acupunture treatment profile

May 2006

Acupuncture T

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AcupunctureTreatment Profiles

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May 2006 EDITION

Prepared by

ACC

P O Box 242, Wellington, New Zealand

www.acc.co.nz

ACC Provider Helpline: 0800 222 070

ACC Enquiry Service Centre: 0800 101 996

IntroductionThe Acupuncture Treatment Profi les were developed by the New Zealand Register of Acupuncturists Inc. in

consultation with the New Zealand Acupuncture Standards Authority in a joint initiative with ACC.

Traditional Chinese Medicine prefaceThe Acupuncture Treatment Profi les are a valuable guide in the application of protocols that are included within

a Traditional Chinese Medical (TCM) diagnosis, providing important information that assists an acupuncturist’s

treatment strategy.

The integration of biomedicine and TCM presents opportunities that complement and support a holistic

approach to treatment. The nature of TCM philosophy is to build an increasingly detailed picture of a person’s

health to assist in rehabilitation. It does this by drawing together many facets, of which biomedical assessment

is an important part. This assessment is incorporated into the overall diagnosis, giving rise to effective

treatment regimes.

A biomedical assessment may limit injury to site only and see it as separate from the patient’s broader

experience as defi ned in TCM. Framed within the context of TCM knowledge however, it can form a potent

tool, enhancing the therapeutic potential of treatment. For reasons of safety and effi cacy it is assumed that

practitioners using these profi les will have reached minimum competency.

Number of treatmentsTreatment numbers stated in this document relate to a specifi c diagnosis without complications, which has

been referred for treatment at an appropriate stage of the healing process.

The numbers have not been developed as evidence-based practice guidelines, but rather to provide a

consensus on acceptable treatment ranges.

TriggersTrigger numbers indicate the number of treatments after which ACC would appropriately seek a review of the

services that have been provided.

Any treatment provided for a particular individual will be considered in consultation with the provider

acupuncturist. The trigger number is the appropriate time for a case manager to approach the provider

acupuncturist and consider requesting a review by an assessor.

Key pointsProfi les have this section added in order to highlight important frontline management for that injury.

Special considerations (WMS and TCM)This section highlights special concerns that need to be considered when treating this condition. A TCM

diagnosis will always involve a Western Medical Science (WMS) diagnosis.

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History (WMS and TCM)This section gives a general overview of the signifi cant factors that should be considered in the history of this

condition, including both Western and Traditional Chinese medicine.

Examination (WMS and TCM)This section outlines the main components that should be undertaken in a normal examination. This is not an

exhaustive list, and does not include factors that would be included as part of a routine TCM case history, as

extensive TCM diagnosis is beyond the scope of this document. The examination procedure should include

most of the following:

• Observation• Active movement testing• Passive movement testing• Accessory movement testing• Palpation• Functional tests

WMS differential diagnosisCurrently acupuncturists are referred patients who have already received a diagnosis from a primary treatment

provider. This section is included, however, because acupuncturists are qualifi ed to provide a provisional

diagnosis, and also to illustrate the range of conditions considered in making the original diagnosis. The list is

not intended to be exhaustive, and practitioners are encouraged to seek further medical advice on conditions

that seem unusual.

WMS complicationsThis section gives some examples of complications that may hinder the recovery time of a patient or move the

patient outside the scope of these “uncomplicated” injury profi les and would then require the appropriate

referral action.

TCM differential diagnosisAcupuncturists are expected to treat from a TCM perspective in addition to considering biomedical diagnoses.

TCM diagnoses that would normally be considered are listed for each type of injury, as well as concurrent

syndromes that may be involved in chronic or recurrent injuries, or injuries that have failed to respond well to

prior treatment. The list is not intended to be exhaustive, and practitioners are expected to treat according to

presenting signs and symptoms in accordance with TCM diagnostic criteria.

TCM complicationsInjuries can become chronic and lead to other disease states as diagnosed in TCM. The complications listed

are some of the more common scenarios that may develop as a result of the injury but this is by no means an

exhaustive list.

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Treatment rehabilitationBoth Western medicine and TCM treatment goals are listed.

This section is further divided into two sub sections: acute and sub-acute. For the purposes of these profi les

acute has been described as within the fi rst 10 to 14 days of an injury occurring, or post surgical intervention.

Sub-acute is considered any time after this.

This section is not intended to be a step-by-step guide to treatment, as these profi les are designed to be used

by fully qualifi ed TCM practitioners with a wide range of backgrounds and clinical experiences. In particular,

where “acupuncture” is listed as a suitable treatment, the selection of points to be used has not been

prescribed here because the treatment used will depend upon the individual patient’s presenting signs and

symptoms and the practitioner’s clinical experience.

Onward referralThis section gives the appropriate referral that should be considered if the patient’s condition causes concern to

the treatment provider.

GP referral may be for considering time off work, medication or further testing and follow-up.

note

Acupuncturists registered with ACC have had extensive training in acupuncture and its various application

techniques.

Many acupuncturists also have training and have gained qualifi cations in other related TCM modalities

such as herbal medicine.

Not all modalities used by ACC acupuncture providers are at this stage funded by ACC. Modalities that are

not funded are indicated with a * symbol throughout the document. Refer to the Glossary for an explanation

of TCM terms.

For the details of modalities funded, please refer to the lists below.

ACC funded rehabilitation:• Acupuncture• Electro-acupuncture• Auricular acupuncture• Laser acupuncture• Moxibustion • Cupping• Gua sha• Tui na (Chinese massage)

Non-ACC funded rehabilitation:• Liniments and herbal plasters*• Herbs and nutritional supplements (Chinese, Western)*• Ion-pumping cords*

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Contents

Read Code reference table PageAnkle

N2174 Tendonitis Achilles ..........................................................................................................................15S34.. Fracture Ankle .................................................................................................................................17S550. Ankle Sprain ................................................................................................................................... 19S5504 Sprain Achilles Tendon ................................................................................................................... 21SE42. Contusion Ankle and Foot exc Toe(s) ............................................................................................... 23

Chest and TrunkS120. Fracture Rib (closed) ....................................................................................................................... 25S5y3. Rib Sprain ......................................................................................................................................28S8… Open Wound Head/Neck/Trunk ...................................................................................................... 30SD10. Abrasion Trunk ............................................................................................................................... 32SE2.. Contusion Trunk .............................................................................................................................. 34SE20. Contusion Breast ............................................................................................................................ 36SE21. Contusion Chest Wall ...................................................................................................................... 38SH2.. Burns Trunk ....................................................................................................................................40

Elbow and ForearmN2131 Medial Epicondylitis – Elbow .......................................................................................................... 43N2132 Lateral Epicondylitis – Elbow .......................................................................................................... 45S2241 Fracture Distal Humerus, Supracondylar (closed) ............................................................................ 47S230./S231. Fracture of Proximal Radius/Ulna .................................................................................................... 50S232./S233. Fracture of Shaft of Radius/Ulna ..................................................................................................... 52S234./S235. Fracture of Distal Radius/Ulna ........................................................................................................ 55S51.. Sprain Elbow/Forearm .................................................................................................................... 58S91.. Open Wound Elbow/Forearm ..........................................................................................................60SD30. Abrasion Lower Arm (no infection) .................................................................................................. 62SE31. Contusion Elbow/Forearm ............................................................................................................... 64SH3.. Burns Arm (excluding Hand) ...........................................................................................................66

FootS352. Fracture Tarsal Bones/Metatarsals (closed) .....................................................................................69S36.. Fracture Phalanges of Foot .............................................................................................................. 72S5512/S5513 Sprain Metatarsophalangeal Joint/Interphalangeal Joint ................................................................. 75SA2../SA3.. Open Wound Foot/Toe(s) ................................................................................................................ 77SE43. Contusion Toe ................................................................................................................................. 79SF322 Crush Injury Foot (closed) ............................................................................................................... 81

HandN220. Tenosynovitis/Synovitis .................................................................................................................. 83S25.. Fracture of Metacarpal Bone ...........................................................................................................86S26.. Fracture Phalanges of Hand ............................................................................................................88S44.. Dislocation/Subluxation of Finger/Thumb ......................................................................................90S5204 Sprain Radial Collateral Ligament (Thumb) ...................................................................................... 92S522. Sprain Thumb ................................................................................................................................. 94S523./S5513 Sprain Finger/Interphalangeal Joint ................................................................................................96

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S92../S9300/S9302 Open Wound Hand/Open Wound Fingers/Open Wound Thumb .......................................................98S935./7G321 Open Wound Fingernail/Avulsion of Nail ....................................................................................... 100S96.. Amputation Finger(s) .................................................................................................................... 102SE33./SE332 Contusion Finger/Thumb/Fingernail (haematoma) ........................................................................ 104SF23./SF231/SF233 Crush Injury Finger(s) (open/closed)/Thumb (closed)/Finger (open) ............................................. 106

Hip and ThighS53.. Sprain Hip/Thigh .......................................................................................................................... 109SE40. Contusion Hip and Thigh................................................................................................................ 111

Knee and Lower LegN2165 Prepatellar Bursitis ........................................................................................................................ 113S33.. Fracture Tibia/Fibula ...................................................................................................................... 115S460. Acute Meniscal Tear (medial) ......................................................................................................... 117S461. Acute Meniscal Tear (lateral) ..........................................................................................................119S533. Sprain Quadriceps Tendon ............................................................................................................. 121S540. Sprain Lateral Collateral Ligament Knee .........................................................................................123S541. Sprain Medial Collateral Ligament Knee .........................................................................................125S542. Sprain Cruciate Ligament Knee ......................................................................................................127S54x1 Sprain Gastrocnemius .................................................................................................................. 129SA100/SA101 Open Wound Knee/Leg .................................................................................................................. 131SD60./SD602 Abrasion Leg/Knee ........................................................................................................................133SE41. Contusion Knee and Lower Leg ......................................................................................................135SE44. Contusion Lower Limb (multiple sites) ...........................................................................................137SH5.. Burns Lower Limb ..........................................................................................................................139

MiscellaneousE2A2. Post-Concussion Syndrome ........................................................................................................... 141S82.. Open Wound Ear ............................................................................................................................143S830./S8342 Open Wound Scalp/Forehead ........................................................................................................145S832./S8341/S8343/S8344/S8345/S836. Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth ......................................................................147S87../S88.. Open Wound Buttock/External Genitalia ....................................................................................... 149S906./S97../S97X./SA6../SA78./SA7X. Amputation at Shoulder/Hand/Elbow/Foot/Upper Leg/Lower Leg .................................................. 151SD000 Abrasion Face ................................................................................................................................153SE0.. Contusion Head/Neck ....................................................................................................................155SE24. Contusion Genital Organs ..............................................................................................................157SH1.. Burns Head/Neck ..........................................................................................................................159TE532 Toxic Reaction Bee Sting ................................................................................................................161TE60. Bite (dog) .....................................................................................................................................163U120. Bite (human) .................................................................................................................................165

ShoulderN211. Rotator Cuff Syndrome ...................................................................................................................167N21z2 Tendonitis Upper Limb ...................................................................................................................170S20.. Fracture Clavicle (closed non-displaced) ........................................................................................172S226. Fracture Humerus (closed proximal) ...............................................................................................174S41.. Dislocation/Subluxation Shoulder .................................................................................................176S50.. Sprain Upper Arm/Shoulder ..........................................................................................................178S500. Sprain Acromio-Clavicular Ligament .............................................................................................. 180S503. Sprain Infraspinatus Tendon ......................................................................................................... 182S504. Rotator Cuff Sprain ....................................................................................................................... 184S507. Sprain Shoulder Joint .....................................................................................................................187

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S5Q2. Rupture of Supraspinatus ............................................................................................................. 189S5Q4. Rupture of Biceps Tendon ..............................................................................................................191S90.. Open Wound Shoulder/Upper Limb ...............................................................................................193SD20. Abrasion Upper Arm (no infection) .................................................................................................195SE3.. Contusion Upper Limb ...................................................................................................................197SE30. Contusion Upper Arm/Shoulder .................................................................................................... 199SF203 Crush Injury Upper Arm ................................................................................................................. 201

SpineN12C0 Cervical Disc Prolapse Radiculopathy ............................................................................................ 203N12C1 Thoracic Disc Prolapse Radiculopathy ........................................................................................... 205N12C2 Lumbar Disc Prolapse Radiculopathy ............................................................................................ 207N131. Chronic/Recurrent Pain (cervical) ..................................................................................................209N142. Low Back Pain, Acute Pain – Lumbar, Lumbago ..............................................................................211N143. Sciatica .........................................................................................................................................214S561. Sprain Sacroiliac Joints ................................................................................................................. 216S570. Sprain Cervical Spine .................................................................................................................... 218S5704 Whiplash .......................................................................................................................................221S571. Sprain Thoracic Spine ................................................................................................................... 223S572. Sprain Lumbar Spine ....................................................................................................................226S574. Sprain Coccyx ...............................................................................................................................228SE23. Contusion Back............................................................................................................................. 230SF110 Crush Injury Back .......................................................................................................................... 232

WristF340. Carpal Tunnel Syndrome ............................................................................................................... 235N2264 Flexor Tendon Rupture Hand/Wrist ................................................................................................ 237S2401 Fracture Scaphoid (closed) ........................................................................................................... 239S24z. Fracture Carpal Bone .....................................................................................................................241S52.. Sprain Wrist/Hand ........................................................................................................................ 243S524. Sprain Tendon Wrist or Hand ......................................................................................................... 246S91.. Open Wound Wrist ........................................................................................................................ 248SE32. Contusion Wrist/Hand .................................................................................................................. 250SF22. Crush Injury Wrist or Hand ............................................................................................................ 252SH4.. Burns Hand(s)/Wrist ..................................................................................................................... 254

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Glossary

AbbreviationsThe channel abbreviations are those as suggested by the World Health Organisation,

LU – LungLI – Large IntestineST – StomachSP – SpleenHT – HeartSI – Small IntestineBL – BladderKI – KidneyPC – PericardiumSJ – San JiaoGB – Gall BladderLR – Liver

Treatment techniquesThis Glossary incorporates TCM concepts and physiological processes from evidence-based studies.

Acupuncture (TCM) The insertion of fi ne, sterile, stainless steel needles into the body at carefully selected points which can be but is not limited to the following:Relieves pain by treating stagnation of Qi and Blood in the affected areas and channelsReleases endogenous opioid peptides e.g. endorphinsTreats Qi block (shock)Calms the Shen (mind-spirit)Reduces oedemaDecrease infl ammationPromotes wound and fracture healing Relieves muscle spasmRestores motor functionPromotes nerve regenerationReduces scarring and adhesionsInduces other changes in: neurotransmitters, blood sugar levels, hormones, amino acids, gastric acid, gastric and gut peristalsis, polypeptides, blood fl ow, blood pressure, blood components e.g. white blood cells etcPromotes immune responsesDilates the bronchi

Treatment rehabilitation:

Acute phase: Lists the types of treatments suggested to obtain a therapeutic result

Sub-acute phase: Lists the types of treatments suggested to obtain a therapeutic result

Electro-acupunctureElectrical stimulation applied to acupuncture needles which:Promotes Blood and Qi circulationProvides pain reliefRestores motor functionPromotes nerve and muscle regenerationReduces oedemaReduces infl ammation

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Reduces scarring and adhesionsPromotes natural opiate releaseChanges: neurotransmitters, blood sugar levels, hormones, amino acids, gastric acid, gastric and gut peristalsis, polypeptides, blood fl ow, blood pressure, blood components e.g. white blood cells etc

Auricular acupunctureA microsystem of the whole body represented on the ear which:May be used alone or adjunctively to reinforce acupuncture and other techniquesAlters brain responses (neurophysiological mechanisms) e.g. relieves nausea, relieves painNormalises the fl ow of Qi and BloodStimulates and regulates channelsAssists organ functionTreats Qi block (shock)

Laser acupunctureThe use of laser light on acupuncture points which:Invigorates Blood and Qi in tissues and channelsReduces oedemaReduces infl ammationStimulates cell growth in connective tissue, tendon, bone, nerve, skinReduces fi brous tissue formation e.g. burns, wounds, post-surgeryStimulates nerve regeneration Especially useful for treating injury in children

MoxibustionThe burning of Moxa (Artemesia Vulgaris) to apply heat to points/areas on the body which:Stops bleeding by warming channelsDispels pathogenic factorsMoves stagnant Blood and Qi in affected areas and channelsFacilitates smooth Qi and Blood circulationWarms and tonifi es QiStrengthens Yang Qi Nourishes and invigorates BloodDisperses Cold and expels WindRelieves pain

CuppingThe application of suction cups to the body which:Removes stagnant Qi and BloodPromotes Blood and Qi circulationDraws to the surface and expels pathogenic factors e.g. Wind obstructing the channelsDispels dampnessRelieves pain by drawing blood into muscle Relieves contracture by drawing blood into ligaments and tendonsAdjusts and enhances Zang Fu functions

Gua sha One of the Chinese therapeutic manual techniques which:Treats diseases of external originRelieves chronic and consistent pain by moving stagnant Qi and BloodPromotes circulation of Qi and BloodReduces bruising

Tui na (Chinese therapeutic massage)One of the Chinese therapeutic manual techniques which:Promotes Qi and Blood circulation in the channelsInvigorates BloodReleases tightness, tension or spasm in muscle, tendon and ligament Breaks up adhesionsReduces scarringProvides gentle stretching and mobilisation/massage of muscles, tendons, ligaments and jointsRelieves pain

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Liniments and herbal plasters (non-alcohol based)*A herbal preparation applied to the body which:Promotes Blood and Qi circulationClears stagnant Qi and BloodReduces infl ammation, swelling and painReleases tightness, tension or spasm in muscle, tendon and ligament Promotes tissue healingPromotes fracture healingResolves bruising

Ion-pumping cords*A specialised treatment technique developed by Dr Yoshio Manaka for the treatment of burns and other conditions which:Comprises copper wires attached to clips, with a diode in one clip so that the electrical fl ow progresses in one direction and connects to acupuncture needles and/or foil placed over the injured areaUses the body’s inherent relative electrical potentialsProvides dramatic local pain relief in the burned area

Muscle-tendino (sinew)Also known as tendino-muscle channels or sinew network vessels

Eight extraordinary vesselsTheir basic function is to supplement the insuffi ciencies of the other channels and also act as reservoirs of evil Qi (Xie Qi )

Fundamental substancesThe following substance defi nitions are taken from TCM theory and philosophy.

Qi Qi is the vital force of life which:Is usually understood to mean “energy”In Chinese medicine has many different forms e.g. Protective energy (Wei Qi) Is the material substrate of the Universe Is the material and spiritual substrate of human lifeIs a primordial impulse which stands at the origin of the Universe and creates all the phenomena within itIs Yang in nature

BloodBlood is a material substance which:Moistens and nourishes the entire body through circulation Is the mother of QiIs inseparable from Qi – Qi infuses life into Blood and without Qi, Blood would not fl owIs a Yin fl uid Moves and circulates with Qi

JingJing is usually translated as “essence” which:Determines our basic constitutional strength Is responsible for determining physical growth and development, reproduction and maintenance of lifeProduces marrow and also fi lls the spinal cord and brainIs a Yin substance

ShenShen is one of the Vital Substances of the body which:Is translated as “spirit” or “mind” Allows the ability to think, form ideas, discriminate and choose appropriatelyCan be seen as the sparkle in the eyes

Jin YeJin Ye embraces all normal fl uid substances of the body, other than blood, and:Has two types:• Jin Liquid e.g. watery fl uids moistening mucous membranes• Ye Humour e.g. thick turbid fl uids e.g. synovial fl uidIs Yin in nature

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ConceptsThe following concept defi nitions are taken from TCM theory and philosophy.

Channels Channels are pathways which:Are known as the Jing Circulate Qi and Blood to the entire bodyAre related to the Zang Fu internallyAre made up of fi ve parts:• Part One – the main, or regular, channels usually referred to as the 12 Channels and known as Jing Mai• Part Two – divergent channels which run with the main channels and are called Jing Bie• Part Three – the sinew channels, or musculo-tendino channels, which are known as the Jin Mai • Part Four – the eight extraordinary vessels, known as the Qi Jing Ba Mai, which are the deepest and most

fundamental of the channel systems, linking to our source Qi and to the universal Qi• Part Five – connecting channels, known as the Luo Mai, which enmesh the body, forming a network running

transversely between the Jing Mai, and also form small superfi cial branches on the surface of the body

Yin YangYin and Yang are the two fundamental forces in the Universe which:Are ever opposing, independent and interchanging Sustain and complement each other Are present in every aspect of life e.g. Qi is Yang, Blood is Yin, sun is Yang, moon is Yin

Zang FuZang Fu are the internal organs which:Are divided into Zang and Fu:• Zang are Yin solid organs – heart, liver, spleen, lung, kidney, pericardium – which transform and store vital

substances in the body• Fu are Yang hollow organs – small intestine, gall bladder, stomach, large intestine, bladder, san jiao – which

are mainly involved in transporting nutrients into, or waste out of, the body

Brain The brain is an extraordinary organ located in the skull which:According to the ancient Chinese, is “the sea of marrow”Is considered to be the same in substance as marrowIs most closely related to the Chinese concept of “Kidney” since the Kidney produces marrow

Bi SyndromeBi is translated as “impediment” and is usually understood to mean “obstruction” which:Is a syndrome of the channels rather than the internal organsPresents as pain, soreness, swelling, distention, heaviness or numbness of muscles, tendons, joints and bonesIs caused by invasion of external climatic pathogenic factors: Wind, Cold and Damp, which lead to stasis of Qi and Blood in the channels and collateralsIs classifi ed into four types:• Wandering Bi in which pathogenic Wind predominates• Painful Bi in which pathogenic Cold predominates• Fixed Bi in which pathogenic Damp predominates• Febrile Bi in which Wind, Cold and Damp, over time, transform into Heat

Xie QiXie Qi is pathogenic or “evil” Qi which:Refers to any external illness-causing factorIs usually related to the six climatic factors: Wind, Cold, Fire, Damp, Summer Heat and Dryness

Stasis/StagnationStasis is sluggish movement which:Refers to the circulation of the fundamental substances Qi and Blood Leads to blockage in channels when the stasis is chronic

Qi BlockQi Block means “extreme shock” which:Means Qi is severely compromised and life is threatened

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Damages the Chinese concept of “Kidney” and its function Occurs in severe trauma

Toxin (Heat/Damp)Heat toxin and damp toxin are external “evil” pathogenic factors which:Cause disease when they enter the body through the skin, body orifi ces or a wound.

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Tendonitis AchillesRead Code: N2174

Number of treatments: 12 Triggers: 16

Key points Infl ammation of the tendon itself or surrounding paratendon (peritendinitis) from overuse causing degenerative and infl ammatory changesTermed Achilles tendinopathy if due to collagen degeneration

Special considerations (WMS and TCM)

Presentation is often sub-acute or chronicRecovery may be prolongedRefer if partial rupture is suspectedUnsuitable footwear

History(WMS and TCM)

Mechanism of injury: unaccustomed running or long walk; change of running routine; change of sports footwear; repetitive stress; overuseAching pain on using tendonTendon feels stiff, especially morningsMay be slow onset (weeks)Previous injury or steroid injectionPrevious history of injuriesPrevious treatment, management, investigations, outcomesFunctional limitationsOccupationGoutJoint problems

Examination(WMS and TCM)

PulseTongueShen and emotionsComplexion colourObservation:• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation:• Associated channels• Mu and shu points• A shi pointsCompare with other sidePalpable crepitus on movement of tendonPain on dorsifl exionTight calf musclesTender thickened tendonCalf squeeze (Thompson test) for tendon ruptureGait/weight-bearing abilityRange of movement of ankle: active, passiveAnkle joint dysfunctionOther joint examination

WMS differential diagnosis

Bursitis (retro-calcaneal)Deep vein thrombosisAchilles tendon rupture (partial or complete)Tendonitis: tibialis posterior, peroneal, fl exor hallucis longusCalcaneal stress fractureOther fracturesBruising/haematomaInfl ammatory arthritis/gout/osteoarthritisSever’s disease (calcaneal epiphysitis) in childrenCompartment syndromeSubtalar or talo crural joint dysfunctionRadiculopathy from lumbar spine

15

WMS complications RecurrenceRupture, particularly after steroid injectionSteroid depositionsSevere biomechanical dysfunction

TCM differential diagnosis

Injury to tendon following traumaQi and Blood stasis in the affected channels following overuse, misuse or traumaStasis of Liver Qi obstructing the fl ow in the affected channels Liver Blood defi ciency failing to nourish tendons and ligamentsBi Syndrome resulting from the accumulation of Damp, Cold, Wind and/or Heat

TCM complications Same as WMS complications above plus:Delayed healing or recurrence if predisposing factors are not corrected e.g. stasis of Liver Qi, Liver Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)

Treatment rehabilitation

WMS goals: Facilitate circulation; decrease infl ammation; reduce oedema; decrease pain; restore range of movement

TCM goals: Clear stasis of Qi, Blood, Damp, Cold, Wind and/or Heat to decrease pain and restore range of movementNourish Blood and reinforce Qi to remove predisposing factors and correct any underlying defi ciencies

Acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser acupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion Tui na Liniments and herbal plasters*Herbs and nutritional supplements*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristHerbal Specialist *

16

Fracture AnkleRead Code: S34..


Key points Most common ankle fractures result from rotation of the talus in the mortise, fracturing one or both malleoliEnsure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Open fractures have a high risk of infectionDelay in treatment increases risk of complicationsLateral versus medial fractures


Mechanism of fracture: eversion, inversion, or external rotationTrauma may be subtle in the elderly e.g. sudden pain after stepping from a kerbHistory of previous fracturesHistory of immediate treatment and carePainSwelling


PulseTongueShen and emotionsComplexion colourObservation:• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation:• Associated channels• Mu and shu points• A shi pointsNeurovascular status of foot: posterior tibialis and dorsalis pedis pulses, capillary returnHaemarthrosisDeformitySwelling BruisingTemperature (especially coldness of the toes)Gait function of hip and kneeRange of movement of ankleMobilityWeight-bearing abilityFunctional limitation


Ankle sprainDislocationFracture of footFracture of tibia/fi bulaLateral or medial ligament injuryTendon or muscle injury

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WMS complications Swelling persisting for weeks or months is commonAvascular necrosisInstability due to lateral ligament ruptureOsteochondral fractureNon-union, delayed union, or malunion of fractureDeep vein thrombosisInfectionSkin breakdownNerve involvementOsteoarthritis


Damage to bone and surrounding structures resulting in Qi and Blood stasis in the affected channels following trauma

TCM complications Same as WMS complications above plus:Non-union of fracture due to factors such as concurrent Kidney Qi and Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)


WMS goals: Decrease pain and swelling; increase blood vascularisation; enhance healing of fracture; restore range of movement

TCM goals: Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and QiNourish Blood and reinforce Qi to enhance union of fracture and restore range of movement and prevent infection Correct any underlying patterns of imbalanceCalm Shen

Advice (WMS and TCM):Acute phase – rest, non-weight bearingFollow orthopaedic advice regarding weight-bearing status and exercise activityBe mindful of medications that reduce gastric acid and therefore reduce calcium uptake e.g. anti-infl ammatories, losec, smoking

Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser acupunctureMoxibustionTui na Liniments and herbal plasters*Herbs and nutritional supplements*

Onward referral Acute phase:Accident and emergency clinic for all fracturesGPPhysiotherapistOsteopathChiropractorPodiatrist Herbal Specialist*

18

Ankle SprainRead Code: S550.


