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A historical review of acupuncture to the

Achilles tendon and the development of a
standardized protocol for its use

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Berj Kishmishian James Selfe

University of Central Lancashire Manchester Metropolitan University
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Journal of the Acupuncture Association of Chartered Physiotherapists, Spring 2012, 69–78

CLINICAL PAPER

A historical review of acupuncture to the Achilles tendon and

the development of a standardized protocol for its use
B. Kishmishian, J. Selfe & J. Richards
Faculty of Health, University of Central Lancashire, Preston, UK

Abstract
Achilles tendon injuries are a common occurrence in the general population. Middle-aged
runners are particularly prone to Achilles tendinopathy, but non-sporting individuals are also
affected by these problems. Tendinopathy accounts for 30–50% of sports injuries, and it has
been identified as a major medical problem associated with overuse that is most prevalent in
sporting and working environments. Acupuncture is widely used in the treatment of
musculoskeletal disorders; however, few studies have investigated the effects of needling on the
Achilles tendon. The first application of acupuncture to the Achilles tendon was recorded in
ancient China. During the twentieth century, this approach evolved into the herringbone
technique, but treatment has not been standardized. This paper reviews the development of
acupuncture to the Achilles tendon, and describes a recently developed standardized and
specific nine-needle acupuncture treatment protocol. The authors also highlight the physiologi-
cal pro-inflammatory changes that occur in the Achilles tendon when this protocol is
administered, and propose that such an approach can be a useful adjunct to the treatment of
Achilles tendinopathy.

Keywords: Achilles tendon, acupuncture, blood flow, herringbone technique, oxygenation.

Introduction The first application of acupuncture to the

Achilles tendon injuries are a common occur- Achilles tendon was recorded in ancient China in
rence in the general population. Middle-aged the Huang Di Nei Jing, more commonly know
runners are particularly prone to Achilles tendi- as The Yellow Emperor’s Classic of Internal Medicine
nopathy (Renström & Woo 2007), but non- (Ni 1995). During the twentieth century, this
sporting individuals are also affected by these approach evolved into the herringbone tech-
problems (Rolf & Movin 1997). Tendinopathy nique, which is taught on Acupuncture Associ-
accounts for 30–50% of sports injuries (Ren- ation of Chartered Physiotherapists (AACP)
ström & Woo 2007), and it has been identified as courses; however, this technique has not been
a major medical problem associated with overuse standardized. It has been suggested that the
that is most prevalent in sporting and working herringbone technique is an effective treatment
environments (Peers 2003). Acupuncture is for Achilles tendinopathy (P. Barlas & K.-W.
widely used in the treatment of musculoskeletal Mak, 2006, personal communication; P. Barlas,
disorders; however, few studies have investigated 2007, personal communication).
the effects of needling on the Achilles tendon. Acupuncture is one of the best known comp-
lementary therapy treatments. It is widely used to
treat musculoskeletal disorders and there is a
Correspondence: Berj Kishmishian, Southport and growing evidence base for its mechanism of pain
Ormskirk NHS Trust, Southport District General relief (Wu et al. 1999; White et al. 2006; NICE
Hospital, Town Lane, Kew, Southport, Merseyside 2009). Nevertheless, the literature reveals a lack
PR8 6PN, UK (e-mail: [email protected]). of understanding about the other physiological
 2012 Acupuncture Association of Chartered Physiotherapists 69
Achilles tendon acupuncture
effects of needling; for example, with respect to injury occurs in the absence of any inflammatory
blood flow and tissue oxygenation, and the markers, thus making a diagnosis of tendinitis
thermal effects of acupuncture such as tissue incorrect, but research has found a degenerative
warming, especially in relation to tendinopathies. and non-inflammatory pathology that is now
However, recently published work by Kubo et al. clinically termed tendinopathy (Peers 2003).
(2010) investigated the effect of using a single Mid-portion Achilles tendinopathy can be
acupuncture needle to stimulate the Achilles diagnosed by localized thickening that is associ-
tendon, and the results included increases in ated with: increased pain and stiffness first thing
blood flow and oxygenation. Furthermore, other in the morning, or after sitting for long periods;
studies have investigated the effects of acupunc- and pain before or during sporting activities. The
ture on tendinopathies (Kleinhenz et al. 1999) condition can have a gradual onset or manifest
and have reported positive results in terms of after heavy activity. On palpation, individuals
increased blood flow (Sandberg et al. 2004). In notice an increase pain in the mid-portion of the
the main, research into tendinopathies has used Achilles tendon, and a thickening/nodule that
acupuncture points derived from traditional moves on active dorsiflexion and plantar flexion.
Chinese medicine (TCM) (Molsberger & Hille Pain tends to increase on maximum ankle dorsi-
1994; Grua et al. 1999; Davidson et al. 2001; Fink flexion, and when performing heel-raises and
et al. 2002), and therefore, the tendons have not functions that involve ankle plantar flexion in
been directly penetrated. weight-bearing.
The present paper reviews the development of The exact cause of Achilles tendon pain is
acupuncture to the Achilles tendon, and unknown. It may be caused by: degenerative
describes a recently developed standardized and changes, such as decreased blood flow and
specific nine-needle acupuncture treatment pro- oxygenation within the tendon; neovasculariza-
tocol. The authors also highlight the physiologi- tion, i.e. an abnormal vascular ingrowth; or
cal pro-inflammatory changes that occur in the neurotransmitters such as glutamine. Neovascu-
Achilles tendon when this protocol is adminis- larization is linked with pain and is thought to be
tered, and propose that such an approach can be an underlying mechanism of overuse tendinopa-
a useful adjunct to the treatment of Achilles thies, although it is unclear whether this is the
tendinopathy. cause of the pathophysiology (Alfredson &
Ohberg 2005).

