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The Management of Sprain, Strains and Trauma - Part Two

by Alon Marcus

TCM Stabilization and Exercise

Management of activity is part of the TCM treatment approach to acute injuries. This approach was also advocated in the West by Hippocrates more than 2400 years ago. Stabilization and restriction of movement with simultaneous exercise was described in the TCM medical book Secret Formula of God for Management of Trauma and Fracture:

Sprains and fractures of the hands and feet are treated by a topical application of ointment wrapped with cloth, fixation with bamboo, and with intermittent exercise. The applicable exercises should be individualized, and the patient must neither over exercising nor under exercise.

For injuries to soft tissues, in order to promote Qi and Blood circulation, prevent stasis and adhesion, and promote healing, the practitioner must create a balance between the need for immobility, stabilization, and mobility. In the acute and middle stages, movement must be soft and fluid to avoid aggravating the condition. In the late and chronic stages, the patient can also use strengthening exercises. Commonly used, especially in acute disorders, are Tai Chi- and Qi Gong-derived techniques. More specific muscle strengthening, stretching, and coordination training is used in middle and chronic stages. Plaster casts are commonly used in the fixation of fractures. Since plaster often contains gypsum (Shi Gao), a stone that is considered to have a cold nature in TCM, patients may develop a Cold syndrome after fixation by a cast (such as stiffness and pain). TCM management of fractures commonly involves early movement and a use of removable bamboo splints.

Herbal Management

In the early and middle stages of acute soft tissue injury, the treatment principles are to activate the Blood, stop bleeding, open the channels and, often, to clear Heat. Representative formulas are Seven-Thousandths of a Tael Powder (Qi Li San) and Trauma Pill (Die Da Wan), which is a warming formula. These formulas facilitate the elimination of Blood-stasis, swelling, bleeding, and pain. The following are basic formulas that can be used in the treatment of soft-tissue sprain and strains. Appropriate modifications are made based on symptoms, signs, and region.

A guiding oral and topical herbal formula for early stage sprains and/or strains is:

Radix Angelicae Sinensis (Dang Gui) 6g
Radix Notoginseng (San Qi) 15g
Radix Rehmanniae (Sheng Di Huang) 9g
Radix Paeoniae Alba (Bai Shao) 9g
Radix Paeoniae Rubra (Chi Shao) 9g
Rhizoma Ligustici Wallichii (Chuan Xiang) 6g
Gummi Olibanum (Ru Xiang) 3g
Resina Myrrhae (Mo Yao) 3g
Herba Lycopodii (Shen Jin Cao) 12g
Fructus Liquidambaris (Lu Lu Tong) 6g
Semen Plantaginis (Che Qian Zi) 12g
Flos Loncerae (Jin Yin Hua) 9g
Flos Chrysanthemi (Ju Hua) 9g
Rhizoma Paridis (Zao Xiu) 6g
Radix et Rhizoma Rhei (Da Huang) 6g3
If swelling is already prominent:
Radix Bupleuri (Chai Hu) 9g
Poriae Cocos (Fu Ling) 20g
Flos Carthami (Hong Hua) 15g4
Radix Paeonia Rubra (Chi Shao) 12g
Semen Persicae (Tao Ren) 6g
Sanguis Draconis (Xue Jie) 9g
Squama Manitis (Chuan Shan Jie) 12g
Semen Trichonsanthis (Gua Lou Ren) 9g
Radix et Rhizoma Rhei (cooked) (Shu Da Huang) 9g
Resina Myrrhae (Mo Yao) 3g
Gummi Olibanum (Ru Xiang) 3g
Radix Notoginseng (San Qi) 12g
Semen Plantaginis (Che Qian Zi) 15g
Semen Coicis Lachryma jobi (Yi Yi Ren) 30g
Rhizoma Dioscoreae Hypoglaucae (Bi Xie) 12g
Nidus Vespae (Feng Fang) 9g
Spina Gleditsiae (Zao Jiao Ci) 6g
Radix Glycyrrhizae (Gan Cao) 3g
Mirablilitum Depuratum (Mang Xiao) topically only
For trauma with stasis, restlessness or complex fracture:
Pollen Typhae (Pu Huang) 30g
Rhizoma Corydalis (Yan Hu Suo) 30g
Radix Paeoniae Rubra (Chi Shao) 30g
Myrrha (Mo Yao) 30g
Radix et Rhizoma Rhei (Da Huang) 30g
Radix Aconiti (Fu Zi) 30g
Fructus Perillae Frutescentis (Su Zi) 30g
(Yun Tai Zi) 30g
Cortex Cinnamomi Cassiae (Gui Xin) 9g
Rhizoma Ligustici Wallichii (Chuan Xiong) 9g
An Lu Zi 9g

Grind into powder and take 3g QID with warm wine.

