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Ask an expert - muscles and bones - feet

19 questions

Q:  I have morton neuromas on both my feet affecting the toe next door to the little toe in both cases. I have had steroid injections in the past but want to look into alternative treatments and thought acupuncture the best place to start. Can you advise me if it is affective please?

A:  We have to be honest and say that there is not a great deal of evidence for the effective treatment of Morton's neuroma with acupuncture. We published an answer through this same section three years ago to a question from a patient who was convinced, and with some justification, that treatment with one of our colleagues has been wholly responsible for a complete improvement in his condition.

We have to say, though, that our clinical experience runs counter to this, which is why the very upbeat tone of webpages like that of this American practitioner

http://acuroots.com/mortons-neuroma-treatment-plan-with-acupuncture-and-tui-na/

(informative as it is) raises a wry smile. If only... Having said that, what he describes in the formation of the tissues which cause the condition is something with which we deal elsewhere on the body, and in theory there is no reason why treatment should not be able to reduce some of the discomfort. However, we would be very surprised if this could be done without the aid of orthotics which reduce some of the pressure on the affected areas while any treatment beds in.

Each case is unique and different, however, and the only real solution is to seek face to face advice from a BAcC member who can look at exactly how the problem manifests in you, and more importantly, can see the overall context in which it is occurring. One of the great strengths of Chinese medicine is that it looks at the whole system, not simply at a symptom which is regarded as merely a warning sign. Thousands of people with identical foot structures to you will walk thousands of miles without getting neuromas, and there may be systemic problems which have predisposed this to happen.

The other recommendation we would make, and we are sure that you have done this already, is to find a good chiropodist or podiatrist who can work alongside any other treatments you try to help to maintain improvements. Working in partnership with other health professionals for problems like yours can often be extremely powerful.


A:  The most obvious advice to offer for the tear in the plantar fascia is to rest the foot as much as possible and to stop any exercise which might put strain on it. The treatment for plantar tears will be much the same as the treatment for plantar fasciitis, on which we said a while ago

Can acupuncture help with plantar fasciitis?

Plantar fasciitis can be a very unpleasant and debilitating problem. 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.

There is less evidence for the treatment of a calcified achilles tendon, but we would probably tend to see both symptoms together as evidence of a disturbance in the flow of energy caused by over-use which has led to a deficiency of flow and in turn a number of blockages in the area. Our practical experience is that there is often a response to treatment, and the main issue is not whether treatment will work but the extent to which it works and how sustainable any change might be.

All in all, though, there is usually an underlying cause of over-use or poor use, and the most important thing alongside rest and treatment is to see if someone can provide the kind of analysis of the mechanical structure of the movements of the foot while running or exercising which show if there are any displacements putting pressure on specific parts of the structure of the foot. Some sports shops offer tread analysis, and this can often highlight a need for orthotics in running shoes which can prevent uneven strain.

Of course, if you are not over-doing the exercise, we would be interested as practitioners to see what other constitutional factors were in play to generate a problem which is normally associated with running. Local injuries are often predicated on overall weaknesses in the system, which is why people living an identical lifestyle can be symptom free.  The skill and art of the Chinese medicine practitioner lies in making sense of the overall picture to ensure that local treatment can not only be effective but stay effective.

As the earlier answer says, the best advice is to visit a BAcC member local to you for a brief assessment where they can take a look at the problem and offer a slightly better informed view than we can offer at a distance.

A:  We have to say that a great deal depends on the extent of the damage resulting from the diabetes, and to a lesser extent whether you have type 1 or type 2 diabetes.  Generally speaking, there is a growing amount of evidence suggesting that acupuncture may be able to help with pain arising from diabetic neuropathy, and a number of studies and papers which make very encouraging noises. We aren't going to reference them here because they are quite complex and not easy going even for us. If you want to look at the scientific evidence, however, you might want to google 'ncbi acupuncture diabetic neuropathy.' This accesses a database of all the studies in the largest medical databases, and will provide with references to dozens of papers.

Numbness of the feet is another matter, however. There are fewer papers, although the ones that we could find, such as this one.

http://www.ncbi.nlm.nih.gov/pubmed/20633522

seem very positive.  Using the same search technique for the term peripheral neuropathy will generate another list of studies, most of which refer to PN induced by chemotherapy, but some of which, including the one we have mentioned, do address the problem from a diabetic perspective.

In traditional Chinese medicine, however, numbness of the feet can be a symptom of a much wider number of problems with the system than the small number usually identified in the west. Chinese medicine has an entirely different diagnostic system based on an understanding of the body as a system of energy in flow, called 'qi'. If this flow is interrupted, for any reason, then pain or numbness can result, and the skill of the practitioner lies in being able to determine whether the flow is damaged by local disturbance of systemic problems. There are functional disturbances in the whole system which can prevent energy getting to the extremities.

This does mean that there can on occasion be symptoms which are automatically assumed to be a part of a larger condition but which may not always be so. A good example for us is the number of patients with low back pain and X-rays with degenerative problems in the spine but who now have no pain although it was assumed that the spinal damage would continue to generate the same problems.

What we would suggest is that you visit a BAcC member local to you for an informal chat to see whether there are particular features of your presentation which encourage them to believe that treatment may help. We are confident that they will be honest in their assessment and tell you if they think there is nothing that they can do. It is likely that this is what they may conclude; the nerve damage caused by diabetes is usually irreversible. However, there is always a possibility that the causal chain is a bit more complex and that they may find diagnostic information which leads them to believe that they may be able to help.

 

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.  

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