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Complex Korean Medicine Treatment for Posterior Ankle Impingement Syndrome: Case Report
후방 발목 충돌 증후군 환자의 복합 한의진료 경과: 증례보고
Korean J Acupunct 2022;39:100-106
Published online September 27, 2022;  https://doi.org/10.14406/acu.2022.011
© 2022 Society for Meridian and Acupoint.

Ji-won Park1 , Da-hyun Kyung2 , Ji-eun Koo3 , Jun-Hyo Bae3 , Su-jin Kim4 , Ji-eun Bae5
박지원1ㆍ경다현2ㆍ구지은3ㆍ배준효3ㆍ김수진4ㆍ배지은5

1Department of Acupuncture & Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine,
2Ophthalmology & Otolaryngology & Dermatology of Korean Medicine, Daejeon Jaseng Hospital of Korean Medicine,
3Department of Rehabilitation Medicine of Korean Medicine, Daejeon Jaseng Hospital of Korean Medicine,
4Department of Korean Medicine Obstetrics and Gynecology, Daejeon Jaseng Hospital of Korean Medicine,
5Department of Korean Internal Medicine, Daejeon Jaseng Hospital of Korean Medicine
Correspondence to: Ji-won Park
Department of Acupuncture & Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine, 58 Munjeong-ro, 48 Beon-gil, Seo-gu, Daejeon 35262, Korea
Tel: +82-42-1577-0007, Fax: +82-42-610-0415, E-mail: lilybells93@jaseng.org
Received July 19, 2022; Revised August 20, 2022; Accepted August 22, 2022.
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Posterior ankle impingement syndrome is one of the impingement syndromes characterized by posterior ankle pain that occurs during forced plantar flexion. This report presents a case of a 48-year-old PAIS patient with os trigonum syndrome accompanied by tenosynovitis of flexor hallucis longus. She was treated with complex Korean medicine to a good effect. The Numeric Rating Scale and the EuroQol 5-Dimension 5-Level were used to measure the impact of Korean medicine on the patient’s pain and quality of life. Decreased NRS and increased EQ-5D-5L scores reflected improvement in her symptoms within 25 days. This study suggests complex Korean medicine treatment for PAIS may be beneficial for alleviating pain and improving quality of life.
Keywords: os trigonum, posterior ankle impingement, flexor hallux longus tenosynovitis, Korean medicine
Introduction

Posterior ankle impingement syndrome (PAIS), characterized by posterior ankle pain, is a painful syndrome that leads to discomfort and disability in individuals1). PAIS is caused by anatomic structures being caught between the bony surfaces of the calcaneus and tibia. Repetitive micro-trauma due to ankle motion may lead to inflammation evoking swelling, pain, and decreased range of motion in the ankle over time2). Os trigonum, an accessory bone derived from failed secondary ossification, is one of the most common osseous lesions related to PAIS3). The prevalence of os trigonum was reported to be about 30%, more usual than previously reported4). Medial to the os trigonum, the flexor hallucis longus (FHL) tendon passes between the medial and lateral tubercle of the talus. Thus, forceful plantar flexion of the ankle rubs the os trigonum against the FHL tendon sheath to induce FHL pathologies like degeneration and tearing5).

In the early stage of PAIS, conservative treatment to balance the muscles and prevent further pathological changes from the collision of the involved structures is recommended. Following failure to manage symptoms after conservative treatment, operative interventions to excise the impinging bone spur are indicated. However, there are some concerns about the safety of the surgical treatment because of the proximity of the neurovascular bundle. Minor complications like superficial infection and hematoma to severe neuro-logical injuries can occur6). Thereby, we report a case that presented with PAIS where tenosynovitis of the FHL coexisted with the os trigonum to suggest complex Korean medicine as an alternative option for PAIS patients.

Case Report

1. Medical history

A 48-year-old woman went to a Korean medicine hospital on May 21st, 2022, with a complaint of swelling and pain in her right ankle which worsened after carrying a heavy load on April 15th, 2022. She described sharp pain on her ankle’s medial side, which worsened when running and climbing stairs. Other than a 2-year-history of recurrent bilateral ankle sprains, she did not have a remarkable past medical history. Upon physical examination, tenderness was present on the posteromedial aspect of the ankle, in front of the Achilles tendon. The right ankle’s ranges of motion were restricted to 20 degrees of plantar flexion and 10 degrees of dorsiflexion. To identify the presence of soft-tissue and osseous abnormalities, radiographs were taken. X-rays and magnetic resonance imaging of the right ankle joint were carried out to reveal os trigonum and fluid collection around the FHL tendon (Fig. 1). The diagnosis of PAIS was confirmed according to these findings. The patient made the decision to try complex Korean medicine and was hospitalized for 25 days.

