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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 163-167

Raktamokshana (wet cupping therapy) in the management of calcified supraspinatus tendinitis presenting as frozen shoulder: A rare case report


Department of Shalyatantra, Institute of Teaching and Research in Ayurveda (INI), Jamnagar, Gujarat, India

Date of Submission28-Apr-2021
Date of Decision21-May-2021
Date of Acceptance11-Jun-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Manisha Mansukh Kapadiya
Department of Shalyatantra, Institute of Teaching and Research in Ayurveda (INI), 6th Floor, Opposite B Division Police Station, Jamnagar - 361 008, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_37_21

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  Abstract 


Calcified tendinitis is one of the most common causes of shoulder pain and is characterized by the evidence of presence of calcific deposition in the rotator cuff. It is seen commonly affecting the supraspinatus tendon; however, it can be present in asymptomatic individuals also. The calcification requires surgical removal after that the tendon reconstitute again itself some times it disappear spontaneously also. In this case report, a 54-year-old male patient presented with painful restricted movements of the right shoulder joint. X-ray right shoulder demonstrated 1.5-cm sized calcific deposition in the supraspinatus tendon and was treated with two sittings of wet cupping therapy (WCT). The patient was assessed by Visual Analog Scale score and active range of movement. This case report shows that the cases of calcified supraspinatus tendinitis may be successfully managed with Raktamokshana (WCT).

Keywords: Ayurveda, calcified supraspinatus tendinitis, cupping, frozen shoulder, Raktamokshana, rotator cuff


How to cite this article:
Kapadiya MM, Jain V, Dudhamal TS. Raktamokshana (wet cupping therapy) in the management of calcified supraspinatus tendinitis presenting as frozen shoulder: A rare case report. BLDE Univ J Health Sci 2022;7:163-7

How to cite this URL:
Kapadiya MM, Jain V, Dudhamal TS. Raktamokshana (wet cupping therapy) in the management of calcified supraspinatus tendinitis presenting as frozen shoulder: A rare case report. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Oct 3];7:163-7. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/163/348272



Acharya sushruta known as father of surgery narrated different type of raktamokshana (bloodletting) methods and shringa (cupping therapy ) one among them is extensively practiced in India by seers.[1] There are two forms of cupping: wet cupping (bloodletting cupping) and dry cupping according to traditional Chinese medicine which is widely practiced in China for musculoskeletal disorders.[2] Wet cupping therapy (WCT) is gaining popularity to treat musculoskeletal disorders, particularly in India to treat cervical pain, lower back pain, frozen shoulder, and hypertension. WCT appears to exert pleiotropic effects and is employed for multiple indications.

Calcifying tendinitis is a common disorder of rotator cuff and usual cause of nontraumatic pain in the shoulder. The underlying cause of calcified tendinitis (CT) is still not fully understood.[3] It is confirmed by radiographic evidences that it is limited to the tendon and does not affect the bone. There are three stages of progressive calcification process, pre-calcific stage, calcific stage, post-calcific stage. During second phase of calcified supraspinatus tendon; it present with acute painful shoulder. The radiograph shows a less well-defined deposit of calcified tissue. The calcium may diffuse into the subacromial or subdeltoid bursa at this stage. The disappearance of the deposit does not always correlate with the clinical course. The patient is significantly incapacitated by pain and limited shoulder movements in late stages of adhesive capsulitis. These calcium deposits are accompanied with an adhesive bursitis.[4] No data has been published that supports how many days it will take to spontaneous resolve.

The supraspinatus tendon is the most common site of occurrence. Usually, the deposits are located 1.5–2.0 cm away from the tendon's insertion on the greater tuberosity.

Gärtner and Simons reported an 85% chance of natural resolution after 3 years for type III deposits, as opposed to 33% for type I and II deposits.[5] However, in some cases, it does not show any signs of resolution and continues to persist as painful shoulder for long time. Recently conservative treatment modalities like steroid injection, platelet rich plasma injection, ultrasound guided needling and extracorporeal shock wave therapy, iontophoresis with acetic acid while surgical treatments include open surgery and arthroscopic treatment for calcified tendons are widely practiced. however, there is numerous limitation to use these procedures.[6] No study has been published on CT managed by WCT. In this case report, a case of calcified supraspinatus tendinitis was resolved by WCT.


