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Ask an expert - muscles and bones - feet

26 questions

Q:  I have had a very sore aching foot for about 2 years now. It tends to swell up in the afternoon and aches constantly. I have been to the doctors many times but have been diagnosed with gout. I was not satisfied with that diagnosis so I have kept going back to my doctors and every person I have seen has given me a different diagnosis. About a year after my first symptoms I developed a very sore knee and had an MRI scan. The doctor told me that I had a meniscal tear and so I attended some physio sessions. My knee did get a bit better but a year forward and I still get a lot of pain in it. During the last couple of months I have also started having chronic pains in my legs so sometimes I walk like an old lady. My doctor thinks that I might have fibromyalgia but I have asked to be referred to the hospital for confirmation of the diagnosis. I am at a loss of what to do - could acupunture help my symptoms and alleviate my pain?

A: This is one of those questions where as traditional acupuncturists we tend to feel an instinctive sense that we can probably help, but where providing evidence can be a little tricky. If we talk in terms of treating the specific symptoms you have, the evidence is equivocal.  As far as gout is concerned, the last time we were asked we said

As our factsheet shows
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/gout.html

 there have been a number of studies, mainly in China, which seem to show encouraging results in the use of acupuncture treatment for gout. As the sheet sasys, however, these are few in number, and because they were conducted in China, doubt is often cast on their methodological soundness. This is often a little unfair, because the focus of Chinese research is often a little different - they are sometimes less concerned to establish whether acupuncture works than what works best. In the West, the former question is paramount and the inappropriate model of drug testing, the randomised control trial, used as the standard test.
 
Since the factsheet was written there has been a systematic review of trials
 
http://www.ncbi.nlm.nih.gov/pubmed/23424263
 
which again gives some very encouraging evidence that acupuncture treatment may be of benefit.
 
There is no doubt that in conventional medicine the use of allopurinol together with a sensible approach to diet, can minimise the attacks that a gout sufferer has. When we take on patients with conditions like this where the medication works, we are always very careful not to let patients stop medication which has been working well. The danger with stopping allopurinol is that it cannot be used to treat an acute attack, and a sudden rise in uric acid caused by a peremptory break might bring one on. If you were considering coming off long term medication we would advise that you discuss the situation with your GP.
 
In summary, though, you could do well to visit a BAcC member local to you to discuss your specific case. Gout appears in many joints, and some are more treatable than others. There are also on occasion a number of ways of understanding the inflammation from a Chinese medicine perspective which offer more clearly defined treatment strategies than others, but this would require a brief face to face asssessment. 

and for fibromyalgia we said

In our experience fibromyalgia can be a difficult condition to treat. As our factsheet shows

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/fibromyalgia.html

there is not a great deal of evidence which would mean that we could say with confidence that acupuncture treatment will work. However, as the factsheet remarks, we are always up against a problem with the way that trials are conducted, and the fact that the so-called 'sham' treatment works as well as the 'real' treatment. From a Chinese medicine perspective, there are no points on the body which don't work at all - everything is made up of energy, called 'qi', and the classically recognised points are simply the most effective places to achieve change.

Anyway, to more specific questions, we usually recommend that someone has four or five sessions if there is any doubt about whether treatment will be effective, and to review progress at this stage. This does mean that you need to have in place some very clear outcomes or markers for what counts as getting better. The trouble with fibromyalgia and similar conditions is that on some days you can feel fine and other days be in considerable pain. It is difficult to get an objective measure, but if there are things which can be measured, such as distance walked or time slept, or painkillers reduced, these can sometimes provide evidence that there is some progress. We are a little surprised that the person treating you is concluding already that nothing is happening, but there are signs which show how well, or indeed if, someone is reacting to treatment, and if these are unchanging, that might be the basis for her view. There are a small number of patients whom one knows almost from the off are not benefiting.

