Avascular Necrosis and Acupuncture: A Comprehensive Guide

Understanding Avascular Necrosis

What is Avascular Necrosis?

Avascular necrosis occurs when blood flow to a bone is disrupted, leading to the death of bone cells (osteocytes). Without adequate blood supply, the affected bone becomes weakened, eventually leading to structural collapse and joint dysfunction. The femoral head (the top of the thigh bone) is the most commonly affected site, but AVN can also occur in the knees, shoulders, ankles, and other bones.

The condition progresses through stages, often classified using systems like the Ficat-Arlet or Steinberg staging systems:

• Stage I: No symptoms; changes visible only on imaging (e.g., MRI).
• Stage II: Mild pain; early bone changes detectable on X-rays.
• Stage III: Moderate to severe pain; bone collapse begins.
• Stage IV: Joint destruction, severe pain, and significant loss of function.

AVN can be unilateral (affecting one side) or bilateral (affecting both sides), with about 50% of cases being bilateral, particularly in non-traumatic cases.

Causes and Risk Factors

The exact cause of AVN is not always clear, but it is typically associated with traumatic or non-traumatic factors that impair blood flow to the bone:

• Traumatic Causes:
  • Fractures or dislocations (e.g., hip dislocation).
  • Joint injuries from sports or accidents.
• Non-Traumatic Causes:
  • Prolonged corticosteroid use (e.g., for autoimmune diseases or organ transplants).
  • Excessive alcohol consumption.
  • Blood clotting disorders (e.g., thrombophilia).
  • Autoimmune diseases (e.g., lupus, rheumatoid arthritis).
  • Sickle cell disease or other hemoglobinopathies.
  • Metabolic disorders (e.g., Gaucher’s disease).
  • Radiation therapy or chemotherapy.
• Risk Factors:
  • Age: More common in adults aged 30–60.
  • Gender: Slightly more prevalent in men.
  • Genetics: Rare familial cases linked to chromosome 12q13.
  • Lifestyle: Smoking, obesity, or high cholesterol may increase risk.

Symptoms of Avascular Necrosis

Symptoms of AVN vary by stage and affected bone but typically include:

• Pain: Dull, aching, or throbbing pain in the affected joint (e.g., hip, groin, or knee), often worsening with weight-bearing activities.
• Reduced Range of Motion: Stiffness or difficulty moving the joint.
• Limping or Difficulty Walking: Common in hip or knee AVN.
• Swelling or Edema: Around the affected joint.
• Joint Instability: In advanced stages, due to bone collapse.
• Functional Impairment: Difficulty performing daily activities like climbing stairs or walking.

The progressive nature of AVN can lead to significant disability, anxiety, and reduced quality of life, especially if untreated.

Conventional Treatments for Avascular Necrosis

Non-Surgical Treatments

Non-surgical treatments aim to manage pain, slow disease progression, and preserve joint function, particularly in early stages (I–II):

• Medications:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.
  • Bisphosphonates (e.g., alendronate) to reduce bone resorption.
  • Anticoagulants or statins in specific cases to address clotting or lipid-related causes.
• Physical Therapy: To maintain joint mobility and strengthen surrounding muscles.
• Core Decompression: A minimally invasive procedure to relieve pressure and stimulate blood flow in the affected bone.
• Lifestyle Modifications: Reducing alcohol consumption, quitting smoking, and managing underlying conditions like diabetes or high cholesterol.

Surgical Treatments

In advanced stages (III–IV) or when non-surgical treatments fail, surgical options are considered:

• Bone Grafting: To replace necrotic bone with healthy tissue.
• Osteotomy: Reshaping the bone to reduce stress on the affected area.
• Total Joint Replacement: Replacing the damaged joint (e.g., hip arthroplasty) with a prosthetic implant.
• Joint Fusion: In severe cases, to stabilize the joint at the cost of mobility.

Limitations of Conventional Treatments

Conventional treatments have notable limitations:

• Medication Side Effects: Long-term NSAID use can cause gastrointestinal issues, while bisphosphonates may lead to jaw osteonecrosis or atypical fractures.
• Surgical Risks: Infection, bleeding, or implant failure are possible complications.
• Cost and Accessibility: Surgical procedures like hip replacement are expensive and may not be feasible for all patients.
• Incomplete Efficacy: Early-stage treatments may not halt disease progression, and surgeries may not restore full function.