Historical review History and theory of acupuncture

The first documented description of acupuncture
Tendinopathy as an organized system of diagnosis and treat-
The Achilles tendon is the thickest and strongest ment is The Yellow Emperor’s Classic of Internal
tendon in the human body (Pearce et al. 2010). Medicine (c. 100–200 BCE). Still recognized
Problems with this structure occur in both the today, this text was based on numerous discus-
general population, and competitive and recrea- sions between Huang Di, the Yellow Emperor,
tional athletes; for example, middle-aged runners and Qi Bo, his minister and teacher (Ni 1995;
are particularly prone to Achilles tendinopathy Eckman 2007).
(Paavola et al. 2002). The concept of Qi (energy flow), which is
The mid-portion is the most common area of central to acupuncture and TCM, were estab-
the Achilles tendon to be affected by injury, lished at the time The Yellow Emperor’s Classic was
possibly because of poor blood supply. This is written. The text suggests that injury and/or pain
located 2–6 cm above the insertion of the tendon are deemed to occur when Qi is inhibited or
and measures an average of 1.8 cm (range=1.2– blocked. Researchers such as White & Ernst
2.6 cm) in diameter (Doral et al. 2010). Its blood (2004) have suggested that the exact anatomical
supply arises from the bony insertion at the locations of acupuncture points were identified
calcaneal tuberosity and the musculotendinous later. The sensation of De Qi is believed to
junction (Maffulli 1999). Histological and bio- represent the connection and interplay between
chemical evidence suggests that tendon overuse the acupuncture needle and the Qi (energy) of