Key points Approximately 90% of ankle sprains involve lateral ligaments (anterior talofi bular, lateral collateral ligament, calcaneofi bular and posterior talofi bular ligaments)Medial ligament sprains, including the deltiod ligament, are rarely isolated and may hide additional sprains or fractureOsteochondral injury/capsulitis requires referral: indications include prolonged (>6 weeks) symptoms of pain, swelling, antalgic gait, decreased range of movement


Children under 12 years rarely sprain ligamentsElderly patients are more likely to fracture than sprainInversion injuries may involve fracture of the fi fth metatarsalAssociated tibialis posterior tendon rupture, especially in patients over 45 yearsFoot should be maintained at 90 degrees fl exion for perfect healing of ligaments


Mechanism of injury: forced inversion (lateral ligaments); eversion (medial ligaments)Compressive injury may indicate osteochondral injuryRecord whether weight-bearing at time of injuryAcute or recurrentLocation of pain: medial or lateralSwellingPain elsewhere in limbLoss of function/instabilityWeight-bearing abilityPrevious history of injuriesPrevious treatment, management, investigations, outcomesOccupational requirementsGeneral health and medication


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGait/weight-bearing abilityProprioceptionSite of tendernessSwelling: often rounded swelling in front of lateral malleolusBruising: may take 12-24 hours, indicates more severe injuryRange of movement of ankleJoint laxity: compare with other ankle; Drawer test for ATFL/GradeCheck full length of fi bula and base of fi fth metatarsal for fracturesNeurovascular statusLumbar spine/hip

19


Lateral or medial sprainFracture: lateral malleolus, base of fi fth metatarsalAnterior inferior tibio-fi bular ligament ruptureRupture of tibialis posterior tendonSubtalar joint dysfunctionPeroneal nerve neuropathyTarsal tunnel syndromeLigamentous laxity

WMS complications Swelling – may persist for weeks or monthsPain syndromeOsteoarthritisInstability – refer for radiographic investigation for ligament damageOsteochondral defectsCapsulitisAvulsion fractureRecurrence


Tissue damage and injury to muscle, tendons and ligaments following traumaQi and blood stasis in the affected channels following traumaLiver Blood defi ciency failing to nourish tendons and ligaments

TCM complications Same as WMS complications above plus:Delayed healing and recurrence due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion by Wind, Cold, Damp and /or Heat (Bi Syndrome)


WMS goals: Decrease infl ammation, pain, oedema and bruising (RICE in fi rst 48 hours); restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction

TCM goals: Clear stasis and re-establish fl ows of Qi and Blood in the affected channels Nourish Blood and reinforce Qi to restore movement Correct any underlying patterns of imbalance

Acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser acupunctureCupping Tui na

Sub-acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser acupunctureMoxibustionCupping Tui naLiniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristHerbal Specialist*20

Sprain Achilles TendonRead Code: S5504


Key points


Recovery may be prolongedSystemic corticosteroid medication may contribute or predispose the patient to injuryRefer if partial rupture is suspected


Mechanism of injury: running, jumping, hurrying up stairsSudden sharp pain at time of injuryPain distributionPrevious injury or steroid injectionPrevious treatment, management, investigations, outcomesFunctional limitations: walking, runningGeneral health: medicationsOccupationGoutOther joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other sidePalpable tender swelling approx. 2.5cm above tendon insertionPossible very tender defect about size of tip of little fi ngerPain on dorsifl exionCalf squeeze (Thompson test) for tendon ruptureGait/weight-bearing abilityRange of movement of ankle: active, passiveAnkle joint dysfunctionLumbar spine/hip dysfunctionOther joint examination


Bursitis (retro calcaneal)Deep vein thrombosisAchilles tendon rupture (partial or complete)Tendonitis: tibialis posterior, peroneal, fl exor hallucis longusCalcaneal stress fractureOs trigonum fractureOther fracturesBruising/haematomaInfl ammatory arthritis/osteoarthristis/goutSever’s disease (calcaneal epiphysitis) in childrenCompartment syndromeSubtalar or talo crural joint dysfunction

21

WMS complications RecurrenceRupture, particularly after steroid injectionSteroid depositionsSevere biomechanical dysfunctionTendonitis


Injury to tendon following traumaQi and Blood stasis in the affected channels following traumaLiver Blood defi ciency failing to nourish tendons and ligaments

TCM complications Same as WMS complications above plus:Delayed healing and recurrence due to factors such as underlying defi ciencies e.g. Liver Blood defi ciency, Kidney Qi defi ciency, Kidney Yin defi ciencyChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)


WMS goals: Decrease infl ammation, pain, bruising and oedema (RICE in fi rst 48 hours); restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction.

TCM goals: Decrease infl ammation, pain, bruising and oedema by clearing stasis and normalising the fl ow of Qi and Blood in the affected channelsNourish Blood and reinforce Qi to restore normal range of movement and prevent adhesion/scarring Correct any underlying patterns of imbalanceCalm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureTui na

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustionCupping Gua shaTui naLiniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristHerbal Specialist*

22

Contusion Ankle and FootRead code: SE42.


Key points


Risk of compartment syndrome in limbs, indicated by severe pain disproportionate to injuryMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: fall, direct blow, vehicle accidentLocation and severity of painOnset of physical signsHistory of immediate managementChronicityPrevious injuries to affected siteFunctional restrictionsNeurological changesMedical conditions and drug therapyEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourConsider associated injuriesRange of movement: knee and ankleStability of ankle jointPalpation: check temperature for infection; check for pulse of dorsalis pedis arteryNerve involvement: sensory and motor changes


Presence or risk of compartment syndromeFractureMuscle or tendon ruptureAbrasionImpaired circulationNerve lesion

WMS complications Compartment syndromeIschaemic contracturesDeep vein thrombosisExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useNeurological signsInfectionSuspected fractureChronic painBiomechanical dysfunction

23


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruising

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat


WMS goals: Enhance healing of contusion; reduce pain and swelling (RICE in fi rst 48 hours); restore range of movement.

TCM goals: Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:Acupuncture Electro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristHerbal Specialist*

24

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Fracture Rib (closed)Read code: S120.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenX-ray should be used to exclude underlying lung damage, e.g. pneumothoraxLower rib fractures may involve damage to spleen, liver or kidneysIf pain is non-traumatic, suspect tumourRib fractures in children can indicate severe trauma (consider non accidental injury) Fractures of 1st and 2nd ribs cause up to 30% mortality due to injury to the aorta and subclavian artery; also brachial plexus injuryVentilation can be compromised by splinting, interference with normal rib and diaphragm movement, haemothorax, pneumothoraxFracture may be missed on X-rayAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Rib fractures in the elderly may require admission to hospitalPosterior rib fractures may present as back injury


Mechanism of injury: direct blow, crush, fall, projectile, CPR, vehicle accidentSingle or multiple fracturesPrevious history of injuriesNature and severity of pain: pain over fracture site worse for deep inspiration and coughingHaemoptysisRespiratory distressFunctional limitationsGeneral health past and presentMedication/steroid use


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsLocalised tenderness and swellingLocalised chest wall deformityBreathing diffi cultyRange of movement: shoulders and trunkPosturePalpation: extent of tendernessDepending on location of pain- consider other structuresLower ribs (L)- spleenLower ribs (R)- liverRibs 11/12- kidneysCirculation

25


Injury to sternum/thoracic spineSterno-clavicular joint strainScapular fractureAcute respiratory distress syndromePneumothoraxPneumoniaPulmonary embolusAbdominal traumaIntercostal muscle strainTumourInjury to visceraOsteoporosisNon-accidental injury

WMS complications PneumothoraxHaemothoraxOrgan damageAtelectasisRetention of sputum/infection/atelectasisCardiac contusion


Damage to bone following trauma Damage to surrounding structures and internal organs resulting in Qi and Blood stasis in the affected channels following traumaSub-acute: chronic Qi and/or Blood stasis in the ST, SP, BL, KI, GB or LR channels and/or luo vesselsPossible involvement of Eight Extraordinary Vessels Underlying defi ciency e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome)

26


WMS goals: Decrease pain; restore range of movement; enhance repair of fracture; increase blood vascularisation; decrease fl uid retention

TCM goals:Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm Shen, Nourish Blood and reinforce Qi to enhance union of fracture and restore range of movement Correct any underlying patterns of imbalance

Advice (WMS and TCM):Acute phase – restFollow orthopaedic advice regarding exercise activityBe mindful of medications that reduce gastric acid and therefore reduce calcium uptake e.g. anti-infl ammatories, losec, smoking

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion

Sub acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorOccupational therapist

27

Rib SprainRead code: S5y3.


Key points Includes costo-vertebral, costo-chondral and chondro-sternal sprainsX-ray can be used to exclude rib fracture or pneumothoraxSignifi cant associated pathology is unlikelyBeware of children- less fracture chance after major trauma equates to a higher risk of intrathoracic damage


Consider pulmonary embolusDecreased lung functionDecreased range of movement of shoulder, cervical spine, thoracic spineChronic pain


Mechanism of injury internal or external: cough, sneeze, external force, fallPrevious history of injuries or painNature and severity of pain: pain on inspiration, sneezing, coughing, stretchingPain on rotation/side fl exionAggravating and relieving factorsDyspnoeaHaemoptysisRespiratory disease, asthma, URTI, smokerSprain of fi rst rib: brachial plexus symptomsFunctional limitationsGeneral health past and presentOsteoporosisMedication


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsLocalised tendernessCheck for bruising and swellingBreathing diffi cultyMuscle spasmRange of movement: shoulders and trunkPostureThoracic and cervical spine


Consider pulmonary embolusContusionRib fracture, including cough fractureDislocationThoracic spine injury/dysfunction/pathological fractureReferred pain from cervical or thoracic spinePleural irritationPneumothoraxCostochondritisOsteoarthritisOsteoporosisMyocardial infarctionReferred pain from organs or vascular disorderInfection: respiratory, herpes zoster, infective endocarditis

28

WMS complications PneumothoraxHaemothoraxContusion of visceraNerve involvementVascular involvementRetention of sputum/infection/atelectasis


Tissue damage and injury to muscle, tendons and ligamentsExternal stagnation of Qi and Blood in surrounding structures and internal organsQi and Blood stasis in local affected area, consider: ST, SP, SI, LI, BL, KI, GB, LU or LR channelsPossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g. Qi defi ciency

TCM complications Same as WMS complications above plus:Delayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome)


WMS goals: Decrease pain and any infl ammation, oedema, or bruising; restore range of movement

TCM goals: Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movementCorrect any underlying patterns of imbalance

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionGua sha Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistChiropractorOsteopath

29

Open Wound Head/Neck/TrunkRead code: S8…


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinic


Penetrating wounds may also involve internal structures


Mechanism of injuryCircumstances of injury: work-related, assault, self-infl ictedHistory of immediate treatmentAssociated symptoms/injuriesPotential for infectionPrevious injury/disabilityMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, tetanus statusEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite and extent of woundSigns/risk of infectionRetained foreign bodiesSensory function/motorRange of movementPain: location, nature, severityOedema: extent and severityBruising: colour, extent


AbrasionCrush injuryFractureLigament, tendon or nerve damageArterial lacerationInternal injury

WMS complications Intra-thoracic or abdominal injuries: pneumothorax, haemothoraxInfectionScarringStiffness


Injury to skin, surrounding tissues and underlying structures Qi and Blood stasis in local area and affected channels, consider: ST, SP, SI, LI, BL, KI, GB, LU or LR channelsQi and Blood stasis in surrounding structures and internal organsPossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g. Qi defi ciency

30

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. tendon, nerve, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinDepending upon the depth of the injury there may be damage to the affected cutaneous region, musculo-tendinous channel, divergent and or main channel, and Zang Fu organsExcessive bleeding may lead to Blood defi ciency


WMS goals:Enhance healing of wound; reduce pain and swelling; restore range of movement

TCM goals:Restore Qi and Blood fl ow to decrease pain Calm Shen Resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Onward referral GP

31

Abrasion TrunkRead code: SD10.


Key points Superfi cial injury or laceration not involving deep structures


In children the greater fl exibility of the rib cage can allow serious underlying injury to occur with little sign of external traumaAbraded skin is prone to hyperpigmentation – advise sunblock for six months after injuryInvolvement of underlying organs, nerve, tendon, muscleMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)Abrasion caused by animals needs caution re: infection


Nature of trauma causing injuryMedical history including medicationGeneral health, tetanus status/symptoms of infectionEmotional response to traumaFunctional limitationsPain: associated pain with underlying structures


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsEffects on breathingDeformityWound size, depth, locationRetained foreign bodiesJoint involvementOedema: extent and severityBruising: extent, severity, colour/signs of infectionPalpation: check temperature for infectionCirculatory problemsNeurological signs


Intra-thoracic or intra-abdominal injuriesUnderlying fractureDeep laceration involving deeper structuresContusion

WMS complications Associated intra-thoracic and abdominal injuriesNerve involvementInfectionScarringInternal bleeding with bleeding disorders


Superfi cial damage to cutaneous regionQi and Blood stasis in local cutaneous region and affected channels following trauma, consider: ST, SP, SI, PC, LI, BL, KI, GB, LU or LR channelsPossible involvement of Eight Extraordinary Vessels

32

TCM complications Same WMS complications above plus:Damage to underlying channel systems and structuresInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinDepending upon the depth of the injury there may be damage to the affected cutaneous region, musculo-tendinous channel, divergent and or main channel


WMS goals: Enhance healing of abrasion; reduce pain and swelling

TCM goals:Restore Qi and Blood fl ow to decrease pain Calm Shen Resolve toxins Correct any underlying patterns of imbalance



Onward referral Accident and Emergency DepartmentGP

33

Contusion TrunkRead code: SE2..


Key points X-Rays should be advised if fracture of bones is suspectedDamage to internal organs is possibleUnremitting or escalating pain needs prompt referral to GP or Accident and Medical Clinic


General healthMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: high or low impact, assaultDirection of forceRespiratory diffi cultyLocation and severity of painHaematuriaEmotional response to traumaGeneral health including medicationsFunctional limitations


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourConsider associated injuriesRange of movement: shoulders, trunkPalpation: check temperature for infectionMuscle spasm


Fracture: ribs, sternum, vertebrae, scapula, iliac crestUnderlying joint pathologyAbrasionPneumothoraxBrachial plexus involvementVisceral injurySpinal injuryFracture

WMS complications PneumothoraxExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyosotis ossifi cansNeurological signsInfectionVisceral damageChronic pain

34


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, SI, PC, LI, BL, KI, GB, LU or LR channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus Damage to surrounding structures eg bone, nerve, tendonChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat


WMS goals: Enhance healing of contusion; reduce pain, swelling and bruising

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and BloodCorrect any underlying patterns of imbalance. Calm Shen


Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCupping Gua shaTui na Liniments and herbal plasters*


35

Contusion BreastRead code: SE20.


Key points Pain is the most signifi cant indicator of severity


Support person present during treatmentPregnancy, lactationEmotional response to injury/examination


Nature of trauma causing injury: accident, assaultEmotional response to traumaGeneral health including medications/bleeding disorder


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous Regions, Tai Yang, Shao Yang etc• Tendino Muscle Channels (Sinew Network Vessels)Palpation• Associated Channels• Mu And Shu Points• A Shi PointsOedema: extent and severityBruising: extent, severity, colourRange of movement: shouldersLocation and nature of painRespiratory problemsSensory changes/paraesthesia


Fracture: ribs, sternumPneumothoraxBreast abscess

WMS complications Mastitis effect on lactationBlocked lymph fl owPneumothoraxExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useInfection


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, PC, HT, KI, GB, LU or LR channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures Chronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance

36




Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*Support bra

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*Support bra

Onward referral CounsellorGPPhysiotherapistOsteopathChiropractorOccupational therapistLactation therapist*

37

Contusion Chest WallRead code: SE21.


Key points X-Rays should be advised if fracture of bones is suspectedDamage to internal organs is possibleEnsure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenX-ray should be used to exclude underlying lung damage, e.g. pneumothoraxLower rib fractures may involve damage to spleen, liver or kidneysIf pain is non-traumatic, suspect tumourRib fractures in children can indicate severe trauma (consider non accidental injury) Fractures of 1st and 2nd ribs cause up to 30% mortality due to injury to the aorta and subclavian artery; also brachial plexus injuryVentilation can be compromised by splinting, interference with normal rib and diaphragm movement, haemothorax, pneumothoraxFracture may be missed on X-rayAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Lung function testsGeneral healthMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)

History(WMS)

Nature of trauma causing injury: high or low impactRespiratory diffi culty/haemoptysis, cough, sputumSite of pain and severityEmotional response to traumaGeneral health including medications/history of bleeding disorderAddominal pain


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourRange of movement: shoulders, trunkPalpation: check temperature for infection, tendernessBreathing: depth, diffi culty, pain, rateMuscle spasm


Fracture: ribs, sternumAbrasionCostocartilage injuryPneumothorax, pulmonary injuryPain referred from thoracic spineBrachial plexus involvementVisceral injurySpinal injuryFracture

38

WMS complications PneumothoraxExcessive bleeding and haematoma as a result of of bleeding disorder or anticoagulant useNeurological signsInfectionVisceral or cardiac involvement


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, BL, PC, HT, KI, GB, LU or LR channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Damage to surrounding structures eg bone, nerve, tendonChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance



TCM goals: Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and BloodCorrect any underlying patterns of imbalance. Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*



39

Burns TrunkRead code: SH2..


Key points Acupuncture is not an appropriate frontline treatment for burns. Ensure that the patient has been assessed by a medical practitioner.Management depends on extent and depth of burn (superfi cial or deep)Refer to hospital if burn is >10% of body surface area: all children; all deep burns; burns with potential problems, e.g. electrical, chemical, circumferential


General healthEmotional response to injuryExposed tendon/boneMore severe burns can involve fl uid loss and secondary organ damage


Cause of burn: fl ame, scald, chemical, electrical, etcPercentage of body area involvedDepth of burnRespiratory diffi culty: inhalation injuryHistory of immediate managementPain level: check pain management is adequateSurgical interventionLength of hospital stayPrevious medical historyFunctional limitationsEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsStage of healingScarringCondition of skin graft donor siteOedemaRange of movement: shoulders, trunkContractures/deformitiesLoss of functionDifferentiate affected structure limiting range of movement: skin, scarring, ligament, muscle, tendon


Underlying conditions before trauma

WMS complications Wound infectionGraft failureContractures and deformitiesScarringChronic painPsychological/social problemsAltered sensation

40


Damage to tissues and local cutaneous region by excess pathogenic Heat causing obstruction to normal fl ows of Qi and Blood in the affected channels, consider: ST, SP, BL, PC, HT, KI, GB, LU or LRIn severe cases consider concurrent Yin fl uid damage and damage to underlying structures (in extreme cases the Zang Fu)Qi block due to frightPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Damage to underlying structures Potential febrile Bi syndromeInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceDamage to Yin and Jin-Ye (fl uids)Prolonged Qi and Blood stasis leading to scarring/contracture


WMS goals: Enhance healing of affected area; reduce pain; restore range of movement

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and BloodCorrect any underlying patterns of imbalance Calm Shen Nourish Yin fl uids

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*Ion pumping cords*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorOccupational therapistCounsellor

41

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Medial Epicondylitis (elbow)Read code: N2131


Key points ‘Golfers’ elbow’Overuse or overload injury of the forearm fl exor musclesMost common in the 40-60 year age groupElbow fl exion and extension are usually painless


Non-steroidal anti-infl ammatory therapyPrevious steroid injection: can be effective but have potential side effects and should not exceed three injectionsOccupational and leisure activities: identify causative and aggravating factors


Mechanism of injury: acute or recurrent injury, or gradual onsetOccupational overuse syndromePain radiating from medial epicondyle into proximal part of fl exorsPain may be minor or debilitating and affecting sleepRecent changes in work equipment or sports trainingDominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesAggravating and relieving factors: worse after activity, better for restCervical or thoracic spine involvement/sensory or motor changeFunctional limitationsOccupationGeneral health past and presentJoint problems


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain on resisted wrist fl exionLocalised tenderness over medial epicondyleReduced grip strengthNormal elbow movementRange of movement of wrist: active, passive, resistedCrepitus of tendonsPalpation: check temperature for infectionCervical or thoracic spine involvement/sensory or motor changeOther joint involvement


Fracture of medial epicondyleCervical nerve root irritationInstability/injury of ligament/tendonFlexor/pronator tendinosisUlnar nerve compressionApophysitisElbow joint pathology/arthritisReferred pain from cervical spine, shoulder or wristInfectionForearm muscle strain

43

WMS complications Fat atrophy from steroid injectionsComplex regional pain syndromeNeural involvementJoint stiffnessMuscle weakness or atrophy


Injury to fl exor muscles and surrounding structures following trauma , overuse or misuseQi and Blood stasis in local area and affected channels, consider: HT, SI or PC channels, following trauma or overuseUnderlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)

TCM complications Same as WMS plus:Damage to underlying structures e.g. elbow joint, nerve, tendon, ligamentChronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Qi defi ciency, Liver Blood defi ciencyShen disturbance


WMS goals: Decrease pain and infl ammation/oedema; restore range of movement

TCM goals:Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCuppingTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistChiropractorOsteopathOccupational therapist

44

Lateral Epicondylitis (elbow)Read code: N2132


Key points ‘Tennis elbow’Overuse or overload injury of the forearm extensor musclesMost common in the 40-60 year age groupElbow fl exion and extension are usually painless


Non-steroidal anti-infl ammatory therapyPrevious steroid injection: can be effective but have potential side effects and should not exceed three injectionsOccupational and leisure activities: identify causative and aggravating factors


Mechanism of injury: acute or recurrent injury, or gradual onsetPain radiating from lateral epicondyle into proximal part of extensorsPain may be minor or debilitating and affecting sleepRecent changes in work equipment or sports trainingOccupational overuse syndromeDominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesAggravating and relieving factors: worse after activity, better for restCervical or thoracic spine involvementFunctional limitationsOccupationGeneral health past and present


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain on passive wrist fl exionPain on resisted wrist extensionLocalised tenderness over anterior aspect of lateral epicondyleReduced grip strengthNormal elbow movementRange of movement of wrist: active, passive, resistedCrepitus of tendonsPalpation: check temperature for infectionCervical or thoracic spine involvement/sensory or motor changeOther joint involvement


Extensor tendinosisRadiohumeral bursitisInstability/injury of ligament/tendonElbow joint pathology/arthritisReferred pain from cervical spine, shoulder or wristRotator cuff injuryInfection

45

WMS complications Degenerative changes to tendonFat atrophy from steroid injectionsComplex regional pain syndromeNeural involvementJoint stiffnessMuscle weakness or atrophy


Injury to extensor muscles and surrounding structures following trauma, overuse or misuseQi and Blood stasis in local area and affected channels, consider: LU, LI, SJ channels, following trauma or overuseUnderlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)

TCM complications Same as WMS plus:Damage to underlying structures eg elbow joint, nerve, tendon, ligamentChronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Qi defi ciency, Liver Blood defi ciencyShen disturbance


WMS goals: Decrease pain and infl ammation/oedema; restore range of movement; clear pathogenic obstruction (if required)

TCM goals:Decrease pain by clearing of local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance




46

Fracture Distal Humerus, Supracondylar (closed)

Read code: S2241


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenSupracondylar fractures are those just proximal to the humeral condylesSupracondylar fractures represent about half of all elbow fractures in childrenRare in adults, and usually require surgeryBony fragments may impinge on the brachial artery causing forearm fl exor compartment ischaemia and muscle death – urgent referral if symptoms include absent radial pulse, pallor, coldness or paraesthesia of forearmInability to extend fi ngers fully, or pain on passive extension, suggest ischaemic changes or development of compartment syndrome – requires referralThe fracture line is generally transverseMost common fracture of the elbow in children 3-11 yearsAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Occupational and leisure activitiesPathological fractures may occur with minimal trauma


Mechanism of fracture: fall onto outstretched arm; direct blow, axial loading through elbowPatients with a risk of pathological fractures (metastatic cancer of bone, Paget’s disease, osteoporosis, bone cyst)PainOedemaDecreased range of motionCirculation, sensory symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of pain: localised to elbowSevere forearm pain may indicate ischaemia – refer to General Practitioner or Emergency DepartmentBruising/swellingRange of elbow movementRange of movement: wrist and shoulderShoulder/wrist/hand joint injuryCirculatory, sensory, motor examinationNormal position of olecranon and medial and lateral epicondyles, unlike dislocation

47


Associated joint sprainSoft tissue injuryDislocationForearm fractureBursitisSeptic arthritisReferral from cervical or thoracic spineReferral from shoulder injuryOsteochondritis of capitulum/radial head

WMS complications Non-union or malunion of fractureDeformityIschaemia: severe pain in forearmNeuropraxia of median, radial or ulnar nerves: can occur in up to 12% of casesDamage to brachial arteryCompartment syndrome and ischaemic contractures


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels Underlying defi ciency e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg soft tissues, nerve, blood vessel, tendonNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance





Acute phase:AcupunctureElectro-acupuncture Auricular Acupuncture

Sub acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

48

Onward referral Acute phase:Accident and emergency clinic GP

Sub acute phase:GPPhysiotherapistOsteopathChiropractor

49

Fracture of Proximal Radius/UlnaRead code: S230./S231.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenIncludes both open and closed fracturesRadial head dislocation or fracture can easily be missedHand dominance/occupation may affect managementAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Hand dominance/occupation may affect managementOsteoporosisForearm nerves/vessels may be damaged


Mechanism of fracture: fall onto outstretched arm; direct blow to elbowSurgical intervention: outcomesPain: location, radiationDominant/non-dominant armPrevious fracturesAlways suspect when a child complains of pain in the elbow after a fallCirculationNerve symptoms, weakness or sensory change in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of pain: location of tendernessRadial head fracture: pain on pronation/supinationOlecranon fracture: decreased elbow extensionSwellingSkin condition: open fracturesSigns of infectionDeformityPost-immobilisation: range of shoulder, elbow, forearm, and wrist movementCirculatory, sensory, or motor problemsFunctional limitationsStrength


Soft tissue injuryContusion of forearmDistal humerus fractureDislocation/subluxation of proximal radio-ulnar jointDislocation of elbow/wristElbow ligament injuryPulled elbow in children

WMS complications Fracture slipping: redisplacement or late angulationNeurovascular injuriesRecovery of full extension may be prolonged

50


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels Underlying defi ciency e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg soft tissues, nerve, blood vessel, tendonNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance



TCM goals:Decrease pain and swelling by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm Shen, Nourish Blood and reinforce Qi to enhance union of fracture and restore range of movement Correct any underlying patterns of imbalance






51

Fracture of Shaft of Radius/UlnaRead code: S232./S233.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenIncludes both open and closed fracturesIncludes isolated fractures of middle third of radius or ulna, including greenstick fractures in childrenGaleazzi’s fracture: fracture of the distal radius with dislocation of the inferior radio-ulnar jointMonteggia’s fracture: fracture of the ulna associated with radial dislocation or rupture of the annular ligamentThere is a higher frequency of morbidity from forearm fractures than elbow or wrist fracturesAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Hand dominance/occupation may affect managementTreatment is largely determined by the amount of angulation and displacementFrequency of open fractures is highDisplaced fractures in adults require perfect reduction (usually surgical) to facilitate supination and pronationOsteoporosisInjury to nerve or vessels


Function of wrist and elbowMechanism of fracture: fall onto outstretched arm; direct blow to armSurgical intervention: outcomesPain: location, radiationDominant/non-dominant armPrevious fracturesCirculation symptomsGeneral health, symptoms of infectionWeakness or sensory change in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of pain: location of tendernessSwellingSkin condition: open fracturesSigns of infectionDeformity, angulation, displacementPost-immobilisation: range of elbow, forearm, wrist, and fi nger movementCirculatory, sensory, or motor problemsFunctional limitationsStrength

52


Associated joint sprain or fractureSoft tissue injuryContusion of forearmDislocation of elbow/wristFracture of elbow or wrist

WMS complications Fracture slipping: redisplacement or late angulation or non-unionAxial mal-rotation of fractured radiusCompartment syndromeNeurological signs: ulnar/median nerve injuryVascular injury: ulnar arteryComplex regional pain syndromeGrowth arrestRadio-ulnar synostosis after delayed treatment (ossifi cation of tissues connecting bones)DeformityOsteoarthritis


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg nerve, blood vessel, tendon, ligamentNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance





Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser Acupuncture


53



54

Fracture of Distal Radius/UlnaRead code: S234./S235.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenIncludes both open and closed fracturesIncludes:Isolated distal radial or ulnar fracturesCombined distal radial and ulnar fracturesColles’ fracture: fracture of the radius at the epiphysis causing dorsal and lateral displacement of the distal bone fragmentSmith fracture: reverse Colles’ causing volar displacement and angulation of distal bone fragmentGrowth plate injuries in childrenIn adults Colles’ fracture is common and often associated with fracture of the ulnar styloid processAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Complications are common with Colles’ and Smith fracturesHand dominance/occupation may affect managementOsteoporosisTetanus statusRisk of infection in open fracturesDamage to nerves and vessels is possible


Mechanism of fracture: fall onto outstretched arm; direct blow to arm (rare)Surgical intervention: outcomesPain: location, radiationDominant/non-dominant armPrevious fractures in the elderlyCirculation symptomsWeakness or sensory changes in fi ngersSymptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of pain: location of tendernessSwellingSkin condition: open fracturesSigns of infectionDeformity, angulation, displacementPost-immobilisation: range of elbow, forearm, wrist, and fi nger movementCirculatory, sensory, or motor problemsFunctional limitationsStrength

55


Other fractures of radius or ulnaFractures of hand, elbow, forearmDislocation of elbow/wristContusion of wrist, forearm, handAssociated joint sprain or fractureSoft tissue injury

WMS complications Fracture slipping: redisplacement or late angulation/non-unionTendon damage/rupture: extensor pollicis longus with Colles’ fractureSubluxation/dislocation of distal radio-ulnar jointNeurological signs: ulnar/median nerve injury/carpal tunnel syndromeOsteoarthritisGrowth arrestComplex regional pain syndromeVascular injury: ulnar arteryWrist ligament ruptures and/or cartilage injury associated with ulnar styloid process fractures


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg nerve, blood vessel, tendon, ligamentNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance







56

Onward referral Acute phase:Accident and emergency clinic GPHand Therapist Preferred Provider

Sub acute phase:GPPhysiotherapistOsteopathChiropractorHand Therapist preferred provider

57

Sprain Elbow/ForearmRead code: S51..


