Electroacupuncture to Strengthen the Quadriceps following ACL Repair Surgery

The practice where I work focuses primarily on athletes. The majority of patients that come in have musculoskeletal complaints and injuries that occurred during their sport. Roughly 80% of these athletes are soccer players ranging from youth soccer to professional levels. Regardless of what the complaint is, everyone is required to move in order to assess if their movement patterns are being performed correctly or not. We ask people to walk so their gait can be observed, they need to demonstrate their ability to balance, and we evaluate one’s squat. These simple tests reveal so much about what is happening within the body. Restrictions are not only felt, but they are also seen.

There are many athletes, mostly soccer players, that come in with an ACL tear. ACL tears are very common in soccer players; most of the ACL tears occur from non-contact or indirect contact mechanisms such as pressing, regaining balance after kicking, and landing after heading (Walden et al, 2015). Regardless of the mechanism, knee valgus was frequently seen at the moment of tear which indicates knee instability. Our approach needs to be individualized, efficient, and safe in order to get these players back on the field. Because many ACL tears are non-contact or indirect, it indicates there are altered biomechanics and neuromuscular function being performed during performance and these need to be addressed and corrected to allow quicker recovery time and prevention of another injury. One modality that is a key component to a quicker recovery is the use of electroacupuncture to the quadriceps following ACL surgery.

Electroacupuncture is the application of a pulsating electrical current to acupuncture needles in order to apply an increased stimulus to those points. Electroacupuncture can produce a stronger stimulus without damaging tissues compared to manipulating the needles by hand and electrostimulation via electrode pads. Electrode pads are superficial whereas the needles are deeper, this allowing better communication with the muscles. The standard treatment for electroacupuncture is 10-20 minutes. Treatment time is significantly reduced as compared to traditional acupuncture. Low frequencies are typically used for the body. The points used for electroacupuncture do not necessarily need to be points along the meridians; they can also be “ashi” points which are essentially tender points found in the body.

Following any knee surgery, it is typical for the quadriceps to become atrophied and weak. According to Stevens-Lapsley et al, recovery of quadriceps muscle force and function following a total knee replacement is suboptimal (2012). This is the same for ACL surgery as well. Following muscular disturbances, like any injury there comes with it a lack or decrease of proprioceptive awareness of that injured area and typically pain. The early addition of neuromuscular electrostimulation effectively improves quadriceps strength and function following a total knee replacement within the first month (Stevens-Lapsley et al, 2012). Neuromuscular electrostimulation is a type of modality that requires the use of electrode pads placed on the skin and delivers an electrical current to the skin and underlying tissues. Another study also suggests that electrical stimulation, combined with rehabilitation, is more effective for improving quadriceps muscle strength within the first two months that just rehabilitation alone (Van Melick et al, 2016). Electroacupuncture does a similar thing, but provides a stronger stimulus because it reaches deeper into the muscles. It is beneficial for improving quadriceps strength, but also for improving proprioception and providing pain relief. While manual acupuncture increases one’s pain threshold, electroacupuncture enhances those effects of manual acupuncture and even had a significant effect on muscle fatigue recovery (Kim et al, 2014). Injury to the ACL on one side causes bilateral proprioception degeneration; studies show that unilateral electroacupuncture of the knee can help bilateral proprioception recovery (Xu et al, 2018). Electroacupuncture has proven to be an effective method for pain relief following a total knee replacement, and can help reduce overuse or abuse or NSAIDs and opioids (Zhong et al, 2019). Electroacupuncture is proven to be a strong modality for improving quadriceps strength, function, and proprioception while providing pain relief, however this modality has the best results when used during the first month following a knee surgery.

Although studies of electroacupuncture discuss a variety of acupuncture points for treating MSK issues including strength, functionality, and proprioception deficits, the points I would use for the treatment plan following an ACL repair surgery are ashi points. I would ideally use two points placed in the proximal and distal portions of the vastus lateralis, one point in the vastus medialis, and the last point in the rectus femoris. However, if I had to choose points along the meridians I would choose SP-10, SP-11, ST-31, ST-32, and GB-34. The first four points are the closest points to the quadriceps muscle.

SP-10 is located on the bulge of the vastus medialis. The needle should be inserted 1-1.5 cun perpendicularly to the point. SP-10 regulates menstruation, invigorates blood, expels dampness, and alleviates nausea. This point also alleviates pain on the inner aspect of the upper thigh. (Lian et al, 2000). This is a good point to be needled because it is right in the muscle belly which will allow for a strong contraction with electroacupuncture.

