Volume 8, Number 4 | Winter 2013

Clinical Report 1 (Acupuncture)
A Clinical Report of Anterior Cruciate Ligament Injury
Treating with Acupuncture and Physical Training forCollegiate Women’s Lacrosse Player

an MRI scan and was diagnosed with ACL
damage. In July, she underwent reconstructive
surgery by semitendinosus tendon graft (STG),
and thereafter received training at the same

Akihito Uehara, Akinori Kihira, Yasuhisa Kaneko

hospital to recover her motor function. Inand Eiji Furuya

November, her attending doctor gave herKuretake College Oriental Medicine Clinical Laboratory

permission to engage in light exercise. A test ofknee extension force in December showed astrength of 73.2kg in the right leg and 45.8kg in[Introduction]
Women’s lacrosse in Japan is a sport where two
teams of 12 members each compete for points byshooting a ball into the opponent’s goal on a field 110m
long and 60m wide, in two 25-minute halves. A total of
8,698 female lacrosse athletes were registered with theJapan Lacrosse Association in fiscal 2013. The sport
requires a variety of movements, such as running,dashing, cutting, and jumping. Injuries to the leg, andparticularly to the ankles and knees, have beenreported as the most common injuries sustained while
playing lacrosse (1, 2).
Below is a report of a case where a lacrosse
athlete who sustained an injury to her knee anterior
cruciate ligament (ACL) while playing lacrosse
received training (TR) and acupuncture treatment(AT) at Kuretake College Oriental Medicine ClinicalLaboratory (KOMCL) with the cooperation of an
orthopedic surgeon in private practice and a surgeon
at a general hospital, and made a successful return

her left leg. The weight bearing index (WBI) was
1.52 for the right leg and 0.95 for her left leg.
4. Training

andacupuncture

treatment:Thepatient’s first treatment session at KOMCL wason December 16.
(1) Chief complaint at the time of the firsttreatment session: Feeling of apprehension
about returning to the sport(2) Subjective

information:The

patient

experienced no pain from activities of dailyliving, but there was irregular pain when she
engaged in weight training, jogging, andother such light exercises in which she
applied her own weight. She also felt pain on
the front and inner sides of her knee during
light knee extension resistance training. She
was told by her doctor that she should aim to
return to the sport in February 2012.
However, she felt strong apprehension atto the sport.

returning to the sport after only the[Patient’s information]

presently undergoing.

functional

1. Patient: 19-year-old female university student,height 154cm, weight 47kg
2. Treatment status: In May 2011 while playing ina lacrosse match, the patient heard a rupturesound and felt intense pain in her left knee whenshe tried to cut in front of the opposing team’s
defense player from the left to right, and fell.
Immediately after the injury, she could not walk,due to the pain and a feeling of weakness.
3. Diagnosis and treatment: The patient first saw
an orthopedic surgeon in private practice, andwas referred to a general hospital, where she had

recoverytraining

shewas(3) Objective information: Acute inflammation(–). Limitation in range of motion of the knee
joint (–). Manual muscle testing (MMT) forleft knee joint extension showed a strength of4 on the right and 5 on the left. Stress test ofthe ligament around the knee (–). McMurray
Test (–). Claudication (–). Left knee flexural
failure and minor pain when walking down
the stairs (+).
(4) Assessment: The patient made good progress
after the surgery, and her obstacles in dailyliving were almost completely eliminated.

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

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Volume 8, Number 4 | Winter 2013

However, when she did a side step, a[Method]

deviation in the center of gravity of her upper(1) TR: Leg motions that were necessary for the

body to the sides of her base of support andsport were categorized into running motions,knee-in were observed, and knee-in was alsoside steps, and cross-over steps and quick turns,

observed when she did a cross-over step.

and resistance TR was implemented with the

These were attributed to the low WBI of hergoal of acquiring stability in the frontal, lateral,left leg, which suggested a lack of absoluteand horizontal directions of each movement andmuscle strength that is demanded by theincreasing muscle strength. With the side steps

sport, and a low ability in performing theand cross-over steps, the patient performed themovements of the sport due to a long absence

movements in front of a mirror and also

from practice. Thus, these two items wererecorded them on video, so she could correct her

considered to be behind the patient’s feelingmovements by herself. She was instructed toof apprehension of returning to the sport.