For simple bone fracture, modifications of Join Bone Powder (Jie Gu San) can be used both topically and orally. Vinegar is mixed in when used topically:

Myrrha (Mo Yao) 12g
Gummi Olibanum (Ru Xiang) 12g
Pyritum (Zi Ran Tong) 6g
Os Draconis (Long Gu) 30g
Talcum (Hua Shi) 30g
Hallyositum Rubrum (Chi Shi Zhi) 12g
Sanguis Draconis (Xue Jie) 9g
Lignum Sappan (Su Mu) 9g
Secreto Moschi Moschiferi (She Xiang) 0.1g
During the subacute and chronic stages of bone fracture, the following herbs are added:
Radix Dipsaci Asperi (Xu Duan) 15g
Ramulus Loranthus Sangjisheng (Sang Ji Sheng) 30g
Cortex Eucommiae Ulmoidis (Du Zhong) 15g
Rhizoma Drynari (Gu Sui Bu) 12g
Cornu Cervu Parvum (Lu Rong) 3g

In the sub acute stage, when bleeding and inflammation have stabilized, the main treatment principles are to prevent secondary Wind-Dampness and malnourishment of sinews and bones. The following guiding formula can be used:

Radix Angelicae Sinensis (Dang Gui) 9g
Gummi Olibanum (Ru Xiang) 3g
Resina Myrrhae (Mo Yao) 3g
Herba Lycopodii (Shen Jin Cao) 12g
Radix et Rhizoma Rhei (Shu Da Huang) 6g
Radix Paeoniae Alba (Bai Shao) 9g
Radix Paeoniae Rubra (Chi Shao) 9g
Radix Notoginseng (San Qi) 9g
Nidus Vespae (Feng Fang) 9g
Radix Ledebouriellae (Fang Feng) 9g
Radix Angelicae Dahuricae (Bai Zhi) 6g
Lignum Sappan (Su Mu) 9g

In the acute late stage and in chronic soft tissue injury, the main pathogenic processes are disharmony between the sinews, channels, and network-vessels. This manifests as pain and the fatigability of the affected tissues. Treatment often consists of nourishing the Blood, re harmonizing the collaterals, and warming the channels to stop the pain and to strengthen the tissues. Representative formulas are Revive Health by Invigorating Blood Decoction (Fu Yuan Huo Xue Tang) and Fixed Bi Empirical Formula (Zhuo Bi Yan Fang). A guiding oral or topical formula for the late stage with stiffness and pain is:

Ramulus Loranthus Sangjisheng (Sang Ji Sheng) 30g

Radix Angelica Sinensis (Dang Gui) 12g
Radix Paeoniae Rubra (Chi Shao) 12g
Caulis Spatholobi (Ji Xue Teng) 12g
Squama Manitis (Chuan Shan Jie) 12g
Radix Salviae Miltiorrhizae (Dan Shen) 12g
Ramulus Mori Albae (Sang Zhi) 9g
Flos Carthami (Hong Hua) 6g
Myrrha (Mo Yao) 9g
Gummi Olibanum (Ru Xiang) 9g
Rhizoma Ligustici Wallichii (Chuan Xiong) 6g
Radix Gentianae Macrophyllae (Qin Jiu) 12g
Radix Clematidis (Wei Ling Xian) 9g
Rhizoma Curcumae Longae (Jiang Huang) 12g
Rhizoma seu Radix Notopterygii (Qiang Huo) 9g
Fructus Psoraleae (Bu Gu Zhi) 9g
Rhizoma Drynari (Gu Sui Bu) 9g
Radix Aconiti Carmichaeli Praeparata (Zhi Chuan Wu) 9g
Herba Asari Cum Radice (Xi Xin) 3g
Secreto Moschi Moschiferi (She Xiang) 0.1g
Scorpio (Quan Xie) 3g
Borneolum (Bing Pian) 0.2g oral use; 3g topical use

A strategy based on modified Pueraria Decoction (Ge Gen Tang) for treating traumatic injury to flash and bone is:

Radix Puerariae (Ge Gen) 30g
Herba Ephedrae (Ma Huang) 9g
Ramulus Cinnamomi Cassiae (Gui Zhi) 10g
Fructus Forsythiae Suspensae (Lian Qiao) 10g
Rhizoma Zingiberis (Sheng Jiang) 3 slices
mix-fried Radix Glycyrrhizae (Zhi Gan Cao) 6g
Radix Paeoniae Lactiflorae (Bai Shao) 15g
Fructus Zizyphi Jujube (Da Zao)12 pieces
Topical soak of Radix Puerariae (Ge Gen) 100g.