Fig. 1. Radiograph of the right ankle. (A) Sagittal X-ray of the right ankle showing the os trigonum. (B) T1-weighted and fat saturation T2-weighted magnetic resonance images showing increased fluid collection around the posteromedial ankle ten-dons in the sagittal, coronal, and axial planes.

2. Treatment

1) Acupuncture/pharmacopuncture treatment: The patient was treated with acupuncture in 2 sessions a day using 0.20×30 mm sterile stainless steel needles (Dongbang Acupuncture, Korea). The acupuncture needles were inserted into the acupoints of SP6, GB34, GB39, SP3, SP4, SP5, SP6, SP9, KI3, BL60, and Ashi points. Electroacupuncture (STN-330 Stratek, Anyang, Korea) was applied at SP3-SP6 and the needles were retained for 10 minutes.

The patient received Shinbaro pharmacopuncture (Jaseng Wonoe Tangjunwon, Namyangju, Korea) once a day. Shinbaro pharmacupuncutre was injected at BL60 and SP5 with disposable, 29-gauge, 12.7 mm needles on a 1 cc syringe (Sungshim Medical, Bucheon, Korea) using up 0.2-1.0 ml per session (Table 1).

Details of interventions using the STRICTA 2010 checklist.

Item Details
Acupuncture rationale 1a) Style of acupuncture (e.g. Traditional Chinese Medicine, Japanese, Korean, Western medical, Five Element, ear acupuncture, etc.) Traditional Korean acupuncture
1b) Reasoning for treatment provided, based on historical context, literature sources, and/or consensus methods, with references where appropriate Literature and clinical experience of experts.
1c) Extent to which treatment was varied The aucpuncture treatmene varied over the course of the study to manage the patient’s changes in pain and sleeping problems
Details of acupuncture 2a) Number of needle insertions per subject per session (mean and range where relevant) 8∼16 needles
2b) Names (or location if no standard name) of points used (uni/bilateral) SP6, GB34, GB39, SP3, SP4, SP5, SP6, SP9, KI3, BL60, and Ashi points
2c) Depth of insertion, based on a specified unit of measurement, or on a particular tissue level 1.0∼2.5 cm
2d) Responses sought (e.g., de qi or muscle twitch response) De-qi sensation
2e) Needle stimulation (e.g. manual or electrical) Electrical stimulation
2f) Needle retention time 10 minutes
2g) Needle type (diameter, length, and manufacturer or material) 0.20×30 mm sterile stainless steel needles (Dongbang Acupuncture, Korea)
Treatment regimen 3a) Number of treatment sessions 42 sessions
3b) Frequency and duration of treatment sessions Twice a day
Other components of treatment 4a) Details of other interventions administered to the acupuncture group (e.g. moxibustion, cupping, herbs, exercises, lifestyle advice) Pharmacopuncture treatment, moxibustion, cupping, herbal treatment
4b) Setting and context of treatment, including instruc-tions to practitioners and information and explanations to patients Procedure of treatments and diagonsis.
Practitioner background 5) Description of participating acupuncturists (qualifi-cation or professional affiliation, years in acupuncture practice, other relevant experience) 3 Korean medicine doctor with 3-25 years of experience
Control or comparator intervention 6a) Rationale for the control or comparator in the context of the research question, with sources that justify the choice(s) No control or comparator interventions
6b) Precise description of the control or comparator. If sham acupuncture or any other type of acupunc-ture-like control is used, provide details as for Items 1 to 3 above No control or comparator interventions


2) Herbal treatment: The patient received oral administration of Chungshinbaro-Hwan (tablet) and Saengganggeo-samtang (decoction) three times a day, 30 minutes after each meal (Table 2).

The composition of herbal medicine.

Herbal medicine Herbal components (g)
Chungshinbaro-Hwan Poria (Hoelen) 0.15, Ginseng Radix 0.07, Achyranthes bidentata Bl. 0.04, Asini Gelatinum 0.02, Rehmanniae Radix 0.62, Cervi Cornus Colla 0.06 g, Mel 0.31, Cibotii Rhizoma 0.02, Eucommiae Cortex 0.02, Saposhnikovia Radix 0.01, Acanthopanacis Cortex 0.01, Scolopendra Corpus 0.01, Atractylodis Rhizoma Alba 0.05, Atractylodis Rhizoma Alba 0.02
Saengganggeosamtang Pinelliae Ternatae Rhizoma 11.25, Zingiberis Rhizoma 7.5, Zizyphus Jujuba 7.5, Scutellariae Radix 5.66, Glycyrrhizae Radix5.66g, Coptidis rhizoma 7.5


2. Assessments

1) Numeric Rating Scale: The Numerical Rating Scale (NRS), an 11-point scale showing the degree of the respondent’s pain, was used and NRS scores were taken every day to record the changes in pain intensity throughout treatment7).