engage in repeated TR at home. Table 1 shows(5) Treatment policy: The short-term goal was

the objectives, activities, and assessment of her“to improve the lack of muscle strength andmotor function” that was behind the patient’s(2) AT: Acupuncture was applied mainly to thefeeling of apprehension, and the long-termlower back and leg using acupuncture needles

goal was “to increase performance after
returning to the sport and prevent re-injury.”
Fig. 1 shows an image of the treatment policy.
It was decided that KOMCL would provide
training (TR) for strengthening muscle
strength and posture control, which forms
the basis of athletic rehabilitation (AR), inaddition to acupuncture treatment (AT) forrelieving muscle fatigue generated by the TR.
Thelearningofsportmotions

wasapproached through AR performed in thetraining field.

Performance

14TR.

50mm long and 0.18mm in diameter. The major
acupoints that were used were the Shenshu(BL23), Dachangshu (BL25), Huantiao (GB30),Yinmen (BL37), Chengji (BL56), Futu (ST32),
Liangqiu (ST34), and Xuehai (SP10). The effectof acupuncture was examined by quantifying
the degree of the symptoms using a visual
analog scale (VAS) and comparing them before
and after the treatment. For significancetesting, significance level was set to 5% or lessin a t-test. Fig. 2 shows the flow of training andacupuncture treatment.
(3)
AR: AR was implemented
once to two times a week by
Treatment policy
accompanying
thepatient’s
Improved
performance
Improved
practice. The movements of her
Training
physical strength
Prevention
knee joint when cutting in andof re-injury
changing directions were recorded
Functional recovery
on video, and the patient wasimmediately shown the video.
Conditioning
Problems in movement werebroken down into frontal, lateral,and horizontal elements, and TR
Muscle fatigue relief,Acupuncture
guidance was given to correct thePain alleviation
movement. The patient’s conditionTime
was reported to her attending
Fig. 1: Treatment policy

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

Volume 8, Number 4 | Winter 2013

surgeon by uploading the video to YouTube andmaking it accessible only by the surgeon. At thehospital, the surgeon assessed the patient’s
condition and provided guidance at a frequency of
about one to two times a month (once in threemonths after she returned to the sport).

Fig. 3 shows a timeline of the patient’s medicaltreatment.

TR,ATandAR

wereeachimplemented by respective personnel, with theAR instructor assigned as the head of the teamand placed in charge of sharing information
with the doctor.

Table 1: Training objectives, activities and assessment

2

Objectivea. Practice of basic running motions andimprovement of muscle strengtha. Same as above3b. Practice of basic lateral travel (side step)
motions and improvement of muscle strengtha. Same as above

1b. Same as above

4c. Practice of basic turnaround (cross-overstep) motionsa – c. The load of each motion is increased, tosimulate motions of the sport that
accompany quick turns* Training (1st to 4th sessions)
Resistance training was performed in
front of a mirror. The patient engaged insimple movements with a certain load,and problems were pointed out so she
could perform repeat exercises at homeand school.
The stability of frontal, lateral andhorizontal movements were evaluatedvisually, and by video recording.
* Acupuncture treatment (4th to 14thsessions)
Using 0.50mm No. 18 needles,
stimulation was applied to the lower
back and leg to a depth of around 10mm.
To examine the immediate effect ofacupuncture treatment, the patient wasasked the intensity of her chiefcomplaint before and after treatmentusing a Visual Analog Scale (VAS), andthe results was evaluated by a t-test(p<0.05).