These challenges have led many patients to explore complementary therapies like acupuncture to manage pain and support healing.

Acupuncture: A Natural Approach to Managing AVN

What is Acupuncture?

Acupuncture is a TOM practice that involves inserting fine, sterile needles into specific points on the body (acupoints) to restore balance to the body’s energy flow, or Energy. According to TOM, disruptions in Energy flow contribute to pain and disease, and acupuncture aims to correct these imbalances. In modern medicine, acupuncture is recognized as a non-pharmacological therapy that stimulates the nervous system, enhances blood circulation, and promotes the release of natural pain-relieving chemicals.

How Acupuncture Works

Acupuncture’s mechanisms are supported by both TOM and modern scientific principles:

• Endorphin Release: Stimulates the release of endorphins, the body’s natural painkillers, reducing pain perception.
• Neurotransmitter Modulation: Influences serotonin, dopamine, and other neurotransmitters to regulate pain and mood.
• Improved Blood Flow: Enhances local and systemic circulation, potentially aiding nutrient delivery to necrotic bone.
• Anti-Inflammatory Effects: Reduces pro-inflammatory cytokines (e.g., IL-1β, IL-6, TNF-α), alleviating inflammation around the affected joint.
• Nerve Stimulation: Activates mechanosensitive ion channels and nerve receptors, modulating pain signals via the gate control theory.
• Autonomic Regulation: Balances the autonomic nervous system, reducing stress and supporting healing processes.

These mechanisms make acupuncture particularly relevant for AVN, where pain management and improved blood flow are critical.

Effectiveness of Acupuncture for Avascular Necrosis

Scientific Evidence

While research on acupuncture for AVN is less extensive than for other conditions like chronic pain or stroke, emerging studies and case reports suggest its potential benefits, particularly in early and middle stages (Ficat-Arlet I–II). Below is a detailed overview of the evidence:

• 2016 Randomized Controlled Trial (Acupotomy vs. Acupuncture): A study compared acupotomy (a technique combining acupuncture and minor surgical release) with conventional acupuncture for AVN of the femoral head. The acupotomy group showed a significantly higher effective rate (90.6% vs. 75%) and greater improvements in Harris Hip Score, indicating better pain relief and functional outcomes. However, conventional acupuncture still improved pain and function significantly (P<0.05), suggesting its value as a non-invasive option.
• 2021 Systematic Review (Medicine, Baltimore): A meta-analysis of randomized controlled trials evaluated acupuncture and moxibustion for early to middle-stage AVN. The review found that acupuncture improved pain scores, hip function, and inflammatory markers (e.g., IL-6, TNF-α) compared to controls, with synergistic effects when combined with herbal medicine.
• 2018 Case Report (Laser Acupuncture): A case study of a 55-year-old woman with bilateral AVN of the femoral head reported significant pain reduction and radiographic improvements after three courses of laser acupuncture (20 sessions each). MRI scans showed regeneration of the femoral head, moving from Stage VI to B II (right) and V to C II (left) on the Pennsylvania classification. The patient avoided surgery, highlighting acupuncture’s potential regenerative effects.
• 2022 Study (Shanghai Journal of Acupuncture and Moxibustion): Researchers combined acupuncture with herbal medicine for mid-stage AVN, reporting reduced osteonecrosis size, lower pain levels, and improved hip function. The study also noted decreased levels of pro-inflammatory cytokines, suggesting acupuncture’s role in reducing inflammation.
• Clinical Observations: Practitioners like Dr. Sinha in Delhi, India, have reported success using acupuncture for AVN over 20 years, noting improvements in pain, mobility, and local blood supply.