70  2012 Acupuncture Association of Chartered Physiotherapists

 B. Kishmishian et al.
the body (VanderPloeg & Yi 2009). The feeling appropriate treatment to alter the flow of Qi
of De Qi has been described as an aching, dull (energy); from a Western perspective, contracted
heaviness or numbness that radiates and spreads tendons require a physiological alteration and
from the acupuncture point, and/or a tingling treatments such as stretching (e.g. involving the
sensation (MacPherson & Asghar 2006). Asghar use of eccentric loading) would be used.
et al. (2010) compared acupuncture causing De The Yellow Emperor’s Classic also discusses what
Qi and acute pain, and found that De Qi to do when blood flow is stagnant or decreased,
sensations resulted in significant deactivations in and suggests that treatment should locate the
the brain, suggesting pain relief. In contrast, appropriate channel so that acupuncture and
these authors detected a mixture of activations bloodletting can allow the Blood and Qi to
and deactivations in the brain in acute pain. escape. Contemporary Western medicine does
Therefore, it is important to note the type of not employ bloodletting techniques; however, it
sensation that a patient feels during acupuncture. does support the idea that the use of acupunc-
Western theories about the mechanism of ture will improve the flow of blood within a
acupuncture have suggested that needling stimu- tendon, thus increasing oxygenation and pro-
lates
 and C-afferent fibres, which results in moting tissue healing. With regard to deciding
the release of endogenous opioids via transmis- which area/points to utilize, The Yellow Emperor’s
sion through the spinal cord (Pomeranz & Chui Classic states that, if the problem is in the bones,
1976; Pomeranz & Warma 1988). Furthermore, the bones should be treated, and if it is in the
it has been reported that acupuncture signalling tendons, then the tendons should be targeted.
is transmitted to the mid-brain, thereby promot- Once again, this approach is also seen in Western
ing pain suppression in the spinal cord. Recent treatments such as dry needling/barbotage, and
magnetic resonance imaging studies have pro- autologous blood and platelet-rich plasma (PRP)
vided evidence of activity within the brain and injections. Dry needling involves the penetration
hypothalamus as a result of acupuncture to the of an abnormal area of tendon tissue and brings
Large Intestine 4 point on the hand and Stomach about an internal haemorrhage (Pearce et al.
36 on the lower leg, which induced pain relief via 2010). Autologous blood injections contain cel-
the descending anti-nociceptive pathway and the lular mediators that promote healing in damaged
limbic regions of the brain (Hui et al. 2005, tendons, and while similar, PRP injections con-
2009). tain higher concentrations of growth factors
In its discussion of different conditions, The (Pearce et al. 2010). Therefore, despite the dif-
Yellow Emperor’s Classic mentions Bi-syndrome, in ferences between TCM and Western medical
which the obstruction of Qi and Blood causes theories, their respective approaches to treat-
stiffness, immobility and pain. Bi-syndrome is an ment do share some similarities; for example,
arthralgic condition, and it is defined as a com- targeting a specific area with acupuncture, and
bination of three pathogens, i.e. Wind, Cold and performing dry needling or administering PRP
Damp, invading the body. The syndrome is injections. With regard to acupuncture treatment
differentiated into five types: Gu Bi (bones) in for the Achilles tendon, it is not known whether
winter; Jin Bi (tendons) in spring; Mai Bi any intended benefits are primarily related to a
(pulses/channels) in summer; Ji Bi (flesh) in late decrease in pain as a result of the treatment or if
summer; and Pi Bi (skin) in autumn. It was this reduction in discomfort is secondary to
believed that specific Bi conditions attack the possible pro-inflammatory physiological changes
body at different times of the year (Ni 1995), but such as increases in tissue warming, blood flow
the classification of injuries by season is not and oxygenation.
consistent with Western medical models. Acupuncture has its critics, of course, some of
Furthermore, Bi is reported to linger in the whom believe that the pain relief brought about
bones and tendons for a long time and cause by needling is caused by the placebo effect via