Key points Injury to muscles, tendons, ligaments, or the joint itselfChildren under 12 years rarely sprain ligaments so should have X-rayElderly patients tend to fracture rather than sprain so should have X-rayConsider tendon rupture in older patients


Elderly patients need early mobilisation to avoid stiffening of joints


Mechanism of injury: often a twisting injury associated with a fallPossibly gradual onset with loss of mobilityDominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesFunctional limitationsOccupationGeneral health past and presentNeck symptomsWeakness or sensory change in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain, tendernessJoint effusionInstability of ligaments or tendonsRange of movement of shoulder, elbow, wristPalpation: check temperature for infectionCervical or thoracic spine involvementNeurological signs: sensory or motor changes


Fracture: radial head, supracondylar humeralDislocationEpicondylitisTenosynovitis/synovitisTendon rupture: biceps, tricepsTriceps tendonitisOlecranon bursitisCervical or thoracic spine referralElbow joint pathologyApophysitisInfectionArthritis

WMS complications TendonitisRecurrent injury, joint instabilityHaemarthrosis/excessive swellingVascular or neural damage, ischaemiaTendon ruptureChronic painLoss of function

58


Injury to muscles, tendons, ligaments or the joint itself Qi and Blood stasis in the muscle-tendino (sinew) and affected channels, consider: LU, LI, HT, SI, PC, or SJ channels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg nerve, blood vesselsDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, bruising and oedema as appropriate; restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction

TCM goals:Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movementCorrect any underlying patterns of imbalance

Acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustionCuppingTui na Liniments and herbal plasters*



59

Open Wound Elbow/ForearmRead code: S91..


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicThorough initial examination by GP will delineate full extent of injuries.


Tendon sheath infection requires urgent hospital treatmentEvidence of vascular or nerve compromise of fi nger or hand requires urgent referralRisk of infection


Mechanism of injuryCircumstances of injury: work-related, assault, self-infl ictedHistory of immediate treatmentAssociated symptoms/injuriesSymptoms of infectionPrevious injury/disabilityMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, tetanus statusEmotional response to traumaAvailability of carers if requiredWeakness or sensory changes in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite and extent of woundSigns/risk of infectionRetained foreign bodiesSensory functionRange of movement: shoulder, elbow, wrist; fi ngersMotor nerve involvementPain: location, nature, severityOedema: extent and severityBruising: colour, extentCirculation: colour/warmth; pulses; capillary refi ll


AbrasionCrush injuryFractureLigament, tendon or nerve damageArterial laceration

WMS complications InfectionScarringStiffness

60


Injury to skin, and surrounding and underlying structures following traumaExternal stagnation of Qi and Blood in surrounding tissuesQi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC, SJ channelsTissue damage to appropriate six divisional cutaneous regions of wound injury and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels Deep wounds can cause injury to muscle-tendino channels

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. tendon, nerve, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Delayed healing due to underlying defi ciencies e.g. Qi defi ciency, Liver defi ciency Damage to underlying channel systems and structures If deep injury the associated muscle-tendino channels are to be consideredExcessive bleeding may lead to Blood defi ciency


WMS goals: Enhance healing of wound; reduce pain and swelling; restore range of movement.

TCM goals:Relieve pain and swelling by clearing Qi and Blood stasis in the affected area and channelsRestore the normal fl ow of Qi and Blood in the affected channels to reduce scarring and adhesions Calm Shen Resolve toxins Correct any underlying patterns of imbalance

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractor

61

Abrasion Lower Arm (no infection)Read code: SD30.


Key points Superfi cial injury or laceration not involving deep structuresSoft tissue injury alone or in combination with a fracture may cause a compartment syndrome – refer if pain is disproportionately severe and poorly localised; severe swelling; hyperaesthesia/paraesthesia in distribution of nerves crossing compartment


Abraded skin is prone to hyperpigmentation – advise sunblock for six months after injuryInvolvement of nerve, tendon, muscleMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryDominant/non-dominant sideCompartment syndrome symptomsMedical history including medicationEmotional response to traumaFunctional limitationsTetanus statusCirculation symptomsWeakness or sensory change in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationJoint involvementCompartment syndrome signsOedema: extent and severityBruising: extent, severity, colourRetained foreign bodiesRange of movement and strength of shoulder, elbow and wrist jointsPalpation: check temperature for infectionNeurological signs


Underlying fractureCompartment syndromeDeep laceration involving deeper structuresContusion

WMS complications Nerve involvementInfectionScarring

62


Superfi cial damage to cutaneous regionQi and Blood stasis in local cutaneous region and affected channels, consider: LU, LI, HT, SI, PC, or SJ channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying channel systems and structuresInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Delayed healing due to underlying defi ciencies e.g. Blood defi ciency, Spleen Qi defi ciency


WMS goals: Enhance healing of abrasion; reduce pain and swelling.

TCM goals:Relieve pain by clearing Qi and Blood stasis in the local cutaneous region and affected channelsRestore normal fl ows of Qi and Blood in the affected channels Calm Shen Resolve toxins Correct any underlying patterns of imbalance



Onward referral GPPhysiotherapistOsteopathChiropractor

63

Contusion Elbow/ForearmRead code: SE31.


Key points Contusion is defi ned as a closed injury, as opposed to abrasionRisk of compartment syndrome indicated by severe pain disproportionate to injury, early intervention and treatment important to hasten recovery


Consider additional injuriesIf not caused by trauma, consider underlying medical conditionsFingernails may require aspiration or drainageMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementLocation and severity of painDominant/non-dominant sideMedical history including medicationEmotional response to traumaWeakness or sensory change in fi ngersCirculation symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsConsider associated injuriesOedema: extent and severityBruising or haematoma: extent, severity, colourPain: location and intensityNerve involvementRange of movement and strength of proximal and distal jointsPalpation: check temperature for infection; peripheral circulation


AbrasionFractureCompartment syndrome: presence or riskLigament, tendon or nerve damageIschaemic changesBenign or malignant lump

WMS complications Compartment syndromeInjury to tendon, nerve or boneIschaemic contracturesInfectionExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useCalcifi cation of haematoma in muscle belly (myositis ossifi cans)Chronic pain

64


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC or SJ channels and connecting and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance


WMS goals: Enhance healing of contusion; reduce pain and swelling.

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance. Calm Shen

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCupping Gua sha Tui na Liniments and herbal plasters*


65

Burns Arm (excluding hand)Read code: SH3..




General healthEmotional response to injuryExposed tendon/boneSkin graft donor siteMore severe burns can involve fl uid loss and secondary organ damage


Cause of burn: fl ame, scald, chemical, electrical, etcPercentage of body area involvedDepth of burnRespiratory diffi culty: inhalation injuryUnilateral/bilateralHistory of immediate managementPain level: check pain management is adequateSurgical interventionLength of hospital stayPrevious medical historyFunctional limitationsEmotional response to traumaSymptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain: severity; constant or with movementStage of healingScarringCondition of skin graft donor siteOedemaRange of movement: elbow, wristNeurovascular status of limbContractures/deformitiesLoss of functionGeneral fi tnessMobilitySigns of infectionDifferentiate affected structure limiting range of movement: skin, scarring, ligament, muscle and tendon



66

WMS complications Wound infectionGraft failureContractures and deformitiesScarringChronic painPsychological/social problemsReduced sensationLoss of function


Damage to tissues and local cutaneous region by excess pathogenic Heat causing obstruction to normal fl ows of Qi and Blood in affected channels, consider: LU, LI, HT, SI, P or SJ channels and connecting and muscle-tendino (sinew) channelsIn severe cases consider concurrent Yin fl uid damage, damage to underlying structures (in extreme cases the Zang Fu)Qi block due to frightPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Potential febrile Bi syndromeInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceDamage to Yin and Jin-Ye (fl uids)Prolonged Qi and Blood stasis leading to scarring/contracture



TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance Calm Shen Nourish Yin fl uids

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureIon-pumping cords*

Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureTui na

Onward referral GPPhysiotherapist OsteopathChiropractorSplint specialist for contracturesOccupational therapistCouncillor

67

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Fracture Tarsal Bones/Metatarsals (closed)

Read code: S352.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenFracture of the fi fth metatarsal is the most common, resulting from an inversion injury after having sprained an ankleAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Effects of gait changes on other joints and soft tissues


Mechanism of fracture:Inversion e.g. base of fi fth metatarsalCrushing e.g. metatarsals 2 – 4Twisting/torsion e.g. Lisfranc fracture/dislocationFall from height e.g. os calcis fractureSnowboarding e.g. lateral process of talusPainSwellingWeight-bearing abilityPain elsewhere in limbPrevious injury, management, outcomes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other footGait/weight-bearing abilityNeurovascular status of foot: posterior tibialis and dorsalis pedis pulses, capillary returnDeformitySwelling BruisingLocation of tendernessRange of movement of ankle and foot jointsFoot stabilityTendon strengthMobilityFunctional limitation

69


Sprain e.g. ankle, metatarsophalangeal jointDislocation e.g. subtalarContusion foot/ankleArthritis, goutAnkle fracture

WMS complications Gait disturbanceCompartment syndromeNon-union/malunion (especially base of fi fth metatarsal)Avascular necrosis (talar neck, navicular body, cuboid)Complex regional pain syndrome (Lisfranc fractures)Post-traumatic arthritis (Lisfranc fractures)OsteomyelitisCellulitis/infectionDeep vein thrombosis


Damage to bone following trauma Damage to surrounding structures resulting in Qi and Blood stasis in the affected channels following traumaQi and/or Blood stasis in the ST, SP, BL, KI, GB or LR channels Possible involvement of Eight Extraordinary Vessels Underlying defi ciency e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Chronic Qi and Blood stasis restricting movement and functionShen disturbance




Advice (WMS and TCM):Acute phase – rest, non weight bearingFollow orthopaedic advice regarding weight bearing status and exercise activityBe mindful of medications that reduce gastric acid and therefore reduce calcium uptake e.g. anti-infl ammatories, losec, smoking


Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*

70


Sub acute:GPPhysiotherapistOsteopathChiropractorPodiatrist

71

Fracture Phalanges of footRead code: S36..


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenFractures in children are more diffi cult to recognise because of multiple growth centresEnsure fracture will heal in shape to fi t comfortably into a shoeAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Usually require little treatmentImportant to prevent rotation or angulation to enable comfortable wearing of shoesDiabetesPeripheral vascular diseaseRisk of infection in open fractures/crush injuries


Mechanism of fracture: stubbed toes, object landing on footHistory of immediate treatment and carePainSwellingWeight-bearing abilityPrevious injury, management, outcomesGeneral health: diabetes, peripheral vascular disease, steroid use, anticoagulants, rheumatoid arthritisSymptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other footGaitNeurovascular status of foot: capillary returnDeformitySwelling BruisingLocation of tendernessRange of movement of toe jointsTendon strengthMobilityWeight-bearing abilityFunctional limitationSigns of infection


Toe dislocationContusionSprainTendon injuryMetatarsal fractureAcute arthrosisGout

72

WMS complications Gait disturbanceNon-unionInfectionArthritisInability to wear shoesChronic leg pain syndromeNeuroma


Damage to bone following trauma Damage to surrounding structures resulting in Qi and Blood stasis in the affected channels following traumaQi and/or Blood stasis in the ST, SP, BL, KI, GB or LR channels Possible involvement of Eight Extraordinary Vessels Underlying defi ciency e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Chronic Qi and Blood stasis restricting movement and functionShen disturbance






Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*

73


Sub acute:GPPhysiotherapistOsteopathChiropractorPodiatrist

74

Sprain Metatarsophalangeal Joint/Interphalangeal Joint

Read code: S5512/S5513


Key points Fracture should be excluded before diagnosis of sprainIncludes haemarthrosis of metatarsophalangeal (MTP) joint and sesamoiditisIn rare cases third degree sprain may result in dislocation

Special considerations

MTP joint strains may refl ect whole foot pathology, especially in runnersIf pain persists after 7-10 days, refer for X-ray for occult fractureToes must heal in normal shape to allow comfortable wearing of shoesGout may be triggered by trauma, presenting 2-5 days after injuryMTP joints must heal with normal mobility to allow normal gaitDiabetesPeripheral vascular disease


Mechanism of injury: twisting, hyperextensionPain: location and severitySwellingWeight-bearing abilityPrevious injury, management, outcomesGeneral health: diabetes, peripheral vascular diseaseSymptoms of infectionArthritis


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other footGait/weight-bearing abilityNeurovascular status of foot: capillary returnDeformitySwelling BruisingLocation of tendernessMobilityFunctional limitationOther joint examination


Fracture of metatarsal neckDislocationInfectionContusionTendon injuryMetatarsalgiaFlexor hallucis tendonitisGoutRheumatoid or osteoarthritisIntra-articular fracture/avulsion fracturePlantar fasciitisInterdigital Neuroma (Morton’s Neuroma)

75

WMS complications GoutChronic metatarsalgiaNeuromaGait disturbanceArthritisChronic leg pain syndrome


Tissue damage and injury to tendons and ligaments following traumaQi and Blood stasis in local area and affected channels, consider: ST, SP, BL, KI, GB or LR channelsPossible involvement of Eight Extraordinary Vessels Underlying pattern of imbalance e.g. Qi defi ciencyLiver Blood failing to nourish tendons and ligaments

TCM complications Same as WMS complications above plus:Delayed healing due to underlying patterns of imbalance e.g. Liver Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, bruising and swelling as appropriate; restore range of movement and normal gait; prevent adhesion/scarring and secondary postural adaptation/dysfunction



Sub acute:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Cupping Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapist ChiropractorOsteopathPodiatrist

76

Open Wound Foot/Toe(s)Read code: SA2../SA3..




Forefoot lacerations and puncture wounds are prone to infection, particularly pseudomonasContinue to assess distal neurovascular and musculotendinous functionMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants, immunosuppresants)


Nature of trauma causing injuryCircumstances of injury: work-related, assault, self-infl ictedMedical history including medicationGeneral health, symptoms of infection, tetanus statusEmotional response to traumaFunctional limitationsSensory changes or weakness


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationRetained foreign bodiesJoint involvementOedema: extent and severityBruising: extent, severity, colourRange of movement of foot and toe jointsPalpation: check temperature for infectionNeurological signsGait


Underlying fractureContusionAbrasionTendon/nerve or vessel involvement

WMS complications Neurovascular injuryInfectionScarringTendon injury

TCM diagnosis Damage to tissues and surrounding structures leading to Qi and Blood stasis in local area and affected channels, consider: ST, SP, BL, KI, GB or LR channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels Underlying pattern of imbalance e.g. Qi defi ciency

77

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. tendon, nerve, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinDepending upon the depth of the injury there may be damage to the affected cutaneous region, musculo-tendinous channel, divergent and or main channel Delayed healing or excessive bleeding may lead to Spleen Qi defi ciency and Blood defi ciency and/or stasis


WMS goals: Enhance healing of wound; reduce pain and swelling

TCM goals:Decrease pain by clearing stasis of Qi and Blood in the local cutaneous region and affected channelsRestore normal fl ow of Qi and Blood in the affected channels Calm Shen Resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureElectro-acupuncture Laser AcupunctureCupping Tui na Liniments and herbal plasters*

Onward referral GP

78

Contusion ToeRead code: SE43.


Key points Severe pain/disproportionate for injury should prompt onward referral


Medical conditions (especially bleeding disorders)DiabetesNeuropathiesDrug therapy (e.g. anticoagulants)Footwear


Nature of trauma causing injury: fall, direct blow (dropped object), vehicle accidentLocation and severity of painChronicityPrevious injuries to affected siteFunctional restrictions: mobility, ability to wear footwearNeurological changes/circulation symptomsMedical conditions and drug therapyGeneral health, signs of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourConsider associated injuriesRange of movement: ankle, foot joints, toesPalpation: check temperature for infectionNerve involvement: sensory and motor changesInvolvement of nail bed


FractureMuscle or tendon ruptureAbrasionImpaired circulationNerve lesionSesamoid dysfunctionInfectionGout/other arthritis

WMS complications Excessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useNeurological signsInfection: requires urgent referralTendon ruptureNail bed injury

79


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, BL, KI, GB, or LR channelsPossible involvement of Eight Extraordinary Vessels



WMS goals: Enhance healing of contusion; reduce pain and swelling; restore range of movement and normal gait



Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristOccupational therapist

80

Crush Injury Foot (closed)Read code: SF322


Key points X-rays should be taken to eliminate possibility of tarsometatarsal (Lisfranc) fractures, which are diffi cult to diagnose and have serious consequences


Medical conditions: bleeding disorders, diabetes, rheumatoid arthritis, osteoarthritis cellulitis, peripheral vascular disease, neuropathiesDrug therapy (e.g. anticoagulants)FootwearCompartment syndromeNerve and vascular injury is possible


Nature of trauma causing injury: fall, direct blow (dropped object), vehicle accidentLocation and severity of painChronicityPrevious injuries to affected siteFunctional restrictions: mobility, ability to wear footwearNeurological symptoms, sensory or motor changesMedical conditions and drug therapyGeneral health: signs of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourConsider associated injuriesAbrasionsDeformityRange of movement: ankle, foot joints, toesPalpation: check temperature for infectionNerve involvement: sensory and motor changesCirculatory impairmentInvolvement of nail bed


FractureMuscle or tendon ruptureInfection/cellulitisGout/other arthritisDisruption of inferior tibia/fi bula jointAnkle joint injuryUndiagnosed fractures of mid-foot with mal-unionLoss of function

81

WMS complications History of bleeding disorder or anticoagulant useInfection: requires urgent referralTendon ruptureNail bed contusionOsteoarthritisChronic painNeuropraxia/nerve injuryCompartment syndrome


Damage to local cutaneous area, soft tissue, tendons and ligaments, and possibly bone following trauma Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, BL, KI, GB or LR channels and connecting and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels



WMS goals: Enhance healing of affected tissues; reduce pain and swelling; restore range of movement and normal gait

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Re-establish the normal fl ow of Qi and Blood in the affected channelsNourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected area and channelsCorrect any underlying patterns of imbalance. Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Laser AcupunctureMoxibustion Cupping Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorPodiatristOccupational therapist

82

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Tenosynovitis/Synovitis Read code: N220.


Key points Tenosynovitis/synovitis involves infl ammation of the synovial sheath around a tendonThe most common injuries are trigger fi nger/thumb, de Quervain’s tenosynovitis, intersection, extensors, and long fl exorsCharacterised by pain after repeated movements or stiffness after a period of rest


May occur following repetitive use, poor technique, or after acute injuryRest is very importantRare in patients under 18 years


Mechanism of injury: usually follows chronic repetitive strainDominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesNature and severity of pain: reproducible with certain movementsEffects on sleepAggravating and relieving factors: worse during and after activity, better for restFunctional limitationsGeneral health past and present, pregnancy, diabetes, rheumatologyOccupational and leisure activities: identify causative and aggravating factorsSensory changes or weakness in fi ngers


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsIdentify area of tenderness and tendons involvedCrepitus of tendonIdentify movements that elicit painDe Quervain’s tenosynovitis: pain along radial aspect of wrist; pain on passive movement of thumbTrigger fi nger: tenderness in distal palm; tendon thickening and nodularity; crepitation and catching of tendon on fl exionLoss of strength/functionWeight-bearing pain indicates joint dysfunctionInfl ammation, heat, swellingCervical spine involvementNeurological symptoms

83


TendonitisJoint pathology (often accompanied by instability)Myxoedema/pregnancyFracture: scaphoidScaphoid – lunate dissociationMuscle tear/strainNerve entrapmentGanglionInfection of soft tissueInfl ammatory arthritis/goutCarpal tunnel syndrome

WMS complications Work requirementsNeural involvementTear or rupture of tendon (especially after steroid injection)Joint stiffnessMuscle weakness/atrophyChronic pain


Injury to tendon following trauma, misuse or overuseQi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC or SJ channels, following misuse, overuse or trauma Underlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)Possible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Liver Qi stagnation, Blood defi ciencyShen disturbance


WMS goals: Decrease pain, oedema and infl ammation; restore range of movement



Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*Herbs and nutritional supplements*

84

Onward referral GPPhysiotherapistChiropractorOsteopathOccupational therapistHand Therapist preferred provider

85

Fracture of Metacarpal BoneRead code: S25..


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenIncludes fractures to head, neck, shaft or base of each metacarpalSplinting or a cast may be used to prevent rotation or shortening at the fracture siteFunctional disability may be minimal despite fracture of fourth or fi fth metacarpalAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Hand dominance or occupation may affect managementAssociated ligamentous or soft tissue injuryLoss of functioning, e.g. hand stiffness, is most commonFractures involving the joint need special consideration


Mechanism of fracture: punch, fall, direct blow, crushForce of impactImmediate management, stability, surgical interventionLocal pain and swellingNerve involvement (sensory changes or weakness in fi ngers)Pre-existing disability or deformityOccupational and leisure activitiesHand dominance


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsComparison with other handOedema Tenderness, pain on moving fi ngersDeformitySoft tissue injury: bruising, lacerations, abrasionsRange of movement of fi ngers and wrist; fi nger extensionFunctional limitations: grip strength, pinch strengthNeurovascular status; sensation or circulation changes


Wrist fracture/dislocationMetacarpophalangeal dislocationContusionSprainPathological fracture

WMS complications Loss of function: stiffness of hand is commonDelayed union/non-unionAvascular necrosisPost-traumatic arthritisInfectionNeural damage

86

TCM diagnosis Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance







Onward referral GPHand Therapist preferred providerPhysiotherapistOccupational therapistOsteopathChiropractor

87

Fracture Phalanx – HandRead code: S26..


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenAccurate reduction and early mobilisation (7–14 days) are important to regain full functionDistal phalanges: usually crush fractures; generally heal well unless intra-articular; disturbance of nail growth is commonMiddle phalanges: tend to be displaced and unstable; watch for signs of rotationProximal phalanges: cause greatest concern, especially of little fi nger; intra-articular fractures usually need internal fi xationAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Hand dominance, occupation, or sporting demands may affect managementFinger stiffness due to joint adhesions can result in permanent loss of range and functionAssociated ligamentous or soft tissue injuryFracture into joint requires special consideration


Mechanism of fracture: direct blow, e.g. hit by ball; rotational, crushForce of impactJoint injuryImmediate management, stability, surgical interventionLocal pain and swellingPre-existing disability or deformityFunctional limitationsOccupational and leisure activities


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsComparison with other handOedema Tenderness, pain on moving fi ngers: exact locationDeformity/displacementSoft tissue injury: bruising, lacerations, abrasionsRange of movement of fi ngers and wrist tendon functionFunctional limitations: grip strength, pinch strengthCirculation to fi ngertips: capillary refi llNerve involvement


Sprain of fi ngerAvulsed or damaged tendons causing deformityDislocation of interphalangeal jointPathological fractureVolar plate injuryRheumatological conditions

88

WMS complications Loss of function: stiffness of fi nger due to joint adhesions is commonDelayed union/non-unionDeformity from tendon injuryPost-traumatic arthritisInfection


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance



TCM goals:Decrease pain by clearing local Qi and Blood stasis Restore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance




Onward referral GPHand Therapist preferred providerPhysiotherapistOsteopathChiropractorOccupational therapist

89

Dislocation/Subluxation of Finger/Thumb

Read code: S44..


Key points Requires immediate reduction by a suitably qualifi ed practitionerSplinting required for 2-3 weeks


Delayed reduction may result in loss of joint motion, joint instability, and functional limitationHand dominance, occupation, or sporting demands may affect managementMobilisation can begin 3-5 days after reduction if stable, and pain and swelling have settled


Mechanism of injury: forced hyperextension or hyperfl exion; lateral or rotational forceImmediate management, stability, surgical interventionLocal pain and swellingPre-existing disability or deformityFunctional limitationsHand dominanceOccupational and leisure activities


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsComparison with other handOedema Infl ammationCheck for underlying tendonitis/tenson rupture or avulsionTenderness, pain on moving fi ngers: exact locationRange of movement of fi ngers and wristStability of joint through active and passive range of movementFunctional limitations: grip strength, pinch strengthCirculation to fi ngertipsNerve involvement (sensory changes or weakness)


Fractures of handSoft tissue injuries: tendon, ligament, muscleOsteoarthritis/arthritisTendonitis

WMS complications Loss of joint motionJoint instabilityOsteoarthritis

TCM diagnosis Dislocation is the diagnostic term used in TCMTrauma leading to Qi and Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels

90

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Liver Blood defi ciency failing to nourish tendons and ligamentsShen disturbance


WMS goals: Decrease pain and infl ammation; enhance healing of joint; strengthen muscles; restore range of movement

TCM goals:Decrease pain by clearing of local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance


Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui na Liniments and herbal plasters*

Onward referral GPHand Therapist preferred providerPhysiotherapistOccupational therapistOsteopath Chiropractor

91

Sprain Radial Collateral Ligament (thumb)

Read code: S5204


Key points Less common than ulnar collateral ligament sprains


Early mobilisation is important (7-10 days after injury)Measure instability in extension by comparison with other sideUnstable injuries or complete collateral ligament tear require referral to specialistElderly patients are more likely to fracture than sprain and require early mobilisationConsider associated injuries: dislocation previously reduced, tendon rupture in elderly


Mechanism of injury: force and directionDuration of symptomsPrevious injury/arthritisOccupational and leisure activitiesPain: location and severityDominant/non-dominant sideFunctional limitationsPast history of injuriesGeneral health


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other handRange of movementTenderness over jointJoint stability: passive and activeNerve or vascular problemsInfl ammationInvolvement of other joints


FractureDislocationMuscle tearMuscle or tendon injuryTendonitis, tenosynovitisJoint pathologyFirst metacarpal joint sprainRheumatological condition

WMS complications Dysfunctional grip from instabilityStiffnessDegeneration of joint surfacesInfectionComplex regional pain syndromeInvolvement of other joints

92


Tissue damage and injury to tendons and ligaments following traumaQi and Blood stasis in the affected channels, consider: LU, LI or PC channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Delayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction


Acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*

Onward referral GPPhysiotherapistChiropractorOsteopathHand Therapist preferred providerOccupational therapist

93

Sprain ThumbRead code: S522.


