Shoulder pain, often attributed to various etiologies, poses a considerable burden on an individual’s quality of life and functional capacity [1,2]. Given the multifactorial nature of chronic shoulder pain, its treatment remains controversial. Recent years a new form of acupuncture, that is, acupuncture combined with herbal medicine, called pharmacopuncture (PA) [3], has emerged as a promising adjunctive therapy for managing musculoskeletal conditions in Korean Medicine (KM). In KM clinical practice, hominis placenta is used to treat various diseases such as gynecological conditions, skin issues, and pain [4] given its anti-inflammatory, antiviral, antioxidative, antimutagenic, and analgesic property effects [5]. To achieve the maximum benefit of PA, ultrasound-guided techniques are considered because they enhance the accuracy, efficacy, and safety of therapeutic stimulation. Many studies have described ultrasound-guided interventions as safe, effective, and accurate because of their ability to dynamically visualize multiple planes [6,7].

Despite the increasing interest and utilization of this treatment technique, literature documenting its effectiveness in patients with shoulder pain remains limited. Herein, we report our experience with integrative KM treatment for a patient suffering from chronic shoulder pain. This study also aimed to present a compelling clinical illustration of the application and outcomes of ultrasound-guided PA, highlighting its potential as an effective therapeutic intervention in this population.

This study was approved by the Institutional Review Board of Kyung Hee University Korean Medicine Hospital (KOMCIRB 2024-04-009-001). The patient provided written informed consent for the publication of this case.

1. Clinical features

A 54-year-old Korean female with shoulder pain visited a KM hospital. In 2016, she experienced slight pain in the right shoulder for the first time, which may have been related to her occupation as a florist. Fortunately, the patient’s pain subsided over time. Since January 2023, the pain site broadened, and the severity worsened; therefore, she first visited the KM hospital for treatment, and the pain alleviated subsequently. However, in May 2023, the pain worsened again after strenuous activity. In July, as the pain persisted, she visited a medical center, and shoulder magnetic resonance imaging detected rotator cuff syndrome and bursitis. On July 31, 2023, she was admitted to a KM hospital for integrative KM treatment.

On July 31, she was admitted to a KM hospital and complained of chronic pain in the anterior region of the right shoulder, which aggravated after overuse or at night. Pain severity, measured using the numeric rating scale (NRS) score, ranged from 4 to 5. All ranges of shoulder movement and physical/neurological examination were normal. However, the empty can test on both sides, cross-body adduction test, acromioclavicular shear test, Yergason’s test, Speed’s test, and Apley’s scratch test on the right side were positive. Typically, the normal long head of the biceps tendon (LHBT) has a hyperechoic and fibrillar structure; however, in this patient, hypo-echogenicity was observed around the LHBT in both longitudinal and transverse views, and fluid accumulation was noted in the bicipital groove. Based on the patient’s medical history, physical examination, and ultrasound findings, the patient’s chronic shoulder pain was suspected to result from a complex pathological condition caused by repetitive motions associated with her occupation. In addition, the LHBT and labral pathology were believed as the most significant contributing factors.

2. Integrative Korean Medicine treatment

The patient received integrative KM treatment, which included acupuncture, PA, and herbal medicine, from July 31, 2023, to August 21, 2023 (Fig. 1).

Figure 1. Timeline of the case. MRI, magnetic resonance imaging; KM, Korean Medicine; NRS, numeric rating scale; BV, bee venom; PA, pharmacopuncture; HPE, hominis placental extract.

1) Acupuncture

The reporting of acupuncture treatment followed the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines (Supplementary Table 1) [8]. Acupuncture (a depth of 5–20 mm, depending on the anatomical location of the acupuncture point) was performed using 0.25 × 40 mm disposable stainless-steel needles (DongBang Acupuncture Inc.) twice a day and retained for 20 minutes. The following acupuncture points were used: GB21, LI15, TE14, SI11, SI12, SI13, and Ashi points on the LHBT, in accordance with the WHO Standard Acupuncture Point Locations [9]. Electroacupuncture (EA) stimulation (STN-111; Stratec) was performed with appropriate frequency and intensity parameters; the frequency of 4 Hz and intensity were increased enough to stimulate the contraction of each muscle. The acupuncture points and targeted muscles for EA were the right EX-B2 (at the level of C5–6), upper trapezius, supraspinatus, infraspinatus, and LHBT.

2) Pharmacopuncture

On August 4, PA was conducted subcutaneously using bee venom (BV), and on August 10, ultrasound-guided PA was conducted using hominis placental extract (HPE, Kirin Herbal Dispensary). Following a negative result from an allergic reaction skin test, 0.1 mL of BV at a concentration of 1:30,000 was administered to the same local points as acupuncture treatment using a 1-mL disposable syringe (30 gauge, Hwajin Medical Co.). To obtain this concentration, 10 mg of dried BV (Yoomil Garden) was diluted with 300 mL of saline (Joongwe Pharmaceuticals).

Regarding the ultrasound-guided HPE PA, standard B-mode ultrasound imaging was conducted with a linear array transducer (3–11 MHz). Before the intervention, the ultrasound probe surfaces were cleaned meticulously with povidone-iodine. The doctor put on the protective facial mask and medical gloves, and the patient’s skin at the intended site of insertion was carefully cleansed using povidone-iodine. PA was conducted using a 26 G × 60-mm disposable stainless-steel needle. The target point was the space below the sheath in the damaged LHBT area. The damaged area was confirmed in the longitudinal view at the tender point 1–2 cm below the greater tubercle of the humerus, switched to the transverse view to reconfirm the lesion area, and then 4 mL of the HPE was injected from the lateral to the medial side through an in-plane approach. After disinfecting the injection site and ensuring that minor bleeding stopped, an injection care band was attached (Fig. 2).

