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When it comes to trigger point needling in the shoulder one of the major muscles we have to address is subscapularis. It plays a unique role as the only rotator cuff muscle to perform internal rotation. It is also notoriously uncomfortable to access. In my days as a massage therapist, I found it was in a similar class to the psoas in the fact that even in seemingly healthy muscle, it is very sensitive. When it comes to needling, it takes significant skill to safely needle. Please see this video for how I like to needle subscapularis!

sub scap needling

In our advanced shoulder course, we teach how to treat subscapularis and the first aspect we discuss is risk to reward. The risk of needling any trigger point should not exceed the reward of it being released. With confident palpation, accurate needling skills and proper training, the risk of needling subscapularis decreases and the reward increases. If these skills are not present, the risks can include pneumothorax, nerve damage or artery puncture. If someone is untrained or uncomfortable with needling subscapularis, we encourage using manual therapy to treat the local trigger points. If you are interested in some of our favourite manual therapy techniques, check out last week’s blog!

Palpation

In my opinion the most important tool to confidently needling subscapularis is

Palpating subscapularis

Palpate where subscap is believed to be and resist internal rotation

manual muscle testing. As mentioned above, the subscapularis performs internal rotation. When palpating what is believed to be suscapularis, resisting internal rotation can help confidently identify the muscle. I like to ask the patient to push their wrist to belly button as a cue (check this out in my video). Another tip is to identify other easy to find landmarks such as intercostals, latissimus dorsi, and the lateral border of the scapula. Once the lateral border of the scapula is located it is simple to find the way to the subscapular fossa. If you know all your surroundings structures, it becomes much easier to find any muscle you attempting to palpate.

Trigger points

As shown in the picture below, the trigger points in subscapularis refer to the posterior shoulder and arm as well as the anterior and posterior wrist. Under palpation is often easy to illicit a clear referral pattern.

Subscap trp

When to treat

Deciding when to treat subscapularis is not always as straightforward as other trigger points acupuncturists treat. With a muscle like the upper trapezius, a trigger point can be palpated and safely released on a patient. In the case of subscapularis, many factors can get in the way. Frozen shoulder is a great example. It can be a major relieving factor to needle these trigger points for decreased range of motion, but the patient needs to have the range of motion to allow access. Manual therapy can help achieve access to this area. The axilla is also a common area for patient’s to be ticklish. This is usually easily overcome by the use of a glove and quick firm pressure. I would say comfortable patient placement with safe access is an absolute must. For me, I prefer to needle subscapularis in supine position with the patient in abduction as seen in the video.

Some common indications for needling the subscapularis can be:

  • Frozen shoulder
  • Decreased internal rotation
  • Posterior shoulder pain
  • Difficulty with putting a bra on (don’t forget Lats and Teres Major!)

Homecare for subscapularis

Homecare for subscapularis is dependent on movement and orthopedic assessment. Sometimes internal rotation with a resistance band is appropriate, but often there is more to it then that. For example, in the case of SICK Scapula, focusing on corrective exercises for the tipping of the scapula and it’s accompanying dyskinesis may prove more useful then direct strengthening to the subscapularis. Some of the most basic shoulder exercises I like can be found in the Trigger Point Acupuncture facebook group or in this video. Another great tool that can be incorporated is kinesiotape. To see an easy and effective taping method, check this video out! Just because we are using homecare to treat other muscles doesn’t mean that Subscapularis won’t be indicated for needling. It is simply that we have to treat the whole pattern, versus just a single muscle….however, that is nothing new to an acupuncturist, we always treat the pattern!

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One of the most under-utilized techniques in the acupuncturist’s tool belt is manual therapy (Tui Na). This modality can be an extremely effective tool to decrease pain and increase range of motion immediately for a patient. Manual therapy is a modality every acupuncture practitioner spent a fair amount of time learning in school. Of course, like any other technique learned, it takes practice and clinical use to stay consistent with.

Often, we do not think there is time in a treatment for manual therapy, so this video shows how you can spend just a few minutes to get fast results. A few minutes before or after treatment can make a world of difference in patient outcome. Remember patients want the fastest results they can get!