chronic pain, but is said to be easily resolved in placebo expectation (VanderPloeg & Yi 2009).
the muscles and skin. It is also suggested that Bi Benedetti et al. (1999) found that a release of
in the tendons contracts these tissues (Ni 1995). endogenous opioids similar to that brought
In TCM, acupuncture is considered to be an about by acupuncture causing increases in pain
 2012 Acupuncture Association of Chartered Physiotherapists 71
Achilles tendon acupuncture
threshold occurred in an expectancy placebo
group. Kong et al. (2009) stated that acupuncture
stimulation may inhibit noxious stimulation via
descending pathways, and expectancy could pos-
sibly work through an emotional circuit. Placebo
studies have been conducted by several authors;
however, there are some difficulties in determi-
ning the placebo effect.
Previous protocols have included needles
inserted into non-acupuncture points, needles
inserted superficially and sham needles that do
not penetrate the skin. All three techniques do
produce activity in the cutaneous afferent nerves,
Figure 1. Herringbone acupuncture technique.
and affect the functional connectivity in the brain
in turn, which can result in a limbic touch
response (Lund & Lundeberg 2006). It is diffi- tissue levels of oxyhaemoglobin, deoxyhaemo-
cult to avoid tendon penetration when perform- globin and THb. However, Kubo et al. (2010)
ing superficial acupuncture in the Achilles region did not go on to investigate a pathological
because of the lack of cutaneous tissue to sup- population.
port the needle. Some authors (Park et al. 2002; An acupuncture technique called ‘‘Hui’’ is also
McManus et al. 2007; Jubb et al. 2008) have stated described in The Yellow Emperor’s Classic. This is
that sham acupuncture is a valid control pro- intended to relieve tension, and help the tissue to
cedure for randomized controlled trials of acu- relax and recover. The Hui approach involves
puncture. These employ a retractable blunt the placement of needles into a tendon vertically
needle that appears to penetrate the skin, and and off to one side (it is not stated whether this
while the participant feels a pricking sensation, should be medial or lateral). Patients are also
the needle is actually retracted up the needle asked to exercise. In order to release muscle
shaft and does not penetrate the skin (McManus tension, the needles are thrust and twisted back-
et al. 2007). Using sham needles to replicate a wards and forwards, and upwards and down-
patient’s acupuncture experience and expectation wards. In current practice, needles can be
without needle penetration is the preferred con- inserted in the tendon in this configuration;
trol procedure in acupuncture research. however, suggesting that someone should exer-
cise with needles inserted in a tendon is not
Herringbone technique recommended because of safety issues, such as
Although many acupuncture points, extra points, needle breakage.
meridians and protocols exist, no research to Therefore, it can concluded from the evidence
date has investigated the effects of direct pen- of The Yellow Emperor’s Classic that, if an individ-
etration using an acupuncture protocol for the ual in ancient China did have treatment for
Achilles tendon. Dry needling of the Achilles Achilles tendinopathy, acupuncture would be
tendon is performed and is an accepted clinical targeted specifically at the tendon itself, not just
technique. Research by Kubo et al. (2010) inves- along a meridian.
tigated the physiological effects on healthy indi- This method has recently been adapted by
viduals of a single acupuncture needle being acupuncturists and is beginning to be referred to
stimulated in the Achilles tendon, and reported as the herringbone technique because of its
an increase in blood flow and oxygenation. appearance (see Fig. 1). The configuration is
These variables were measured with a near-infra- achieved by inserting needles vertically, medially
red reflectance spectroscopy (NIRS) monitor and laterally (i.e. parallel) to the tendon. The
that analysed total haemoglobin (THb), which herringbone technique is mainly used in the
corresponds to blood volume and oxygen satu- Achilles tendon because of its accessibility and is
ration (StO2 ) in the Achilles tendon. The instru- taught on acupuncture courses (P. Barlas &
ment uses three lasers to calculate the relative K.-W. Mak, 2006, personal communication).