  Case Report Top


A 54-year-old male patient visited the outdoor patient department of Shalyatantra with complaints of painful right shoulder joint and pain radiating up to the right elbow joint for the last year while restricted movement of the right shoulder joint for the last 6 months. It started gradually as a throbbing type of continuous pain and increased during the night that disturbed the sleep. The patient is a laundry worker for the last 14 years and doing daily work with 10-kg heavy iron. The patient is not known to be diabetic or hypertensive or not known to have any cardiac ailment. The patient has had three intra-articular Gemcort injections in 15-day interval by an orthopedic surgeon but with limited relief. The last injection was taken 5 days before visit to the Ayurveda. The patient did not get relief either in pain or in stiffness of the shoulder joint.

Clinically, the patient had swelling at the right shoulder and Grade II tenderness at the glenohumeral joint. The patient had forward flexion of 40°, abduction of 40°, and extension of 10°, while internal rotation and external rotation were found to be within normal limits. Cuff strength was intact clinically and to assess impingement was difficult. The X-ray of right shoulder joint anteroposterior view [Figure 1] alone was done. Radiographs demonstrated calcific deposits in the region of the supraspinatus tendon. Approximately, the size of calcification was 1.5 cm, and according to Gartner and heyer classification, it was type I [Table 1] and [Table 2].
Figure 1: X-ray findings: Radiograph shows calcific tendinitis (arrow) in supraspinatus portion of rotator cuff

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Table 1: Assessment before treatment and after treatment

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Table 2: Case timeline for management of frozen shoulder

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Case management

The patient was managed with two sittings of WCT.

Cupping procedure

The patient was advised to take Mudgayusha 1 h before the procedure. Informed written consent was taken before procedure and vitals were checked. Local Abhyanga (massage) with Bala taila and Dashmool kwatha nadi swedana was done at the right shoulder joint. In sitting position, four modified Shringa Yantra (Chinese cup) were applied on the most tender point at the right shoulder and a negative pressure was created by suction and maintained for 3–4 min and then the cups were removed. Approximately 1-cm deep needling was done with a 24G needle on the demarcated area of cups. Then again, cups were reapplied on the needle-marked area and negative pressure was created by suction. After termination of bleeding, cups were removed and the site cleaned with povidone-iodine solution followed by Haridra (Curcuma longa L.) powder dusting was done. The patient was advised to avoid water contact at least for 24 h. The same procedure was repeated after 15 days of interval.

Follow-up and outcome

The assessment was done on the basis of improvement in symptoms and changes in X-ray. On the 1st consultation, Visual Analog Scale (VAS) score was 7, stiffness was Grade IV, while active range of motion including abduction 40° [Figure 2], flexion 40° [Figure 3], and extension 30° [Figure 4] was measured by goniometer. No improvement was noticed in internal rotation while shoulder in abduction. After the 1st sitting of cupping therapy, pain decreased from VAS-6–4. However, improvement in active ROM ; abduction 170°C [Figure 5], flexion 165°C [Figure 6], extension 50°C [Figure 7] was achieved, complete pain relief (VAS 0) and calcified deposits in the region of the supraspinatus tendon dissolved [Figure 8] after 2nd sitting of cupping.
Figure 2: Images of range of movement: Abduction before wet cupping therapy

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Figure 3: Images of range of movement: Flexion before wet cupping therapy

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Figure 4: Images of range of movement: Extension before wet cupping therapy

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Figure 5: Images of range of movement: Abduction after wet cupping therapy

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Figure 6: Images of range of movement: Flexion after wet cupping therapy

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Figure 7: Images of range of movement: Extension after wet cupping therapy

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Figure 8: X-ray findings: Radiograph shows complete resolve of calcification

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  Discussion Top


CT most frequently arises in the supraspinatus tendon; it may involve other tendons of rotator cuff muscle. It is caused by deposition of calcium phosphate crystals, mostly carbonate hydroxyapatite.[7] Although this may be an asymptomatic condition and recognized condition for shoulder joint pain which can persist for weeks to years. Calcification in many soft tissues causes dysfunction and pain. It results as a healing response to injury or inflammation after overuse.[8]