Key points Includes ulnar collateral ligament sprain (skier’s thumb/gamekeeper’s thumb), capsular strain of fi rst metacarpophalangeal joint, interphalangeal joint strainCapsular sprains require active rehabilitation; joint may require immobilisation to prevent hyperextensionUnstable injuries or complete collateral ligament tear require referral to specialistElderly patients are more likely to fracture than sprain and require early mobilisationConsider associated injuries: dislocation previously reduced, tendon rupture in elderly


Measure instability in extension using comparison with non-injured sideEarly mobilisation is important (7-10 days after injury)Past history of injuries


Mechanism of injury: force and directionCapsular sprain of fi rst metacarpophalangeal joint: hyperextension and abduction; axial compressionDuration of symptomsPrevious injury/arthritisOccupational and leisure activitiesPain: location and severityDominant/non-dominant sideFunctional limitationsGeneral health


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other handRange of movementInstability in extensionTenderness over jointJoint stability: passive and activeLoss of grip or pinch strengthNerve or vascular problemsInfl ammationInvolvement of other joints


FractureDislocationMuscle or tendon injuryTendonitis, tenosynovitisJoint pathology

94

WMS complications Dysfunctional grip from instabilityStiffnessDegeneration of joint surfacesInfectionComplex regional pain syndromeInvolvement of other joints

TCM diagnosis Tissue damage and injury to tendons and ligaments following traumaQi and Blood stasis in the affected channels, consider: LU, LI or PC channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels



WMS goals:Decrease pain, infl ammation, bruising and oedema as appropriate; restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction


Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*


Onward referral GPPhysiotherapistChiropractorOsteopathHand Therapist preferred providerOccupational therapist

95

Sprain Finger/Interphalangeal Joint

Read code: S523./S5513


Key points Includes metacarpophalangeal joint strains, and proximal and distal interphalangeal joint strainsGrades 1-2 sprain likely capsular, ligaments, tendon, volar plate


Restore mobility while maintaining stabilityChildren under 12 years rarely sprain ligaments (likely to fracture growth plates or suffer greenstick injury)Elderly patients more likely to fracture than sprainElderly more likely to rupture tendons


Mechanism of injury: force and directionTractionTorsional forceDuration of symptomsAcute or chronic eventSite of painRecurrenceDominant/non-dominant sideHistory of dislocationFunctional limitationsOccupational and leisure activitiesGeneral healthOther joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other handTendernessSwellingDeformityStabilityRange of movement: passive and activeTendon functionLoss of grip strengthNerve or vascular problemsInvolvement of other joints


FractureDislocationTendon injuryTendonitis, tenosynovitisJoint pathology: arthritisNeurovascular injuryInfection96

WMS complications Chronic recurrent tendonitisUnstable jointsBoutonnière deformity (from volar plate injury)Chronic mallet deformityJoint degeneration


Tissue damage and injury to tendons and ligamentsQi and Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle -tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels





Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*


Onward referral GPPhysiotherapistChiropractorOsteopathHand Therapist preferred provider

97

Open Wound Hand/Open Wound Fingers/Open Wound Thumb

Read code: S92../S9300/S9302


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicTendon injuries normally treated after surgical repair


Punch injuries (lacerations from opponent’s teeth over metacarpal heads) carry a very high risk of infectionSeveral structures (skin, tendon, nerve, muscle, bone) may be involved


Mechanism of injury: force and directionCircumstances of injury: work-related, assault, self-infl ictedPosture of hand at time of injuryPain, paraesthesia, anaesthesia, weakness, loss of functionPotential for infectionHand dominancePrevious injury/disabilityHistory of acute managementMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, symptoms of infectionEmotional response to traumaOccupational and leisure activitiesTetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous Regions, Tai Yang, Shao Yang Etc• Tendino Muscle Channels (Sinew Network Vessels)Palpation• Associated Channels• Mu And Shu Points• A Shi PointsSite and extent of woundCirculation: colour, warmth, pulses, capillary refi llSigns/risk of infectionMotor function: range of movement of wrist and fi ngersSensory functionStrength: resisted range of movementResting posture of handOedema: extent and severity



WMS complications InfectionScarringStiffnessContracture/adherenceTendon rupture

98


Qi and Blood stasis in local affected area and channels, consider: LU, LI, HT, SI, PC or SJ channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. tendon, nerve, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Delayed healing due to underlying defi ciencies e.g. Qi defi ciency, Blood defi ciency


WMS goals: Enhance healing of wound; reduce pain and swelling; restore range of movement

TCM goals:Decrease pain by clearing stasis of Qi and Blood in the affected cutaneous area and channelsRestore the normal fl ow of Qi and Blood fl ow in the affected areas and channels Calm Shen Resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureCupping Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistHand Therapist preferred providerOccupational therapistOsteopathChiropractor

99

Open Wound Fingernail/Avulsion of Nail

Read code: S935./7G321




Inadequate repair of damage to nail bed or matrix may result in long-term nail deformityOften associated with fracture of distal phalanx


Mechanism of injury: laceration, degloving, crushPotential for infectionHand dominanceHistory of acute managementMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, symptoms of infectionEmotional response to traumaOccupational and leisure activitiesTetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite and extent of wound: exposed bone, compound factureRange of movement of fi ngersSensory functionOedema: extent and severityLoss of functionTendernessSigns of infection


Loss of nail bedFracture of distal phalanx

WMS complications Nail deformityNon-adherence of new nailPersistent mallet fi ngerOsteomyelitis/cellulitisAltered sensation


Qi and Blood stasis in local affected area and channels, consider: LU, LI, HT, SI, PC or SJ channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels

100



WMS goals: Enhance healing of wound; reduce pain and swelling; restore range of movement

TCM goals:Decrease pain by clearing stasis of Qi and Blood in the affected cutaneous area and channelsRestore the normal fl ow of Qi and Blood in the affected area and channels resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureCupping Tui na Liniments and herbal plasters*

Onward referral GPHand Therapist preferred providerOccupational therapist

101

Amputation Finger(s)Read code: S96..

Number of treatments: 18–36 Triggers: 24

Key points Finger amputations would normally be treated only after initial assessment and treatment by a GP/Accident and Emergency clinicTreatment may follow either re-attachment of fi nger or treatment of wound

Special considerations(WMS and TCM)

Loss of function affecting occupational and leisure activitiesPsychological impact of injury


Mechanism of injuryCircumstances of injury: work-related, assault, self-infl ictedOccupational and leisure activitiesHand dominanceHistory of acute managementMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, symptoms of infectionEmotional response to traumaTetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsExtent of injury: number of fi ngers involved, level of amputationPain: severity, effects on sleep, phantom limb syndromeAssociated injuriesSigns of infectionRange of movement of proximal jointsLoss of functionScarring

WMS complications Infection/osteomyelitisPhantom limb syndromeLoss of grip strengthDecreased sensitivityCold intoleranceCosmetic disability


AmputationQi and Blood stasis in local cutaneous area and affected channels, consider: LU, LI, HT, SI, PC or SJ channelsPossible involvement of Eight Extraordinary Vessels

102

TCM complications Same as WMS complications above plus:Invasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Delayed healing due to underlying defi ciencies e.g. Liver Blood defi ciency and or stasisShen disturbance


WMS goals: Enhance healing of wound; decrease infl ammation, bruising and oedema as appropriate; reduce pain including phantom limb syndrome; restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction

TCM goals:Decrease pain by clearing stasis of Qi and Blood in the affected cutaneous area and channelsRestore normal fl ow of Qi and Blood fl ow in the affected channelsCalm Shen Resolve toxins Correct any underlying patterns of imbalance

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser Acupuncture


Phantom limb pain:AcupunctureElectro-acupuncture

Onward referral GPPhysiotherapistHand Therapist preferred providerOccupational therapistOsteopathChiropractor

103

Contusion Finger/Thumb/Finger nail (haematoma)

Read code: SE33./SE332


Key points Contusion is defi ned as a closed injury, as opposed to abrasionContusions to limbs carry a risk of compartment syndrome, indicated by pain disproportionate to the injury


Consider additional injuriesIf not caused by trauma, consider underlying medical conditionsFingernails may require aspiration or drainage by a qualifi ed practitionerMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)Early treatment to reduce swelling and encourage movement essential


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementPain: severity and locationDominant/non-dominant sideMedical history including medicationEmotional response to traumaOccupational and leisure activitiesGeneral health; symptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourHaematomaConsider associated injuries: fracture, nerve involvement, circulatory problemsPain: location and intensityRange of movement: fi ngers, thumb, wristPalpation: check temperature for infection; peripheral circulation


Compartment syndrome: presence or riskAbrasionFractureLigament, tendon or nerve damageIschaemic changesBenign or malignant lump

104

WMS complications Compartment syndromeInjury to tendon, nerve or boneIschaemic contracturesExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyositis ossifi cans (calcifi cation of haematoma in muscle belly)InfectionChronic pain

TCM diagnosis Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels



WMS goals: Enhance healing of contusion; reduce pain and swelling; restore range of movement.



Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOccupational therapistOsteopathChiropractorHand Therapist preferred provider

105

Crush Injury Finger (open/closed)/Thumb (closed)/Finger (open)

Read code: SF23./SF231/SF233


Key points Mechanism of injury involves force from two sidesLikely multiple-tissue involvementEarly intervention – balance rest and gentle motion essential to prevent complications and deformity and preserve function


Management of associated injuries: fractures, tendon, nerve, soft tissue, skinRisk of compartment syndromeHaematoma under fi ngernail may require drainage or nail removal: refer if haematoma covers >50% of nailConsider tendon rupture/divisionSplinting is importantMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: blow with implement, crush in door, machinerySite of painDominant/non-dominant sideOccupational and leisure activitiesHistory of immediate managementMedical history including medicationGeneral health; symptoms of infection, tetanus statusEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourHaematoma under fi ngernail: size, painMallet fi nger deformity (avulsion of extensor tendon)Range of movement and strength of wrist and fi ngers/thumbPalpation: check temperature for infection; peripheral circulation, tendernessSensation in fi ngers/thumb: digital nerve injury


FractureLacerationCellulitisSoft tissue injury: strain or tearCirculatory problemsNerve injury

106

WMS complications Compartment syndrome/ischaemic contractureTraumatic myositis (infl ammation of muscle following trauma)Osteomyelitis/cellulitisSeparation of new nail from nail bed if signifi cant nail bed injuryLigament ruptureInjury to nerve, tendon or muscle


Damage to local cutaneous area, soft tissue, tendons and ligaments, and possibly bone following traumaLeaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following trauma consider: LU, LI, HT, SI, P or SJ channels and muscle-tendino (sinew) channelsSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingPossible involvement of Eight Extraordinary Vessels Qi block due to fright, in severe trauma



WMS goals: Enhance healing of injured area; reduce pain and swelling.

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected area and channelsCorrect any underlying patterns of imbalance. Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureCuppingTui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionGua sha Tui na Liniments and herbal plasters*


107

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Sprain Hip/ThighRead code: S53..


Key points Children and the elderly require careful assessment or referral where the history is not consistent with the severity of symptoms


Children under 12 years rarely sprain ligaments: consider infection, irritable hip, slipped upper femoral epiphysis (SUFE), Perthes’ disorder, and traction apophysitis (avulsion fracture)Elderly patients are more likely to fracture bones than sprain ligamentsElderly patients need early mobilisationElderly patients are more likely to suffer tendon rupture


Mechanism of injury: fall, sudden acceleration/deceleration, sudden movement e.g. kickingPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentAggravating and relieving factorsFunctional limitationsGeneral health past and present: arthritis, symptoms of infection, involvement of other joints


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: posture, gaitPalpation: tenderness; include lower backRange of movement: active, passive, resistedSensory and motor changesOther joint signs


ContusionFracture/dislocationInfection/arthritisTendon rupture/strainReferred pain from lower back/sacroiliac joint/kneeHerniaGreater trochanteric bursitisTumour (severe unremitting pain)OsteoporosisPain of visceral originDeep vein thrombosis

WMS complications Chronic or recurrent injuryTendonitisOsteoarthritisMyositis ossifi cansLoss of function

109


Damage to soft tissue, joint, tendon and ligament following trauma or overuseQi and Blood stasis in local area and affected channels, consider: BL and GB channelsPossible involvement of Eight Extraordinary Vessels Chronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Underlying pattern of imbalance e.g. Liver Blood defi ciency leading to Qi and Blood stasis

TCM complications Same as WMS complications above plus:Delayed healing due to underlying patterns of imbalance e.g. Liver Blood defi ciencyChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; restore range of movement and normal gait; prevent secondary postural adaptation/dysfunction


Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Tui naLiniments and herbal plasters*


110

Contusion Hip and ThighRead code: SE40.


Key points All urethral injuries should be referred to a specialist – suspect in cases of perineal bruising


Risk of compartment syndrome in limbs, indicated by severe pain disproportionate to injuryExisting degenerative changes in hip or spineMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: fall, direct blow, vehicle accidentLocation and severity of painHaematuriaMedical conditions and drug therapyEmotional response to traumaGeneral health; involvement of other joints, sensory and motor symptomsConsider associated injuriesBruising to perineum requires referral


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous Regions, Tai Yang, Shao Yang Etc• Tendino Muscle Channels (Sinew Network Vessels)Palpation• Associated Channels• Mu And Shu Points• A Shi PointsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourRange of movement hip and kneePalpation: check temperature for infectionSensory and motor signs


Presence or risk of compartment syndromeFractureHip dislocation/instabilityAbrasionMuscle ruptureImpaired circulationDeep vein thrombosisNeurological condition

WMS complications Compartment syndromeExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyosotis ossifi cans (calcifi cation of haematoma in muscle belly)Traumatic myositis (infl ammation of muscle following trauma)Infection


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: ST, SP, BL, KI, GB, or LR, connecting and muscle-tendino channelsPossible involvement of Eight Extraordinary Vessels

111



WMS goals: Enhance healing of contusion; reduce pain and swelling



Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCuppingGua sha Tui na Liniments and herbal plasters*


112

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Prepatellar BursitisRead code: N2165


Key points Risk of deep vein thrombosis if immobilised: use quadriceps exercisesRetinacular tightening


Avoid aggravating activity: e.g. kneelingConsider infection


Mechanism of injury: repetitive trauma (e.g. kneeling), blow to patella, penetration of skin over patellaSite of painPrevious history of injuriesHistory of arthritisPrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health; symptoms of infection, other joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other kneeWell-defi ned prepatellar swellingSite of tendernessBroken skinSigns of infectionRange of movement of knee: active, passive, resistedOther joint involvement


Infl ammation of knee joint/patellar tendonSeptic bursitis, arthritis (osteoarthritis or infl ammatory)Injury to patellaInfectionFat pad infl ammationOsgood-Schlatter diseasePatello-femoral syndrome

WMS complications Infection/septic bursitisMuscle wastingRecurrent fl uid accumulationProgressive enlargement of bursaFat pad impingement


Qi and Blood stasis in local affected area and channels, consider: ST, SP, BL, KI, GB or LR channels, following misuse, overuse or trauma Underlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)Possible involvement of Eight Extraordinary Vessels

113

TCM complications Same as WMS complications above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Liver Qi stagnation, Blood defi ciencyShen disturbance


WMS goals: Decrease pain, infl ammation and oedema as appropriate; restore range of movement; clear obstruction if required


Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureMoxibustion CuppingGua sha Tui naLiniments and herbal plasters*


114

Fracture Tibia/FibulaRead code: S33..


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenMost common long bone fracturedTibia/fi bula fractures in children can indicate severe trauma, and may indicate physical abuseNormally treated after surgical reduction of fracture, during or after immobilisation in plaster castIsolated fracture of fi bula: acute patient may be able to stand and move knee and ankle joints – refer if fracture is suspected after direct blow to fi bulaAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Commonly both bones are fractured, though either can occur aloneTibial fractures are often open and require hospitalisation for elevation, pain relief, and monitoring of circulationNerve or vessel damage is possible


Mechanism of fracture: often torsional, e.g. skiing; fall from height onto feet; direct blow, e.g. vehicle accidentHistory of immediate treatment and careInability to bear weightPainSwellingJoint painSensory change or weakness in leg/footGeneral health, symptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• cutaneous regions, tai yang, shao yang etc• tendino muscle channels (sinew network vessels)Palpation• associated channels• mu and shu points• a shi pointsGait, ability to walk (isolated fi bula fracture)Soft tissue damageDeformityBruisingTendernessSwellingCrepitusProprioceptionFunctional limitationCirculatory, sensory, or motor problemsOther joint signs


Soft tissue injuryCompartment syndromeFracture or sprain of knee or ankleTendonitisPeripheral vascular injuryDeep vein thrombosis

115

WMS complications Non-union (relatively common in tibial fractures)Delayed union, or malunion of fractureArthritisFat emboliPeroneal nerve injuryCompartment syndromeDeep vein thrombosisInfectionSkin breakdown


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: ST, SP, BL, KI, GB or LR channels Possible involvement of Eight Extraordinary Vessels Qi block due to severe fright

TCM complications Same as WMS complications above plus:Non-union of fracture or delayed healing due to Kidney Qi defi ciencyand/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance



TCM goals:Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing, restore range of movement Correct any underlying patterns of imbalance


Acute phase:AcupunctureElectro-acupuncture Auricular acupuncture

Sub acute:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion CuppingTui naLiniments and herbal plasters*

Onward referral Accident and emergency clinic for open fractureGPPhysiotherapistOsteopathChiropractorPodiatrist116

Acute Meniscal Tear (medial)Read code: S460.


Key points Medial meniscal tear is more common than lateralMechanism of injury causes meniscus to be compressed between tibial and femoral condyles and then subjected to a twisting forceOften occur with anterior cruciate ligament (ACL) tearsMeniscal tears may present as chronic knee pain in older peoplePersistent locking indicates bucket handle tear and requires surgery


May require arthroscopy


Mechanism of injury: usually twisting injury with fl exed knee over fi xed foot – abduction force with external rotation of lower leg on femurSudden onset of pain with activity or kneelingDegree of force involvedSwelling usually >4 hours or next dayMobility since injuryKnee may lock or give wayPain localised to medial joint linePrevious history of injuriesPrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health and other joint symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsEffusionPain on hyperextension or hyperfl exion of kneePain on external rotation of lower leg with knee at 90 degreesSite of tenderness and reproducible pain: medial joint lineRange of movement of knee: may have springy resistance to extensionTest for ligamentous instabilityPossibly weakened or atrophied quadricepsOther joint involvement


Torn ligamentOsteochondral fractureDislocation/subluxation of patellaInfl ammatory or degenerative joint diseaseMuscle tear: hamstrings, gastrocnemius, popliteusBaker’s cystInfectionPatello-femoral syndrome

WMS complications Muscle wasting: quadriceps, especially vastus medialis obliqueOsteoarthritisChronic painInstabilityLoose bodies in joint

117


Qi and/or Blood stasis in the affected channels following trauma, consider: ST, SP, BL, KI, GB or LR channels Possible involvement of Eight Extraordinary Vessels Liver Blood defi ciency failing to nourish tendons and ligaments

TCM complications Same as WMS complications above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Qi defi ciency, Liver Blood defi ciencyShen disturbance


WMS goals: Decrease pain, infl ammation, oedema; restore range of movement


Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureMoxibustionTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion CuppingTui naLiniments and herbal plasters*


118

Acute Meniscal Tear (lateral)Read code: S461.


Key points Medial meniscal tear is more common than lateralMechanism of injury causes meniscus to be compressed between tibial and femoral condyles and then subjected to a twisting forceMeniscal tears may present as chronic knee pain in older peopleMay be associated with anterior cruciate ligament injuryPersistent locking indicates bucket handle tear and requires surgery


Lateral tears often require more rehabilitation than medial tearsMay require arthroscopyEarly rehabilitation is essential to reduce effusion


Mechanism of injury: usually twisting injury with fl exed knee over fi xed foot – adduction force with internal rotation of lower leg on femurSudden onset of pain with activity or kneelingDegree of force involvedSwelling usually >4 hours or next dayMobility since injuryKnee may lock or give wayPain: at lateral joint line, may radiate up and down thighPrevious history of injuriesPrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health and other joint symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsEffusionPain on hyperextension or hyperfl exion of kneePain on internal rotation of lower leg with knee at 90 degreesSite of tenderness and reproducible pain: lateral joint linePalpable and visible lump when knee is examined at 45 degreesRange of movement of knee: may have springy resistance to extension; limited extensionTest for ligamentous instability, especially anterior cruciate ligamentPossibly weakened or atrophied quadricepsOther joint involvement


Torn ligament, especially anterior cruciateOsteochondral fractureDislocation/subluxation of patellaIlio-tibial band friction syndromeInfl ammatory or degenerative joint diseaseMuscle tear: hamstrings, gastrocnemius, popliteusTibia/fi bula joint dysfunctionBaker’s cystInfectionPatello-femoral syndrome

119

WMS complications Quadriceps muscle wastingDegenerative joint diseaseChronic painLoose bodies in jointMeniscal cyst


Qi and/or Blood stasis in the affected channels following trauma, consider: ST, SP, BL, KI, GB or LR channels Possible involvement of Eight Extraordinary Vessels Liver Blood defi ciency failing to nourish tendons and ligaments

TCM complications Same as WMS complications above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Qi defi ciency, Liver Blood defi ciencyShen disturbance


WMS goals: Decrease pain, infl ammation, oedema; restore range of movement



Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion Cupping Gua shaTui naLiniments and herbal plasters*

Onward referral GPPhysiotherapistChiropractorOsteopathPodiatrist

120

Sprain Quadriceps TendonRead code: S533.


Key points The rectus femoris muscle covers both the hip and knee, so it is important to consider both jointsElderly patients are more likely to fracture bones than sprain ligamentsElderly patients are more likely to suffer tendon ruptureChildren under 12 years rarely sprain ligaments: consider infection, irritable hip, slipped upper femoral epiphysis (SUFE), Perthes’ disorder, avulsion fractureSpinal pain may refer to the thigh


Elderly patients need early mobilisation to avoid stiffening of joints


Mechanism of injury: direct blow, twisting injury, over-stretchingSite of painPrevious history of injuries including lumbar spine and hip jointPrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSwellingGap in tendonSite of tendernessAbility to actively straight leg raiseRange of movement of knee: active, passive, resistedPatello-femoral joint signsPain and/or instability when stressing tendonOther joint involvement, back and hip function


Fracture (pathological fracture)Infection/abscessTendon or muscle tearTraction apophysitisLumbar spine strainSacroiliac joint dysfunctionContusion/haematomaHerniaTraumatic osteitis pubic symphysisChildren: consider infection, irritable hip, slipped upper femoral epiphysis (SUFE), Perthes’ disorder, cancer, and avulsion fractureBursitisOsgood-Schlatter diseasePatello-femoral syndromePatella fracturePlica’s syndromeInfrapatella fat pad

121

WMS complications Chronic or recurrent injuryTendonitisMuscle wastingQuadriceps haematomaMyositis ossifi cansLoss of function


Qi and/or Blood stasis in the affected channels following trauma, consider: St, SP, BL, KI, GB or LR channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels





Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustionTui naLiniments for herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion CuppingGua shaTui naLiniments and herbal plasters*


122

Sprain Lateral CollateralLigament Knee

Read code: S540.


Key points If the knee has been subjected a sideways force while fully extended, a posterior capsular tear may be involved, which should be referredLateral collateral ligament damage is much less common than medial, and is less likely to tearChildren under 12 years rarely sprain ligamentsElderly patients are more likely to fracture than sprain


Large knee effusions can cause loss of range of motion and muscle wasting, so early rehabilitation is essentialAssociated injuries are likely to be present, especially meniscal tear


Mechanism of injury: usually direct outward force to medial side of fl exed weight-bearing kneeLocation of pain/tendernessSwelling at time of injuryLoss of functionLocking, giving way, clickingWeight-bearing abilityPrevious history of injuriesPrevious treatment, management, investigations, outcomesGeneral health and medication: steroid use, diabetes, rheumatoid arthritis


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGaitSwellingRange of movement of kneeLigament tests: Drawer test, degree of instabilityLumbar spine/hipOther joint involvement, signs of infection


Posterior capsule tearCruciate ligament injuryMeniscus injuryIlio-tibial band problemFracturePatellar dislocation/subluxation/fractureMuscle tear: hamstrings, gastrocnemius, popliteusInfl ammatory or degenerative joint disease

WMS complications Quadriceps muscle wastingMeniscal injuryOsteoarthritisInstability 123


Tissue damage and injury to tendons and ligaments following traumaQi and Blood stasis in the affected channels, consider: St, SP, BL, KI, GB or LR channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels





Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureMoxibustion Tui naLiniments and herbal plasters*



124

Sprain Medial CollateralLigament Knee

Read code: S541.


Key points If the knee has been subjected a sideways force while fully extended, a posterior capsular tear may be involved, which should be referredMedial collateral ligament damage is much more common than lateralChildren under 12 years rarely sprain ligamentsElderly patients are more likely to fracture than sprain


Large knee effusions can cause loss of range of motion and muscle wasting, so early rehabilitation is essentialAssociated injuries are likely to be present, especially meniscal tear


Mechanism of injury: usually direct inward force to lateral side of fl exed weight-bearing knee; external tibial rotationLocation of pain/tendernessMedial knee pain above or below jointSwelling at time of injuryLoss of functionLocking, giving way, clickingWeight-bearing abilityPrevious history of injuriesPrevious treatment, management, investigations, outcomesGeneral health and medication: steroid use, diabetes, rheumatoid arthritisOther joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGaitSwelling: localised over medial aspect of kneePalpable tenderness proximal rather than distal to kneeRange of movement of kneeLigament tests: Drawer test, degree of instabilityLumbar spine/hipOther joint involvement, signs of infection


Posterior capsule tearCruciate ligament injuryMeniscus injuryFracturePatellar dislocation/subluxation/fracturePatellar tendonPatello-femoral syndromeMuscle tear: hamstrings, gastrocnemius, popliteusBursitisMeniscal cystDegenerative or infl ammatory diseaseDeep vein thrombosis

125

WMS complications Quadriceps muscle wastingMeniscal injuryOsteoarthritisInstabilityPatello-femoral syndrome


Tissue damage and injury to tendons and ligaments following traumaQi and Blood stasis in the affected channels, consider: St, SP, BL, KI, GB or LR channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels








126

Sprain Cruciate Ligament KneeRead code: S542.