72  2012 Acupuncture Association of Chartered Physiotherapists

 B. Kishmishian et al.
The physiological theory behind this approach
is similar to that for dry needling, PRP or
autologous blood injections, i.e. it is intended
to produce a warming effect that will increase
blood flow, oxygenation and nutrient supply in
order to aid tissue repair within an injured
tendon (Giombini et al. 2007; Pearce et al. 2010).
Furthermore, by stimulating an inflammatory
response through local hyperthermia/warming,
which increases blood flow and oxygen supply in
the selected region, it also assists in the drainage Figure 2. Needle placement indicators 2, 4 and 6 cm
from the Achilles insertion.
of cellular debris (Giombini et al. 2007), and
theoretically stimulates the formation of granula-
tion tissue, which helps to continue the healing in any modern literature, there is no standardized
process and strengthens the tendon (Edwards & protocol describing the duration and frequency
Calandruccio 2003; James et al. 2007). of stimulation, how far to place needles from
Strong pilot-study-level evidence (Fullerton & each other, the required depth, or where exactly
Reeves 2010) supports the use of autologous within the tendon these should be inserted.
blood and PRP injections to aid recovery in The present authors’ current research project
tendinopathy. However, De Vos et al. (2010) is investigating mid-portion Achilles tendinopa-
failed to find any significant difference between thy and, therefore, the herringbone technique
individuals with Achilles tendinopathy treated seen in Fig. 1 was adapted for the study. A new
with a PRP or saline injection. Like acupuncture, standardized nine-needle protocol with a more
this may be related to placebo expectation distal needle placement, as shown in Fig. 2, was
(Brown et al. 2006), or it is possible that inserting deemed to cover the Achilles mid-portion
a needle into the tendon can elicit a healing adequately during pilot trials, whereas the pre-
response. To date, we do not know whether vious configuration shown in Fig. 1 did not. As
injecting a substance or merely inserting a needle mentioned above, most tendinopathies occur in
provides the benefit. the mid-portion, which is defined as being
As part of the developmental work for the first 2–6 cm from the calcaneal tuberosity.
author’s (B. K.’s) doctorate, it was decided to A standard nine-needle placement was chosen
perform a study investigating the changes in because this covered the mid-portion of the
physiological parameters when administering Achilles tendon and it was thought that having
acupuncture, sham acupuncture and eccentric nine needles rather than 12 would both be
exercises to the Achilles tendon in healthy sub- acceptable to research participants and patients
jects prior to investigating the effects of needling and still provide a clinically meaningful interven-
on a pathological group. tion. Using fewer needles in clinical practice may
be more cost-effective. To standardize needle
placement initially, it was decided to measure a
Development of the Achilles point from the Achilles insertion (i.e. the calca-
tendon acupuncture technique neal tuberosity), and then mark the skin at 2, 4
Acupuncture treatment for the Achilles tendon and 6 cm from the calcaneal tuberosity. Three
traditionally involved inserting needles both cen- needles were to be inserted vertically and off to
trally and to one side of the tendon, and this each side of the tendon at each mark (Fig. 2).
approach developed over time into the herring- This technique proved to be reproducible.
bone technique, in which nine and 12 needles are Care needs to be taken because of anthropo-
inserted centrally and to both sides of the metric differences in each individual’s limb
affected area (Fig. 1). This modality was taught length and this problem arose during the pilot
to the first author by Dr Panos Barlas, who came study. One participant’s overall measurement
across the technique during his travels in China. was 1.4 m, whilst another’s was 2 m, resulting in
Since the herringbone technique is not discussed markers that were 2 cm apart, and thus, not
 2012 Acupuncture Association of Chartered Physiotherapists 73
Achilles tendon acupuncture
sterilized stainless steel needles (Hegu Svenska
AB, Landsbro, Sweden) with a diameter of
0.25 mm and a length of 30 mm were inserted to
the target depth of 5–10 mm. The needles were
stimulated for 60 s every 5 min in a twisting/
thrusting manner for a total treatment time of
30 min, which represents common clinical prac-
tice. Research using ultrasonography (Kubo et al.
2008) has suggested that the thickness of
Figure 3. Needle placement indicators at one-quarter,
the skin surrounding the Achilles tendon is
half and three-quarters of the distance from the Achilles 2.20.3 mm at its superficial surface and 7.8
insertion. 0.4 mm at its deep surface, with tendon diameter
averaging 1.8 cm (Doral et al. 2010), and there-
fore, all acupuncture needles were deemed to
have penetrated the Achilles tendon. In Kubo
et al.’s (2010) study, one needle was stimulated
in the Achilles tendon for 3 min and left in
place for a further 2 min. This method of
acupuncture/dry needling does not follow the
present authors’ clinical practice or the teaching
of AACP courses, and therefore, it was not used
when standardizing the new nine-needle-specific
Figure 4. Needle placement at one-quarter, half and acupuncture protocol for the Achilles tendon.
three-quarters of the distance from the Achilles insertion. A Streitberger sham needle was chosen
because of its validation (Streitberger &
located in the same area of the tendon. There- Kleinhenz 1998), realistic appearance, feel and
fore, the specific Achilles tendon acupuncture quality during use. Other sham needles in circu-
protocol was developed further by normalizing lation were found to be too bulky to perform the
needle placement by taking each participant’s nine-needle-specific technique on the Achilles
limb length into account. This technique tendon. The sham needles were supplied by
measured the distance from the Achilles tuber- Asiamed (Suhl, Germany) with instructions for
osity to the popliteal crease in the knee. The use, and were 0.30 mm in diameter and 30 mm
distance was then halved and marked in the in length. Plastic rings covered in sterile tape
mid-calf region, then halved again into a quarter were required to ensure that the sham needle did
and marked around the tendinomuscular junc- not move. In order to maintain standardization,
tion. The most distal quarter was then divided plastic rings covered with sterile tape were also
into quarters from the calcaneal tuberosity, end- used for the penetrative acupuncture, even
ing in the region of the tendinomuscular junc- though needles would be inserted independently
tion. Needles were then placed at one-quarter, in normal clinical practice.
half and three-quarters of the distance from the The standardized Achilles tendon acupuncture
calcaneal tuberosity (Figs 3 & 4). This new and protocol has been successfully used clinically by
specific acupuncture protocol developed from the first author (B. K.) in his current practice to
the herringbone technique allows acupuncture at reduce pain and return individuals to their pre-
the Achilles tendon to be standardized and vious functional levels. The protocol has also
reproducible for individuals of different statures, been used to measure changes to Achilles tendon
and ensures that the mid-portion of an indi- warming, blood flow and oxygenation in healthy
vidual’s Achilles tendon is targeted. subjects. The first author (B. K.) is currently
Acupuncture treatment was provided by the conducting a study using the protocol shown in
first author (B. K.), who is a member of AACP Figs 3 and 4 to gain a normative data set on
and who followed the Association’s guidelines at healthy subjects before investigating its use with
all times after attaining ethical approval. Hegu a pathological group.

