of the plantar archdecreased, increasing the load on the heel and thus
resulted in the development of inflammation. The
influence on the nervous innervation and circulationof the heel is not clear, but since the inflammation of
the heel became chronic, it therefore probably led tothe development of hyperalgesia and at the sametime caused the swelling conceivably somecompression of the peripheral nerves. Accordingly,
improvement of the local muscle tension also
improved the mobility of the ankle joint and in
conjunction with ensuring the circulation treatmentof the neck and shoulder symptoms helped to reduce14

the load on the left lower leg. If the patient would
have had experience with acupuncture treatment,
some additional treatment of the back and lumbar
regions to improve the tension of the antigravity
muscles in general. In case an imbalance in muscle
power were observed, additional treatment toincrease muscle power should be considered.
Concepts applicable to this patient showed, that
local symptoms apparently relate to the entire bodyand a generalized unbalance in turn may lead to
local manifestations. Moreover, regional symptoms
or generalized unbalance may sometimes betriggered by anomalies of internal organs caused byviscero-somatic reflexes. Otherwise stress or otherpsychologic factors can possibly result in anomaliesof the autonomic nervous or endocrine systems. I
believe, these concepts do not represent the oriental
traditional medical views on pathophysiology, butrather discuss acupuncture treatment as theconnection between oriental and western medicine.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)