Key points Anterior cruciate ligament rupture is a serious and disabling injury that may result in chronic instability – degenerative joint changes can resultAnterior cruciate ligament ruptures are associated with early haemarthrosisPosterior cruciate ligament ruptures are extracapsular and not always associated with knee joint effusionSeventy per cent of anterior cruciate ligament ruptures require surgeryPosterior cruciate ligament ruptures rarely require surgical repairMay occur following unresolved previous injuryChildren under 12 years rarely sprain ligamentsElderly patients are more likely to fracture than sprainElderly patients are more likely to rupture tendons


Static muscle exercises should be started early to prevent muscle wastingKnee should not be immobilised for more than two daysAssociated meniscus injury is commonAssociated patello-femoral pain/bursitis/hip and lumbar pain/collateral ligament injuriesConsider tendon rupture in elderly patients


Mechanism of injury: internal tibial rotation on fl exed knee; sudden change in direction/deceleration;abduction force, e.g. rugby tackle; landing from a jump; forced fl exionPosterior cruciate ligament: direct blow to anterior tibia with fl exed knee; severe hyperextension injuryAudible pop/felt snap in kneeIf previous injury: loss of function; knee gives wayRapid swelling (within four hours) implies cruciate ligament rupture or fractureWeight-bearing abilityPosterior cruciate ligament: popliteal pain radiating to calf; may be little or no swelling; minimal disability;Previous history of injuriesPrevious treatment, management, investigations, outcomesGeneral health other joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsJoint may be locked due to effusion, anterior cruciate tag, or associated meniscal tearCheck quadriceps mechanismGait/swellingDiffuse tenderness on joint lineRange of movement Ligament tests/joint stability: Drawer testMuscle spasm/wastingLumbar spine/hipSigns of infection and other joint involvement

127


Collateral ligament injuryMeniscus injuryFracturePatellar dislocation/subluxation/fractureRupture of quadriceps mechanismBursitisInfectionDeep vein thrombosis

WMS complications Muscle wasting causing worsening instabilityMeniscal injuryOsteoarthritis InstabilityPatello-femoral syndromePatellar dislocation


Tissue damage and injury to ligament following traumaQi and Blood stasis in the affected channels, consider: St, SP, BL, KI, GB or LR channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels







Onward referral GPPhysiotherapistChiropractorOsteopathOccupational therapistPodiatrist

128

Sprain GastrocnemiusRead code: S54x1


Key points Usually a rupture of the medial head of gastrocnemius at the junction where the Achilles tendon merges with the muscle


Often an injury of middle-aged athletesFull tears require referralDeep vein thrombosis often missed


Mechanism of injury: often occurs during dorsifl exion with extended knee; sudden acceleration/decelerationSudden sharp pain in calf, like being struck from behindLocalised tenderness and hardnessBruising over rupture sitePrevious history of injuriesPrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health, medications


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsGait, unable to put heel to groundPain on dorsifl exion of ankle and resisted plantar fl exionSite of pain and swelling: upper medial calfPalpation: step or gap in muscle


Deep vein thrombosisReferred pain from spine/sacrum or kneeBaker’s cystMuscle strain: plantaris, soleusCellulitis/infectionAchilles tendon sprainRadiculopathy from lumbar spine

WMS complications NecrosisAchilles tendon injuryTendonitisRuptureCompartment syndrome


Tissue damage and injury to muscle, tendons and ligaments following traumaQi and Blood stasis in the affected channels, consider: BL, or GB channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels


129


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; restore range of movement and function



Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustion CuppingGua shaTui naLiniments and herbal plasters*


130

Open Wound Knee/LegRead code: SA100/SA101


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicSoft tissue injury alone or in combination with a fracture may cause a compartment syndrome – refer if pain is disproportionately severe and poorly localised; severe swelling; hyperaesthesia/paraesthesia in distribution of nerves crossing compartmentNormal distal pulses, skin colour and capillary return do not exclude compartment syndrome


Continue to assess distal neurovascular and musculotendinous functionMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury, risk of penetration into jointCircumstances of injury: work-related, assault, self-infl ictedCompartment syndrome symptomsMedical history including medicationEmotional response to traumaFunctional limitationsGeneral health; symptoms of infection, tetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationRetained foreign bodiesJoint involvementCompartment syndrome signs: pain on passive stretching or active fl exion of affected muscles; distal sensory abnormalitiesOedema: extent and severityBruising: extent, severity, colourRange of movement and strength of hip, knee and ankle jointsPalpation: check temperature for infectionNeurological signs


Underlying fractureCompartment syndromeContusionAbrasion

WMS complications Ischaemic contractures from compartment syndromeExcessive bleeding due to bleeding disorder or anticoagulant useNeurovascular injuryInfectionScarringPenetration of joint with risk of sepsisTendon ruptureDeep vein thrombosis

131


Damage to tissue and surrounding structures causing Qi and Blood stasis in local area and affected channels, consider: ST, SP, BL, KI, GB or LR channels and fi ne luo distributionPossible involvement of Eight Extraordinary Vessels




TCM goals:Relieve pain by clearing stasis of Qi and Blood in the affected area and channelsRestore normal fl ow of Qi and Blood fl ow in the affected channels Calm Shen Resolve toxins Correct any underlying patterns of imbalance

Acute phase:AcupunctureAuricular acupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureCupping Tui na Liniments and herbal plasters*

Onward referral GP

132

Abrasion Leg/KneeRead code: SD60./SD602


Key points Superfi cial injury or laceration not involving deep structuresSoft tissue injury alone or in combination with a fracture may cause a compartment syndrome – refer if pain is disproportionately severe and poorly localised; severe swelling; hyperaesthesia/paraesthesia in distribution of nerves crossing compartmentNormal distal pulses, skin colour and capillary return do not exclude compartment syndrome


Abraded skin is prone to hyperpigmentation – advise sunblock for six months after injury


Nature of trauma causing injuryCompartment syndrome symptomsMedical history including medicationEmotional response to traumaFunctional limitations change in sensationMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)General health; symptoms of infection, tetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationRetained foreign bodiesJoint involvementCompartment syndrome signs: pain on passive stretching or active fl exion of affected muscles; distal sensory abnormalitiesOedema: extent and severityBruising: extent, severity, colourRange of movement and strength of hip, knee and ankle jointsPalpation: check temperature for infectionNeurological signs


Underlying fractureCompartment syndromeDeep laceration involving deeper structuresContusionJoint sprain

WMS complications Ischaemic contractures from compartment syndromeExcessive bleeding due to bleeding disorder or anticoagulant useNerve involvementInfectionScarringDeep vein thrombosis 133


Superfi cial damage to cutaneous region following traumaQi and Blood stasis in local cutaneous region and affected channels, consider: St, SP, BL, KI, GB or LR channels and fi ne luo distributionPossible involvement of Eight Extraordinary Vessels



WMS goals:Enhance healing of abrasion; reduce pain and swelling

TCM goals:Relieve pain by clearing stasis of Qi and Blood in the affected area and channelsRestore normal fl ow of Qi and Blood fl ow in the affected channels Calm Shen Resolve toxins Correct any underlying patterns of imbalance

Acute phase:AcupunctureAuricular acupunctureLaser AcupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureCupping Tui na Liniments and herbal plasters*

Onward referral GP

134

Contusion Knee and Lower LegRead code: SE41.


Key points




Nature of trauma causing injury: fall, direct blow, vehicle accidentLocation and severity of painChronicityPrevious injuries to affected siteFunctional restrictionsNeurological changesMedical conditions and drug therapyEmotional response to traumaGeneral health, symptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSeverity of swelling in limbsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourHaematoma: site, sizeConsider associated injuriesRange of movement: knee and ankleStability of joints: knee and ankleMuscle wastingPalpation: check temperature for infectionPeripheral circulationNerve involvement


Presence or risk of compartment syndromeFracture: head of fi bula, tibia, patella, condylesEpiphysitis in childrenMuscle or tendon ruptureAbrasionImpaired circulationNeurovascular injuryDeep vein thrombosis

135

WMS complications Compartment syndromeIschaemic contracturesDeep vein thrombosisExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyosotis ossifi cans (calcifi cation of haematoma in muscle belly)Traumatic myositis (infl ammation of muscle following trauma)Neurological injuryInfection/cellulitisChronic pain


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: ST, SP, BL, KI, GB or LR channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels



WMS goals: Enhance healing of contusion; reduce pain and swelling; restore range of movement

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected area and channelsCorrect any underlying patterns of imbalance Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Laser acupunctureMoxibustionCuppingGua sha Tui na Liniments and herbal plasters*


136

Contusion Lower Limb(multiple sites)

Read code: SE44.


Key points




Nature of trauma causing injury: fall, direct blow, vehicle accidentLocation and severity of painChronicityPrevious injuries to affected sitesFunctional restrictionsNeurological changesMedical conditions and drug therapyEmotional response to traumaGeneral health, symptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSeverity of swelling in limbsGait, weight-bearing abilityOedema: extent and severityBruising: extent, severity, colourHaematoma: site, sizeConsider associated injuriesAnatomical structures and tissues affectedRange of movement: knee, ankle, footStability of joints: knee and ankleMuscle wastingPalpation: check temperature for infectionPeripheral circulationNerve involvement: sensory or motor problems


Presence or risk of compartment syndromeFracture: head of fi bula, tibia, patella, condylesMuscle, tendon, or ligament ruptureDisruption of superior or inferior tibia - fi bula jointAbrasionImpaired circulationNeurovascular injuryDeep vein thrombosis

137

WMS complications Compartment syndromeIschaemic contracturesDeep vein thrombosisExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyosotis ossifi cans (calcifi cation of haematoma in muscle belly)Traumatic myositis (infl ammation of muscle following trauma)Neurological injuryInfection/cellulitisChronic pain


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: ST, SP, BL, KI, GB or LR channelsPossible involvement of Eight Extraordinary Vessels Qi block due to fright, in severe trauma





Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Laser acupunctureMoxibustionCupping Gua sha Tui na Liniments and herbal plasters*


138

Burns Lower LimbRead code: SH5..




General healthEmotional response to injuryExposed tendon/boneSkin graft donor siteSevere burns are associated with fl uid loss and secondary organ damage


Cause of burn: fl ame, scald, chemical, electrical, etcPercentage of body area involvedHistory of immediate managementDepth of burnRespiratory diffi culty: inhalation injuryUnilateral/bilateralPain level: check pain management is adequateSurgical interventionLength of hospital stayPrevious medical historyGeneral health and medication: diabetes, immunocompromise, symptoms of infectionFunctional limitationsEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain: severity; constant or with movementStage of healingRisk or presence of infectionScarringCondition of skin graft donor siteOedemaRange of movement: knee, ankleNeurovascular status of limbContractures/deformitiesLoss of functionGeneral fi tnessMobility: ability to bear weight



139

WMS complications Wound infectionGraft failureContractures and deformitiesScarringChronic painPsychological/social problemsReduced sensationInternal organ compromise


Damage to tissues and local cutaneous region by excess pathogenic Heat causing obstruction to normal fl ows of Qi and Blood in the affected channels, consider: ST, SP, BL, KI, GB or LR channelsIn severe cases consider concurrent Yin fl uid damage and damage to underlying structures (in extreme cases the Zang Fu)Qi block due to frightPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Potential febrile Bi syndromeInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceDamage to Yin fl uids and Jin-Ye (body fl uids)Prolonged Qi and Blood stasis leading to scarring/contracture



TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and BloodCorrect any underlying patterns of imbalance Calm Shen Nourish Yin fl uids and Jin-Ye

Acute phase:AcupunctureAuricular acupunctureLaser acupunctureIon pumping cords*

Sub-acute phase:AcupunctureAuricular acupunctureLaser acupunctureTui na

Onward referral GPPhysiotherapistOsteopathChiropractorOccupational therapistCouncillor

140

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Post-Concussion SyndromeRead code: E2A2.


Key points Post-concussion syndrome may occur even after relatively minor head injury: symptoms include decreased concentration, headaches, sleepiness, fatigue, irritability, dizzinessEnsure that original injury was thoroughly assessed by a suitably qualifi ed practitioner and that intra-cranial haemorrhage and cervical spine injury have been considered and excludedIf a sports injury, ensure patient is complying with guidelines regarding time out of sport after concussion, to avoid Second Impact Syndrome (a second blow to the head while still suffering effects of fi rst concussion, causing serious cerebral oedema out of proportion to the force of impact)


Recovery may be slow (1-3 months)Five percent of patients may still be impaired after two yearsOccupational and leisure activities: high levels of concentration required; use of potentially dangerous machinery/equipment, including drivingMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Head injury: force of impact, loss of consciousnessAssociated injuriesHistory of immediate treatmentMedical history including medicationHeadacheDecreased concentrationMemory diffi cultiesSleep disorderEasily fatiguedIrritability/aggressionAnxiety/depression/affective disorderDizziness, tinnitus, vertigoPhotophobia, blurred visionSocial/relationship dysfunctionOccupational diffi cultiesPrevious psychiatric historySymptoms worse after work/exerciseOnset/worsening of symptoms after head injuryEmotional response to condition


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsAbrasion/head woundPain: location, nature, severityOedema: extent and severityBruising: colour, extentCervical spine involvement


StrokePsychiatric conditionsChronic fatigue syndrome

141

WMS complications Psychosocial problems, especially depressionWork demandsAssociated cervical spine injurySkull fractureIntracranial haemorrhageDural tear with cerebro-spinal fl uid leakage


Injury to brain and/or spinal marrow (Jing) following traumaQi and Blood stasis in the affected channels, consider: ST, BL, SJ, LI, SI and GB channelsPossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g Liver Yang rising, Heart fi re

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to underlying structures eg bone, blood vessel, nerveBrain dysfunction expressed as Zang Fu patterns of imbalance eg disorders of Heart, Liver, Kidney Chronic Qi and Blood stasis Post traumatic patterns may develop e.g. Liver Blood defi ciency, Liver wind and marrow (Jing) defi ciency


WMS goals: Provide support while natural healing takes place

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels to reduce pain and swellingNourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected areaCorrect any underlying patterns of imbalance. Calm Shen Subdue Liver Wind

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui na

Onward referral GPHead Injury SocietyOccupational therapist

142

Open Wound EarRead code: S82..




Lacerations of auricular cartilage should be treated with antibiotics prophylacticallyAcute vertigo or deafness implies inner or middle ear damageMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryAssociated injuries: head injury, loss of consciousnessHistory of immediate treatmentAcute vertigo/deafnessMedical history including medicationEmotional response to traumaGeneral health, tetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsWound size, depth, locationRetained foreign bodiesPalpation: check temperature for infectionTrauma to tympanic membrane/external auditory canalHearing lossPain: location, nature, severityOedema: extent and severityBruising: colour, extent


Underlying facial fractureDeep laceration involving deeper structuresContusionHead injury

WMS complications Chronic tympanic membrane perforationsExternal auditory canal stenosisAuricular cartilage necrosis secondary to infectionAuricular cartilage overgrowth secondary to auricular haematomaScarring


Injury to skin and surrounding structures following traumaQi and Blood stasis in local cutaneous area and affected channels, consider: SI, SJ and GB channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Injury to underlying channel systemsInjury to surrounding structures eg brain, tympanic membrane, nerve, blood vesselInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding caused by Spleen Qi defi ciency

143


WMS goals:Enhance healing of wound; reduce pain and swelling

TCM goals:Disperse stasis of Qi and Blood in affected region and channels to reduce pain and swellingRestore normal Qi and Blood fl ow to affected channels to enhance wound healing and reduce scarring Calm Shen Resolve toxins Correct any underlying patterns of imbalance e.g. tonify Spleen QiSupplement Qi and Liver Blood if required

Acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustion

Sub-acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustionTui na Liniments and herbal plasters*

Onward referral GP

144

Open Wound Scalp/ForeheadRead code: S830./S8342


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicEnsure that cervical spine injury has been considered and excluded by a suitably qualifi ed practitioner


Fatal air embolism may occur via apparently trivial wounds involving the great veins of the neckMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryAssociated injuries: head injury, loss of consciousness, symptoms of concussionHistory of immediate treatmentMedical history including medication, history of bleeding disorder or anticoagulant useEmotional response to traumaGeneral health, tetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsWound size, depth, locationRetained foreign bodiesPalpation: check temperature for infectionPain: location, nature, severityOedema: extent and severityBruising: colour, extentSensory changes and facial movements, including eye


Underlying skull fractureDeep laceration involving deeper structuresContusionHead injury

WMS complications InfectionAssociated head/cervical spine injurySkull or facial fractureIntracranial haemorrhageDural tear with cerebro-spinal fl uid leakageScarringDamage to nerve or vessels


Injury to skin and surrounding tissue following traumaQi and Blood stasis in local cutaneous area and affected channels, consider: ST, BL, SI, SJ and GB channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels

145

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg brain, spine, blood vesselInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding caused by Spleen Qi defi ciency



TCM goals:Disperse stasis of Qi and Blood in affected region and channels to reduce pain and swellingRestore normal Qi and Blood fl ow to affected channels to enhance wound healing and reduce scarring Calm Shen Resolve toxins Correct any underlying patterns of imbalance e.g. tonify Spleen QiSupplement Qi and Liver Blood if required



Onward referral GP

146

Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth

Read code: S832./S8341/S8343/S8344/S8345/S836.




Medical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryAssociated injuries: head injury, loss of consciousnessHistory of immediate treatmentSymptoms of fracture of orbit: diplopia, pain on upward or lateral gazeSymptoms of mandibular/maxillary fracture: pain on bitingMedical history including medicationEmotional response to traumaGeneral health, tetanus statusSymptoms of infection


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsWound size, depth, locationInjury inside mouthPeriorbital injury: visual acuity/eye movementsCheek injury: facial nerve function; parotid duct damageRetained foreign bodiesPalpation: check temperature for infectionPain: location, nature, severityOedema: extent and severityBruising: colour, extentTooth injury


Underlying skull/facial fractureDeep laceration involving deeper structuresContusion

WMS complications Nerve, blood vessel, muscle, or eye injuryFacial fractureInfection: can be fatal if cavernous sinus thrombosis occursFacial palsyScarring of eyelids/tissue loss: epiphora/corneal exposureSalivary fi stulaAssociated head/cervical spine injury


Injury to skin and surrounding structures following traumaQi and Blood stasis in local cutaneous area and affected channels, consider: LI, ST, SI, BL, SJ and GB channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels

147

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to surrounding structures eg nerve, blood vessel, eye, muscle, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding caused by Spleen Qi defi ciency



TCM goals:Disperse stasis of Qi and Blood in affected region and channels to reduce pain and swellingRestore normal Qi and Blood fl ow to affected channels to enhance wound healing and reduce scarringCalm Shen Resolve toxins Correct any underlying patterns of imbalance e.g. tonify Spleen QiSupplement Qi and Liver Blood if required



Onward referral GP

148

Open Wound Buttock/External Genitalia

Read code: S87../S88..


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicAnogenital trauma in children and adults may represent sexual abuse/assaultConsider trauma to rectum/vagina/urethra/testes even in apparently superfi cial wounds


Examination should only be performed if necessary, and always with patient consent and a support person for the patient presentDo not examine or use local points with children, as repeated examination may be traumaticAll urethral injuries should be referred: suspect urethral injury with perineal bruisingIf assault is involved, ensure that patient has appropriate support from relevant agenciesMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)General health, tetanus statusSymptoms of infection


Nature of trauma causing injury: fall, direct blow, vehicle accident, sexual assaultLocation and severity of pain/haematuria/dysuriaOedemaHaematomaBlood loss via rectum/vagina/urethraHistory of immediate managementChronicityPrevious injuries to affected siteNeurological symptoms: sensory and motor function changesMedical conditions and drug therapyEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsExamination should only be performed if necessary, and always with patient consent and a support person for the patient presentSize, depth and location of woundOedema: extent and severityBruising: extent, severity, colourBruising of perineum suggests urethral injury and requires referralNerve involvement: sensory and motor changes

149


Sciatic nerve injuryAbrasionContusionFracturePenetrating injury, with internal organ damage

WMS complications Neurological injuryInfectionScarringInjury to rectum/anal canal/genito-urinary system, bowelPsychological/social problems


Injury to skin and surrounding structures following traumaQi and Blood stasis in local cutaneous area and affected channels, consider: ST, SP, BL, KI, GB and LR channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to surrounding structures eg nerve, Genito-urinary tract, bowelInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding may lead to Blood defi ciencyExcessive bleeding caused by Spleen Qi defi ciency



TCM goals:Disperse stasis of Qi and Blood in affected region and channels to reduce pain and swellingRestore normal Qi and Blood fl ow to affected channels to enhance wound healing and reduce scarringCalm Shen Resolve toxins Correct any underlying patterns of imbalance e.g. tonify Spleen QiSupplement Qi and Liver Blood if required


Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Onward referral GPCounsellor

150

Amputation at Shoulder/Hand/at Elbow/Foot/Upper Leg/Lower Leg

Read code: S906./S97../S97X./SA6../SA78./SA7X.


Key points Post-operative treatment following limb amputation with or without reattachmentTreatment to assist in regaining function of reattached limb/healing of wound/phantom limb syndrome


Loss of function affecting occupational and leisure activitiesPsychological impact of injury


Mechanism of injuryCircumstances of injury: work-related, vehicle accident, assaultOccupational and leisure activitiesHand dominanceHistory of acute managementMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertension, symptoms of infectionEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsTime since injuryExtent of injury: limb involved, level of amputationReattachment: degree of function recoveredPain: severity, effects on sleep, phantom limb syndromeAssociated injuriesSigns of infectionRange of movement of proximal jointsLoss of function


WMS complications InfectionPsychological traumaBlood loss


TCM diagnosis is regarded as amputationQi and Blood stasis in affected channelsTissue damage and associated stagnation of Qi and Blood of the muscle tendino (sinew) channelsPhantom limb pain is regarded as a mental disease involving Shen disturbance

151

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to surrounding structures eg joint, nerve, blood vesselInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding may lead to Blood defi ciencyShen disturbance


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; enhance healing of wound/function of reattached limb; reduce pain including phantom limb syndrome; prevent adhesion/scarring and secondary postural adaptation/dysfunction

TCM goals:Relieve pain by clearing Qi and Blood stasis in the affected region and channelsNormalise the Zang fu, channels and collaterals to arrest the phantom limb painRestore the normal fl ow of Qi and Blood in the channels to enhance wound healing and reduce scarring and adhesions Calm Shen Resolve toxins Correct any underlying patterns of imbalance e.g. tonify Spleen QiSupplement Qi and Liver Blood if required

Acute phase: AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustion

Sub-acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser Acupuncture MoxibustionCuppingTui na Liniments and herbal plasters*

Phantom limb pain:AcupunctureElectro-acupunctureAuricular AcupunctureLaser Acupuncture

Onward referral GPOccupational therapistCouncillor

152

Abrasion FaceRead code: SD000


Key points Superfi cial injury or laceration not involving deep structures


Abraded skin is prone to hyperpigmentation – advise sunblock for six months after injuryMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryAssociated injuries: head injury, loss of consciousnessMedical history including medicationSymptoms of fracture of orbit: diplopia, pain on upward or lateral gazeSymptoms of mandibular/maxillary fracture: pain on bitingEmotional response to traumaFunctional limitationsGeneral health, tetanus status


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsWound size, depth, locationPeriorbital injuries: visual acuityOedema: extent and severityBruising: extent, severity, colourRetained foreign bodiesPalpation: check temperature for infectionNeurological signs


Underlying facial fractureOcular traumaDeep laceration involving deeper structuresContusion

WMS complications Excessive bleeding as a result of bleeding disorder or anticoagulant useNerve involvementInfectionScarringMissed underlying injury


Superfi cial damage to cutaneous region following traumaQi and Blood stasis in local cutaneous region and affected channels, consider: LI, ST, SI, BL, SJ and GB channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying channel systems and structuresDamage to surrounding structures eg bone, eye, muscleInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Delayed healing due to underlying defi ciencies e.g. Blood defi ciency, Spleen Qi defi ciency

153



TCM goals:Relieve pain by clearing Qi and Blood stasis in the affected region and channelsRestore normal fl ow of Qi and Blood fl ow to heal abrasion and reduce scarring Calm Shen Resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureAuricular acupunctureLaser AcupunctureMoxibustionLiniments and herbal plasters*

Onward referral GP

154

Contusion Head/NeckRead code: SE0..


Key points Children and elderly especially vulnerable to head injury with a contusion


Refer nasal and aural injuries to exclude possibility of haematomaMay require counselling, particularly if assault is involvedCervical instabilityMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: fall, direct blow (including assault), vehicle accidentLocation and severity of painHistory of immediate managementChronicityPrevious injuries to affected siteFunctional restrictionsMedical conditions and drug therapyEmotional response to traumaPost-concussion syndrome symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourConsider associated injuriesPalpation: check temperature for infectionNerve involvement: sensory and motor changesCervical assessmentTemporomandibular joint assessmentEffects on vision


FractureAbrasionDental injuryHead injurySpinal injury

WMS complications Risk of avascular/septic necrosis of nasal or aural cartilageExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useNeurological injuryInfectionChronic painPsychological/social problems


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: LI, ST, SI, BL, SJ or GB channelsPossible involvement of Eight Extraordinary Vessels

155

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to surrounding structures eg bone, nerve, joint, ear, noseChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance



TCM goals: Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance. Calm Shen

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistCounsellorDentistOccupational therapist

156

Contusion Genital OrgansRead code: SE24.


Key points


Examination should only be performed if necessary, and always with patient consent and a support person for the patient presentDo not examine or use local points with children, as repeated examination may be traumaticAll urethral injuries should be referred: suspect urethral injury with perineal bruisingIf assault is involved, ensure that patient has appropriate support from relevant agenciesMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: fall, direct blow, vehicle accident, sexual assaultLocation and severity of painOedemaHaematomaHaematuria, dysuriaHistory of immediate managementChronicityPrevious injuries to affected siteNeurological symptoms: sensory and motor function changesMedical conditions and drug therapyEmotional response to traumaPsychological screen


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsExamination should only be performed if necessary, and always with patient consent and a support person for the patient presentOedema: extent and severityBruising: extent, severity, colourBruising of perineum suggests urethral injury and requires referralIntegrity of skinStability of pubic symphysisConsider associated injuriesNerve involvement: sensory and motor changes


FractureAbrasionLumbar spine injuryHip joint injuryContusion of lower limbSacro-iliac joint injury

157

WMS complications Excessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useNeurological signsInfectionSuspected fractureChronic painPsychological disorderDamage to internal genital structures, urethra, perineum


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: ST, SP, BL, KI, or LR channelsPossible involvement of Eight Extraordinary Vessels Blood or Shen disorder

TCM complications Same as WMS complications above plusDamage to underlying channel systemsDamage to surrounding structures eg nerve, bone, jointChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance


WMS goals: Enhance healing of contusion; reduce pain and swelling;

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalanceCalm Shen

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*

Onward referral GPCounsellorOccupational therapist

158

Burns Head/NeckRead code: SH1..


Key points Acupuncture is not an appropriate frontline treatment for burns. Ensure that the patient has been assessed by a medical practitioner.Patients with possible inhalation injury should be transferred to hospital urgentlyManagement depends on extent and depth of burn (superfi cial or deep)Refer to hospital if burn is >10% of body surface area: all children; all deep burns; burns with potential problems, e.g. electrical, chemical, circumferentialOral and perioral burns are the most common electrical injury in children, from chewing on a live cable: apparently trivial burns may later cause severe haemorrhage from the labial artery


May require long-term management (up to a year) depending on severityGeneral healthEmotional response to injuryExposed tendon/boneGraft donor siteSevere burns may be associated with fl uid loss and secondary organ damage


Cause of burn: fl ame, scald, chemical, electrical, etcRisk of inhalation injuryTime and duration of exposureHistory of immediate managementDepth of burnPain level: check pain management is adequateSurgical interventionLength of hospital stayPrevious medical history: asthma, respiratory disease, diabetes, compromised immune systemFunctional limitationsEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPainLocation of burnStage of healingScarring, contractures/deformitiesCondition of skin graft donor siteOedemaRange of movement: facial muscles, neckLoss of functionDifferentiate affected structure limiting range of movement: skin, scarring, ligament, muscle, tendon


Underlying conditions before trauma 159

WMS complications Airway compromisePerioral electrical burns: delayed haemorrhage, scarring, impaired jaw growth, abnormal speech developmentWound infectionGraft failureContractures and deformitiesScarringChronic painPsychological/social problemsReduced sensation


Damage to tissues and local cutaneous region by excess pathogenic Heat causing obstruction to normal fl ows of Qi and Blood in the affected channels, consider: LI, ST, SI, BL, SJ and GB channelsIn severe cases consider concurrent Yin fl uid damage and damage to underlying structures (in extreme cases the Zang Fu)Qi block due to frightPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying channel systemsDamage to surrounding structures e.g. muscle, facial tissues, bonePotential febrile Bi syndromeInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceDamage to Yin (fl uids) and Jin-Ye (body fl uids)Prolonged Qi and Blood stasis leading to scarring/contracture


WMS goals: Enhance healing of affected area; reduce pain, restore range of movement

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channels, enhance wound healing, and reduce scarring and adhesionsCorrect any underlying patterns of imbalance Calm Shen Nourish Yin fl uids

Acute phase:AcupunctureAuricular acupunctureLaser AcupunctureIon-pumping cords*

Sub-acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureTui na

Onward referral GPPhysiotherapistOccupational therapistCouncillor

160

Toxic Reaction Bee StingRead code: TE532


Key points Treatment is usually only required if complications involving soft tissues occur, such as impaired circulation in distal extremity from secondary oedema


Confi rm identifi cation of stinging insectMedical history: anaphylaxis, allergiesSite of sting(s)


Number of stingsSites involvedMost recent previous bee stings and reactionPrevious anaphylaxisCurrent medications and allergiesSymptoms after sting: itching, sneezing, tongue swelling, shortness of breathExtent of tissue damage


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSites of stings for erythema and swellingSkin rashDistal circulationOedema: extent and severityRange of movement of affected joints: active, passive, resisted


Urticaria/hivesOther invertebrate bite: wasp, spider, antLocalised infection/cellulitisSprainNeural involvementTendinopathyCompartment syndrome

WMS complications Local erythema/infection/cellulitisImpaired circulation in distal extremity from secondary oedemaCorneal ulceration (from corneal sting)Retained sting, granuloma, skin necrosisSerum sickness-like illness at 10-21 daysRarely: encephalitis, neuritis, vasculitis, nephrosis, coagulopathy, renal failureAnaphylaxis

161


Local injury to skin and subcutaneous tissuesLocal Qi and Blood stasis at site of sting in cutaneous area, affected channels and associated fi ne luo distributionTissue damage to appropriate six divisional cutaneous regions where wound is located and associated fi ne luo distributionSystemic reactions: Differentiate according to TCM principles and presenting symptoms, signs and history

TCM complications Same as WMS complications above plus:Damage to soft tissues and surrounding structures e.g. nerve, blood vesselQi block secondary to anaphylaxis or allergyInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceQi and Blood stasis


WMS goals: Reduce pain, erythema and swelling

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance Resolve toxins Calm Shen


Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser Acupuncture

Onward referral GP

162

Bite (dog) Read code: TE60.