74  2012 Acupuncture Association of Chartered Physiotherapists

 B. Kishmishian et al.
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Figure 5. Tissue oxygen saturation (StO2 ) at baseline, and at the beginning of acupuncture to the Achilles tendon and
30 min later.
A sample of the results of the normative data the development of a standardized protocol for
supports the findings of Kubo et al. 2010. Figure the herringbone technique, more research into
5 shows a uniform increase in StO2 following a this topic is needed. The clinical relevance of
30-min treatment involving acupuncture to the such a study is currently being investigated by the
Achilles tendon. Furthermore, StO2 remained first author (B. K.). The overall aim is to test
elevated against baseline measures until testing whether there is evidence that acupuncture acts
ended 30 min later. This suggests that acupunc- as a pro-inflammatory mediator in conjunction
ture to the Achilles tendon does increase oxy- with eccentric exercises to promote healing, de-
genation and that it may possibly have clinical crease pain and return individuals with Achilles
relevance to the healing processes of individuals tendinopathy to their previous functional levels.
with tendinopathy. The results support the find- At present, little is known about the
ings of Kubo et al. (2010), who only used a single pro-inflammatory and physiological effects of
needle in a dry needling fashion, as opposed to a acupuncture, especially with regard to tendin-
traditional method. opathies. Although some studies have investi-
Figure 6 suggests that there was little mean gated the effects of acupuncture to tendinopa-
temperature change in the distal Achilles tendon thies on pain, there has been no research into the
amongst the 10 participants when they received Achilles tendon with a pathological group. To
acupuncture to this area. On closer inspection of date, only one study (Kubo et al. 2010) has
the data, variations in the group become clear: examined the effects of directly needling any
six participants displayed an increase in tempera- tendon within an acupuncture treatment or pro-
ture during needle insertion, while the other tocol, and therefore, although the future of
four showed a decrease. On completion of the pro-inflammatory treatments does look promis-
treatment, five subjects’ temperature remained ing, further evidence is required to determine
elevated, while the decrease demonstrated in the whether such treatments constitute best practice.
other five subjects also persisted.
Numerous small pilot studies have reported
changes in physiological parameters that were
Discussion measured with NIRS and thermal imaging
Despite the theory behind using a treatment such equipment. However, because of the different
as acupuncture for Achilles tendon injuries and effects between subjects associated with using
 2012 Acupuncture Association of Chartered Physiotherapists 75
Achilles tendon acupuncture
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Figure 6. Temperature changes identified by thermal imaging in the distal portion of the Achilles tendon of 10 participants
undergoing acupuncture treatment.

