Case Report J Complement Med Alt Healthcare

Volume 1 Issue 2 -February 2017 Copyright © All rights are reserved by Jan Kersschot

Rotator Cuff Case Report: Diagnosis and Treatment

Using the Biopuncture Protocol
Jan Kersschot*
Private Clinic, Antwerp Area, Belgium
Submission: December 15, 2016; Published: February 14, 2017
*Corresponding author: Jan Kersschot, Private Clinic, Antwerp Area, Belgium, Email:

Keywords: Rotator cuff; Functional diagnosis; Intramuscular injection; Biopuncture

Introduction
measured). Ultrasound (April 14, 2016) was normal, except for
A female patient presented with pain in the right shoulder
an inflammatory tendinopathy of the supraspinatus tendon,
and limitation of both abduction and internal rotation of the
and a few small peri-tubercular calcifications. No lab tests were
right arm for several months. She received two intra-articular
performed. Clinical examination revealed muscular pain points
cortisone injections from a first doctor, but she reported that
in the anterior and lateral part of the deltoid muscle. No other
she experienced no improvement. She looked for an approach
clinical tests were performed.
without corticosteroids and contacted a second doctor. Clinical
examination revealed painful points in the deltoid muscle. Timeline
Ultrasound revealed tendinopathy with calcifications. Her pain,
A. First Week of January 2016: Pain in the Right Shoulder
limitation of abduction and internal rotation of the right arm
(Gradual Onset).
improved after six sessions with intramuscular injections of
ultra-low dose medications (ULDMs) in her right deltoid muscle. B. February 2016: Intra-articular Joint Injection of
This technique is also described as Biopuncture [1]. ULDMs are Cortisone in the Right Shoulder (the patient reported no
defined as medications containing one or several ingredients clinical improvement after the first injection).
which are homeopathically diluted below Avogadro’s number.
C. March 2016: Intra-articular Joint Injection of Cortisone
Patient Information and Presenting Concerns in the Right Shoulder (the patient reported no clinical
improvement after the second injection).
Patient is a Caucasian female, born on December 11, 1956,
and works in a bank in Belgium as a financial assistant for D. March 2016 till May 2016: Six sessions of ULDM
several decades. Her medical, family and psychosocial history is injections in the deltoid muscle (the patient reported gradual
negative. She complained about pain in the right shoulder and clinical improvement).
limitation of abduction and internal rotation of the right arm for
several months. She cannot recall any specific activities related
Diagnostic Focus and Assessment
to the shoulder complaints.

Clinical Findings
The patient presented with pain in the right shoulder. When
the patient was asked to pinpoint the exact location of her pain,
she pointed to the anterior and lateral part of the right deltoid
muscle. The pain was not referring to the neck or elbow. There
was no numbness in the arm or hand. There was no pain during
the night. The pain in the deltoid muscle was worse during
abduction of the arm. Abduction was limited to about the Figure 1: Patient Shows Pain Zone nr 1 (Anterior Part of the
Right Deltoid Muscle).
horizontal level (90°), internal rotation was also limited (not

J Complement Med Alt Healthcare J1(2): JCMAH.MS.ID.555559 (2017) 001

 Journal of Complementary Medicine & Alternative Healthcare

Table 1: Clinical Picture of the Muscle Dysfunction.