It is also possible in the early stages of treatment to feel worse rather than better, although in our experience this usually only lasts for about a day or two at most, and if someone feels worse for longer than this we tend to look at what else is going on.  However, in conditions like fibromyalgia and polymyalgia, the persistence of the condition can often mean that the feeling of being slightly worse can persist for quite a while too, so it may simply fall within what is sometimes called a healing response, and be perfectly normal. However, after four or five sessions this should not really continue, and if it does, then it calls into question whether it is worth continuing with treatment.

However, the interesting aspect of your account is that the problems seem to be progressing towards the trunk from the extremities, and it is very much within the understanding of Chinese medicine that disease progression often goes from the outside to the inside, from the extremities to the centre. A practitioner would be fascinated by this. At the same time the way in which the symptoms have presented - swelling, tears, and pain - suggest a number of recognisable presentations when look at from our perspective.

Acupuncture could probably provide some pain relief, but the question would be how much relief and how sustainable. Since its increasing popularity in the 1970s it has become a feature of most pain management centres, and the main issue is whether the expense of treatment is justified for the amount and duration of pain relief it offers. It has often been a concern that acupuncture has become a middle class options for financial reasons, and nowhere is this more obvious than pain relief, where having deep pockets can make a major difference. Each practitioner works in different ways, though, and many make concessions for people whose need is great but whose funds are limited.

The best advice we can give is that you visit a BAcC member local to you for a brief informal visit to see what is going on. This is always going to be more effective than arm's length opinion from us, and most members are happy to give up a little time without charge to establish whether acupuncture treatment is the best option or whether other therapies may be more apropriate.

A:  As you can imagine we have been asked this question a number of times, and a typical answer was:

Can acupuncture help with plantar fasciitis?

Plantar fasciitis can be a very unpleasant and debilitating problem, as you no doubt know. There is some evidence for the use of acupuncture treatment, as this paper shows,

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094706

and if you google 'acupuncture' and 'plantar fasciitis' you will find a number of other papers which suggest that there may be benefits from treatment. However, the combined weight of the various studies is not enough to be able to give an unqualified recommendation.


 

That said, the strength of Chinese medicine is that it operates from an entirely different paradigm or theoretical basis, and has different ways of making sense of the symptoms which a patient is experiencing. This can sometimes offer treatment options which would not necessarily translate into a western understanding of physiology, although there is usually an overlap. The system of medicine rests on a theory of energy, called 'qi', whose flow and balance determine how well the various systems of the body function. Many problems like plantar fasciitis point to local blockages and disturbances, often due to over-use or poor gait, which once they have become established remain a problem even after someone's habits have changed. Symptoms such as this can also point to more systemic problems, and the skill of the practitioner lies in making a clear diagnosis of the whole system before starting to correct aspects of it.

In this case, since the presentations of plantar fasciitis can be very different, we would advise you to visit a BAcC member local to you for a brief face to face assessment of the problem before committing to treatment. We are fairly sure that you will have seen a chiropodist as well as your GP, but if you have not, we would highly recommend that you do. There are a number of treatment options which can work alongside acupuncture treatment to great effect, and with these sorts of problems it is often a combined approach which pays the greatest dividends.

We believe that this remains sound advice. Our own personal experience of treating the condition is that if the treatment is going to work it begins to show evidence of change fairly promptly. The real problem with chronic conditions like this is that it can occasionally lead to a treatment habit developing where hope triumphs over experience and treatment can continue far beyond a time when it is clear that nothing is happening. If you did decide to go ahead it would be wise to identify as objective as possible outcome markers for improvement, something which can be measured, and to ensure that progress is reviewed carefully every three or four sessions.

As an additional aside we have recently heard a number of reports of osteopathy being used to good effect alongside acupuncture treatment to provide better relief, as well as reflexology often being mentioned as a worthwhile option. We mention this because if acupuncture did fail to generate results it is good to know that there are other options for treatment available.  

Q: I have been diagnosed with tendinitis of the ankle/foot . It is very disabling . The doctor told me that the only cure is rest. Would a course of acupuncture help?