Key points Bites must be referred for initial assessment and management by a medical practitioner/nurseCritical treatment strategy is thorough wound cleansing by a medical practitioner/nurseClose follow-up at 24-48 hours advisable by medical practitioner/nurse.Check tetanus statusManagement depends on location, depth and tissues involved


Infection risk is 5-20%Thorough wound cleansing is criticalUsually slow-healingPuncture wounds more liable to become infected than lacerationsHand, wrist, or foot injuries may cause loss of function


Possibility of exposure to rabies (if bite occurred overseas)Time elapsed since injuryHistory of immediate management: cleaning of wounds, antibioticsLocation of injuriesDepth of biteBlood lossTissues affectedGeneral health: medications, symptoms of infectionTetanus statusEmotional response to injury


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsLocation and number of affected sitesNature of wounds: depth, tissues affected, tissue loss, risk of infectionSigns of infection: erythema, heatRange of movement of affected joints, risk of joint penetrationCirculation distal to woundsNerve involvementCellulitis/systemic infection


Consider other causes of wounds, including self-harmCellulitisSkin conditions

WMS complications InfectionInjury of nerve, bone, blood vessels, tendon, jointSeptic arthritisCirculatory problems


Injury to skin and surrounding structures following traumaQi and Blood stasis at site of bite in local cutaneous region and affected channelsPossible involvement of Eight Extraordinary Vessels

163

TCM complications Same as WMS complications above plus:Damage to underlying channel systems depending on the depth of the injuryDamage to surrounding structures eg subcutaneous tissue, muscle, nerve, blood vessel, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding may lead to Blood defi ciencyExcessive bleeding caused by Spleen Qi defi ciencyShen disturbance


WMS goals: Reduce pain, erythema and swelling; enhance healing of injured area; treat according to signs and symptoms

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood, enhance wound healing and reduce scarring and adhesionsCorrect any underlying patterns of imbalance Resolve toxins Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser Acupuncture

Sub-acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Onward referral GP

164

Bite (human) Read code: U120.


Key points Bites must be referred for initial assessment and management by a medical practitioner/nurse.Critical treatment strategy is thorough wound cleansing by a medical practitioner/nurseClose follow-up at 24-48 hours advisable by medical practitioner/nurse.Check tetanus statusManagement depends on location, depth and tissues involved


Infection risk is 5-20%Risk of tendon infection and septic arthritis with injury to metacarpophalangeal joints (punch to mouth) – requires referralRisk of scalp infection in children (bite to head)Risk of deep tendon infection with bites to fi ngerThorough wound cleansing is critical


Circumstances of injury: fi ght, assaultTime elapsed since injuryHistory of immediate management: cleaning of wounds, antibioticsLocation of injuriesDepth of biteBlood lossTissues affectedGeneral health, medications, symptoms of infectionTetanus statusEmotional response to injury


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsLocation and number of affected sitesNature of wounds: depth, tissues affected, tissue loss, risk of infectionSigns of infection: erythema, heat/systemic infectionRange of movement of affected jointsCirculation distal to woundsNerve involvement


Consider other causes of wounds, including self-harmCellulitisSkin conditionsFracture

WMS complications InfectionInjury of nerve, bone, blood vessels, tendon, jointSeptic arthritisCirculatory problems


Injury to skin and surrounding structures following traumaQi and Blood stasis at site of bite in local cutaneous region and affected channelsPossible involvement of Eight Extraordinary Vessels

165

TCM complications Same as WMS complications above plus:Damage to underlying channel systems depending on the depth of the injuryDamage to surrounding structures eg subcutaneous tissue, muscle, nerve, blood vessel, boneInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinExcessive bleeding may lead to Blood defi ciencyExcessive bleeding caused by Spleen Qi defi ciencyShen disturbance


WMS goals: Reduce pain, erythema and swelling; enhance healing of injured area; treat according to presenting signs and symptoms

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood, enhance wound healing and reduce scarring and adhesionsCorrect any underlying patterns of imbalance Resolve toxinsCalm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular acupunctureLaser acupuncture

Sub-acute phase:AcupunctureElectro-acupunctureAuricular acupunctureLaser AcupunctureMoxibustion Tui na Liniments and herbal plasters*

Onward referral GP

166

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Rotator Cuff SyndromeRead code: N211.


Key points The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis muscles as they insert onto the head of the humerusRotator cuff disorders frequently involve degenerative changes in tendinous tissue before the onset of symptomsMicro trauma to tendons results in reduced circulation, formation of scar tissue, and deposition of calcium saltsPain initially presents as a dull ache in the deltoid region, frequently after strenuous exercisePain from tendon infl ammation may become persistent and nocturnalThe patient may present with a long history of pain with associated tendon degeneration or ruptureRotator cuff syndrome is associated with a painful arc on abduction between 60 to 120 degrees, caused by osteophytes, infl amed sub-acromial bursa, infl amed/swollen rotator cuff, excessive elevation of the humeral head, anatomical variation such as hooked acromionTendon degeneration from gradual onset damage is age relatedIncludes rotator cuff tendinoplasty


Cervical spine referral and involvementPatients who have had cuff corticosteroid injections are more likely to develop tearsShape of acromionPatients aged 35-50 yearsFailure of conservative treatment may require surgical intervention


AgeOccupational and leisure activitiesMechanism of injuryRepetitive or strenuous overhead work or sporting activityFall onto outstretched armPrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsReferred pain to neck or deltoid insertionNature and severity of painNight painAggravating and relieving factors including posturalFunctional limitationsGeneral health past and presentOsteoarthritis of glenohumeral or acromio-clavicular jointsSpecial questions: steroids, anticoagulants, diabetes, rheumatoid arthritis

167


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual inspection: compare with other shoulderPainful arc on abduction, 60-120 degreesRange of movement: active, passive and resistedPalpation: sensation changes, skin temperature, tenderness on tendon insertions, cervical spine, ah shi pointsSubscapularis lift-off testMuscle strength and wastingNeurovascular functionInstabilityCrepitusSwellingStructural information from X-rays


Muscle tear/ruptureSubscapularis or biceps tendon ruptureSterno-clavicular jointAcromio-clavicular jointAdhesive capsulitis (frozen shoulder)BursitisSubluxationCalcifi c tendonitisInstabilityAvascular necrosis of humeral headCervical/thoracic spineMedical condition: cancer, cardiac condition, glenohumeral arthritisNeurological disease/involvement

WMS complications Fracture/dislocation/avulsionSubscapularis or biceps tendon ruptureInfl ammatory diseases, including bursitisCalcifi cationFrozen shoulder


Injury to tendon following trauma, overuse or misuseQi and Blood stasis in local area and affected channels, consider: LU, LI, SI, SJ or GB channels, following misuse, overuse or trauma Underlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)Possible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding and underlying structures e.g. shoulder joint, nerve, muscleChronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Liver Qi stagnation, Blood defi ciencyShen disturbance

168


WMS goals: Decrease pain, infl ammation and oedema as required; maintain and restore range of motion


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui naLiniments and herbal plasters*


169

Tendonitis Upper LimbRead code: N21z2


Key points This profi le describes bicipital tendonitis (tenosynovitis of the long head of biceps brachii)Painful arc on abduction may confuse diagnosis with rotator cuff lesionConsidered as an overuse injury


Age – usually young to middle-aged adultsTendonitis may be secondary to poor shoulder/scapula functionOccupational and leisure activities


Mechanism of injury: usually follows chronic repetitive strain, e.g. home-decorating, tennis, freestyle swimming, etc.Dominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptoms: pain on front of shoulder, radiating to just below elbowNature and severity of pain: dull pain, sharp with certain movementsEffects on sleepAggravating and relieving factors: worse after activity, better for restFunctional limitationsGeneral health past and present


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain on resisted elbow fl exionPain on resisted supinationPainful arc on abduction if intrascapular part of tendon is involvedPossible tenderness along course of tendon in bicipital groove, worse with external rotationPain on active external rotationNeurological signs and symptoms


Rotator cuff syndromeRupture of tendonReferred cervical painPeripheral nerve conditions

WMS complications Rupture of tendonSubluxation of tendon out of bicipital groove


Injury to tendon following trauma, overuse or misuseQi and Blood stasis in local area and affected channels, consider: LU, LI or PC channels and LU and PC muscle channels following misuse, overuse or trauma Underlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)Possible involvement of Eight Extraordinary Vessels

170

TCM complications Same as WMS complications above plus:Damage to underlying channel systems and structuresChronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Liver Qi stagnation, Blood defi ciencyShen disturbance


WMS goals: Decrease pain, infl ammation and oedema as required; clear obstruction if required; maintain and restore range of movement


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingTui naLiniments and herbal plasters*


171

Fracture Clavicle (closed non-displaced)

Read code: S20..


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenClavicular fractures are common injuriesNearly 50% of all clavicular fractures occur before 7 years of age as greenstick fracturesAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Displaced clavicle fragments can injure nearby structures, e.g. blood vessels, lung, brachial plexusImmobilisation and support of arm is essential for patient comfortImpaction/displacement/conminuted


Fall onto side or outstretched handDirect blow to shoulderFall onto point of shoulderOccupation/sportOsteoporosisMalignancyCirculationSensory or motor changeGeneral healthRespiratory symptoms, cough, sputum, pain


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual examination for asymmetryDiffi culty breathing could indicate pneumothoraxPalpation: tenderness local to fractureSwellingCrepitusOedemaDeformityBruisingCirculation, sensory, or motor problems of arm and hand


Acromio-clavicular or sterno-clavicular joint injuryCervical spine injuryRib fracturesDislocation of shoulder jointRotator cuff injuryPneumothorax172

WMS complications Delayed union/non-union of fractureNeurovascular injuryInjury to lungDeformity


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, KI or ST channels Possible involvement of Eight Extraordinary Vessels Qi block due to severe fright

TCM complications Same as WMS complications above plus:Damage to underlying structures eg nerve, tendon, blood vesselNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance





Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionCupping


Onward referral Accident and emergency clinic GPOccupational therapistPhysiotherapist

173

Fracture Humerus (closed proximal)Read code: S226.


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenIn children greenstick fracture of the surgical neck is the most common typeAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Elderly patients more prone to fracture due to osteoporosisNon-displaced fractures require support, then mobilisation after 1-2 weeksRadial nerve damage is relatively commonImpaction/displacement/conminutedRisk of pathological fracture with history of metastatic bone cancer, Paget’s disease, osteoporosis, bone cyst


Mechanism of fractureDirect blow, e.g. motor vehicle accident, contact sportFall onto outstretched abducted armAxial loading through elbowRisk factors for pathological fracturePainOedemaDecreased range of movementGeneral health, medicationsSensory or motor changes to the hand


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of painBruising/swellingPosition of arm/elbow/shoulder/handRange of shoulder movement, active and passiveCervical spine involvementAcromio-clavicular or sterno-clavicular joint injuryWrist/elbow/hand joint injuryCirculatory, sensory, or motor problems


Dislocation of shoulderFractured clavicle, elbow, scapulaAcromio-clavicular joint dislocationRotator cuff injuryCervical spine involvement, with or without neural symptoms

WMS complications Non-union or malunion of fractureUnstable fractureNerve injury: ulnar, radial, axillary; brachial plexusAvascular necrosisJoint stiffness, especially in the elderly

174


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels Qi block due to severe fright

TCM complications Same as WMS complications above plus:Damage to underlying structures eg nerve, blood vessel, tendon, ligamentNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain and swelling; immobilise to enhance healing of fracture; restore range of movement




Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Onward referral Accident and emergency clinic GPPhysiotherapist

175

Dislocation/Subluxation ShoulderRead code: S41..


Key points Anterior dislocations account for 95% of shoulder dislocations


Reduction of dislocations should only be undertaken by a suitably qualifi ed, experienced practitionerThe fi rst dislocation is usually far more painful than subsequent dislocation of the same shoulderRecurrence rate is high, especially in patients under 20 yearsOften involves anterior dislocation of the glehohumeral jointChildren are more likely to fracture the proximal humerusPatients over 40 years have a high incidence of complete rupture of the supraspinatus tendonLevel of activity/sport/work demands


Mechanism of injury: signifi cant trauma unless recurrentAnterior dislocation: abduction, external rotation, extension; fall onto outstretched handPosterior dislocation: severe internal rotation and adduction; fall onto outstretched arm; direct blowInferior dislocation: hyperabduction of armTime period between dislocation and relocationPrevious shoulder injuries, treatments, outcomesSeverity and nature of painFunctional limitations, daily activitiesWeakness and sensory changeFamily historyDominant or non-dominant limbGeneral health past and presentSpecial questions: steroids, anticoagulants, X-ray, neurology, drugs, diabetes, rheumatoid arthritis


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsObservation: swelling, skin condition, muscle-wasting, postureRange of movement of shoulder, elbow and wrist, active and passivePalpation: sensation changes, skin temperature, swelling, painAcromio-clavicular joint involvementCheck for underlying tendonitisCervical spine involvementCirculatory, sensory, or motor problems


Fracture of humerusRotator cuff tearAcromio-clavicular joint injuryShallow joint structure

176

WMS complications Nerve involvement/brachial plexus lesionRecurrenceRotator cuff tearAssociated fractures, e.g. greater tuberosityVascular injury, especially axillary artery


Dislocation is the diagnostic term used in TCMTrauma leading to Qi and Blood stasis in the affected channels, consider: LU, LI, SI, GB or SJ channels and BL muscle channel

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg joint, tendon, nerve, ligamentChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Liver Blood defi ciency failing to nourish tendons and ligamentsShen disturbance


WMS goals: Decrease pain and infl ammation; assist healing; strengthen muscles; increase range of movement; treat underlying contributing factors

TCM goals: Decrease pain by clearing local Qi and Blood stasisRestore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance


Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustion Cupping Gua shaTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistPhysiotherapistOccupational therapist

177

Sprain Upper Arm/ShoulderRead code: S50..


Key points This Read code may include:Sub-acromial bursitisStrains of long head of biceps, deltoid, triceps, coracobrachialisCapsulitis


Brachial plexus or cervical nerve involvement


Mechanism of injury may be variable, but can include:Repetitive overhead work or sporting activity (throwing)Fall onto outstretched armSudden forceful movement such as overstretchingDirect blowPrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsNature and severity of painNight painAggravating and relieving factorsFunctional limitationsOccupational historyGeneral health past and presentHistory of sensory or motor changesOther joint involvement


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual inspection: compare both shoulders for deformity/swellingRange of movement: active, passive and resistedPalpation: tenderness skin temperature changes.InstabilityNeurovascular statusCervical spine involvement


FractureContusionReferred pain from cervical spinePeripheral nerve condition

WMS complications Restricted shoulder movementChronic pain and infl ammation/tendonitisInstability


Tissue damage and injury to muscle, tendons and ligamentsQi and Blood stasis in the affected channels, consider: LU, LI, HT, SI, SJ, GB or PC channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

178

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. nerve, boneDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance





Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingGua shaTui naLiniments and herbal plasters*


179

Sprain Acromio-Clavicular Ligament

Read code: S500.


Key points Elderly patients are more likely to suffer fracture than sprainChildren under 12 years rarely sprain ligaments


Early mobilisation is recommendedElderly patients are more prone to stiffening of joint, e.g. frozen shoulderElderly patients are more likely to rupture tendons


Direct impactFall onto outstretched armFall onto point of shoulderLevel of activity/sport/work demandsHeavy labour such as carrying heavy loadsRepetitive actionPrevious shoulder dislocationFracture to surrounding areaPrevious history of injuriesPrevious treatment, management, investigations, outcomesNature and severity of painAggravating and relieving factorsFunctional limitationsGeneral health past and presentSensory and motor changes of armMedications


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous Regions, Tai Yang, Shao Yang Etc• Tendino Muscle Channels (Sinew Network Vessels)Palpation• Associated Channels• Mu And Shu Points• A Shi PointsVisual inspection: compare with uninjured side for deformitySwelling, bruising, abrasion (possibility of infection)Range of movement of shoulder and neckPain over distal end of clavicle, worse for passive elevation of shoulderPalpation: extreme tenderness over acromio-clavicular joint, skin temperature changesStep or instability in acromio-clavicular jointIncreased pain with weight bearing and horizontal adductionWeakness or sensory changeCervical spine involvement


Shoulder dislocationRotator cuff sprainFracture clavicle or humerusMuscle sprain: supraspinatusBursitisContusionCervical spine injury

180

WMS complications Severe sprain can also affect conoid and trapezoid ligaments (between clavicle and coracoid process), causing tenderness above coracoid processNon-healing/non-unionUnstable jointDelayed rupture of major sprainsTendonitis in partial tearFrozen shoulder in elderlyDamage to underlying structures (neurovascular, tendon, lung)


Tissue damage or injury to joint, tendons and ligamentsQi and Blood stasis in the affected channels, consider: LU, LI, SI, SJ or GB channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg muscle, joint, tendon, ligamentDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance





Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingGua sha Tui naLiniments and herbal plasters*


181

Sprain Infraspinatus TendonRead code: S503.


Key points Elderly patients are more likely to fracture and to develop joint stiffeningLess common than supraspinatus injuryMay be an extension of supraspinatus injury


If a sling is being used check that neck range of movement is not impairedAdhesive capsulitis (frozen shoulder)


Acute onset: recent sprain or traumaChronic onset: possible overuse or poor technique such as lifting, throwingPrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsNature and severity of painNight painAggravating and relieving factorsFunctional limitationsOccupational historyGeneral health past and presentSensory or motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsConsider possibility of fracturePain on resisted external rotationLocalised tenderness over tendon (posterior aspect of shoulder joint)Pain over deltoid area and sometimes front of shoulderSkin temperature changesCervical or thoracic spine involvementRange of shoulder movement: active, passive and resistedNeurological signs


CapsulitisBursitisAcromio-clavicular joint strainRupture of long head of bicepsRupture of supraspinatus tendonCervical or thoracic spine involvementInstabilityFractureSubluxation/dislocationCalcifi c tendonitis

182

WMS complications Tendon ruptureChronic recurrent injuryTendonitisLoss of functionInstability


Tissue damage or injury to tendons Qi and Blood stasis in the affected channels, consider: LI, SI or SJ channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. spine, nerve, ligamentDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance




Acute phase:AcupunctureAuricular AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureMoxibustion CuppingTui naLiniments and herbal plasters*


183

Sprain Rotator Cuff Read code: S504.


Key points Red fl ag: inability to push a hand away from lumbar region indicates a major tear of the rotator cuffElderly patients are more likely to fracture and to develop joint stiffeningPatients over 40 years with signifi cant shoulder injury are more likely to have a rotator cuff tearPatients over 40 years with a dislocated shoulder have a 50% likelihood of rotator cuff tearSee ‘Key points’ for rotator cuff syndrome


Signifi cant rotator cuff tears do not heal well due to poor blood supply and require surgical repair ideally within three weeks – refer early to a specialistInability to perform active external rotation can indicate signifi cant rotator cuff tearEarly mobilisation, rest and ice speed recoveryChronic underlying degenerative conditionsInfl ammatory arthritis such as rheumatoidSteroid therapy


Onset: sudden or insidiousMechanism of injury: direct blow, throwing injury, fallPrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsNature and severity of painNight painAggravating and relieving factorsFunctional limitationsOccupational and leisure activitiesGeneral health past and presentNeurological symptoms, sensory or motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other side for deformity/swellingConsider possibility of fractureRange of movement: active, passive and resistedAbduction; internal and external rotationPainful arc indicates impingement (a negative test does not exclude rotator cuff sprain)Involvement of cervical or thoracic spine, scapula, elbow, acromio-clavicular jointCirculatory, sensory or motor problemsPalpation: skin temperature changes

184


Other joints: cervical, thoracic, acromio-clavicularNerve entrapmentCalcifi c tendonitisRuptured biceps tendonImpingementSubluxation/dislocationSubacromial bursitisFractureInfectionPathology: infl ammatory arthritis, herpes zoster, cancer

WMS complications AvulsionComplete tearCalcifi cationSubacromial bursitisInstabilityImpingementChronic pain and infl ammation/tendonitis


Tissue damage or injury to tendons and ligamentsQi and Blood stasis in the affected channels, consider: LU, LI, SI, SJ or GB channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. cuff tear, bone, blood vesselDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; restore range of movement; prevent adhesion/scarring, muscle thickening, and secondary postural adaptation/dysfunction


Acute phase:AcupunctureAuricular AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser acupunctureMoxibustion Cupping Gua shaTui naLiniments and herbal plasters*

185


186

Sprain Shoulder JointRead code: S507.


Key points Comprises ligamentous or capsular injury to the glenohumeral jointRed fl ag: inability to push a hand away from lumbar region indicates a major tear of the rotator cuffElderly patients are more likely to fracture and to develop joint stiffening


Occupational and leisure activities


Mechanism of injuryFallTraumaTwisting injurySporting injuryPrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsNature and severity of painPain in shoulder jointAggravating and relieving factorsFunctional limitationsGeneral health past and presentNeurological symptoms, sensory or motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual inspection, swelling, obvious deformity if dislocatedConsider possibility of fractureRange of movement: active, passive and resistedReduced passive ranges of movement with pain at end pointAbduction and external rotation especially restrictedInvolvement of cervical or thoracic spine, scapular functionCirculatory, sensory or motor problemsPalpation: skin temperature changesTenderness


Tendonitis/bursitisFractureLabral tearAcromio-clavicular or sterno-clavicular jointCervical and thoracic spineBiceps or supraspinatus tendonitis

187

WMS complications Adhesive capsulitis/frozen shoulderShoulder joint instabilityDisuse atrophyNeurological complicationsTraumatic arthritisRecurrent or chronic injuryTendonitis


Ligamentous or capsular injury to the glenohumoral joint Qi and Blood stasis in the affected channels, consider: LU, LI, SI, SJ or GB channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. bone, nerve, tendonDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance




Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionCuppingLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingGua shaTui naLiniments and herbal plasters*


188

Rupture of SupraspinatusRead code: S5Q2.


Key points Often misdiagnosed as rotator cuff strain


Occasionally caused by inappropriate use of steroidsFunctional impairment is variableSevere functional impairment may require surgery


Mechanism of injury: trauma or repetitive strain (lifting weights)Corticosteroid injectionSteroid abuseDominant/non-dominant sidePrevious history of injuriesPrevious treatment, management, investigations, outcomesArea of symptomsNature and severity of painEffects on sleepAggravating and relieving factorsFunctional limitationsOccupational and leisure activitiesGeneral health past and presentSpecial questions: anticoagulants, diabetes, rheumatoid arthritisNeurological symptoms, sensory or motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other side: deformity, swelling, bruising, skin condition, muscle wasting, posturePossibility of ligament injuryRange of movement: active, passive and resisted: shoulder, elbow, wristInvolvement of cervical spinePalpation: skin temperature changesNeurological symptoms, sensory or motor changes


Shoulder sprainRotator cuff strain/tearFractured humerusPectoralis major strain/tearSubluxation/dislocationGlenoid labrum tearAcromio-clavicular joint injuryCervical and thoracic spineMedical condition: cardiac, cancerCalcifi cationAbdominal referral

WMS complications Loss of function/strengthDeformityInstability 189


Tissue damage or injury to tendons and ligaments following trauma, overuse or misuseQi and Blood stasis in the affected channels, consider: LI, SI or SJ channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. joint, bone, nerveDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, and oedema as appropriate; restore range of movement; prevent adhesion/scarring and secondary postural adaptation/dysfunction


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionLiniments and herbal plasters*



190

Rupture of Biceps TendonRead code: S5Q4.


Key points Often misdiagnosed as rotator cuff strain


Occasionally caused by inappropriate use of steroidsFunctional impairment is variableDistal rupture requires early referral to specialist


Mechanism of injury:Acute: sudden loading of bicepsSub acute: gradual onset (repeated loading); possibly loss of power; possibly acute pain in anterior shoulder/upper armCorticosteroid injectionSteroid abuseDominant/non-dominant sideOccupational and leisure activitiesNeurological symptoms, sensory and motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsCompare with other side: deformity, swelling, bruising, skin condition, muscle wasting, postureMoved muscle belly accentuated by contraction, may be painlessTenderness at bicipital grooveRange of motionLoss of power of elbow fl exion/forearm supination


Shoulder sprainRotator cuff strain/tearFractured humerusPectoralis major strain/tearSubluxation/dislocation/fracture of shoulderCervical and thoracic spineMedical condition: cardiac, cancer

WMS complications DeformityLoss of function/strengthInstability


Tissue damage and injury to tendons following trauma, overuse and misuseQi and Blood stasis in the affected channels, consider: LU, HT or PC channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

191

TCM complications Same as WMS complications above plus:Damage to surrounding structures e.g. joint, bone, nerveDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain; limit dysfunction


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLiniments and herbal plasters*

Sub-Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureMoxibustionGua shaTui naLiniments and herbal plasters*

Onward referral GPPhysiotherapist

192

Open Wound Shoulder/Upper LimbRead code: S90..


Key points Open wounds would be treated only after initial assessment and treatment by a Medical Practitioner/Nurse/Accident and Emergency clinicSoft tissue injury alone or in combination with a fracture may cause a compartment syndrome – refer if pain is disproportionately severe and poorly localised; severe swelling; hyperaesthesia/paraesthesia in distribution of nerves crossing compartmentNormal distal pulses, skin colour and capillary return do not exclude compartment syndrome


Continue to assess distal neurovascular and musculotendinous functionMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryCircumstances of injury: work-related, assault, self-infl ictedDominant/non-dominant sideCompartment syndrome symptomsMedical history including medicationEmotional response to traumaFunctional limitationsGeneral health, tetanus statusNeurological symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationRetained foreign bodiesJoint involvementCompartment syndrome signs: pain on passive stretching or active fl exion of affected muscles; distal sensory abnormalitiesOedema: extent and severityBruising: extent, severity, colourRange of movement and strength of shoulder and elbow jointsPalpation: check temperature for infectionNeurological signs, circulation


Underlying fractureCompartment syndromeContusionAbrasion

WMS complications Ischaemic contractures from compartment syndromeNeurovascular injuryInfectionScarring

193


Injury to skin, surrounding tissues and underlying structures Qi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC, SJ or GB channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels




TCM goals:Disperse pain and swelling by clearing stasis in local cutaneous region, and affected channelsRestore normal fl ow of Qi and Blood in the affected channels to heal wound and reduce scarring and adhesions Calm Shen Resolve toxins Correct any underlying patterns of imbalance

Acute phase:AcupunctureAuricular acupunctureLaser AcupunctureMoxibustion


Onward referral GP

194

Abrasion Upper Arm (no infection)Read code: SD20.


Key points Superfi cial injury or laceration not involving deep structuresSoft tissue injury alone or in combination with a fracture may cause a compartment syndrome – refer if pain is disproportionately severe and poorly localised; severe swelling; hyperaesthesia/paraesthesia in distribution of nerves crossing compartmentNormal distal pulses, skin colour and capillary return do not exclude compartment syndrome


Abraded skin is prone to hyperpigmentation – advise sunblock for six months after injuryInvolvement of nerve, tendon, muscleMedical conditions (especially bleeding disorders, diabetes)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryDominant/non-dominant sideCompartment syndrome symptomsMedical history including medicationEmotional response to traumaFunctional limitationsGeneral health, tetanus statusNeurological symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityWound size, depth, locationRetained foreign bodiesJoint involvementCompartment syndrome signs: pain on passive stretching or active fl exion of affected muscles; distal sensory abnormalitiesOedema: extent and severityBruising: extent, severity, colourRange of movement and strength of shoulder and elbow jointsPalpation: check temperature for infectionNeurological signs, circulation


Underlying fractureCompartment syndromeDeep laceration involving deeper structuresContusion

195

WMS complications Ischaemic contractures from compartment syndromeExcessive bleeding due to history of bleeding disorder or anticoagulant useNerve or tendon involvementInfectionScarring


Superfi cial damage to cutaneous regionQi and Blood stasis in local cutaneous region and affected channels, consider: LU, LI, HT, SI, PC, SJ or GB channels and fi ne luo distributionPossible involvement of Eight Extraordinary Vessels




TCM goals:Disperse pain and swelling by clearing stasis in local cutaneous region, and affected channelsRestore normal fl ow of Qi and Blood in the affected channels to heal abrasion and reduce scarring Calm Shen Resolve toxins Correct any underlying patterns of imbalance



Onward referral GP

196

Contusion Upper LimbRead code: SE3..