For upper extremity add: Rhizoma Curcumae Longae (Jiang Huang) and Ramulus Mori Albi (Sang Zhi).

For lower extremity or the lumbar region add: Radix Achy¬ranthis Bidentatae (Niu Xi).

For severe pain, swelling, and distension add: Rhizoma Cyperi Rotundi (Xiang Fu), Resina Olibani (Ru Xiang) and Resina Myrrhae (Mo Yao).

For traumatic injury and multiple abscesses (i.e., secondary infection) due to Blood-stasis, Removing Blood-stasis Pueraria Decoction (San Xue Ge Gen Tang) can be added to antibiotic therapy:

Radix Puerariae (Ge Gen) 2.5-12g
Rhizoma Pinelliae (Ban Xia) 2.5-9g
Rhizoma (Chuan Xiong) 2.5g-6
Radix Ledebouriellae (Fang Feng) 2.5g-9
Rhizoma seu Radix Notopterygii (Qiang Huo) 2.5-9g
Rhizoma Cimicifugae (Sheng Ma) 2.5g-4g
Radix Platycodi (Jie Geng) 2.5-9g
Radix Angelicae Dahuricae (Bai Zhi) 1.5-6g
Radix Glycyrrhizae (Gan Cao) 1.5-3g
Herba Asari (Xi Xin) 1.5g
Folium Perillae (Su Ye) 1.5g-6g
Rhizoma Cypri (Xiang Fu) 1.5-6g
Flos Carthami (Hong Hua) 1.5-6g

For late-stage weakness from traumatic injury and bleeding, use Disperse Wind and Nourish Blood Decoction (Shu Feng Yang Xue Tang):

Herba Schizonepetae (Jing Jie) 6g
Rhizoma et Radix Notopterugii (Qiang Hou) 9g
Radix Ledebouriellae/Siler (Fang Feng) 9g
Rhizoma Ligustici (Chuan Xiang) 9g
Radix Trichosanthis (Tiang Hua Fen) 15g
Radix Paeoniae (Bai Shao) 12g
Radix Gentianae Macrophyllae (Qin Jiu) 12g
Herba Menthae (Bo He) 5g
Radix Angelicae Sinensis (Dang Gui) 12g
Flos Carthami (Hong Hua) 6g

Table 10-5 summarizes the basic treatment principles and classical external formulas used in the treatment of acute injuries. Table 10-6 summarizes commonly used classical formulas for external application in chronic or late stages. Table 10-4 summarizes commonly used classical formulas for oral intake in all stages.

Other Natural Therapies for Sprains and Strains

Proteolytic enzymes have anti-inflammatory, oedema-reducing properties and analgesic effects. The analgesic effects are probably due to inhibition of inflammation as well as direct influences on nociceptors. In recent years a significant reduction of pain in various rheumatic diseases including periarthritis of the shoulder, osteoarthritis of the knee, and painful vertebral syndromes have shown effects equivalent to non-steroidal anti-inflammatory agents (NSAIDs) in pain scores (Klein and Kullich 1999). Serratia peptidase (SP) is an anti-inflammatory in wide clinical use throughout Europe and Asia as a viable alternative to salicylates, ibuprofen, and the more potent NSAIDs. Unlike the NSAIDs, SP has no inhibitory effects on prostaglandins and is devoid of gastrointestinal side effects. It is an anti-inflammatory proteolytic enzyme isolated from the microorganism, Serratia E 15. This enzyme is naturally present in the silk worm (Bombyx Batryticatus, Jiang Can) intestine and is processed commercially through fermentation. SP is a metalloprotein with a molecular weight of 50,000. Each molecule contains one zinc atom. This immunologically active enzyme is completely bound to the alpha 2 macroglobulin in biological fluids. Histologic studies reveal powerful anti-inflammatory effects of this naturally occurring enzyme.

SP has been introduced and admitted as a standard treatment in Germany and other European countries for treatment of inflammatory and traumatic swellings. In one double-blind study conducted by Esch et al, sixty-six patients with fresh rupture of the lateral ligament treated surgically, were divided into three randomized groups. In the group receiving the SP, the swelling had decreased by 50% on the third post-operative day. In the other two control groups (elevation of the leg, and bed rest, with or without the application of ice), no reduction in swelling had occurred. The difference was of major statistical significance. Decreasing pain correlated for the most part with the reduction in swelling. The patients receiving SP became pain-free more rapidly than the control groups. By the tenth day all patients in the SP treated group were free of pain. The therapeutic daily dose has been reported at one or two tablets (5 mg) three times daily. Serraflazyme, a preparation available in the United States, contains 5mg SP formulated as an enteric coated tablet (Dorman, personal communication). Bromelain, three or four capsules three times per day on an empty stomach, and other proteolytic enzymes may be helpful, as well.