A:  We have to be honest and say that this is one of the areas of treatment where the formal evidence is not that good but the evidence by word of mouth from practitioners is pretty good. We have done the usual searches of databases to see if things have changed much from the last time we answered questions about tendonitis in the Achilles tendon, and the answer is 'not much.' There are quite a few studies of tendonitis in  various areas of the body, and both these and the systematic reviews tend to conclude that evidence looks promising but that larger and better trials may be necessary. There are frequently criticisms of the trial methodologies which are often used to undermine the provenance  of their results.

However, from a Chinese medicine perspective the proper functioning of tendons, their flexibility and strength, is seen to be a part of the wider functional responsibilities of some of the Organs (these are capitalised to distinguish them from organs as we understand them in the West) . If there is a functional disturbance of an Organ which could impact on the tendons, then it is highly probable that a skilled practitioner will see further evidence of Organic failure, and by treating the system as a whole begin to restore balance and proper function. Even where this is not the case, the theories of the flow of energy in channels known as meridians means that there are sometimes local blockages, occasionally bilateral, which can impair the nourishment of local tissue and cause weakness and pain.

We think the best advice we can give is that you see if a BAcC member local to you is happy to give up a small amount of time without charge to give you a brief face to face assessment of what might be possible. Most are only too happy to do this, and if they think that they can help they will give you an idea of what might be involved in terms of frequency and cost of treatment. They may also recommend other modalities which may help. We have seen many patients benefit from reflexology either alongside or instead of acupuncture treatment, and some forms of massage can also be very helpful.

A:There is no evidence that we can find, at least not in English, that acupuncture has been successfully used to treat bunion pain. There may well be papers amongst the many thousands published in Chinese each year, but none have as yet been translated. Working on the premise that important papers often make it into English you could probably assume that this means that there are no landmark studies.

From a western perspective once a bunion, always a bunion, unless you have an operation. The thickened skin and additional bone growth are not likely to be dealt with by anything short of surgery, and the best that is usually offered is anti-inflammatory medication to reduce the secondary inflammation and management advice - wider shoes, forms of cushioning.

There is a long and well-researched tradition in Chinese medicine of the use of acupuncture to deal with chronic pain, and the question in this case is simply how much pain relief treatment may provide and how sustainable it is. If treatment offered relief for a week or so, then it may be a worthwhile continuing programme, but it would not be realistic to look for anything beyond temporary relief alongside conservative management strategies like better footwear and padding.

There may be some merit in talking to a BAcC member local to you who can give you advice on the unique presentation of your problem, but as a general rule we would have to say that the chances of radical change in an area which it is difficult not to irritate in daily life are relatively small.

Plantar fasciitis can be a very unpleasant and debilitating problem, as you no doubt know. There is some evidence for the use of acupuncture treatment, as this paper shows,

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094706

 

and if you google 'acupuncture' and 'plantar fasciitis' you will find a number of other papers which suggest that there may be benefits from treatment. However, the combined weight of the various studies is not enough to be able to give an unqualified recommendation.

That said, the strength of Chinese medicine is that it operates from an entirely different paradigm or theoretical basis, and has different ways of making sense of the symptoms which a patient is experiencing. This can sometimes offer treatment options which would not necessarily translate into a western understanding of physiology, although there is usually an overlap. The system of medicine rests on a theory of energy, called 'qi', whose flow and balance determine how well the various systems of the body function. Many problems like plantar fasciitis point to local blockages and disturbances, often due to over-use or poor gait, which once they have become established remain a problem even after someone's habits have changed. Symptoms such as this can also point to more systemic problems, and the skill of the practitioner lies in making a clear diagnosis of the whole system before starting to correct aspects of it.

In this case, since the presentations of plantar fasciitis can be very different, we would advise you to visit a BAcC member local to you for a brief face to face assessment of the problem before committing to treatment. We are fairly sure that you will have seen a chiropodist as well as your GP, but if you have not, we would highly recommend that you do. There are a number of treatment options which can work alongside acupuncture treatment to great effect, and with these sorts of problems it is often a combined approach which pays the greatest dividends.

 

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