A 56-year-old woman with a two-year history of bilateral knee osteoarthritis experiencing an acute, hot, and swollen flare-up was successfully managed using a combined internal and external Damp-Heat clearing herbal strategy alongside acupuncture.

Case ID: CHC-0067

Case Summary

This case describes a 56-year-old woman whose physically demanding, long-standing job resulted in chronic bilateral knee osteoarthritis. She recently suffered an acute exacerbation characterized by severe red, swollen, hot, and painful knees that failed to respond to conventional steroid injections and pain medication. The original report documented a conventional diagnosis of bilateral knee osteoarthritis and a TCM assessment of Knee Impediment (Xi Bi) driven by Damp-Heat and Blood Stasis. She was managed through a highly integrative approach utilizing acupuncture, a localized cold herbal compress, and an internal modified Simiao San (Four-Marvel Powder) decoction to rapidly extinguish the joint inflammation and restore mobility.

Patient Presentation

• Patient: 56-year-old female (Surname: Liang).
• Main Complaint: Bilateral knee pain for 2 years, with an acute exacerbation featuring red, swollen, hot, and painful joints for 1 week.
• History: The patient sought her initial consultation in March 2023. She had a heavier physique and a job requiring prolonged standing, leading to a two-year history of knee pain (worse when climbing stairs) and fatigue. One week prior, after prolonged standing, the pain severely worsened, especially in the right knee, heavily restricting her ability to squat or bend her knees. Previous hospital admission utilizing steroid anti-inflammatories, painkillers, and external patches provided no significant relief.
• Symptoms: Severe, fixed, needle-like pain in the knees (right worse than left). The pain was unendurable upon pressing, relieved by cold, and worse at night. This was accompanied by thirst, irritability, poor appetite and sleep, yellow urine, and dry stools.

Examination and Diagnosis

• Physical Exam: Mild muscle atrophy in both thighs. Knees were moderately swollen, slightly red, and hot to the touch, with a varus (bow-legged) deformity. Clicking and grinding sounds were present during movement. The meniscus grinding test was positive (+).
• Imaging & Labs: DR showed hyperplastic arthritis in both knees. Right knee MRI showed cartilage damage, osteophyte formation, subchondral bone marrow edema/cystic changes, grade II meniscus injury, and chronic ACL injury. ESR was elevated (47 mm/h), and CRP was elevated (20 mg/L).
• Conventional Diagnosis: Bilateral knee osteoarthritis.
• TCM Tongue and Pulse: The tongue was red with a yellow, greasy coating and stasis spots (瘀斑). The pulse was slippery and rapid (脉滑数).

TCM Assessment

The original practitioner interpreted the presentation as Knee Impediment driven by Damp-Heat and Blood Stasis (膝痹病 – 湿热瘀阻证).

According to the holistic principles of yin and yang Chinese Medicine osteoarthritis is fundamentally rooted in aging (declining Liver and Kidney essence failing to nourish the bones) combined with external wear and tear. In this patient, years of prolonged standing caused chronic localized Qi and blood stagnation. Furthermore, her heavier physique indicated an underlying Spleen deficiency generating internal dampness.

The chronic stasis and trapped dampness eventually transformed into aggressive Heat. This Damp-Heat toxin lodged directly in the knee joints, causing the visible redness, heat, swelling, elevated inflammatory markers (CRP/ESR), and severe needle-like pain. The red tongue with a yellow greasy coating and stasis spots, combined with the slippery-rapid pulse, provided textbook objective confirmation of this intense Damp-Heat and Blood Stasis pattern.

Treatment Approach

The primary treatment principle was to clear heat and resolve dampness, invigorate blood and resolve stasis (清热利湿，活血化瘀). The strategy utilized a three-pronged approach: acupuncture to unblock the meridians, an external cold herbal compress to rapidly pull the inflammatory heat out of the joint, and an internal damp-heat clearing decoction to resolve the systemic metabolic root.

Interventions and Herbal Formulas

• Acupuncture Therapy: Applied using a reducing (泻法) technique to clear heat and drain excess. Points included Liangqiu (ST34), Xuehai (SP10), Yanglingquan (GB34), Yinlingquan (SP9), Xiyan (EX-LE4), Xuanzhong (GB39), Kunlun (BL60), Sanyinjiao (SP6), Zusanli (ST36), Ququan (LR8), and Xiyangguan (GB33). Retained for 20-30 minutes, 5 sessions per course.
• External Cold Compress (Zhao’s Xianren Cebai San): Specifically suited for acute damp-heat flare-ups. A mixture of the hospital’s proprietary blood-moving liquid (200ml), Biota tops trauma powder (Cebai Dieda Fen, 100mg), and mashed fresh Cactus (Xianren Zhang, 150g) was applied as a cold compress to the knees for 4-6 hours, 1-2 times daily.
• Internal Herbal Formula (Initial Visit): A 15-herb decoction acting as a modified Simiao San (Four-Marvel Powder).
  • Clearing Damp-Heat: Cang Zhu (10g) and Huang Bo (9g) form the core of Simiao San to forcefully dry dampness and clear heat from the lower body. Yi Yi Ren (Coix Seed, 30g) gently leaches out dampness without damaging Yin. Ku Shen (Sophora Flavescens, 10g) strongly clears localized damp-heat.
  • Moving Blood and Resolving Stasis: Jiang Huang (Turmeric, 10g), Sheng Di (10g), San Qi (Notoginseng, 10g), Tao Ren (10g), and Hong Hua (10g) cool the blood and aggressively break up the localized micro-clots causing the needle-like pain.
  • Clearing Toxicity and Relaxing Sinews: Lian Qiao (10g) and Ren Dong Teng (Honeysuckle Stem, 15g) clear heat-toxicity and unblock the collaterals. Mu Gua (9g), Qin Jiao (15g), Fang Ji (10g), and Chuan Niu Xi (15g) relax the tight sinews, drain dampness, and guide the medicinal effects downward to the knees.
  • Administration: 5 doses, water decocted, taken warm morning and evening.

Follow-Up

• Second Visit: After 5 days of outpatient treatment, the patient’s pain was significantly relieved, and walking became much easier. Only mild pain remained when climbing stairs. She was instructed to continue the same treatment plan, reduce knee weight-bearing, and use a cane if necessary.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the highly targeted approach to an acute, hot flare-up of osteoarthritis. Standard osteoarthritis is often treated as a cold-deficiency condition by warming the joints. However, this patient’s joints were red, hot, and highly inflamed (elevated CRP/ESR), presenting a classic Damp-Heat presentation.

Instead of utilizing standard warming herbs—which would have worsened the inflammation just as the prior steroid and patch treatments failed—Professor Zhao aggressively cooled the joint. The external use of mashed fresh Cactus (Xianren Zhang) combined with cold compresses directly extracted the localized heat, while the internal Simiao San resolved the metabolic dampness, achieving rapid pain relief in just 5 days.

---

Source Original source: Zhanjiang Second Hospital of Traditional Chinese Medicine Original title: 【以案说医】招仕富：内外结合治疗双膝骨性关节炎案 Practitioner: Professor Zhao Shifu (招仕富) Publication date: August 27, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation