Background: Patients may present with multi-system symptoms of unclear etiology. Acupuncture is an appealing therapeutic modality in such circumstances because its efficacy has been validated in syndromes involving most organ systems.

Objective: To describe the outcome of a patient with pain unexplained by conventional medicine who was treated with acupuncture.

Design: Case report.

Setting: Physician acupuncturist's practice.

Patient: A man with a 40-year history of knee pain and sequelae affecting his quality of life.

Intervention: Treatment with acupuncture to disperse excess Fire, tonify the controlling element, and release Internal and External Dragons.

Main Outcome: Measures Subjective assessment of knee pain, related insomnia, and sexual dysfunction. Results After 1 month, the patient reported an 80% reduction in his knee pain, better sleep, and an improvement in his sexual function. This improvement was noted during a 10-month follow-up period.

Conclusion: Acupuncture successfully alleviated knee pain and its sequelae in this patient. Acupuncture may be considered as a therapeutic alternative in patients with symptom complexes that cannot be treated satisfactorily with available modalities in conventional medicine.

The following report describes a patient with unusual medical symptoms in which an allopathic diagnosis was not possible. This patient's condition failed to improve with conventional medical therapy, but dramatically responded to acupuncture.

A 61-year-old man presented with a 40-year history of intense pressure and pain in both knees. Symptoms began as a teenager without a history of preceding injury or concomitant illness. Initially, the diagnosis was "growing pains" and later on, gout was suspected. Treatment produced no relief of his symptoms.

The pressure sensation continued for almost 40 years, which intensified significantly during the last 2 years. The patient began to have right elbow and shoulder discomfort. Pressure would start to build up in his knees around 10 p.m. and continue until about 2 a.m. The pressure became so intense that he walked to achieve mild relief. When the pain slowly subsided in the early morning hours, he was able to sleep. A complaint of a "clicking noise" on movement was reported to be intermittent in both knee joints. Analgesics, anti-inflammatory drugs, tranquilizers, and oral narcotic drugs were prescribed without benefit. Physical therapy produced no substantial improvement. The patient consulted internists, rheumatologists, and orthopedists. He underwent exhaustive investigations, none of which were remarkable except a positive HLA-B27 test result. An arthritis panel (including erythrocyte sedimentation rate, uric acid, antinuclear antibody, and rheumatoid factor) produced no significant findings. Radiological studies revealed questionable narrowing of both knee joints. The lumbosacral spine was normal. Magnetic resonance imaging (MRI) of the right knee revealed a "questionable area on the medial meniscus."

Arthroscopy of both knee joints revealed identical findings of large suprapatellar plica and degenerative tears of the posterior horns of the medial meniscus. The joint surfaces were normal and synovitis was absent.

A partial medial meniscectomy and resection of medial plicae were carried out in both knees. The patient reported an improvement in the clicking noise but in the next 4 months, no change in the knee pain. He was then referred for acupuncture.

The patient's review of systems was remarkable for an insidious onset of impotence and insomnia for many years. The psychosocial evaluation revealed that as a teenager, his mother's nocturnal alcoholic episodes were a source of severe embarrassment for him, and remained well into adulthood. The patient denied using alcohol and tobacco. A review of the patient's medical and surgical histories was unremarkable. Clinical examination did not demonstrate evidence of synovitis, effusion, tenderness, or pain on manipulation of the knee or elbow joints contrary to the patient's complaint of pain and pressure in the elbows and both knee joints. There was mild tenderness over the superior aspects of the bicipital grooves of both shoulders. The rest of the clinical examination was negative.

Allopathic Medicine Diagnosis

No diagnosis could be established. Acupuncture Diagnosis

1. Excess Fire in Jue Yin-Shao Yang axis (spasm-like pain, insomnia, aggravation at the time of highest flow of Ron Qi through Gall Bladder and Liver meridians).
2. Significant emotional trauma related to mother's nocturnal alcoholism - External Dragon, and perpetuation of the problem secondary to Internal Dragon. Knee pain occurred exclusively in the evening.

Rationale for Treatment

1. Disperse excess Fire.
2. Tonify the controlling element.
3. Release of Internal and External Dragons.

Treatment

The patient received 6 acupuncture treatments over 6 weeks:

• Week 1: N, N+1 in the Jue Yin-Shao Yang circuit. LR 3, LR 5, MH 6, TH 5, and GB 3, 4, all in dispersion.
• Week 2: Same as above + GV 20 + bilateral eye of the knee points + 3 tender points along the LI meridian of the right upper arm and shoulder region, including LI 14.
• Week 3: Five-Phase treatment KI 3(-) - KI 7(+) (4-Hz tonification for 15 minutes). SP 9(-) - LI 11(+) (4-Hz tonification for 15 minutes). LR 2, MH 6, GV 20, all in dispersion.
• Week 4: Internal Dragon treatment CV 14, ST 25, 32, and 41, all left in dispersion. The patient also received auricular stimulation of the 5 Master Points, elbow - knee points (Phase 1). The auricular stimulation was done bilaterally using 10 Hz for 20 seconds each.
• Week 5: External Dragon treatment GV 20, BL 11, 23, and 61 for 15 minutes. BL 11(-) - BL 23(+) were tonified (4 Hz). Auricular stimulation was done as in the fourth session.
• Week 6: Internal Dragon and auricular stimulation as in the fourth session. RESULTS

After the 2nd week, the patient's sleep improved and there was a slight decrease in the intensity of knee pain. After the 3rd week, sleep continued improving. He also had 1 completely pain-free night. However, on the day preceding the 4th week, the patient again had severe pain. During the next 2 visits, he reported steady improvement in pain and sleep. The pain in his right shoulder and elbows was completely resolved. After a 1-month follow-up, he reported an 80% reduction in his knee pain and an improvement in his sexual function. No relapse was reported during 10 months of follow-up visits.

Acupuncture may activate the body's pain-modulating system, thereby changing the processing and perception of noxious information at various levels of the nervous system.1 This may involve elaboration of endogenous opioids2,3 and their effects on peripheral, central, and autonomic nervous systems.4,5 However, transient increases in the level of endorphins and/or transient changes in the nervous system may not explain how the symptoms were relieved after 6 short sessions, and improvement maintained for a minimum of 10 months.

Any speculation regarding the actual mechanism of action of the acupuncture treatment in this particular patient is beyond the scope of this article. This case demonstrates how acupuncture successfully relieved an unusual symptom complex of bilateral knee pain of more than 40 years' duration. The patient's shoulder and elbow pain, insomnia, and sexual dysfunction also improved. Acupuncture should be considered as a therapeutic alternative in patients with symptom complexes that cannot be explained in terms of allopathic medicine or treated satisfactorily with available modalities in conventional medicine.