SP-11 is located 6 cun proximal to SP-10 (bulge of vastus medialis). This point should be needled 0.5-1 cun perpendicular to the point, just above the femoral artery. Sp-11 clears heat, mobilizes the urinary tract, and expels urine. (Lian et al, 2000).

ST-31 is located at the level of the inferior gluteal fold on the connecting line between the ASIS and the superior lateral corner of the patella. This point should be needled 1-2 cun perpendicular to the point. ST-31 decongests and activates the stomach channel. This point is also indicated for pain, restricted movement, and numbness in the lower extremity. (Lian et al, 2000). According to our notes, in addition to the previous benefits, ST-31 is indicated for difficulty flexing and extending the knee. This is an excellent point for post-ACL surgery because the joint will be painful and stiff, and in some cases there are reports of numbness at or around the surgical scars; range of motion is an especially critical aspect to work on following surgery as well because lack of full knee extension will cause poorer outcomes.

ST-32 is located on the connecting line between the ASIS and superior lateral corner of the patella, 6 cun proximal to this corner. This point should be needled 1-2 cun perpendicular to the point. St-32 activates the stomach channel and alleviates pain. It also helps with pain and paresthesias in the groin area, hip, and lower extremity. (Lian et al, 2000). This point is also beneficial after ACL repair surgery due to the pain and paresthesias felt in the lower extremity.

The first four points will be hooked up to electrodes in order to stimulate muscle contraction of the quadriceps. Quadricep muscle strength is another critical aspect following knee surgery that will lead to poor outcomes if not addressed properly. Low frequency, pulsed electrical current will be used for 10 minutes. The patient will be instructed to contract the quadriceps ten times at the same time as the electrical pulses, then relax for twenty pulses. This treatment is intended to activate the weakened quadriceps and help it remember how to “work” since it will likely be atrophied. In addition to the four points hooked up to electrodes, the point GB-34 will be applied. GB-34 is located in the depression anterior and distal to the head of the fibula and should be needled 1-1.5 cun perpendicular to that point. It decongests the liver, promotes gallbladder function, makes tendons supple, and alleviates pain. (Lian et al, 2000). GB-34 is especially beneficial for pain in the region of the knee joint since this point is known as the universal point for musculoskeletal pain anywhere in the body. This point should be used in addition to any musculoskeletal treatment.

With a 100 hour acupuncture certification, I feel confident enough to treat certain musculoskeletal conditions with electroacupuncture. I have seen multiple athletes come in post-ACL surgery and be treated with electroacupuncture to the quadriceps and it seem to really help these athletes make the most of their rehabilitation. However, this modality is only used during the first few weeks post-surgery as they start to progress more heavily into the rehabilitation protocols. The athletes where I work are pushed to their limits in a safe and efficient manner in order for them to return to their sport quicker than traditional physical therapy clinics. All in all, electroacupuncture is an excellent modality to incorporate to the early stages of the rehabilitation process and there are many studies to back it up.

References

Kim, S, Lee, N, Park, S, et al. J Acupunct Meridian Stud 2014; 7(5): 250-257.

http://dx.doi.org/10.1016/j.jams.2014.01.005.

Lian, Y, Chen, C, Hammes, M, et al. The Seirin Pictorial Atlas of Acupuncture: An illustrated manual of acupuncture points 2000. ISBN: 3-8290-2996-9.

Stevens-Lapsley, J, Balter, J, Wolfe, P, et al. Phys Ther 2012; 92(2): 210-226. Doi: 10.2522/ptj.20110124.

Van Melick, N, Van Cingel, REH, Brooijmans, F, et al. Br J Sports Med 2016; 50: 1506-1515. Doi: 10.1136/bjsports-2015-095898.

Walden, M, Krosshaug, T, Bjorneboe, J, et al. Br J Sports Med 2015; 49: 1452-1460. Doi: 10.1136/bjsports-2014-094573.

Xu, J, Zhou, X, Guo, X, et al. Med Sci Monit 2018; 24: 5473-5479. Doi: 10.12659/MSM909508.

Zhong, S, Huang, H, Xie, J, et al. BMJ Open 2019; 9: e026084. Doi: 10.1136/bmjopen-2018-026084.

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