Table 10-1: Soft Tissue Damage


Caused by physical force exerted on tendon-periosteal junction. Palpability and symptoms depend on location.


Identified by analyzing:

•joint movements

•loss of sensation

•presence of marked muscle contraction.

Modern neurological knowledge is useful in this evaluation.


Non-treatment of traumatic injury and/or chronic Phlegm and Blood-stasis can lead to:

•channel blockage and formation of “hard nodules”

•insufficiency of tissue nourishment.

Tissues can react by hardening, resulting in dysfunction, pain aggravation, and formation of osseous lesions.


Chronic Obstruction Bi syndrome accompanied by damage due to injury can lead to hardening which becomes interarticular free bodies.


Inflamed tissue (where chronic Fire and/or Cold congeals Phlegm and Blood) may transform into “hardness” spurs that attach to joint surface. (Spurs usually develop along stress lines and Sharpey’s fibres.)

Table 10-2: Stages of Soft Tissue Damage EARLY STAGE




First 2-3 days.

Begins 4-14 days after mild-to-moderate or severe injury.

Begins about 2 weeks after injury. Usually results from severe trauma and/or weakness.

Atypical. Usually due to secondary factors, e.g., improper treatment, continuing weakness/deficiency.

Characterized by:

severe pain

local Blood-stasis

reddish-purplish colour



local warmth

very noticeable dysfunction

Characterized by:

partly reduced swelling

some absorption of Blood-stasis

greenish-purplish colour

slightly warm skin

pain reduced greatly

still noticeable dysfunction

Characterized by:

change of ecchymotic colour to yellow-brown

symptoms reduced greatly

dysfunctions may not be noticeable

(Usually) Characterized by:

persistent, mild swelling

development of adhesions and scars

dull pain (ache)

sluggish movement of affected parts

painful end-feels

Mild to moderate types may recover.

Usually goes to middle stage.

Recovery usually with mild-to-moderate types.

Treated correctly, should heal 1-2 weeks.

Recovery expected within 5 weeks of injury, if did not heal by second week of treatment.

May progress to chronic

Recovery variable.

Good in Mild-Moderate types.

Similar to middle stage.





Goes to middle stage, but middle stage is more prolonged.

By day 14, patient should be improved noticeably, with partial recovery of functions.

May be prolonged. Symptoms may vary greatly by location.

May be prolonged. Symptoms may vary greatly by location.

Table 10-3: Contemporary TCM Classification of Soft Tissue Damage CAUSE AND LOCATION




Injury due to indirect (intrinsic) forces such as:

•sudden movement.

•heavy lifting.

Occurs mostly in sinews:

•periarticular fascia.





Mild impairment of collateral circulation within:




Includes mild lacerations of tissues that do not lead to joint pathology.

Acute stage 1-10th day.

Middle stage 4th-14th day.L

Late stage 2ed-4 weeks.


Constitutionally strong patient with effective treatment, unlikely to progress to chronic stage.

With severe injury, tissue severed, or when patient’s Righteous is weak its likely to progress. to chronic stage, characterized by:

•muscular rigidity/flaccidity.

•local skin paleness/redness.

•swelling and/or tissue hyperplasia or atrophy.


Injury from extrinsic force (trauma).

Characterized by damage directly under injuring force to sinews and/or bones:

•subcutaneous tissue.





Altered Position from Torn Tissue.

Malpositioned tissues accompanied by obvious Blood-stasis, swelling, loss of normal function.

Affected tissues may include:







Constitutionally strong patient with effective treatment, unlikely to progress to chronic stage.

Severe injury, tissue severed, or patient’s. Original Qi weak likely to progress to chronic stage, characterized by:

•muscular rigidity/flaccidity.

•local skin paleness.

•swelling and/or tissue hyperplasia or atrophy.

Table 10-4: Internal Herbal Medication: Acute Soft Tissue Injuries INTERNAL HERBAL APPLICATIONS: ACUTE SOFT TISSUE INJURIES

Pathologic Processes

•Blockage of Qi.

•Blockage of Blood circulation.


•Severe pain due to stasis and ecchymosis.

Treatment Principles

•Activate the Blood.

•Dissolve stasis.

•Stop bleeding.

•Regulate Qi.

•Clear Heat.