When to use manual therapy

                Every practitioner will have their preference. I used to always perform manual therapy before needling, but have shifted into using the techniques more post treatment. The major exception to this is the needle sensitive patient or acute muscle spasm (i.e. torticollis). Using manual therapy before needling can decrease the discomfort of needling for a needle sensitive patient.IMG-0355 The reasoning is simple; manual therapy to MTrP will decrease the active response of the trigger point. If a patient is hypersensitive to needling, 30 seconds of manual therapy to oversensitive trigger points makes all the difference in the world.  After treatment it can quickly make a difference in pain and range of motion on top of what acupuncture had already achieved. This manual therapy can really be the icing on the cake of a great treatment.

Get immediate relief of symptoms

When performing manual therapy post treatment, it is pivotal that it provides immediate relief and increase ROM. When utilized on top of acupuncture it can accelerate the treatment effect. As discussed in this short video a combination of passive flexion and active flexion with compression on a MTrP can help to decrease the pain quickly. If the patient is sensitive to pressure passive flexion performed correctly should decrease pain in the point by approximately 60%. Hold pressure in the decreased pain state at least 30 seconds and up to 2 minutes then retest and the pain point should be less sensitive. This technique is often called positional release or strain counter-strain. If the patient is less sensitive to deeper techniques applying pressure through flexion of the muscle can create a quick decrease in trigger points. A combination of the two can be beneficial and quickly attained.

For quickly increasing ROM I add PNF (Proprioceptive Neuromuscular Facilitation) or Muscle Energy techniques along with the above techniques. My personal favourite version of these is a method of Contract-Relax technique which works through reciprocal inhibition. For example, when a patient has decreased lateral flexion in the cervical spine they are placed in passive flexion. Once a range where the muscle restricts movement is attained the patient restricts lateral flexion in the opposing direction for several seconds. After a few seconds the patient relaxes and passive range of motion increases. The results are instant and are phenomenal for increasing range of motion.

Create a well-rounded treatment

As acupuncturists we often fall into the trap of thinking our needles are a hammer and every problem is a nail. We have a complete scope of practice to treat a variety of conditions and should use the tools in our tool bag as efficiently as possible and to the best of our ability. When treating pain combining just a few minutes of manual techniques can be an excellent way to create a well-rounded approach to the patient’s symptoms. Please comment with your favourite manual therapy techniques to use on patients!

Information in the above contains statements related to the below:
Bron, Carel et al. “Treatment of Myofascial Trigger Points in Patients with Chronic Shoulder Pain: A Randomized, Controlled Trial.” BMC Medicine 9 (2011): 8. PMC. Web. 29 Mar. 2018.
https://www.jiscs.com/Article.aspx?a=11
Hindle, Kayla B. et al. “Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function.” Journal of Human Kinetics 31 (2012): 105–113. PMC. Web. 13 Apr. 2018.

 

 

When we think of treating shoulder, elbow, and hand pain, many practitioners do not often consider Brachialis, however it can be a very effective trigger point to treat. Considered a prime mover for elbow flexion, brachialis lays under the more commonly thought of biceps brachii. Brachialis originates from the lower half of the humerus (anterior aspect) and travels over the cubital fossa to attach to the coranoid process of the ulna and the ulnar tuberosity.  The trigger points in brachialis can be easily palpated and well accessed with acupuncture needles.

The common trigger points of brachialis are palpated when the patient is supine

Brachialis Trigger Pointd

with passive elbow flexion and the forearm is pronated. Palpate the bicep tendon and then travel superior and lateral to the bicep (essentially underneath) to note the taut bands of brachialis. When learning to find these trigger points, it is important to differentiate the biceps from brachialis. This can be easily done by manual muscle testing. While both muscles perform elbow flexion, the biceps also perform supination and shoulder flexion. If resisted supination is performed, the brachialis will not contract but the biceps will. This simple maneuver can help assure muscle identification between the two.