1 Muscular Pain (Local Pain or Referred Pain)

2 Muscular Weakness

3 Restriction of Movement (Joint Hypo mobility)

4 Muscular Stiffness

Therapeutic Focus and Assessment

Figure 2: Patient Shows Pain Zone nr 2 (Lateral Part of the Right
The patient received local intramuscular injections at a depth
Deltoid Muscle). of 2cm in the deltoid muscle: three injections in the anterior
part and three injections in the lateral part of the muscle. In a
In this patient, the conventional diagnosis (CD), based on the syringe of 5mL, the following products were used: 2mL of the
ultrasound, was rotator cuff pathology, with calcifications of the ULDM and 3mL of sodium chloride. On March 23 and March 29,
supraspinatus tendon. But the clinical examination was based on the ULDM was Myosotis Compositum, on April 5 and April 18
the pain zones as identified by the patient (Figure 1&2). In this Arnica Compositum was used. On April 25 and May 3, Ferrum
zone, a palpation-guided diagnostic approach was performed Compositum was used
(Figure 3&4). In two areas of the deltoid muscle (anterior part
The visual analog scale was used to check the pain during
and lateral part), muscular pain points were identified. Such
treatment. She had 8/10 on March 23, 8/10 on March 29,
muscular pain points can produce several clinical symptoms, as
7/10 on April 5, 6/10 on April 18, 4/10 on April 25 and 2/10
described in Table 1. It was hypothesized that these muscular
on May 3. Follow-up by phone confirmed that the pain in the
pain points produced the pain in the shoulder and the restriction
deltoid muscle subsided almost completely, and she cancelled
of movement in the right arm (functional diagnosis: FD). This
the seventh appointment. There was no opportunity to have a
hypothesis was tested by applying biopuncture into these two
follow-up ultrasound investigation or a follow-up ultrasound
muscular pain points [2]. Remark: The photographs were not
clinical examination. She refused CT or MRI scan because of
taken during the first session; that is why one can notice the blue
claustrophobic reactions to such environments.
spot of a previous injection.
To exclude the influence of other therapeutic interventions,
a mono therapy was applied, meaning that apart from the
injections no other therapeutic measures (such as oral
support with painkillers/NSAIDs or local application of Arnica
Compositum) were applied.

Follow-up and Outcomes

The patient was asked to come for treatment once a week
(remark: there was a two weeks’ interval after the third session
for practical reasons). After the first two sessions, the patient
experienced only minor improvement of the pain in the shoulder,
Figure 3: Doctor Examines Pain Zone nr 1 (Anterior Part of the but the internal rotation and abduction of the arm were slightly
Right Deltoid Muscle). better. The latter was not measured with hard data, but was
reported subjectively by the patient (e.g., she mentioned that
she was able again to wash her hair with both hands and to put
on her bra with both hands on the back). After a series of six
sessions, the shoulder pain as well as the internal rotation and
abduction of the arm improved substantially.

Discussion
The conventional approach of rotator cuff is mainly based
on clinical examination, X-rays, Ultrasound and MRIa (magnetic
resonance imaging). In some cases, a series of three intralesional
injections (e.g., intra-articular joint injections or bursa
injections) with cortisone are given. Although the side effects are
Figure 4: Doctor Examines Pain Zone nr 2 (Lateral Part of the
Right Deltoid Muscle). very well known and the long term results disappointing, this

002 How to cite this article: Kersschot J. Biopuncture. J Complement Med Alt Healthcare. 2017; 1(2): 555559.
 Journal of Complementary Medicine & Alternative Healthcare