Injury with Bi Syndrome (Wind-Damp/rheumatism)

•Eliminate Wind-Damp.

•Harmonize the collaterals.

Weak Muscles/Tendons

•Supplement Spleen, Liver and Kidney with above principles.

Early Stage Treatment Principles

•Dissolve stasis, activate Blood, stop pain, stop bleeding.

Common Formula

•Stop pain powder (Zhi Tong San).

•Yunnan white powder (Yunnan Baha’i).

Middle Stage Treatment Principles

Swelling and Pain Reduced Gradually and Noticeably.

•Relax the sinews.

•Activate the Blood.

•Reduce swelling.

Common Formulas

•Relaxing tendon pill (Shu Jin Wan).

•Relaxing sinew and activating Blood Tea (Shu Jin Huo Xue Teng).

•Supplementing sinew pill (Bu Jin Wan).

Late Stage, Chronic Stage Treatment Principles

Often accompanied by Wind-Damp, manifest as local swelling, fatigue, muscle contractions, loss of normal function, pain (may be aggravated by weather changes).

•Nourish and vitalize the Blood.

•Harmonize the Collaterals.

•Disperse Wind.

•Eliminate Dampness.

•Stop Pain.

Common Formulas

•All-Inclusive Great Tonifying Tea (Shi Quan Da Bu Tang).

•Minor Invigorate the Collaterals Special Pill (Xiao Luo Luo Dan).

•Fantastically Effective Pill to Invigorate the Collaterals (Huo Luo Xiao Ling Dun).

•Major Invigorate the Collaterals Special Pill (Da Huo Luo Dan).

•Remove Painful Obstruction Tea (Juan Bi Tong).

Elderly Weak patients

Treatment Principles

•Supplement Liver, Kidney, Blood.

•Eliminate Pathogenic Factors and Blood-stasis.

Common Formulas

•Bushen Zengjin Tong (Tonify Kidney Strengthen Sinews Tea).

•Bushen Huoxue Tong (Tonify Kidney Invigorate Blood Tea).

•Major Invigorate the Collaterals Special Pill (Da Hou Luo Dan).

Table 10-5: Injury: Basic Treatment Principles, External Applications, and Formulas: Acute Stage


•Activate Blood.

•Dissolve Stasis.

•Eliminate Swelling.

•Regulate Qi to Stop Pain.


•Three Colours Herbal Ointment (Sanshe Gao).

•Dissolving Blood-stasis Plaster (Huaxue Zhi Gao).

•Stopping Pain Ointment (Zhitong Gao).

•Regulate Qi to Stop Pain Plaster (Liqi Zhitong Gao).


If the injury has local heat and redness, in order to:

•Dissolve Blood-stasis.

•Clear Heat.

•Eliminate Toxin.

•Reduce Swelling.

•Stop Bleeding.


•Activating Blood Ointment (Huoxue Gao).

•Clearing Ying Ointment (Qing Ying Gao).

•Four-Yellow Paste (Sihuang Gao).

•Gold-yellow Paste (Jinhuang Gao).


For minor injuries, in order to:

•Relax Sinews.

•Activate the Blood.


•Thousand Flower Oil (Wanhua Yao).

•Fr. Foeniculi Oil (Xue Xiang oil).

Table 10-6: Injury: Basic Treatment Principles External Applications Formulas: Late Stage

Late Stage,

Certain Chronic Stages

Pain prolonged.

Tissues impaired functionally.

Treatment Principles

•Activate the Blood.

•Stop bleeding.

•Dispel stasis.

•Stop pain.

Common Formulas

•Thousands of responses ointment (Wan Fu Zi Gao).

•Pearl ointment (Zhen Zhu Gao).

•Transforming channels plaster (Huajian Gao).

Chronic Stages

Skin over lesion cold, somewhat white.

Muscles and tendons hardened, swollen, spasmodic.

Treatment Principles

•Warm the channels.

•Stop pain.

•Facilitate joint movement.

Possible Formulas

•Herbal hydrotherapy.

•(Ba Xian Shao Yao Tang, Hai Tong Pi Tang).

•Topical spirits. A nice combination that can yield a warming effect is to first use Zheng Gu Shui followed by Po Sum On, the area is then wrapped and the patient mobilizes the affected joint.

•Huoxue Jiu (activate Blood spirit).

Chronic Pain with Wind-Damp Bi


Treatment Principles

•Warm the channels.

•Eliminate Wind-Damp.

•Stop pain.

Possible Formulas

•External application of steamed herbs.

•Teng Yao, Tang Feng Shan.


—Dog skin plaster (Goupi Gao).

—Transform channels plaster (Juajian Gao).



See book.

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