Mechanisms of Effectiveness in AVN

Acupuncture’s effectiveness in AVN is attributed to several physiological mechanisms:

• Enhanced Blood Circulation: AVN results from inadequate blood supply to the bone. Acupuncture stimulates local blood flow, potentially delivering oxygen and nutrients to the necrotic area, supporting tissue repair. Studies suggest acupuncture increases microcirculation, which may slow disease progression in early stages.
• Pain Modulation: By activating A-delta and C nerve fibers, acupuncture inhibits pain signals in the spinal cord and brain, reducing the perception of joint pain. This is particularly beneficial for patients with chronic, throbbing pain.
• Anti-Inflammatory Effects: Acupuncture reduces levels of pro-inflammatory cytokines (e.g., IL-1β, IL-6, TNF-α), which are elevated in AVN and contribute to tissue damage. This anti-inflammatory action may protect surrounding healthy bone and cartilage.
• Neuroplasticity and Tissue Repair: Acupuncture may promote neuroplasticity and tissue regeneration by stimulating growth factors like brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF), which support angiogenesis and bone repair.
• Stress Reduction: Chronic pain in AVN often leads to stress and anxiety, which can exacerbate symptoms. Acupuncture’s regulation of the hypothalamic-pituitary-adrenal (HPA) axis reduces stress hormones, improving overall well-being.

Limitations and Considerations

While promising, the evidence for acupuncture in AVN has limitations:

• Small Sample Sizes: Many studies, particularly case reports, involve small cohorts, limiting generalizability.
• Lack of Large-Scale RCTs: More robust, large-scale randomized controlled trials are needed to confirm acupuncture’s efficacy compared to conventional treatments.
• Stage-Specific Efficacy: Acupuncture appears most effective in early to middle stages (I–II), with limited evidence for advanced stages (III–IV) where joint collapse has occurred.
• Combination Therapies: Many studies combine acupuncture with herbal medicine or other TOM modalities, making it challenging to isolate acupuncture’s effects.

Despite these limitations, acupuncture’s low-risk profile, minimal side effects, and potential to complement conventional treatments make it a valuable option for AVN management.

Key Acupoints for Avascular Necrosis

Acupuncture for AVN involves the strategic selection of acupoints tailored to the affected joint (most commonly the hip), the patient’s symptoms, and underlying TOM imbalances. The goal is to enhance blood flow, reduce pain and inflammation, and support tissue repair. Below is a detailed explanation of the primary acupoints used in AVN treatment, their anatomical locations, functions, and specific applications, along with considerations for distal and supplementary points.

Primary Acupoints for AVN (Hip-Focused)

GB30 (Huantiao)

• Location: On the buttock, at the junction of the lateral one-third and medial two-thirds of the line connecting the greater trochanter of the femur and the sacral hiatus.
• Function: GB30 is a key point for hip pain and lower limb disorders. It stimulates blood flow to the hip joint, reduces inflammation, and alleviates pain by activating the sciatic nerve and surrounding muscles. It also promotes Energy flow along the Gallbladder meridian, addressing stagnation in the hip.
• Application in AVN: Ideal for femoral head AVN, as it directly targets the hip joint, reducing groin and thigh pain. It is often used in combination with other points to enhance circulation to the necrotic bone.

GB34 (Yanglingquan)

• Location: On the lateral aspect of the lower leg, in the depression anterior and inferior to the head of the fibula.
• Function: Known as the “influential point of tendons,” GB34 strengthens tendons and muscles around the hip and knee, improves joint stability, and enhances blood circulation. It also reduces inflammation and modulates pain pathways in the lower body. Studies highlight its role in activating brain areas related to movement and pain processing.
• Application in AVN: Frequently used in hip AVN to support joint function, reduce stiffness, and promote blood flow to the femoral head. Its distal location makes it effective for systemic effects.

ST36 (Zusanli)

• Location: On the anterior aspect of the lower leg, four finger-widths below the kneecap and one finger-width lateral to the tibial crest.
• Function: ST36 is a powerhouse acupoint that boosts overall energy (Energy), enhances circulation, and supports tissue repair. It stimulates the release of endorphins and reduces systemic inflammation, making it a cornerstone of pain management in TOM.
• Application in AVN: Used to improve general vitality and blood flow, supporting healing in the affected bone. It is particularly effective for patients with fatigue or weakness accompanying AVN.

SP6 (Sanyinjiao)

• Location: On the medial aspect of the lower leg, three finger-widths above the medial malleolus, posterior to the tibia.
• Function: SP6 is a critical point for nourishing blood and yin, reducing inflammation, and promoting systemic healing. It is commonly used for lower body pain and circulatory issues, as it connects the Spleen, Liver, and Kidney meridians.
• Application in AVN: Supports blood flow to the lower limbs and pelvis, aiding in nutrient delivery to the femoral head. It also addresses associated symptoms like edema or muscle weakness.