procedure is still standard today. Instead of cortisone, one could to a change in management that is ultimately beneficial to the
also inject Traumeel [3,4] or Traumeel and Zeel [5] into the joint. individual patient. This is not only true for shoulder pain, but
But these injections with ULDMs are not always efficient. This also for other clinical situations, such as neck pain and low back
lack of clinical outcome (in some cases) is sometimes regarded pain [6,7].
as a failure of the medication, especially when this has been
Numerous investigations with plain radiography,
done in a setting of a clinical study. But one could wonder if
myelography, computed tomography and magnetic-resonance
the injection with the ULDM was given at the right location. If a
scans of, for example, hip, neck, low back, shoulder or knee,
shoulder pain has its origin in the deltoid muscle, intra-articular
have confirmed the high prevalence of abnormal findings in
injections with ULDMs will not produce any short or long term
asymptomatic subjects [8-16]. There are also a lot of false-
effects-apart from the effect of the needle on pain modulation
negative results. Recent investigations in the field of rotator
(e.g., gate control).
cuff tears have illustrated the diagnostic shortcomings of MRIa
The patient presented with both shoulder pain on the (magnetic resonance imaging with arthrography): the test is
anterior and lateral part of the deltoid muscle, and limitation very specific but not sensitive for rotator cuff tears [17-19].
of shoulder joint mobility. This clinical picture is very common MRIa without arthrography is also highly sensitive, but has a
in general practice, and in some cases the origin of the pain low positive predictive value and low specificity and accuracy
and limited shoulder movement is intra-articular, sometimes in detecting full-thickness rotator cuff tears [20]. The authors of
peri-articular and sometimes both. Radiological tools may this study postulated that even a total shoulder arthroplasty in
reveal different types of injuries, such as osteoarthritis, joint patients with severe glenohumeral osteoarthritis is not always
degeneration, bursitis, supraspinatus tendinopathy (partial built on solid decision making. If we consider these facts along
tears, tears) and/or calcifications. These findings are then directly with the high percentage of false positive MRIa reports on rotator
correlated to the clinical picture of the patient, hypothesizing cuff tears, we also understand the concern of the authors of a
that the radiological findings are really relevant for that patient 2011 study who state, “If MRIa is chosen as a diagnostic adjunct,
(Hypothesis 1). Nobody will deny the findings by the radiologist, careful consideration should be given to its interpretation to
but we know that there are many false positive and false negative avoid unnecessary or possibly aggravating surgical intervention”
radiological findings (see later). False positive findings may [21].
lead to unnecessary treatment options (e.g., surgery), and false
The major strength of this case is that it illustrates the
negative findings may leave the patient with the frustration that
importance of the muscular factor in common orthopedic
nobody seems to find the cause of the pain, and doctors often
complaints, such as shoulder pain. The basic idea of the
conclude that the pain is mainly psychogenic and not somatic.
importance of myofascial pain was first introduced and
When patients present with shoulder pain with a partial illustrated by Travell & Simons in their trigger point manual
tear of the supraspinatus tendon and/or with calcifications [22]. They describe the referred pain patterns for trigger points,
near the supraspinatus tendon, the question remains: Are these and how these can be responsible for common orthopedic
radiological findings really the cause of the clinical picture? And complaints. Muscular dysfunction is not only responsible for
what about patients who have pain in the shoulder but who do pain, but also for lack of strength in certain muscles and lack of
not have any abnormal findings on X-rays, Ultrasound and MRIa? myorelaxation of the affected muscles, leading to limited range of
What if we find pain points in the deltoid muscle, exactly in the motion. According to the protocol by Travell & Simons, injections
area where that particular patient is complaining about? Could are given at a distance from the pain zone, in the trigger points
we presume that these muscular pain points are the origin of which refer the actual pain. However, the technique applied here
the pain (Hypothesis 2)? The only way to find out is to test this consists of local injections in myofascial pain points (injections
second hypothesis in a particular patient by treating these soft in the pain zone itself), not injections into trigger points which
tissue lesions. If one could obtain clinical improvement in that are actually at a distance from the pain zone.
way, without prescribing conventional pain killers or NSAIDs,
In this patient, the conventional approach (intra-articular
one could conclude that the second hypothesis may be valid.
cortisone injections) produced no positive clinical outcome,
These days, physicians tend to rely more and more on and the difference between conventional diagnosis (CD) and
technical support by medical imagery and less and less on their functional diagnosis (FD) was crucial in order to have a positive
clinical skills such as palpation of muscles. Radiology is of course outcome with the injections into the muscular pain points.
a great tool to diagnose a brain tumor and to further guide the In other words, the injections were not applied at the site of
surgeon during his therapeutic process to locate the exact area the enthesopathy (tuberculum majus) or at the site of the
of incision. However, in many cases, the radiological findings may calcifications, but exclusively at the pain points in the deltoid
be misleading. The ultimate criterion for the usefulness of any muscle.
diagnostic test is whether it adds crucial information beyond
The limitations of this case include the lack of hard data
that otherwise available, and whether this information leads
because there is no follow-up of the ultrasound investigation,

003 How to cite this article: Kersschot J. Biopuncture. J Complement Med Alt Healthcare. 2017; 1(2): 555559.
 Journal of Complementary Medicine & Alternative Healthcare

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004 How to cite this article: Kersschot J. Biopuncture. J Complement Med Alt Healthcare. 2017; 1(2): 555559.