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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!

If you enjoyed this post please subscribe! And remember the above is for educational purposes only. Online reading and videos are not a substitute for in person training by a qualified professional. The author is not responsible for your actions should you use anything in the above article.

 

 

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.

 

 

False Grip Gymnastics Rings

I work with CrossFit enthusiasts regularly to help them improve specific gymnastic skills

 

As a hand balancing instructor, I work with CrossFit enthusiasts regularly to help them improve specific gymnastic skills. As a Bellevue acupuncturist, I see CrossFit enthusiasts with injuries some avoidable, some not.   Regardless of my relationship with the athlete, I’ve learned they enjoy taking their health and fitness seriously and want to reach their full potential. To help do that, I have compiled my top 3 tips for the Crossfit athlete.

Prehab– CrossFit can be very hard on the shoulders. In order to continue to train injury and pain free, consider a prehab routine. In the case of Crossfit, strengthening the core, rotator cuff and periscapular muscles should be considered.  Check out the video to see some great exercises that can help keep shoulders healthy and prepared for the stress that a good WOD can put on them.

Periodization– Creating a cycle of intensity in your exercise program helps achieve goals and improve the overall quality of said program. This is especially true if you compete in any CrossFit competitions, but works great for every CrossFit enthusiast. If you look at any professional athlete’s training program you will clearly see periodization.  It is an annual plan to layout goals, how to achieve them, and how to do so without getting avoidably injured. It is not written in stone and can be modified to meet an athlete’s individual needs. If you take baseball as an example, these athletes have a clear off season. This does not mean they sit on the couch and eat chips though. The professional athlete will utilize the off season to work on specific skills and to maintain overall health. During spring training season, they take sport specific time to get ready for serious competition. As spring training comes to the end, official season begins. This is when there is constant training and a high level competition occurring. This shows a clear annual training plan for these athletes and it keeps them at their best.  So how would this look for a CrossFit competitor?

If we break down skills of CrossFit into three aspects; gymnastics skills, weight lifting, and high intensity cardio, then periodization will be easier to implement. Most CrossFitters I work with tend to have a preference for a specific area, which from a competitors stand point can come back to bite them. Having a planned approach can all skills will be addressed to be well rounded. A good plan can also prepare the athlete for a competition. For example, take a certain competition, say the CrossFit Open, and make it the main event of the year. Planning that time to be a physical peak would be great to focus on. Divide the rest of the year into cycles where skills are focused on in divided sections. An example is to focus on gymnastic skills such as muscle ups and handstand walks for a few weeks, then switch to a focus on weight lifting for a few weeks followed by cardio skills (i.e. double unders). When working on specific skills, it doesn’t mean that is the only thing you do during this time, just that these skills will be the focus. Continue to rotate these during your off season. Perhaps two months before the Open, enter your own “spring training” where you begin to combine the skills you work on in a way that directly mimics how the Open competition will be. This is a good time to even check out other local competitions or encourage your gym to have an in-house competition. As the Open gets closer (about a week before,) taper the workouts down and take some rest days. The skills have been trained, mimicking of real life challenge has been performed, so taking some time to ease off will be very beneficial. Rest, prevent injuries, and prepare mentally. This will allow you to enter the Open fresh, trained and ready to PR!

Recovery– I could probably write an entire book on recovery, but some important aspects to ensuring an adequate recovery are:

Stretch– All too often people want to get in and get out with a workout. They will slam out a new personal record on the WOD, then get out of the gym to get on with their day. Taking just a few minutes to work on flexibility will not only help with recovery, but improve one’s overall skill level.

Sleep– Something people often neglect is rest. The body needs adequate sleep to work on recovery. When we sleep, we enter a parasympathetic state (rest and digest). The body gets a chance to relax and focus on repairing the day’s work. Personally, before sleeping is when I like to take my herbs and supplements tailored to recovery. I tend to think of sleep as my time to prepare so that tomorrow’s work out can be even better than today’s.

Nutrition– The best way to ensure the body recovers, is to make sure it is adequately nourished. This can be accomplished with a combination of good whole foods and quality supplementation. If you look back at our blog about supplements for athletes, it will give you a small intro into recovery supplementation. As far as diet goes, one simple tip is to be sure to get protein within 30 minutes after a workout. Protein is the building block for muscles. Feed the body protein and it will get to work on healing everything that is torn down during a workout.

Health Team– There is a reason they are called health care professionals. Take the time to have a team that is familiar with your health goals. This can be a Naturopath focusing in the nutritional aspects, an acupuncturist that focuses on sports (like the one’s at Pins and Needles!) helping manage pain and keeping muscles healthy, and a massage therapist to keep the kinks out.

 

Implementing these three tips into your life can really help improve athletic ability within CrossFit. Be sure to take the time to speak with professionals (health care and coaches) to reach your specific goals. If you have specific questions please feel free to leave a comment or contact us! And don’t forget to subscribe to our blog for more great tips!

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