acupuncture, sham acupuncture combined with apply the technique to a pathological group.
eccentric exercise and eccentric exercise alone, There is no reason why other acupuncture
the present authors decided that it was important physiotherapists should not try this technique in
to understand more about each different inter- the meantime. No adverse effects were identified
vention in isolation and its effect on the norma- during the pilot or normative phases of this
tive data set before combining these with a research, or when it was used in clinical practice.
treatment that has no published data with regard Clinicians within the first author’s (B. K.’s) place
to its effects on the Achilles tendon. Therefore, of work have reported that the protocol is easy
the pilot data have allowed important changes to to use and participants found the technique
be made to the normative data study, which has acceptable.
now been completed and was being analysed at Readers are encouraged to contact the first
the time of writing. These new data will help to author (B. K.) and write to the Journal regarding
predict physiological effects and differences this approach.
when administering acupuncture, sham acupunc-
ture and eccentric exercises to the Achilles ten-
don in healthy participants. Acknowledgements
The implication of the findings of the present I would like to thank my co-authors, Professor
authors’ pilot and normative data are that NIRS James Selfe and Professor Jim Richards, for their
and thermal imaging with a standardized proto- ongoing guidance and support of my studies.
col are reliable methods of measuring the physio- I am very grateful to Dr Panos Barlas and
logical processes occurring within the Achilles Kam-Wah Mak for sharing their expertise in
tendon when using acupuncture, sham acupunc- acupuncture and encouraging me to begin my
ture or eccentric loading. Further analysis of the doctorate. I would also like thank Southport and
normative data will be performed in the doctoral Formby District General Hospital, Southport,
phase of the first author’s (B. K.’s) research. especially Jean Axon and Sue Davies, for provid-
The protocol developed in the present study is ing me with the support and flexibility that I
a work in progress and the next phase will be to needed to pursue my studies. Finally, I would like