LI4 (Hegu)

• Location: On the hand, in the webbing between the thumb and index finger, at the highest point of the muscle when the thumb and finger are pressed together.
• Function: LI4 is a potent analgesic point that relieves pain throughout the body, including the head, face, and limbs. It promotes Energy flow, reduces inflammation, and enhances relaxation by stimulating endorphin release.
• Application in AVN: Used as a distal point to provide systemic pain relief and reduce stress, which can exacerbate AVN symptoms. It complements local hip points like GB30 and GB34.

BL40 (Weizhong)

• Location: At the midpoint of the popliteal crease, in the depression behind the knee.
• Function: BL40 is the “influential point of the lower back,” effective for relieving pain and stiffness in the lower back, hips, and legs. It enhances blood flow and reduces muscle tension in the posterior chain, which supports the hip joint.
• Application in AVN: Targets hip and lower back pain, especially in patients with radiating pain or limping due to femoral head AVN.

Supplementary Acupoints for AVN

In addition to hip-focused points, acupuncturists may select supplementary points based on the patient’s condition and TOM diagnosis:

GB20 (Fengchi):

• Location: At the base of the skull, in the depression between the upper trapezius and sternocleidomastoid muscles.
• Function: Reduces systemic inflammation, alleviates stress, and supports circulation to the head and upper body. It is often used to address tension that exacerbates pain perception.
• Application in AVN: Included for patients with stress-related symptom amplification or when AVN affects upper body joints (e.g., shoulder).

LV3 (Taichong):

• Location: On the foot, between the first and second toes, in the depression proximal to the metatarsal bones.
• Function: LV3 calms the nervous system, reduces pain, and promotes smooth Energy flow, particularly in the lower body. It is effective for stress relief and muscle relaxation.
• Application in AVN: Used to enhance systemic circulation and alleviate pain in the lower limbs, complementing hip-specific points.

LI11 (Quchi):

• Location: At the lateral end of the elbow crease when the arm is flexed.
• Function: LI11 reduces inflammation, clears heat (in TOM terms), and supports immune function. It is effective for joint pain and swelling.
• Application in AVN: Included for patients with significant joint inflammation or edema around the affected area.

GB31 (Fengshi):

• Location: On the lateral aspect of the thigh, approximately seven finger-widths above the popliteal crease.
• Function: Relieves pain and stiffness in the thigh and hip, enhances local circulation, and supports muscle relaxation.
• Application in AVN: Directly targets thigh pain and supports blood flow to the femoral head, especially in early-stage AVN.

Customization and Techniques

• Individualized Selection: Acupoints are chosen based on the affected joint (e.g., hip, knee, shoulder), the stage of AVN, and the patient’s TOM diagnosis (e.g., blood stasis, Energy deficiency). For example, hip AVN prioritizes GB30 and GB34, while shoulder AVN may include LI15 (Jianyu) or SI9 (Jianzhen).
• Needle Stimulation: Needles are inserted to a depth that activates underlying nerves and muscles, typically 0.5–2 inches depending on the point. Manual twirling, lifting, or electroacupuncture (mild electrical stimulation) may be used to enhance effects, particularly for severe pain.
• Moxibustion: Heat therapy using moxa (dried mugwort) may be applied to points like ST36 or GB34 to further stimulate circulation and promote healing.
• Laser Acupuncture: As seen in the 2018 case report, low-level laser therapy applied to acupoints (e.g., GB30, GB34, LI4) can reduce pain and promote bone regeneration, offering a non-invasive alternative for needle-averse patients.
• De Energy Sensation: Achieving the “De Energy” sensation (tingling, warmth, or heaviness at the needle site) is considered essential for efficacy, as it indicates nerve activation and Energy flow.

Treatment Protocol

• Session Duration: 30–60 minutes per session, with needles retained for 15–40 minutes.
• Frequency: 1–3 sessions per week, with 6–12 sessions for an initial course, followed by maintenance sessions as needed.
• Electroacupuncture or Laser: May be used for enhanced pain relief or regenerative effects, particularly in early-stage AVN.

By targeting these acupoints, acupuncture addresses both localized pain and systemic factors, offering a comprehensive approach to AVN management.