Main activity
Squat
3 sets of 5Squat
3 sets of 10
Side step
3 sets of 5Squat
3 sets of 10
Side step
3 sets of 10
Cross-over step
3 sets of 5
Jumping motions thathave been performed
above in each activity
3 sets of 5

Assessment
The lower back flexes noticeably whensquatting.
The lower back flexes somewhat whensquatting.
The upper body center of mass deviates
to the sides of the base of support.
There is hardly any flexing of the lower
back when squatting.
The upper body center of mass is
contained within the base of support.
No clear instability is seen.
The emergence of instability isremarkably small despite the increasein load.

Flow of treatment at KOMCL
Medicalinterview

Assessment andguidance in thepractice field

Measurement oftreatment effectTreatment

Manualexamination

Establishment ofa treatment plan

InformedconsentFig. 2: Flow and content of treatmentThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 4 | Winter 2013

February2012

December 2011

May 2011

KOMCL- Muscle strengthening andmotor learning- Acupuncture treatment- “Performanceenhancement andrecurrence prevention”
was established as thegoal after returning tothe sport.

Practice field

Retired fromsport- Surgery- Medical rehabilitation- Reporting of regulartreatment sessions andassessments to KOMCL- WBI measured on
February 3, 2012 was 1.49
for the right side, 1.25 forthe left side, so theattending doctor gave thepatient permission toreturn to the sport.
- Removal of the bolt in
November 2012

Return tosport

Hospital

October 2012

- Athletic rehabilitation(motion confirmation,training guidance)- Taping and other suchtreatment- Videotaping of motions
during practice andverification by the doctor
via YouTube- Up-down conditioning
guidance

Fig. 3: Timeline from surgery to retirement from the sport[Result](1) TR: Training was conducted a total of four times
until February 2012. In the fourth TR, animprovement was confirmed in the patient’s sidestep motion. Similarly, an improvement was also
seen in quick turns in lateral jumping
movements.
(2) AT: The first treatment was applied immediately
after the fourth training session. Thereafter, it
was applied at a frequency of one to two times amonth, to alleviate pain and other complaints,
and to relieve fatigue. The treatment was applied
14 times in all, from the first treatment toOctober 2012 when the patient retired fromcollegiate sports. According to the VAS, theaverage level of the patient’s chief complaint was
40.6±21.6mm
beforetreatment
and26.2±15.8mm after treatment, and showed asignificant drop after treatment (p<0.01). Table 2
shows the VAS values before and after eachtreatment in regard to the chief complaint.
(3) AR: AR was conducted seven times until
February 2012. An improvement was confirmedin the knee-in condition when changing
directions. The WBI measured at the hospital in
the same month was 1.49 for the right leg and1.25 for the left, so the attending doctor gave thepatient permission to return to the sport. The
patient experienced no re-injury until she retired
from collegiate sports in October, and was able toplay in all student league matches.
Table 2: Complaints at the time of acupuncture treatment
and VAS values before and after treatment
Numberoftreatment
sessions
1234567891011121314(Unit: mm)
VAS value VAS value(before(aftertreatment)
treatment)

Complaint

Lower back pain
Heaviness in lower backLower back pain
Fatigue in the leg
Pain on inner side of right knee
Whole body fatigue
Conditioning
Conditioning
Pain on the outer side of the rightfoot
Pain on the front of the right hip joint
Lower back pain
Pain on the outer side of the rightfootWhole body fatigue
Leg fatigue
Leg fatigue
Pain on the bottom of the right footPain on the outer side of the rightknee
Pain on the bottom of the right footLeg fatigue
Pain on the outer side of the rightknee
Pain on the front of the right hip joint
Pain on the outer side of the right
thigh
Pain on the bottom of the right foot

15
49
38
28
63
13
0
0
30
20
25

21
25
35
23
45
50
0
20
11
14

21

11

64
47
57
61
50

34
15
19
45
40

62
60
55

55
37
41

70
59

49
35

47

23

Average
SD

40.6
21.6

26.215.8

Note: “Conditioning” is used when there is no pain or other such physical findings,and treatment is applied for the purpose of maintaining and enhancing health

16

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

Volume 8, Number 4 | Winter 2013

institution, and generally must strive to return to[Observations]
KOMCL was established within Kuretake College

their sport after engaging only in self conditioning.