Joshi et al., conveyed that; in Dhatukshaya Janya Samprapti (pathology of tissue degeneration), bloodletting through modified Shringa Yantra (wet cupping) which eliminates Vata vitiated blood from localized circulatory pathways (micro-vascular structures) and recommend adequate fresh blood flow that restores normal joint function. .[9]

Chen et al. reported 32 cases of frozen shoulder associated with supraspinatus tendon calcification which leads to acute pain consequential in frozen shoulder. The authors yielded results by arthroscopic brisement of the glenohumeral joint and making multiple punctures in the supraspinatus calcified tendon.[10]

Nurudeen H explained cupping mediated clearance microparticles clearance theory (MCT). It significantly increases microvasculature causing the clearance of microparticles at the local site of application in a fashion akin to apheresis. The clearance of microparticles from the local microcirculation may reduce the disease pathophysiology by targeting the major disease drivers such as chronic inflammation and endothelial dysfunction.[11]

In this study, the negative suction generated by cup created pressure difference between skin and blood vessels increasing the blood flow. Needling followed by negative suction may aspirate these chronic deposits leading to adequate relief in pain and in restoring the joint function. It might decrease intratendinous pressure by adequate disruption through the needle. Negative suction after needling causes bleeding in the demarcated area which may lead the calcified material to escape with blood or absorb or disperse into the subacromial space. In this case, calcification in tendon was completely dissolved after two sittings of WCT and yielded a complete range of motion of the shoulder joint except internal rotation in extension. Cupping might restore normal circulation. Increased circulation in turn improves oxygen supply and cell metabolism, reducing the amount of inflammatory or toxic substances.[12]

Limitation of the study

As this is a single case report which limits the exploration of this result in similar population. Hence, it is suggested that further study should be carried out in a more number of subjects. The effect and the relevant mechanism behind how cupping therapy resolves calcification as an effective treatment for this condition is still to known.

Informed consent

informed written consent for publication of this case report had been taken from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the Director, ITRA, Jamnagar.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shastri A. Editor of sushruta Samhita sutrasthana jalaukavacharaniya adhyayam 13/8 reprint chaukhambha Sanskrit sansthan: Varanasi. 2014; p-57.  Back to cited text no. 1
    
2.
Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One 2012;7:e31793.  Back to cited text no. 2
    
3.
Kachewar SG, Kulkarni DS. Calcific tendinitis of the rotator cuff: A review. J Clin Diagn Res 2013;7:1482-5.  Back to cited text no. 3
    
4.
Bradley M, Bharmra MS, Robson MJ. Ultrasound guided aspiration of symptomatic supraspinatus calcific deposits. Br J Radiol 1995;68:716-9.  Back to cited text no. 4
    
5.
Gärtner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res 1990;254:111-20.  Back to cited text no. 5
    
6.
DE Carli A, Pulcinelli F, Rose GD, Pitino D, Ferretti A. Calcific tendinitis of the shoulder. Joints 2014;2:130-6.  Back to cited text no. 6
    
7.
Goldman AB. Calcific tendonitis of the long head of biceps brachii distal to the gleno-humeral joint: Plain film radiographic findings. AJR 1989;153:1011-6.  Back to cited text no. 7
    
8.
Available from: http://sci-hub.se/10.1056/NEJM199905203402011. [Last accessed on 2021 Apr 09].  Back to cited text no. 8
    
9.
Joshi F, Mahanta V, Dudhamal TS, Gupta SK. Effect of Agnikarma (therapeutic heat burns) and Raktamokshana (therapeutic bloodletting) in the management of Kati Sandhigata Vata (lumbar spondylosis). Ayu 2019;40:79-88.  Back to cited text no. 9
  [Full text]  
10.
Chen SK, Chou PH, Lue YJ, Lu YM. Treatment for frozen shoulder combined with calcific tendinitis of the supraspinatus. Kaohsiung J Med Sci 2008;24:78-84.  Back to cited text no. 10
    
11.
Hassan N, Rizwhan S, Waheeb A, Hisham J, Ali M. Microparticle clearance theory: An update to the potential mechanisms of action of cupping therapy, Adv Integr Med 2020;8:68-72.  Back to cited text no. 11
    
12.
Available from: https://www.hindawi.com/journals/ecam/2012/429718/. [Last accessed on 2021 Apr 09].  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2]



 

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