Benefits of Acupuncture for Avascular Necrosis

Acupuncture offers several advantages for AVN patients:

• Non-Invasive Pain Relief: Provides a drug-free alternative to manage chronic pain, reducing reliance on NSAIDs or opioids.
• Improved Circulation: Enhances blood flow to the affected bone, potentially slowing disease progression in early stages.
• Reduced Inflammation: Lowers inflammatory markers, protecting surrounding tissues.
• Minimal Side Effects: When performed by a licensed practitioner, risks are limited to minor bruising or soreness.
• Holistic Benefits: Addresses stress, fatigue, and emotional distress, improving overall quality of life.

What to Expect During Acupuncture Treatment

Initial Consultation

A licensed acupuncturist will:

• Review medical history, AVN diagnosis, and imaging results (e.g., MRI, X-ray).
• Assess pain patterns, triggers, and functional limitations.
• Perform a TOM diagnosis to identify imbalances (e.g., blood stasis, Energy deficiency).

Treatment Sessions

• Environment: Conducted in a calm, sterile setting with disposable needles.
• Procedure: Needles are inserted into selected acupoints, with possible manual or electrical stimulation. Moxibustion or laser therapy may be included.
• Patient Experience: Mild tingling or warmth at needle sites; some experience immediate pain relief, while others notice gradual improvements.

Treatment Course

• Initial Phase: 6–12 sessions over 2–6 weeks, depending on severity.
• Maintenance Phase: Monthly or biweekly sessions to sustain benefits.
• Progress Monitoring: Pain scores, Harris Hip Score, or imaging may be used to track outcomes.

Integrating Acupuncture with Other Therapies

Combination with Conventional Treatments

• Medications: Acupuncture may reduce the need for NSAIDs or bisphosphonates, minimizing side effects.
• Physical Therapy: Enhances mobility and muscle strength when combined with acupuncture.
• Core Decompression: Acupuncture may support post-procedure recovery by improving blood flow and reducing pain.

Lifestyle Modifications

• Diet: An anti-inflammatory diet (e.g., rich in omega-3s, low in processed foods) supports acupuncture’s effects.
• Exercise: Low-impact activities like swimming or yoga maintain joint mobility.
• Weight Management: Reducing body weight alleviates stress on weight-bearing joints.

Other TOM Modalities

• Herbal Medicine: TOM formulas (e.g., Epimedium for bone health) may complement acupuncture.
• Cupping or Tui Na: Massage or cupping can enhance circulation and muscle relaxation.

Safety and Risks of Acupuncture

Side Effects

• Minor bruising or soreness at needle sites.
• Temporary fatigue or lightheadedness.
• Rare risk of infection if non-sterile needles are used (avoidable with licensed practitioners).

Precautions

• Choose a certified acupuncturist (e.g., NCCAOM-certified).
• Ensure single-use, sterile needles.
• Inform the practitioner about medications, bleeding disorders, or pregnancy.
• Avoid acupuncture during acute infections or skin conditions at insertion sites.

Choosing the Right Acupuncturist

• Credentials: Verify certification from reputable organizations.
• Experience: Seek practitioners with expertise in musculoskeletal or neuropathic conditions.
• Treatment Plan: Discuss session frequency, costs, and expected outcomes.
• Patient Reviews: Check testimonials for success in treating AVN or similar conditions.

Conclusion

Avascular necrosis is a challenging condition that can lead to significant pain and disability. While conventional treatments like medications and surgery are effective for some, their limitations prompt many to explore acupuncture as a complementary or alternative therapy. Acupuncture offers a non-invasive, low-risk approach to managing pain, improving blood flow, and supporting tissue repair, particularly in early to middle-stage AVN. By targeting specific acupoints like GB30, GB34, and ST36, acupuncture addresses both localized and systemic factors, enhancing patients’ quality of life.

Supported by emerging scientific evidence and centuries of TOM practice, acupuncture is a promising option for AVN patients seeking holistic care. Consulting a licensed acupuncturist and integrating acupuncture with lifestyle changes and conventional treatments can optimize outcomes, offering hope for pain relief and improved function.

Fuji Wellness:

• Address: 132-0031 Matsushima 1-chome, 21-14, Tokyo, Japan
• Chat with us: Click here
• Email: sunnyphamsensei@gmail.com