Key points Contusion is defi ned as a closed injury, c.f. abrasionContusions to limbs carry a risk of compartment syndrome, indicated by pain disproportionate to the injury


Medical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementPain: severity and locationDominant/non-dominant sideMedical history including medicationEmotional response to traumaNeurovascular symptomsCervical symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourHaematomaConsider associated injuries: fracture, nerve involvement, circulatory problemsPain: location and intensityRange of movement, sensation, and strength of proximal and distal jointsPalpation: check temperature for infection; peripheral circulation


AbrasionFractureLigament, tendon or nerve damage especially brachial plexusMuscle strain or tear

WMS complications Compartment syndromeInjury to tendon, nerve or boneIschaemic contracturesExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyositis ossifi cans (calcifi cation of haematoma in muscle belly)Neurological/circulation disturbancesInfectionChronic pain

197


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg bone, nerve, tendonChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat




Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Cupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua shaTui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOccupational therapist

198

Contusion Upper Arm/ShoulderRead code: SE30.


Key points Contusion is defi ned as a closed injury, c.f. abrasionContusions to limbs carry a risk of compartment syndrome, indicated by pain disproportionate to the injury


Medical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)Cervical spine symptoms


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementPain: severity and locationDominant/non-dominant sideMedical history including medicationEmotional response to traumaNeurovascular symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourHaematomaConsider associated injuries: fracture, nerve involvement, circulatory problemsPain: location and intensityPalpation: check temperature for infection; peripheral circulationRange of movement, sensation, and strength of shoulder and elbow joints and hand


Compartment syndrome: presence or riskAbrasionFractureLigament, tendon or nerve damageMuscle strain or tearUnderlying joint pathologyCervical and thoracic spine involvementBursitis

199

WMS complications Compartment syndromeInjury to tendon, nerve or boneIschaemic contracturesExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyositis ossifi cans (calcifi cation of haematoma in muscle belly)Chronic painMuscle atrophy, ruptureInfectionNeurovascular compromise


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to surrounding structures eg tendon, nerve, ligamentChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat



TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance Calm Shen

Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Cupping Tui na Liniments and herbal plasters*


Onward referral GPOccupational therapistPhysiotherapist

200

Crush Injury Upper ArmRead code: SF203


Key points Mechanism of injury involves force from two sides


Risk of compartment syndrome, indicated by pain disproportionate to the injuryNeurovascular status should be monitoredMedical conditions (especially bleeding disorders, diabetes, immunocompromise)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: industrial machinery (rollers), vehicle accidentAssociated injuriesHistory of immediate managementDominant/non-dominant sideMedical history including medication, tetanus statusEmotional response to traumaNeurological symptoms, sensory or motorCirculation changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsAssess risk of compartment syndromeOedema: extent and severityBruising: extent, severity, colourSkin laceration, abrasion, bony tendernessRange of movement and strength of shoulder and elbow jointsPalpation: check temperature for infection; peripheral circulationNeurological signs


FractureLacerationSoft tissue injury: strain or tearCirculatory problemsNerve injury

WMS complications Compartment syndrome with ischaemic contractures if unrecognisedExcessive bleeding due to bleeding disorder or anticoagulant useMyositis ossifi cansNerve injuryTendon injuryMuscle injuryNecrosisInfection

201


Damage to local cutaneous area, soft tissue, tendons and ligaments, and possibly bone following traumaLeaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels consider: LU, LI, HT, ST, PC or SJ channels and connecting and muscle-tendino (sinew) channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingPossible involvement of Eight Extraordinary Vessels Qi block due to fright, in severe trauma

TCM complications Same as WMS complications above plus:Damage to channel systems and surrounding structures eg bone, nerve, tendon, blood vesselChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance


WMS goals: Enhance healing of injuries; reduce pain and swelling

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance Calm Shen

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui na Liniments and herbal plasters*


202

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Cervical Disc Prolapse RadiculopathyRead code: N12C0


Key points Pain follows dermatomal distribution of affected nerve root(s), most commonly C5 and C6Cause may be non-traumatic, e.g. osteophytes due to cervical spondylosis, tumoursDisc prolapse usually compresses the nerve root inferior to it, e.g. C4 disc compresses C5 nerveMore common in 35-65 age groups


Previous medical history, especially cancers, osteoarthritis, rheumatoid arthritisTumours tend to cause bilateral painVertebro-basilar insuffi ciencyWeakness or numbness in limbs, loss of normal bladder or bowel constitute a medical emergency


Mechanism of injuryPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradualAggravating and relieving factorsArea of symptoms: identify dermatomes involved; pain in upper trapezius; stiffness of neck with limited range of movement; involvement of arms, legs, bladder or bowel. Nature and severity of pain: numbness/tingling; sharp aching pain in neck radiating down one or both arms; onset of pain may be abrupt, e.g. on sudden movement of neckNight painFunctional limitationsGeneral health past and present


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsActive and passive range of neck movementPalpation: reproduction of numbness/tingling; local soft tissue structures, cervical joints, levator scapula muscleUpper limb tension testCompression/distraction testNeurological sensory and motor signs in upper and lower limbs


FractureDegeneration of facet joints/discsLateral canal stenosisReferred cardiac or gallbladder painThoracic outlet syndromeT4 syndromeReferred pain from pulmonary sulcus tumour (Pancoast tumour)NeuromaAcromio-clavicular strain

203

WMS complications Fracture/suspected instabilitySpinal cord compression Trauma upon pre-existing injuryOsteoarthritisVertebro-basilar insuffi ciency


Arthralgia syndromeQi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, LI, SJ and GB channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction


WMS goals: Decrease pain, infl ammation, numbness and tingling; restore range of movement

TCM goals:Decrease pain by clearing local Qi and Blood stasisNourish Blood and reinforce Qi to restore normal fl ows of Blood and Qi in the affected channelsCorrect any underlying patterns of imbalance Calm ShenNourish Kidney, Liver and Spleen to promote healing of joints and ligamentsNourish Liver Blood and supplement Qi

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*



204

Thoracic Disc Prolapse RadiculopathyRead code: N12C1


Key points Intervertebral disc prolapse is very uncommon in the thoracic spineMost disc protrusions occur below T9, most commonly at T11-T12The thoracic spine is the most common site in the vertebral column for metastatic tumours, especially from breast, lung and prostate cancerPain present day and night may indicate cancerAcute non-traumatic onset of thoracic pain could indicate serious cardiac or vascular problems


Previous medical history, especially cancers, osteoarthritis, osteoporosis, cardiac conditions Weakness or numbness in limbs, loss of bladder or bowel function constitute a medical emergency Age: increased risk of cancer, compression fracture, osteoporosisGeneral healthWork and leisure activities


Mechanism of injuryPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradualAggravating and relieving factorsInvolvement of legs, bladder or bowel. Nature and severity of painNight painFunctional limitationsGeneral health past and present: Scheuermann’s disorder


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: scoliosis, kyphosis, postureRange of movement: active, passive, accessoryPalpation: reproduction of pain; spinous processesArea of symptoms: identify dermatomes involved; record any sensory or motor loss


Muscle strainCompression fractureRib fractureFacet jointsCervical pain referralScheuermann’s disorderCardiovascular disorderCancerSevere infection: TB, pleurisy, brucellosisPneumothoraxOsteoporosisReferred pain from pulmonary sulcus tumour (Pancoast tumour)Acromio-clavicular strain

205

WMS complications Respiratory conditionsKyphosis, scoliosisOsteoporosisSpinal cord compression


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, and GB channelsArthralgia syndromePossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction, Kidney and Spleen Qi defi ciencyJing defi ciency predisposing to spine pathology


WMS goals: Decrease pain, infl ammation, numbness and tingling; restore range of movement



Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCupping Gua sha Tui naLiniments and herbal plasters*


206

Lumbar Disc Prolapse RadiculopathyRead code: N12C2


Key points Radicular pain caused by nerve root compression from a disc protrusionLeg pain typically relates to the dermatome and myotome innervated by the affected nerve root, most commonly L5 or S1.Leg pain may occur without back pain, and can vary considerably in intensityThese symptoms can also be caused by pelvic disease and tumours, especially from prostate, breast, bronchial, thyroid and kidney cancer and melanoma, which can metastasise to the spineCauda equina syndrome (saddle anaesthesia, bowel or bladder dysfunction) indicate a medical emergency


Previous medical history, especially cancers, osteoarthritis, osteoporosisAge: more common > 30 years; increased risk of cancer, osteoporosis with ageGeneral healthWork and leisure activities


Mechanism of injury: lifting, twisting, can be spontaneousPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentNature and severity of pain/numbness and tingling; weakness.Involvement of legs, bladder or bowel. Area of pain: identify dermatome/myotome involvedNight painFunctional limitationsGeneral health past and present


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: scoliosis, kyphosis, posture, walkingRange of movementStraight leg raising testPalpation: lumbar/gluteal muscle spasms; SI jointsArea of symptoms: identify dermatomes involved; record any sensory or motor loss


Tumour (severe unremitting pain)Cauda equina syndromeSacro-iliac joint dysfunctionSpondylosis/spondylolisthesisFacet jointsPiriformis syndromeOsteoporosisPain of visceral originCardiovascular disorder/arterial occlusion

WMS complications Cauda equina syndromePeripheralisation of symptoms

207


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, KI and GB channelsArthralgia syndromePossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g. Kidney Qi defi ciency, Qi and Liver Blood defi ciency



WMS goals: Decrease pain, infl ammation, numbness and tingling; release secondary muscle adaptation and restore range of movement


Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser AcupunctureMoxibustion Tui naLiniments and herbal plasters*


Onward referral GP PhysiotherapistChiropractorOsteopathOccupational therapist

208

Chronic/Recurrent Pain (cervical)Read code: N131.


Key points Non-traumatic causes include spinal degeneration, osteophyte formation, disc degeneration


Previous medical history, especially cancers, arthritic diseases, cardiovascular diseaseVertebro-basilar insuffi ciency Weakness or numbness in limbs, loss of bladder or bowel function constitute a medical emergency Loss of consciousnessInstability


Mechanism of injuryPrevious history of injuriesDizziness, blurred vision, tinnitus, nausea, headaches, chest pain, loss of balance, loss of consciousness, dysphagiaPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradualChronicityArea of symptoms: pain/stiffness in upper trapezius; stiffness of neck with limited range of movementNature and severity of painAggravating and relieving factorsNight painFunctional limitationsGeneral health past and present: rheumatoid arthritis, polymyalgia rheumatica, cerebrovascular diseaseMedication: e.g. steroids, anticoagulantsNeurological symptoms, sensory or motor changes


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsActive range of movement: cervical spine, shoulder girdleNeurological examination required if symptoms present below shoulder levelPosturePalpation: spinal irregularities, temperature


FractureDegeneration of facet joints/discsReferred dental painTemporo-mandibular joint dysfunctionReferred cardiac or gallbladder painCarotid/vertebral artery occlusionRheumatoid arthritisPolymyalgia rheumaticaOsteoarthritisOsteoporosisReferred pain from pulmonary sulcus tumour (Pancoast tumour)

209

WMS complications Trauma upon pre-existing injury or degenerationSpinal cord compression Vertebro-basilar insuffi ciency/vertebral artery spasmRadiculopathy/acute nerve root compression syndromeOsteoarthritis


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, LI, SJ and GB channelsDefi ciency of YinKidney Jing defi ciency predisposing to spine pathology Arthralgia syndromePossible involvement of Eight Extraordinary Vessels Wind/Cold/Damp Bi syndrome obstructing Qi and/or Blood circulation locallyUnderlying patterns of imbalance e.g. Qi and Liver Blood defi ciency

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat Bi obstructionFebrile Bi syndrome Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction, Kidney and Spleen Qi defi ciency


WMS goals: Decrease pain and infl ammation; restore range of movement; reduce numbness and tingling if present

TCM goals:Decrease pain by clearing local Qi and Blood stasisNourish Blood and reinforce Qi to restore normal fl ows of Blood and Qi in the affected channelsClear Heat/drain Damp/expel Wind/disperse Cold according to presenting patternCorrect any underlying patterns of imbalance Calm ShenNourish Kidney, Liver and Spleen to promote healing of joints and ligamentsNourish Liver Blood and supplement Qi

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustion Laser AcupunctureTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui naLiniments to and herbal plasters*


210

Low Back Pain, Acute Pain – Lumbar, Lumbago

Read code: N142.


Key points Soft tissue injuries are uncommon causes of low back pain alone. Most lumbar problems originate from apophyseal joints or intervertebral joints, or from degenerative changesLumbar pain can also be caused by pelvic disease and tumours, especially from prostate, breast, bronchial, thyroid and kidney cancer and melanoma, which can metastasise to the spine (may be indicated by weight loss, history of cancer, low grade fever, severe unremitting pain)Cauda equina syndrome (saddle anaesthesia, bowel or bladder dysfunction) indicate a medical emergency


Previous medical history, especially cancers, osteoarthritis, osteoporosis, cardiovascular disordersAge: increased risk of cancer or osteoporosis with age


Mechanism of injury: trauma, repetitive overuse, increased bodyweight, degenerative changes, poor postureTiming of injury related to symptom developmentPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentNature and severity of pain; constant or intermittentInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retentionArea of painNight painAggravating and relieving factorsOccupational historyFunctional limitationsGeneral health past and present: osteoporosis, neoplasmsMedication


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsRed fl ag indicatorsVisual: posture, gait, scoliosis, kyphosisStraight leg raising testArea/level of dysfunctionPalpation: lumbar spine joint fi xation; lower back muscle spasm; SI joints; tendernessRange of movementNeurological signs

211


Chronic low back pain (requires different management)RadiculopathyFractureTumour (severe unremitting pain)Cauda equina syndromeInfl ammatory diseasesSacro-iliac joint dysfunctionSpondylosis, spondylolisthesisFacet jointsHamstring/hip strainPiriformis syndromeOsteoporosisPain of visceral origin

WMS complications Cauda equina syndromeSpinal canal stenosisPsychological effects of back pain (yellow fl ags)


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, KI and GB channelsArthralgia syndromePossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g. Kidney Qi defi ciency, Qi and Liver Blood defi ciency Underlying Jing defi ciency predisposing to spine pathology


212


WMS goals: Decrease pain; restore range of movement and normal gait; release secondary muscle adaptation

TCM goals:Decrease pain by clearing local Qi and Blood stasisClear Heat/drain Damp/expel Wind/disperse Cold according to presenting patternNourish Blood and reinforce Qi to restore normal fl ows of Blood and Qi in the affected channelsCorrect any underlying patterns of imbalance Calm ShenNourish Kidney, Liver and Spleen to promote healing of joints and ligamentsNourish Liver Blood and supplement Qi




213

SciaticaRead code: N143.


Key points Sciatica is pain in the distribution of the sciatic nerve or its branches (L4 to S3) caused by nerve pressure or irritationIncludes: facet joint dysfunction, sacroiliac joint dysfunction, piriformis syndromeLeg pain may occur without back pain, and can vary considerably in intensitySciatica symptoms can also be caused by pelvic disease and by tumours, especially from prostate, breast, bronchial, thyroid and kidney cancer and melanoma, which can metastasise to the spineCauda equina syndrome (saddle anaesthesia, bowel or bladder dysfunction) indicate a medical emergencyPatient should be encouraged to remain active within pain threshold


Previous medical history, especially cancers, osteoarthritis, osteoporosisAge: increased risk of cancer or osteoporosis


Mechanism of injuryTiming of injury related to symptom developmentPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentNature and severity of painNight painArea of pain: identify dermatome/myotome involvedInvolvement of legs (weakness or numbness) of bladder or bowel incontinence or retentionOccupationFunctional limitationsGeneral health past and present: arthritis, osteoporosis, neoplasms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: posture, gaitStraight leg raising testPalpation: lumbar/sacral pain, sacroiliac joint, piriformis spasm/syndromeArea of symptoms: identify dermatomes involved; record any sensory loss or motor change


Chronic low back pain (requires different management)RadiculopathyFractureTumour (severe unremitting pain)Cauda equina syndromeSacro-iliac joint dysfunctionSpondylosis, spondylolisthesisFacet jointsOsteoporosisPeripheral vascular disorder/arterial occlusion

214

WMS complications Cauda equina syndromePsychological effects of back pain (yellow fl ags)Radiculopathy





WMS goals: Decrease pain, numbness, and tingling; restore range of movement and normal gait; release secondary muscle adaptation


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustion Cupping Gua sha Tui naLiniments and herbal plasters*


215

Sprain Sacroiliac JointsRead code: S561.


Key points Sacroiliac joint sprain does not ususally cause pain below the kneeBreast and prostate cancer can metastasise to the upper femur and pelvisCauda equina syndrome (saddle anaesthesia, bowel or bladder dysfunction) indicate a medical emergencyPatient should be encouraged to remain active


Previous medical history, especially cancers, osteoarthritis, osteoporosisAge: increased risk of cancer or osteoporosisSacroiliac joint can be the common site of infl ammatory arthritis


Mechanism of injuryPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentNature and severity of pain; constant or intermittentInvolvement of legs (weakness or numbness) bladder or bowel functionArea of pain: dull ache in buttock, can refer to groin or posterior thighNight painAggravating and relieving factorsFunctional limitationsGeneral health past and present: arthritis, medication


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: posture, gaitPalpation: lower back or hip muscle spasm; tenderness over sacroiliac jointsRange of movementNeurological examinationOther joints and general signs of infection/infl ammation


RadiculopathyFractureTumour (severe unremitting pain)Cauda equina syndromeInfl ammatory diseasesSpondylosisFacet joint dysfunctionHamstring/hip strainLumbar instabilitySprain of gluteus medius/quadratus lumborumOsteoporosisPain of visceral origin

WMS complications Ongoing pain

216







Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustionCuppingTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Moxibustion Cupping Gua sha Tui naLiniments and herbal plasters*


217

Sprain Cervical SpineRead code: S570.


Key points Includes soft tissue injury with potential involvement of facet joints or intervertebral discs.


Previous medical history, especially cancers, arthritic diseases, cardiovascular diseaseVertebro-basilar insuffi ciencyWeakness or numbness in limbs, loss of normal bladder or bowel function constitute a medical emergency Degenerative changesInstability


Mechanism of injuryTime relationship of symptoms to injuryPrevious history of injuriesDizziness, blurred vision, tinnitus, nausea, headaches, chest pain, loss of balance, loss of consciousness, dysphagiaPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradualArea of symptoms: pain/stiffness in upper trapezius; stiffness of neck with limited range of movementInvolvement of arms and legs (weakness or numbness) bladder or bowel functionNature and severity of painAggravating and relieving factorsNight painFunctional limitationsOccupational and leisure activitiesGeneral health past and present: rheumatoid arthritis, polymyalgia rheumatica, cerebrovascular diseaseMedication


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsRange of movement: active and passiveNeurological examination, motor and sensory function of arms and legsPosturePalpation: spinal irregularities; cervical joints

218


Chronic neck pain (requires different management)FractureDegeneration of facet joints/discsReferred dental painTemporo-mandibular joint dysfunctionReferred cardiac or gallbladder painCarotid/vertebral artery occlusionCanal stenosisRheumatoid arthritis/infl ammatory diseaseSevere osteoarthritisOsteoporosisReferred pain from pulmonary sulcus tumour (Pancoast tumour)Herpes zosterMeningitis

WMS complications Spinal cord compressionChronic neck painFracture/suspected instabilityTrauma upon pre-existing injury or degenerationVertebro-basilar insuffi ciency/vertebral artery spasmRadiculopathy/acute nerve root compression syndrome


Arthralgia syndromeQi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, LI, SI, SJ and GB channelsPossible involvement of Eight Extraordinary Vessels Yin defi ciency Kidney Qi defi ciency leading to spine pathology

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction

219


WMS goals: Decrease pain and infl ammation; restore range of movement

TCM goals:Decrease pain by clearing local Qi and Blood stasisNourish Blood and reinforce Qi to restore normal fl ows of Blood and Qi in the affected channelsCorrect any underlying patterns of imbalance Calm ShenNourish YinNourish Kidney, Liver and Spleen to promote healing of joints and ligamentsClear Heat/drain Damp/expel Wind/disperse Cold according to presenting pattern




220

WhiplashRead code: S5704


Key points Whiplash injury is caused by hyperextension of the neck followed by recoil hyperfl exionInjury may involve muscle, nerve roots, ligaments, apophyseal joints and intervertebral discsDamage to apophyseal joints can be severe, with microfractures and long-term dysfunctionPain may not present until some days after injury


Previous neck injuries or degenerative changesVertebro-basilar insuffi ciencyWeakness or numbness in limbs, loss of normal bladder or bowel function constitute a medical emergency Instability


Mechanism of injuryPrevious history of injuries: treatment, management, investigations, outcomesDizziness, blurred vision, tinnitus, nausea, headaches, chest pain, loss of balance, loss of consciousness, dysphagia, dyspnoeaAnxiety, depression, symptoms of concussionNature and severity of pain and stiffnessInvolvement of legs or arms (weakness or numbness) bladder or bowel incontinence or retentionRadiation of pain: shoulders, mid-scapular region, arms, hands; paraesthesia of ulnar border of handAggravating and relieving factorsNight painFunctional limitationsOccupational and leisure activitiesGeneral health past and presentMedicationHead injury


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsRange of movement: activePosturePalpation: muscle spasm; cervical jointsNeurological examination


FractureDegeneration of facet joints/discsCervical disc lesion

221

WMS complications Fracture/suspected instabilityTrauma upon pre-existing injury or degenerationOsteoarthritisRadiculopathyConcussionHeadaches


Tissue damage leading to Qi and/or Blood stasis in the affected channels due to trauma, consider: BL, LI, SJ and GB channelsPossible involvement of Eight Extraordinary Vessels Tissue damage to tendons and ligaments

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction Kidney Qi defi ciency leading to spinal pathology


WMS goals: Decrease pain and infl ammation; restore range of movement

TCM goals:Decrease pain by clearing local Qi and Blood stasisNourish Blood and reinforce Qi to restore normal fl ows of Blood and Qi in the affected channelsCorrect any underlying patterns of imbalance Calm ShenNourish Kidney, Liver and Spleen to promote healing of joints and ligamentsClear Heat/drain Damp/expel Wind/disperse Cold according to presenting pattern


Sub-acute phase:Acupuncture: Electro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui naLiniments and herbal plasters*


222

Sprain Thoracic SpineRead code: S571.


Key points Musculoskeletal thoracic pain is often due to poor posture. Lower cervical and thoracic spinal joints may also be involvedThe thoracic spine is the most common site in the vertebral column for metastatic tumours, especially from breast, lung and prostate cancerPain present day and night may indicate cancerAcute non-traumatic onset of thoracic pain could indicate serious cardiac or vascular problems


Age: increased risk of cancer, compression fracture, osteoporosisWeakness or numbness in limbs, loss of normal bladder or bowel function constitute a medical emergency


Previous medical history, especially cancers, osteoarthritis, osteoporosis, cardiac conditions, respiratory functionMechanism of injuryPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradualInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retentionLocation of painAggravating and relieving factorsNature and severity of painNight painFunctional limitationsGeneral health past and present: Scheuermann’s disorder, medications


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: scoliosis, kyphosis, postureSkin lesions: herpes zosterRange of movement: active, passive, accessoryPalpation: spinous processes; reproduction of painRespiratory function, circulationNeurological examination legs and armsKyphosis, scoliosis

223


Disc prolapseCompression fractureRib fractureFacet jointsCervical pain referralAnkylosing spondylitisScheuermann’s disorderCardiovascular disorderCancerPulmonary infection: TB, pleurisy, brucellosis, pneumoniaPneumothoraxOsteoporosisReferred pain from pulmonary sulcus tumour (Pancoast tumour)Acromio-clavicular strainPulmonary Embolus

WMS complications Reduced respiratory functionFractureSpinal cord compression Rib involvement


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, and GB channelsArthralgia syndromePossible involvement of Eight Extraordinary Vessels Jing defi ciency leading to spinal pathology

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction, Kidney and Spleen Qi defi ciencyJing defi ciency leading to spine pathology

224


WMS goals: Decrease pain; restore range of movement


Acute phase:Acupuncture Electro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Gua sha Tui naLiniments and herbal plasters*



225

Sprain Lumbar SpineRead code: S572.


Key points Lumbar pain can be caused by pelvic disease and tumours, (may be indicated by weight loss, history of cancer, low grade fever, severe unremitting pain)Cauda equina syndrome (saddle anaesthesia, bowel or bladder dysfunction) indicate a medical emergency


Previous medical history, especially cancers, osteoarthritis, osteoporosis


Mechanism of injuryTiming of injury related to symptom developmentPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retention Nature and severity of pain; constant or intermittent; area of pain, night painAggravating and relieving factorsOccupational historyFunctional limitationsGeneral health past and present: arthritis, osteoporosis, neoplasmsMedications


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual: posture, gaitNeurological signs: nerve root and cauda equina syndromeNeuromuscular testing as appropriate/indicatedPalpation: lumbar spine joint fi xation; lower back muscle spasm; tendernessRange of movement


Chronic low back pain (requires different management)RadiculopathyFractureTumour (severe unremitting pain)Cauda equina syndromeInfl ammatory diseasesSacro-iliac joint dysfunctionSpondylosis, spondylolisthesisFacet jointsHamstring/hip strainOsteoporosisPain of visceral origin

226

WMS complications Cauda equina syndromeSpinal canal stenosisChronic low back pain or history of repetitive injuryPsychological/social problems


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, KI and GB channelsArthralgia syndromePossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g Qi and Liver Blood defi ciency Kidney Qi and Jing defi ciency leading to spine pathology

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction, Kidney and Spleen Qi defi ciency







227

Sprain CoccyxRead code: S574.


Key points Work and leisure activities: amount of time spent seated


Mechanism of injury: fall onto buttocks; trauma; post-partumInvolvement of legs (weakness or numbness), loss of bladder and bowel function consitutes a medical emergencyPrevious history of injuries

History Mechanism of injuryTiming of injury related to symptom developmentPrevious history of injuriesPrevious treatment, management, investigations, outcomesOnset of pain: sudden or gradual, recurrentInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retention Nature and severity of pain; constant or intermittent; area of pain, night painAggravating and relieving factorsOccupational historyFunctional limitationsGeneral health past and present: arthritis, osteoporosis, neoplasms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual PalpationNeurological examination


FractureSacro-iliac joint dysfunctionLumbar spine Pain of visceral originCyst or abscess

WMS complications FracturePelvic rim injuryConstipation


Qi and/or Blood stasis in the affected channels due to trauma and/or overuse, consider: BL, KI and GB channelsPossible involvement of Eight Extraordinary Vessels Underlying patterns of imbalance e.g. Kidney Qi defi ciency

TCM complications Same as WMS complications above plus:Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbanceUnderlying patterns of imbalance e.g. Liver Blood defi ciency causing Bi obstruction, Kidney and Spleen Qi defi ciencyJing defi ciency predisposing to spine pathology228


WMS goals: Decrease pain; improve mobility; release secondary muscle adaptation; clear obstruction



Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Cupping Tui naLiniments and herbal plasters*


229

Contusion BackRead code: SE23.