Once the practitioner has palpated the trigger points, needling the brachialis can be performed. My preferred method is to isolate the muscle between two fingers (compressing muscle and spreading skin), then insert the needle as shown in our YouTube video. The depth of insertion varies based on patient body habitus. To consider how much twitch may be needed see last week’s post!

Looking at the trigger point patterns, brachialis has referrals to the shoulder, elbow and hand, similar to that of biceps. The taut bands of brachialis can often be even more pronounced than biceps trigger points. More interesting is to consider what kind of patients may have certain active trigger points vs those that are present in others. For example, the athlete that performs a great deal of pulling motions (crossfit, gymnasts, grappling) is a definite candidate for the brachialis trigger points, as is the body builder. Occupational hazards may be landscapers or mail carriers as they both often work with prolonged elbow flexion. The only function of Brachialis is elbow flexion, so any activity that is reliant on sustained elbow flexion can create these trigger points.

Simple home care methods can include self massage and stretching. One of the most efficient methods  to perform self massage on brachialis is with a lacrosse ball (or I very much love “Rock Balls”). The patient can place the ball between the wall and their brachialis and apply tolerable pressure to the trigger point. When instructing patients on how to do this, I recommend demonstration and observation to make sure it can be performed correctly in a pain free manner. There are also several ways to stretch the brachilias (see photo below for two ways) depending on the mobility level of the patient. A combination of home care and Trigger Point Acupuncture can be very effective at dealing with Brachialis trigger points.

 

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The preceding is for educational purposes only and is not intended to treat or diagnose any disease. Trigger point needling should only be performed by those with adequate training and license to do so. The author is not responsible for your actions.

 

 

 

 

 

 

When we teach our courses one of the most common questions is about intensity of needling. Specifically, how much mechanical irritation is needed to relieve a trigger point. This is, of course, a loaded question. There is a great deal of research that is done to try to answer this. Research will also examine whether or not a twitch response is necessary for pain relief. However, in practice the amount of twitch response varies quite a bit not only from patient to patient, but often from location of the body.

The upper trapezius is an very common area to illicit a large twitch response multiple times. Depending on the severity of the patient’s pain level and their comfort Upper Trap Needlingwith trigger point needling, the amount of stimulation can greatly differ. If the patient is coming in after an MVA for example, less may very well be more. If the patient is a high-level athlete they may do better with a higher level of stimulation. This can only be assessed after building a relationship with the patient.

So how much stimulation should I use?

If it is the first time a patient is receiving trigger point acupuncture, I highly recommend starting with low to moderate levels of stimulation. It is very easy to increase the treatment intensity the second visit, but it is impossible to take back treatment intensity after the fact. Proper communication the patient can really help determine the treatment intensity. This does differ from the TCM tonification/sedation methods. We always have patients report back on how they felt afterwards and there are two questions that are key:

1.How long were you sore?

2.How long did you have a decrease in pain?

How long were you sore?

                Soreness is common after trigger point needling. Soreness is not pain! The soreness associated with trigger point needling should be likened to that of post work out. If a patient notes an increase in pain or lasting pain, then decreasing mechanical stimulation or utilizing more superficial fascial needling may be indicated. Manual therapy can also greatly help patients that have an increase in pain from needling.

How long did you have a decrease in pain?

                This question serves two purposes, and one of those is to see if an increase in stimulation is indicated. If the patient noted little to no soreness and only a brief or no relief, increasing stimulation can be indicated. This question can also can indicate treatment frequency for the patient. It is very common to have trigger point needling patients come in for shorter intervals at the beginning such as twice a week for two to four weeks depending on condition or whether or not they are seeking care with other providers.

One of the other major concepts to get across to patients is that less can be more. While we are going for a twitch response we don’t want the patient to be in pain. More often than not, a twitch response isn’t particularly painful, it is just a new sensation. If the patient is associating pain with a particular trigger point being needled it shouldn’t necessarily be a grin and bare it situation. That is why communication is key. In my opinion, communication during the needling process of trigger points is more interactive than that of needling acupuncture points with therapeutic properties. If we can communicate goals of needling with the patient, then needling intensity can be better attained creating more positive treatment outcomes.

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