Figure 2. Ultrasound-guided pharmacopuncture. (A1, A2) Ultrasound images showing the transverse view of long head of biceps tendon. (B1, B2) Under ultrasound-guided pharmacopuncture, the targeted area can be safely, effectively, and accurately approached through simultaneous ultrasound imaging. The yellow boxes in (A2) and (B2) indicate regions in the Doppler ultrasound view, highlighting blood flow and vascularity around the long head of biceps tendon.

3) Herbal medicine

The herbal decoctions “danggwisu-san variants,” which consisted of Angelicae gigantis radix, Curcumae longae rhizoma, Osterici radix, Paeoniae radix, Astragali radix, Cinnamomi ramulus, Citri unshius pericarpium, Amomi fructus, Atractylodis rhizoma alba, Crataegi fructus, Pinelliae tuber, Clematidis radix, Corydalis tuber, Persicae Semen, Zingiberis rhizoma, Zizyphi fructus (Table 1), and “pyeongjingeonbi-tang” were administered three times a day.

Table 1 . Herb composition of danggwisu-san variants.

Herb		Dose (g)
Angelicae gigantis radix	當歸	5
Curcumae longae rhizoma	薑黃	4
Osterici radix	羌活	4
Paeoniae radix	赤芍藥	4
Astragali radix	黃芪	4
Cinnamomi ramulus	桂枝	3
Citri unshius pericarpium	陳皮	3
Amomi fructus	砂仁	3
Atractylodis rhizoma alba	蒼朮	3
Crataegi fructus	山楂	3
Pinelliae tuber	半夏	3
Clematidis radix	威靈仙	3
Corydalis tuber	玄胡索	2
Persicae semen	桃仁	2
Zingiberis rhizoma	生薑	4
Zizyphi fructus	大棗	4

3. Clinical outcomes

Pain and dysfunction were assessed using the NRS [10] and shoulder pain and disability index (SPADI), and the patient’s overall health status and well-being were evaluated using the EuroQol five-dimensional three-level questionnaire (EQ-5D-3L) and EuroQol visual analog scale (EQ-VAS) [11-13]. Adverse events during treatment were also assessed for safety. NRS and safety evaluations were performed daily, whereas SPADI, EQ-5D-3L, and EQ-VAS evaluations were conducted twice, at admission and discharge. Follow-up ultrasound sonography was conducted on August 21. Overall, the fluid accumulation observed in the bicipital groove generally decreased, and the pattern of the structures surrounding the LHBT improved.

The pain NRS score of the right shoulder decreased gradually from 4 to 1 (Supplementary Fig. 1). The SPADI-pain and SPADI-disability scores decreased from 19 to 8 and from 19 to 4, respectively. Accordingly, the SPADI-total score decreased from 38 to 12 (Supplementary Fig. 2). The EQ-5D-3L scores were maintained or decreased as follows: mobility (1 to 1), self-care (1 to 1), usual activities (2 to 1), pain/discomfort (2 to 2), and anxiety/depression (1 to 1). The EQ-VAS score increased from 70 to 90 (Supplementary Fig. 3). Only minor bleeding was observed at the acupuncture or injection sites, and no severe adverse events occurred during treatment.

Although acupuncture, the traditional modality in KM, is well-known for its clinically relevant effect on chronic pain [14], to our knowledge, this is the first case study to report the effectiveness and safety of integrative KM treatment including ultrasound-guided PA in a patient with chronic shoulder pain. According to a previous retrospective review of 410 inpatients with shoulder pain in KM hospitals, the most frequently used KM interventions for treating shoulder pain are acupuncture, PA, and moxibustion [15]. Improvements in pain intensity, shoulder function, and quality of life underscore the clinical utility of this approach. Notably, pain severity decreased after each PA injection. Furthermore, the absence of severe adverse effects highlights the safety of ultrasound- guided PA.

However, this case report has several limitations. Given that the patient received integrated therapy, determining the effectiveness of each intervention is difficult. Further high-quality investigations of BV and HPE PA are required to identify the exact effects of each treatment. Although further research is warranted to validate these findings in larger cohorts and compare the effectiveness of ultrasound-guided PA with conventional treatments, this case study lays the foundation for exploring therapeutic options for the management of chronic biceps tendinitis that presented as chronic shoulder pain. These findings may offer clinicians and researchers valuable insights for optimizing patient care and outcomes in musculoskeletal practice.

Recently, researchers are introducing useful methods for conducting randomized controlled trials of ultrasound-guided interventions. Further rigorous randomized studies with a long-term follow-up period and large sample sizes are warranted to confirm treatment effectiveness and safety.

Supplementary data is available at https://doi.org/10.13045/jar.24.0021.

We would like to thank Dr. Yoohyun Sim for her assistance with integrative Korean Medicine treatment.

Conceptualization: TK, SL. Data curation: TK, SL. Formal analysis: TK. Investigation: TK, YK, SN, HJ. Methodology: JSL, TK. Project administration: TK. Resources: TK, SL. Software: JSL. Supervision: SL. Visualization: JSL. Writing – original draft: TK, JSL. Writing – review & editing: SL.

The authors have no conflicts of interest to declare.

None.

Before the study, the patient provided us with an informed consent form for the academic use of the medical records and answers to the questionnaire. This study was approved by the Institutional Review Board of Kyung Hee University Korean Medicine Hospital (KOMCIRB 2024-04-009-001).