2) European Quality of Life–5 Dimensions: The EuroQol 5-Dimension 5-Level (EQ-5D-5L) is an index for rating a patient’s health-related quality of life in 5 categories8). The quality of life for the patient was taken by EQ-5D-5L at the period of admission, after 1 week, and at discharge.

3. Ethics statement

The medical records of the patient were acquired retrospectively and approved for use by the Institutional Review Board of Jaseng Hospital of Korean Medicine (IRB file no.:2022-07-007).

4. Progress note

On the 1st day of inpatient treatment, the patient initially rated her right ankle pain as 6/10 on the NRS and the EQ-5D-5D score was 0.53 (Fig. 2). As treatment continued, she experienced improvement in pain and swelling. On May 24th, 2022, the 4th day of hospitalization, she reported that her pain had reduced to 4/10. On May 27th, 2022, she described her quality of life as slightly improved since her difficulty with walking and climbing stairs had been reduced. On June 10th, 2022, her pain and swelling were significantly alleviated. At the time of discharge, she experienced further alleviation in her overall symptoms, verified by an increased EQ-5D-5L score (0.694) and a decreased NRS score (1/10). She expressed satisfaction with the complex Korean medicine treatment and there were no adverse events during hospitalization.

Fig. 2. The changes of outcomes before and after treatments. (A) Changes in NRS Score. (B) Changes in EQ-5D-5L Score.
Discussion

PAIS is a clinical syndrome, distinguished by posterior ankle pain aggravated by hyperplantar flexion, for which awareness has increased to due imaging advances9). Although PAIS is mostly seen among dancers and atheltes, this syndrome can even affect individuals who are not involved in sports or dancing. Once considered a syndrome, clinical examination and complete history of the patient should be checked. For differential diagnosis, MRI to assess anatomic variations such as accessory muscles and detect soft tissue pathologies is used10).

When dealing with symptomatic PAIS, conservative therapy including rest, physiotherapy, and anti-inflammatory medication is considered to be the first option. This case of a PAIS patient who was confirmed to have an os trigonum accompanied by tenosynovitis of FHL also received Korean medicine as the first line of treatment.

Acupuncture, a traditional treatment originating from the meridian theory, has been reported to be safe and effective for ankle pain11). Acupuncture may have helped relieve the patient’s symptoms by enhancing the lesions’ local blood supply and facilitating the repair of tendons and other soft tissues12).

Pharmoacupuncture, a combination of two major elements of traditional Korean medicine, stimulates acupuncture points by injecting herbal extracts subcutaneously13). Shinbaro pharmoacupucnture extracted from GCSB-5 (Eucommia ulmoides cortex, Acanthopanax sessiliflorum cortex, Achyranthis bidentata radix, Saposhnikovia divaricata radix, and Cibotium barometz rhizoma) is known to have anti-inflammation and nerve regenerating properties14,15). When injected into the posteromedial region of the ankle, close to the tendons, it may help alleviate pain and recover the damage in the soft tissues.

Herbal medicine is made from extracting active ingredients from multiple herbs. Chungshinbaro-Hwan, whose precise mechanism has yet to be elucidated but there are some pharmacological studies on each component, includes Ginseng Radix, Achyranthes bidentata Bl., and Rehmanniae Radix which have been to found have anti-inflammatory effects16-18). Additionally, the patient was given Saengganggeosamtang as she complained of difficulty sleeping. Saengganggeosamtang consists of 6 herbs among which Pinelliae rhizoma and Zizyphus Jujuba have been widely reported to improve sleep disorders by their sedative and anti-convulsive effects19,20). As well as sleeping problems, all of the patient’s other body systems were broadly obtained to reach the most appropriate prescription.

Some limitations of this study should be noted. First, it was a study of a single case for generalized results. Second, since this study had no control groups, there is no confidence in being certain that the outcomes were due to the curative effect of the complex Korean medicine. Third, the sole therapeutic effect of each treatment could not be separated from the others since they were administered integrally.

However, this case study is significant in that this is the first time, to our knowledge, that a reported case with os trigonum complicated by tenosynovitis was treated with complex Korean medicine. During inpatient treatment, the patient’s course of recovery was closely observed without experiencing any side effects. Hopefully, this study may provide a beginning for further exploring the use of Korean medicine for these types of syndromes. Further studies including randomized controlled trials with larger samples are needed to determine this study’s findings.

Conclusion

The current case report suggests that PAIS patients with os trigonum and FHL tendon lesions might benefit from treatment with complex Korean medicine.

Acknowledgement

None.

Funding

None.

Data availability

The authors can provide upon reasonable request.

Conflicts of Interest

The authors have declared that no conflicts of interest exists.

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