Key points


Medical conditions (especially bleeding disorders)Contusion to kidneyDrug therapy (e.g. anticoagulants)Underlying back conditions


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementPain: severity and locationMedical history including medicationEmotional response to traumaHaematuria/dysuriaFunctional limitations


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsTemperature, pulse.Oedema Bruising /Haematoma : extent, severity, colourConsider associated injuries: fracture, nerve involvement, circulatory problems, kidneyPain: location and intensityRange of movementMuscle involvementInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retention


FractureUnderlying joint pathologyAbrasionMuscle strain or tearInternal injury

WMS complications Spinal injuryMyositis ossifi cans (calcifi cation of haematoma in muscle belly)Excessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useInjury to tendon , nerve or boneInfectionChronic painOrgan damage, particularly kidneyPelvic injury

230


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local cutaneous region and affected channels, consider: BL and GB channelsPossible involvement of Eight Extraordinary Vessels




TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected channelsCorrect any underlying patterns of imbalance. Calm Shen Clear Heat/drain Damp/expel Wind/disperse Cold according to presenting pattern




231

Crush Injury BackRead code: SF110




Medical conditions (especially bleeding disorders, diabetes, immunocompromise)Drug therapy (e.g. anticoagulants)Contusion to kidneyUnderlying back conditions


Nature of trauma causing injuryAssociated injuriesHistory of immediate managementMedical history including medicationAcute or chronicInvolvement of legs (weakness or numbness) bladder or bowel incontinence or retentionPain: distribution, behaviourFunctional limitationsEmotional response to traumaHaematuria/dysuria


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourSkin laceration, abrasionRange of movement: spine and peripheral proximal jointsPosturePalpation: check temperature for infection, tenderness over renal angleMuscle spasm/injuryNeurological signs


Intervertebral disc involvementFacet joint dysfunctionFractureLacerationSoft tissue injury: strain or tearCirculatory problemsNerve injuryUnderlying joint pathologyOrgan damage

WMS complications Myositis ossifi cansAssociated tendon or muscle injuryInfectionOrgan damage, particularly kidneyCauda equina syndrome (medical emergency)

232


Qi and Blood stasis in the affected area and channels following trauma, consider BL and GB channelsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Depending upon the depth of the injury there may be damage to the affected cutaneous region, musculo-tendinous channel, divergent and or main channel and underlying structures such as Zang Fu or boneShen disturbanceUnderlying patterns of imbalance e.g. Kidney and Spleen Qi defi ciency


WMS goals: Enhance healing of affected area; reduce pain, oedema, infl ammation and bruising; restore range of movement

TCM goals:Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Liver Blood and reinforce Qi to re-establish the normal fl ow of Qi and BloodNourish Kidney, Liver and Spleen to promote healing of bones, soft tissues, tendons and ligamentsCorrect any underlying patterns of imbalance Calm Shen Clear Heat/drain Damp/expel Wind/disperse Cold according to presenting pattern

Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureTui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture MoxibustionCupping Gua shaTui na Liniments and herbal plasters*


233

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Carpal Tunnel SyndromeRead code: F340.


Key points Compression of the median nerve typically affects palmar aspect of lateral three and a half fi ngers


Encourage patient to identify and modify/avoid exacerbating factorsCausal or associated factors also include trauma, fi brosis, rheumatoid arthritis, myxoedema, gout, pregnancy, premenstrual oedema, hypothyroidism, and diabetes mellitus and weight gain


Mechanism of injury: often follows repetitive rapid wrist and fi nger motion under loadGradual onsetPins and needles in fi ngers, often at night, relieved by shaking of handsLoss of sensation or paraesthesia in median nerve distributionClumsiness, loss of grip strengthPain in the wrist may radiate into fi ngers or up into armCervical spine symptomsOedema of wristPrevious wrist fracture or other injuryDominant/non-dominant sidePrevious treatment, management, investigations, outcomesEffects on sleep, worse at nightAggravating and relieving factors: worse after activity, better for restOccupational and leisure activities, especially involving force and repetitionFunctional limitationsGeneral health past and presentPregnancyDiabetes Weight gain


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsTinel testPhalen testSensory changes in median nerve distributionLoss of grip strengthCarpal jointsWeakness or atrophy of thenar musclesShoulder and arm functionInfl ammation, heat, swellingCervical spine examinationOther joint involvement

235


Nerve root compressionBrachial neuritisProximal nerve entrapmentThoracic outlet syndromeTendonitis/tenosynovitis of wrist or elbowJoint pathology/arthritisPrevious fracture/trauma to wristMuscle tear/strainPeripheral neuropathy

WMS complications Chronic painNerve damage: loss of motor or sensory functionTear or rupture of tendon (especially after steroid injection)Scar adhesion post surgery


Injury to tendon and nerve following traumaQi and Blood stasis in local area and affected channels, consider: LU, HT or PC channels

TCM complications Same as WMS complications above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Liver Qi stagnation, Blood defi ciencyShen disturbance


WMS goals: Decrease pain, paraesthesia, oedema and infl ammation; restore range of movement


Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser acupuncture MoxibustionTui naLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser acupuncture MoxibustionTui naLiniments and herbal plasters*


236

Flexor Tendon Rupture hand/wristRead code: N2264


Key points Usually seen after surgical repair


Can be secondary to rheumatoid or osteoarthritisOccasionally due to inappropriate use of corticosteroidsMay follow prolonged period of tendinosis


Mechanism of injury: forced hyperextension of digitPrevious steroid injectionDominant/non-dominant sideNature and severity of painFunctional limitationsOccupational and leisure activitiesGeneral health past and present: rheumatoid or osteoarthritis


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsVisual inspection: swellingRange of movement: fi nger (passive only until sub-acute), wristPain on movementLoss of functionResting position: splint requirementNeurological examination


Sprain/strainFractureInfectionCarpal ligament injuryOpen wound with tendon lacerationNerve dysfunction

WMS complications Adhesion, scarringContracture of interphalangeal jointOsteoarthritisJoint subluxationLoss of function


Injury to tendon following trauma, misuse or overuseQi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC or SJ channels and connecting and muscle-tendino (sinew) channels, following misuse, overuse or trauma Underlying Liver Blood defi ciency failing to nourish tendons and ligaments or external pathogen obstruction (Bi syndrome)Possible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Chronic Qi and Blood stasis can lead to further invasion of pathogenic factors such as Wind, Cold, Damp and Heat (Bi syndrome)Delayed healing or recurrence if underlying defi ciencies are not corrected e.g. Qi defi ciency, Liver Blood defi ciency Shen disturbance

237


WMS goals: Decrease pain and infl ammation; enhance tendon repair; restore range of movement; prevent adhesion/scarring; specifi c goals dependent upon site of rupture and degree of functional impairment involved




Onward referral GPHand Therapist preferred providerPhysiotherapistChiropractorOsteopath

238

Fracture Scaphoid (closed)Read code: S2401


Key points Ensure that the patient has been assessed by a medical practitioner and appropriate radiological investigations and stabilisation treatment have been undertakenOften missed initially as pain may not be severeInitial X-rays may not show a fractureMay be associated with lunate dislocationUsually seen after immobilisation or surgeryRare in children and the elderlyAcupuncture is useful in the acute and sub-acute phases to assist in relief of pain, resolution of infl ammation and oedema, restoration of blood circulation, repair of damaged tissue and return to normal function


Bone scan is recommended if fracture is suspected but X-rays appear normalDelayed union, non-union, and avascular necrosis of scaphoid are relatively commonWrist ligament injuriesOther local fractures Presentation may be several days after injury


Mechanism of fracture: fall onto outstretched hand; kickback from starting motors, etc.Local pain and swellingPain may decrease 2-3 days after injuryOccupational and leisure activities


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite of pain: over dorsal and palmar aspects of scaphoid; tenderness in anatomical snuffbox (less specifi c)SwellingIntolerance of wrist extensionFinger movementFunctional limitations


Bennett’s fracture of thumb metacarpalFracture of radial styloidDislocation of wristTendonitisWrist sprainScapho-lunate ligament injuryCarpal tunnel syndromeArthritis

239

WMS complications Displaced fractureNon-union or malunion of fractureAssociated ligament damageAvascular necrosis of proximal fragmentComplex regional pain syndromeOsteoarthritis


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, or LI channels Possible involvement of Eight Extraordinary Vessels

TCM complications Non-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain and swelling; increase blood vascularisation; enhance healing of fracture; restore range of movement and function



Acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureMoxibustion

Sub acute:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion Liniments and herbal plasters*

Onward referral GPHand Therapist preferred providerPhysiotherapistOsteopathChiropractor

240

Fracture Carpal BoneRead code: S24z.


Key points May be missed on X-rayCarpal bone fractures may cause neurovascular problems in the handUsually requires immobilisation in plaster cast


Degree of force involved indicates likelihood of serious injuryDocument neurovascular status of hand at regular intervalsCarpal instabilities may develop early or late after a carpal injuryAssociated ligamentous or soft tissue injury


Mechanism of fracture: generally fall onto outstretched handLunate fracture: extension injury; impact to heel of handTriquetrum fracture: dorso-ulnar pain and swellingHook of hamate fracture: caused by e.g. golf club hitting groundPisiform fracture: direct blow; local tendernessForce of impactLocal pain and swellingNerve involvement/circulationHand dominance Occupational and leisure activities


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema and point tenderness, possibly bruisingDeformityRange of movement: fl exion, extension, pronation, supinationFinger movementFunctional limitations: grip strengthNeurological examination


Ligament or cartilage injuryForearm fractureDislocation of wristTendonitisScapholunate instability

WMS complications Hamate and pisiform fractures: ulnar nerve palsyLunate dislocation or perilunate fracture: median nerve damageCarpal instabilityNon-union or malunion of fractureAssociated ligament damageAvascular necrosisInter-articular adhesion with loss of movement


Damage to bone following trauma Qi and/or Blood stasis in the affected channels, consider: LU, LI, HT, SI, PC or SJ channels Possible involvement of Eight Extraordinary Vessels

241

TCM complications Same as WMS complications above plus:Damage to underlying structures eg tendon, nerveNon-union of fracture or delayed healing due to Kidney Qi defi ciency and/or Blood defi ciency and stasisChronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain and swelling; increase blood vascularisation; restore range of movement

TCM goals:Decrease pain by clearing local Qi and Blood stasis Restore normal fl ows of Blood and Qi in the affected channelsCalm ShenNourish Blood and reinforce Qi to enhance healing and restore range of movement Correct any underlying patterns of imbalance


Acute phase:AcupunctureElectro-acupunctureAuricular AcupunctureLaser Acupuncture


Onward referral GPHand Therapist preferred providerPhysiotherapistOccupational therapistOsteopathChiropractor

242

Sprain Wrist/HandRead code: S52..


Key points Includes ligament, tendon attachment, muscular and joint injuryMay be acute, chronic, or gradual onsetElderly patients are more likely to fracture than sprainChildren under 12 years rarely sprain ligaments: X-ray to check for fractureConsider scaphoid fracture in adultsConsider tendon rupture in the elderly


Grade of sprain: range of movement with no defi nite end point indicates ruptureRequires early mobilisation, especially in the elderly: risk of frozen shoulder with prolonged immobilisation


Mechanism of injury: fall, trauma, twisting injury while gripping fi xed objectGradual onset: work and leisure activitiesDuration of symptomsPain: location and severityPrevious injury or pathologyDominant/non-dominant sidePrevious treatment, management, investigations, outcomesEffects on sleepHand dominance Occupational and leisure activitiesFunctional limitationsGeneral health past and presentOther joint involvementNeurovascular symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityTendernessLoss of grip strengthInfl ammation, heat, swellingRange of movement: active, passiveNerve or vascular problems in handCrepitusLateral stabilityCervical or thoracic spine involvementExamination of other joints

243


Triangular fi bro-cartilage injuryFractureDislocationScapho-lunate disassociationTendonitis, tenosynovitisLigamentous instabilityJoint pathologyCarpal tunnel syndromeTendon ruptureReferred pain from cervical spineAcute nerve or arterial injury

WMS complications Chronic recurrent tendonitisUnstable jointsChronic painVascular or nerve injuryCarpal tunnel syndrome


Tissue damage and injury to muscle, tendons and ligaments following traumaQi and Blood stasis in the affected area and channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. bone, nerve, and tendonDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance






244


245

Sprain Tendon Wrist or HandRead code: S524.


Key points Elderly patients are more likely to fracture than sprainChildren under 12 years rarely sprain ligaments: X-ray to check for fractureConsider scaphoid fracture in adultsConsider tendon rupture in the elderly


Requires early mobilisation, especially in the elderly: risk of frozen shoulder with prolonged immobilisation


Mechanism of injury: fall, trauma, twisting injury while gripping fi xed objectGradual onset: work and leisure activitiesDuration of symptomsPain: location and severityWeakness: muscles involvedPrevious injury or pathologyDominant/non-dominant sidePrevious treatment, management, investigations, outcomesFunctional limitationsGeneral health past and present, underlying infl ammatory conditionSensory or motor symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsDeformityTendernessLoss of grip strengthInfl ammation, heat, swellingRange of movement: hand, wrist, elbow; active, passiveStrength: hand, wrist, elbowCrepitusNerve or vascular examinations of the handCervical or thoracic spine involvement


Triangular fi bro-cartilage injuryLigament or joint sprainFractureDislocationScapho-lunate disassociationTendonitis, tenosynovitisTendon avulsionAvascular necrosisLigamentous instabilityJoint pathologyCarpal tunnel syndromePeripheral nerve condition

246

WMS complications Tendon ruptureChronic painVascular or nerve injuryCarpal tunnel syndrome


Tissue damage and injury to tendon following traumaQi and Blood stasis in the affected area and channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsLiver Blood defi ciency failing to nourish tendons and ligamentsPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. blood vessels, nervesDelayed healing due to underlying patterns of imbalance e.g. Qi defi ciency, Liver Blood defi ciency Chronic stasis of Qi and Blood may lead to invasion of pathogenic factors, Wind, Cold, Damp and/or Heat (Bi syndrome) Shen disturbance


WMS goals: Decrease pain, infl ammation, oedema and bruising as appropriate; restore range of movement; prevent adhesion/scarring/dysfunction





247

Open Wound WristRead code: S91..




Tendon sheath injury or infection requires urgent hospital treatmentEvidence of vascular compromise of fi nger or hand requires urgent referralSelf-infl icted wounds require psychiatric assessment


Mechanism of injuryCircumstances of injury: work-related, assault, self-infl ictedHistory of immediate treatmentAssociated symptoms/injuriesPotential for infection, tetanus statusOccupational and leisure activitiesPrevious injury/disabilityMedical history including medication: immunosuppressants, corticosteroidsGeneral health: diabetes, hypertensionEmotional response to trauma


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsSite and extent of woundSigns/risk of infectionRetained foreign bodiesSensory functionRange of movement: wrist; fi ngersMotor nerve involvementPain: location, nature, severityOedema: extent and severityBruising: colour, extentCirculation: colour/warmth; pulses; capillary refi llPotential fracture: deformity, local tendernessLigamentous stability: fi nger joints



WMS complications InfectionScarringStiffnessNeurological/tendon injury

248


Injury to local cutaneous area, soft tissues, tendon and ligament and possibly bone following trauma Qi and Blood stasis in local area and affected channels, consider: LU, LI, HT, SI, PC or SJ channels and associated fi ne luo distributionPossible involvement of Eight Extraordinary Vessels



WMS goals: Enhance healing of wound; reduce pain and swelling; restore range of movement; specifi c goals depend on structures involved in injury

TCM goals:Decrease pain by clearing Qi and Blood stasis in the affected area and channels Restore normal fl ows of Qi and Blood in the affected channels to enhance wound healing Calm Shen Resolve toxins Correct any underlying patterns of imbalance


Sub-acute phase:AcupunctureElectro-acupuncture Laser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*

Onward referral GPPhysiotherapistOsteopathChiropractorHand Therapist preferred provider

249

Contusion Wrist/HandRead code: SE32.


Key points Contusions to limbs carry a risk of compartment syndrome, indicated by pain disproportionate to the injury


Consider additional injuriesIf not caused by trauma, consider underlying medical conditionsFingernails may require aspiration or drainageMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injury: determine force involved and depth of injuryHistory of acute managementPain: severity and locationDominant/non-dominant sideMedical history including medicationEmotional response to traumaOccupational and leisure activitiesNeurovascular symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsOedema: extent and severityBruising: extent, severity, colourHaematomaConsider associated injuries: fracture, nerve involvement, circulatory problemsPain: location and intensityRange of movementPalpation: check temperature for infection; peripheral circulation


Compartment syndrome: presence or riskAbrasionFractureLigament, tendon or nerve damageMuscle strain or tearIschaemic changes

WMS complications Compartment syndromeInjury to tendon, nerve or boneIschaemic contractures/circulation disturbancesExcessive bleeding and haematoma as a result of bleeding disorder or anticoagulant useMyosotis ossifi cans (calcifi cation of haematoma in muscle belly)InfectionChronic painNeurological injuryHaematoma of nail bed requiring drainage

250


Leaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels





Acute phase:AcupunctureElectro-acupuncture Laser AcupunctureMoxibustionCuppingTui na Liniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Laser AcupunctureMoxibustionCupping Tui na Liniments and herbal plasters*


251

Crush Injury Wrist or HandRead code: SF22.




Management of associated injuries: fractures, tendon, nerve, soft tissue, skinRisk of compartment syndrome, indicated by pain disproportionate to the injurySplinting is importantMedical conditions (especially bleeding disorders)Drug therapy (e.g. anticoagulants)


Nature of trauma causing injuryAssociated injuriesSite of painDominant/non-dominant sideHistory of immediate managementMedical history including medicationTetanus statusEmotional response to traumaOccupational and leisure activitiesNeurological and ciculation symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsAssess risk of compartment syndromeDeformityOedema: extent and severityBruising: extent, severity, colour, bony tendernessSkin laceration, abrasionRange of movement and strength of wrist and fi ngersPalpation: check temperature for infection; peripheral circulationNeurological signs


FractureLacerationCellulitisSoft tissue injury: strain or tearCirculatory problemsNerve injury

WMS complications Compartment syndrome/ischaemic contractureMyositis ossifi cansNerve, tendon, muscle injuryFractureNecrosis/infection

252


Injury to local cutaneous area, soft tissues, tendons and ligaments, and possibly bone following traumaLeaking of blood out of vessels with Blood and Qi stasis in local tissues and affected channels following traumaSpleen Qi defi ciency, Blood Heat may lead to excessive or prolonged bruisingQi and Blood stasis in local affected channels, consider: LU, LI, HT, SI, PC or SJ channels and muscle-tendino (sinew) channelsPossible involvement of Eight Extraordinary Vessels Qi block due to fright, in severe trauma

TCM complications Same as WMS complications above plus:Damage to underlying structures e.g. muscle, nerve, tendon, boneChronic stasis of Qi and Blood leading to invasion by Wind, Cold, Damp and/or Heat (Bi Syndrome)Excessive bruising due to Spleen Qi defi ciency, Blood Heat Shen disturbance


WMS goals: Enhance healing of injured area; reduce pain and swelling


Acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureLiniments and herbal plasters*

Sub-acute phase:AcupunctureElectro-acupuncture Auricular AcupunctureLaser AcupunctureMoxibustion CuppingGua sha Tui na Liniments and herbal plasters*


253

Burns Hand(s)/WristRead code: SH4..




General healthEmotional response to injuryExposed tendon/boneSkin graft donor siteSevere burns may be associated with fl uid loss and secondary organ damage


Cause of burn: fl ame, scald, chemical, electrical, etcPercentage of body area involvedDepth of burnRespiratory diffi culty: inhalation injuryUnilateral/bilateralPain level: check pain management is adequateSurgical interventionLength of hospital stayPrevious medical historyFunctional limitationsEmotional response to traumaOccupational and leisure activitiesSensory and motor symptoms


PulseTongueShen and emotionsComplexion colourObservation• Cutaneous regions, tai yang, shao yang etc• Tendino muscle channels (sinew network vessels)Palpation• Associated channels• Mu and shu points• A shi pointsPain: severity; constant or with movementStage of healingScarringCondition of skin graft donor siteOedemaRange of movement: fi ngers, wristNeurovascular status of limbContractures/deformities


WMS complications Wound infectionGraft failureContractures and deformitiesScarringPsychological/social problemsSensation alterationLoss of function254


Injury to tissues and local cutaneous region by excess pathogenic Heat causing obstruction to normal fl ows of Qi and Blood in the affected channels, consider: ST, SP, BL, KI, GB or LR channelsIn severe cases consider concurrent Yin fl uid damage and damage to underlying structures (in extreme cases the Zang Fu)Qi block due to frightPossible involvement of Eight Extraordinary Vessels

TCM complications Same as WMS above plus:Damage to underlying structures e.g. muscle, tendon, ligamentPotential febrile Bi syndromeInvasion by external pathogenic Xie Qi (Evil Qi) Heat Toxin and or Damp ToxinShen disturbanceDamage to Yin and Jin-Ye (fl uids)Prolonged Qi and Blood stasis leading to scarring/contracture



TCM goals: Disperse stasis of Blood and Qi in the local tissues and affected channels Nourish Blood and reinforce Qi to re-establish the normal fl ow of Qi and Blood in the affected area and channelsCorrect any underlying patterns of imbalance Calm Shen Nourish Yin fl uids

Acute phase:AcupunctureAuricular AcupunctureLaser AcupunctureIon-pumping cords*

Sub-acute phase:AcupunctureAuricular acupunctureLaser acupunctureTui na

Onward referral GPPhysiotherapistOsteopathChiropractorOccupational therapistHand Therapist preferred providerCouncillor

255

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Read Code reference tableRead code Description Treatments Trigger Page

E2A2. Post-Concussion Syndrome 12 16 141

F340. Carpal Tunnel Syndrome 12 16 235

N12C0 Cervical Disc Prolapse Radiculopathy 16-20 22 203

N12C1 Thoracic Disc Prolapse Radiculopathy 13-18 20 205

N12C2 Lumbar Disc Prolapse Radiculopathy 16-22 24 207

N131. Chronic/Recurrent Pain (cervical) 12-16 18 209

N142. Low Back Pain, Acute Pain – Lumbar, Lumbago

9 13 211

N143. Sciatica 12 16 214

N211. Rotator Cuff Syndrome 12-16 18 167

N2131 Medial Epicondylitis (elbow) 12 14 43

N2132 Lateral Epicondylitis (elbow) 12 16 45

N2165 Prepatellar Bursitis 10 14 113

N2174 Tendonitis Achilles 12 16 15

N21z2 Tendonitis Upper Limb 11 15 170

N220. Tenosynovitis/Synovitis 16 16 83

N2264 Flexor Tendon Rupture Hand /Wrist 20 24 237

S120. Fracture Rib (closed) 8 10 25

S20.. Fracture Clavicle (closed non-displaced) 6 8 172

S226. Fracture Humerus (closed proximal) 8 14 174

S2241 Fracture Distal Humerus, Supracondylar (closed)

8 14 47

S230./S231.

Fracture of Proximal Radius/Ulna 11 15 50

S232./S233.

Fracture of Shaft of Radius/Ulna 11 15 52

S234./S235.

Fracture of Distal Radius/Ulna 11 15 55

S2401 Fracture Scaphoid (closed) 12 16 239

S24z. Fracture Carpal Bone 12 16 241

257

Read code Description Treatments Trigger Page

S25.. Fracture of Metacarpal Bone 12 16 86

S26.. Fracture Phalanx – Hand 12 14 88

S33.. Fracture Tibia/Fibula 12 16 115

S34.. Fracture Ankle 10 14 17

S352. Fracture Tarsal Bones/Metatarsals (closed) 10 12 69

S36.. Fracture Phalanges (Foot, closed) 6 8 72

S41.. Dislocation/Subluxation Shoulder 10 14 176

S44.. Dislocation/Subluxation of Finger/Thumb 20 20 90

S460. Acute Meniscal Tear (medial) 10 12 117

S461. Acute Meniscal Tear (lateral) 8 12 119

S50.. Sprain Upper Arm/Shoulder 8 12 178

S500. Sprain Acromio-Clavicular Ligament 10 12 180

S503. Sprain Infraspinatus Tendon 12 16 182

S504. Sprain Rotator Cuff 10 16 184

S507. Sprain Shoulder Joint 10 12 187

S51.. Sprain Elbow/Forearm 9 11 58

S52.. Sprain Wrist/Hand 10 12 243

S5204 Sprain Radial Collateral Ligament (thumb) 10 12 92

S522. Sprain Thumb 10 12 94

S523./S5513

Sprain Finger/Interphalangeal Joint 10 12 96

S524. Sprain Tendon Wrist or Hand 10 12 246

S53.. Sprain Hip/Thigh 8 12 109

S533. Sprain Quadriceps Tendon 8 14 121

S540. Sprain Lateral Collateral Ligament Knee 10 14 123

S541. Sprain Medial Collateral Ligament Knee 10 14 125

S542. Sprain Cruciate Ligament Knee 12 16 127

S54x1 Sprain Gastrocnemius 8 12 129

S550. Sprain Ankle 10 14 19

S5504 Sprain Achilles Tendon 10 14 21

S5512/S5513

Sprain Metatarsophalangeal Joint/Interphalangeal Joint

8 12 75

258


S561. Sprain Sacroiliac Joints 14 18 216

S570. Sprain Cervical Spine 9 14 218

S5704 Whiplash 12 16 221

S571. Sprain Thoracic Spine 9 11 223

S572. Sprain Lumbar Spine 12 16 226

S574. Sprain Coccyx 8 12 228

S5Q2. Rupture of Supraspinatus 12 16 189

S5Q4. Rupture of Biceps Tendon 12 16 191

S5y3. Rib Sprain 8 12 28

S8… Open Wound Trunk/head/neck 9 13 30

S82.. Open Wound Ear 12 16 143

S830./S8342

Open Wound Scalp/Forehead 12 16 145

S832./S8341/S8343/S8344/S8345/S836.

Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth

16 20 147

S87../S88.. Open Wound Buttock/External Genitalia 12 16 149

S90.. Open Wound Shoulder/Upper Limb 16 20 193

S906./S97../S97X./SA6../SA78./SA7X.

Amputation at Shoulder/Hand/at Elbow/Foot/Upper Leg/Lower Leg

18-36 24 151

S91.. Open Wound Elbow/Forearm 9 13 60

S91.. Open Wound Wrist 12 16 248

S92../S9300/S9302

Open Wound Hand/Fingers/Thumb 20 24 98

S935./7G321

Open Wound Fingernail/Avulsion of Nail 5 6 100

S96.. Amputation Finger 18-36 24 102

SA100/SA101

Open Wound Knee/Leg 12 16 131

259


SA2../SA3.. Open Wound Foot/Toe(s) 10 14 77

SD000 Abrasion Face 6 8 153

SD10. Abrasion Trunk 4 6 32

SD20. Abrasion Upper Arm (no infection) 6 8 195

SD30. Abrasion Lower Arm (no infection) 4 6 62

SD60./SD602

Abrasion Leg/Knee 4 6 133

SE0.. Contusion Head/Neck 8 10 155

SE2.. Contusion Trunk 10 12 34

SE20. Contusion Breast 10 12 36

SE21. Contusion Chest Wall 10 12 38

SE23. Contusion Back 10 12 230

SE24. Contusion Genital Organs 8 10 157

SE3.. Contusion Upper Limb 10 12 197

SE30. Contusion Upper Arm/Shoulder 10 12 199

SE31. Contusion Elbow/Forearm 10 12 64

SE32. Contusion Wrist/Hand 10 13 250

SE33./SE332

Contusion Finger/Thumb/Fingenail (haematoma)

10 15 104

SE40. Contusion Hip and Thigh 10 12 111

SE41. Contusion Knee and Lower Leg 9 10 135

SE42. Contusion Ankle and Foot 6 8 23

SE43. Contusion Toe 9 11 79

SE44. Contusion Lower Limb (multiple sites) 10 14 137

SF110 Crush Injury Back 12 16 232

SF203 Crush Injury Upper Arm 12 16 201

SF22. Crush Injury Wrist or Hand 24 30 252

SF23./SF231/SF233

Crush Injury Finger (open/closed)/Thumb (closed)

24 30 106

SF322 Crush Injury Foot (closed) 12 18 81

SH1.. Burns Head/Neck 20 24 159

SH2.. Burns Trunk 20 24 40

260


SH3.. Burns Arm (excluding Hand) 20 24 66

SH4.. Burns Hand(s)/Wrist 24 30 254

SH5.. Burns Lower Limb 20-30 24 139

TE532 Toxic Reaction Bee Sting 10 22 161

TE60. Bite (dog) 8 12 163

U120. Bite (human) 6 10 165

261

May 2006

Acupuncture T

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AcupunctureTreatment Profiles

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acupunture treatment profile

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