76  2012 Acupuncture Association of Chartered Physiotherapists

 B. Kishmishian et al.
to express my gratitude to my family, especially uonoterapia. [Acupuncture in the treatment of lateral
my wife Anna and baby boy Yerevan, who have epicondylitis: evaluation of the effectiveness and com-
to put up with me for another 4 years of study! parison with ultrasound therapy.] Giornale Italiano di
Riflessoterapia ed Agopuntura 11 (2), 63–69. [In Italian.]
Hui K. K. S., Liu J., Marina O., et al. (2005) The integrated
response of the human cerebro-cerebellar and limbic
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Achilles tendon acupuncture
Ni M. (1995) The Yellow Emperor’s Classic of Medicine: A now works as a clinical specialist musculoskeletal physio-
New Translation of the Neijing Suwen with Commentary. therapist for Southport and Ormskirk NHS Trust. Berj
Shambhala Publications, Boston, MA.
is also currently undertaking a part-time MPhil/PhD on
Paavola M., Kannus P., Järvinen T. A. H., et al. (2002)
Achilles tendinopathy. The Journal of Bone and Joint Surgery the effects of acupuncture and eccentric exercise on the
84A (11), 2062–2076. Achilles tendon at the University of Central Lancashire
Park J., White A., Stevinson C., Ernst E. & James M (UCLan), Preston. At the time of writing, he was in the
(2002) Validating a new non-penetrating sham acupunc- third year of the MPhil stage of his studies and had
ture device: two randomised control trials. Acupuncture in collected data on a healthy population group. In the PhD
Medicine 20 (4), 168–174.
phase, he will focus on a pathological group of patients
Pearce C., Donley B. & Calder J. D. F. (2010) Achilles
tendinopathy: non-operative treatment. In: Achilles Ten- with Achilles tendinopathy.
dinopathy: Current Concepts (eds J. Calder, J. Karlsson, N. Professor James Selfe graduated in 1984, and then
Maffulli, H. Therman & C. Niek van Diyk), pp. 79–87. worked clinically as a musculoskeletal physiotherapist in
DJO Publications, Guildford. both the British and Australian public and private sectors
Peers K. (2003) Extracorporeal Shock Wave Therapy in Chronic for a decade. Following this, he became a lecturer and then
Achilles and Patellar Tendinopathy. Acta Biomedica
Lovaniensia, 287. Leuven University Press, Leuven.
a senior lecturer at Bradford School of Physiotherapy and
Pomeranz B. & Chui D. (1976) Naloxone blockade of latterly Bradford University for approximately 9 years
acupuncture analgesia: endorphin implicated. Life Sciences before moving to UCLan as Reader in Physiotherapy.
19 (11), 1757–1762. While at Bradford, James completed a doctorate in
Pomeranz B. & Warma N. (1988) Electroacupuncture outcome measures for patellofemoral joint dysfunction. His
suppression of a nociceptive reflex is potentiated by two main clinical interest remains the management of muscu-
repeated electroacupuncture treatments: the first opioid
effect potentiates a second non-opioid effect. Brain
loskeletal disorders, particularly the patellofemoral joint of
Research 452 (1–2), 232–236. the knee. He has published over 100 peer-reviewed papers
Renström P. A. F. H. & Woo S. L.-Y. (2007) Tendinopa- and conference abstracts, contributed chapters to four
thy: a major medical problem in sport: In: Tendinopathy in books, and co-authored Red Flags: A Guide to
Athletes (eds S. L.-Y. Woo, P. A. F. H. Renström & S. P. Identifying Serious Pathology of the Spine
Arnoczky), pp. 1–10. Blackwell Publishing, Oxford. Physiotherapy (2006) and Red Flags II: A Guide
Rolf C. & Movin T. (1997) Etiology, histopathology, and
outcome of surgery in achillodynia. Foot and Ankle
to Solving Serious Pathology of the Spine (2009)
International 18 (9), 565–569. with Sue Greenhalgh. James was awarded a Fellowship of
Sandberg M., Lindberg L.-G. & Gerdle B. (2004) Periph- the Chartered Society of Physiotherapy in 2008.
eral effects of needle stimulation (acupuncture) on skin Professor Jim Richards worked for 10 years as a senior
and muscle blood flow in fibromyalgia. European Journal lecturer at the University of Salford, Salford, Greater
of Pain 8 (2), 163–171.
Manchester, and has taught biomechanics to prosthetists
Streitberger K. & Kleinhenz J. (1998) Introducing a
placebo needle into acupuncture research. The Lancet 352 and orthotists, podiatrists, physiotherapists, sports thera-
(9125), 364–365. pists, and undergraduate and postgraduate medical stu-
VanderPloeg K. & Yi X. (2009) Acupuncture in modern dents. He was appointed Professor of Biomechanics and
society. Journal of Acupuncture and Meridian Studies 2 (1), Research Lead for Allied Health Professions at UCLan
26–33. in 2004. His work includes the clinical application of
White A., Tough E. & Cummings M. (2006) A review of
biomechanics, the development of new assessment tools for
acupuncture clinical trials indexed during 2005. Acupunc-
ture in Medicine 24 (1), 39–49. chronic disease, the conservative and surgical management of
White A. & Ernst E. (2004) A brief history of acupunc- orthopaedic and neurological conditions, and the develop-
ture. Rheumatology 43 (5), 662–663. ment of evidence-based approaches for improving clinical
Wu M.-T., Hsieh J.-C., Xiong J., et al. (1999) Central management and rehabilitation. Jim has authored many
nervous pathway for acupuncture stimulation: localiza- research papers, and written and edited a number of
tion of processing with functional MR imaging of the
textbooks, including Biomechanics in Clinic and
brain – preliminary experience. Radiology 212 (1), 133–
141. Research: An Interactive Teaching and Learning
Course (2008) and the forthcoming fifth edition
Berj Kishmishian graduated with a BSc in Sport and of Whittle’s Gait Analysis. He has also contributed to
Exercise Science from St Martin’s College, Lancaster, in Tidy’s Physiotherapy (2003, 2008 and 2011) and the
2001. In 2004, he graduated from Robert Gordon forthcoming tenth edition of Mercer’s Orthopaedic
University, Aberdeen, with an MSc in Physiotherapy. He Surgery.

78  2012 Acupuncture Association of Chartered Physiotherapists