in November 2007, with the mandate to engage inToday, the development of social networks and cloudthe clinical practice, research, and education ofstorage systems allows information about theacupuncture. It has provided acupuncture treatment

movements of an athlete in the field to be shared

to members of women’s collegiate lacrosse teams

with concerned parties who are not present on-site.

since its establishment, and has treated a total ofThus, it can be said that taking advantage of

1,547 lacrosse players from April 2008 to Marchtechnology to achieve smooth sharing of information

2014.

with medical institutions was a large factor in

Acupuncture is widely used for conditioning by
sports athletes, but at KOMCL, importance is placedmitigating the patient’s feeling of apprehension andallowing her to return to the sport.

not only on treatment by acupuncture, but also on

The patient had received acupuncture treatment

engaging athletes to perform active TR. This is

only once in the past, and had a strong resistancebecause it is believed that strengthening physicalagainst AT from the beginning of TR. Therefore, only

strength through TR relatively lowers the exercise

TR was conducted on the first to third treatment

intensity of the sport, and helps prevent injury. On

sessions, and AT was implemented only after she

the other hand, the accumulation of fatigue fromactually felt the effects of the TR and fostered acontinued TR and sport activities is believed tofeeling of trust in the personnel in charge of AT. It

heighten the risk of injury, so relieving fatigue is also

appears that the patient’s realization that receiving

an important issue. With regard to this point,

AT to actively relieve the fatigue from the TR would

previous studies suggest that AT is effective incontribute to realizing her goal, prompted her torelieving muscle fatigue and controlling the delayed

receive AT and undergo regular treatment even after

onset of muscle soreness (3, 4, 5).

completion of her TR program. Many young people

This was a successful case in which various

tend to have a feeling of resistance to AT, but tocombinedstrengthen their willingness to receive AT, it is

toward achieving the patient’s goal after undergoing

important to share patients’ goals and deepen their

ACL reconstructive surgery, with the result that theunderstanding that AT is effective in achieving thosepatient’s lack of muscle strength and motor functions

goals.

treatment

methods

wereeffectively

were improved, performance was enhanced, and reinjury was prevented. The reason why the goal was
ultimately able to be achieved was because thepatient’s information was shared between the
medicalinstitution

andpractice

field

from

immediately after the injury, and the medical
institution, KOMCL, and practice field were eachable to make an input in their respective capacities
based on an accurate understanding of the patient’scondition. In Japan, many amateur sports lack anadequate medical support system, so most athletes
who undergo surgery for ACL damage have few
opportunities to receive specialized treatment otherthan functional recovery training at a medical[Conclusion]
1. In order for us acupuncturists to help athletes
who have sustained injury to return to theirsport in the amateur sports world, which lacks
an adequate medical support system, it isimportant to share information among medical
institutions, acupuncture clinics, and the sport
field, and take measures to ensure that medical
cooperation can be continued.
2. In order for injured athletes to return to their sport,
acupuncture treatment and other such passivetreatment could be more effective when combinedwith exercise therapy and other active therapy.

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

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Volume 8, Number 4 | Winter 2013

Reference
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AthleticAssociation

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2. Sanomura

M,

Hosokawa

Y,

NakamuraC,

Fukubayashi T.: Collegiate women’s lacrosse
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Jpn J Phys Fitness Sports Med, 62 (5): 399-411,
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3. Kaneko Y, Furuya E, Sakamoto A: The Effect ofPress Tack Needle Treatment on Muscle Sorenessafter Triathlon Race:Placebo-controlled Study. J

JSAM, 56 (2): 158-165, 2006
4. Furuya E, Kaneko Y, Uehara A, Uehara I,Soejima K, Sakamoto A: Effect of the Press Tack
Needle on Recovery from Muscle Fatigue byRandomized Controlled Trial:sham controlled
study. J JSAM, 59 (4): 375-383, 2009
5. Furuya E, Kaneko Y, Uehara A, Sakamoto A:Effectiveness of acupuncture in the control oflower back pain of sailors at the National Sports
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