Upper Trapezius Pain and Dysfunction

Upper trapezius trigger point pain pattern

Restriction and pain associated with the upper trapezius muscle is a common finding in my clinical practice and something I address often with patients. Stress, excessive sitting at a computer, and poor core support are but a few of the things that can lead to this muscle forming painful trigger points (hypersensitive nodules that refer pain). The image on the left from Travell and Simon's excellent book, Myofascial Pain and Dysfunction: A Trigger Point Manual, illustrates the common pain referral from this muscle. Many people suffering from chronic neck pain and stiffness and/or muscle tension headaches will likely find this a familiar pain pattern.

Trigger point based acupuncture (trigger point dry needling), trigger point injection, and deep tissue myofascial release techniques are all excellent resources I use to treat this common complain. However, self stretching can be an excellent resource as well and here is a video showing a self stretch I frequently give my patients.

Upper Trapezius Stretch

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Frozen Shoulder and Related Conditions

Supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus myostrain, and subscapularis myostrain can often be diagnosed as Frozen Shoulder.

“Frozen shoulder” is a common diagnosis given for those experiencing shoulder pain, stiffness and a decrease in mobility. True frozen shoulder, which is called adhesive capsulitis, refers to a condition where there is a buildup of scar tissue in the joint capsule of the shoulder. There exist several other conditions which often get called “frozen shoulder,” but those can be more precisely differentiated. The most common of these conditions that I see in clinical practice are: supraspinatus tendinopathy; bicipital tenosynovitis; infraspinatus myostrain; and subscapularis myostrain. Each of these involves different structures, has variation in pain patterns and referrals, and, more importantly, requires a different treatment for a successful outcome.

Frozen shoulder and related conditions affect many people of different ages and they affect both men and women. Those between 40-60 years of age are more frequently afflicted with shoulder problems, and women experience shoulder pain much more frequently than men. 2-5% of the population in this age demographic will experience this problem. There is evidence showing that hormonal changes during menopause are linked to the greater frequency of shoulder pain experienced by women.

These conditions may be caused by trauma or they may come on insidiously, in which case there seems to be no apparent cause, although it’s possible that postural imbalances, age, nutritional deficiencies, changes in hormone levels, diabetes, Parkinson’s and other conditions may be contributing factors. Proper differentiation is crucial when treating so that mechanism of injury can be determined, target tissue can be assessed and treated, postural disparities can be corrected, and proper use of medicinals can be employed (herbals, nutraceuticals, or pharmaceuticals depending on the scope and treatment philosophy of the physician). In Sports Medicine Acupuncture®, this is extremely important as the injury or cause of pain will guide the proper use of acupuncture, myofascial release (a type of clinical, deep tissue massage), corrective exercises, and herbal medicine prescription.

I will discuss the four main causes of shoulder pain and stiffness in future posts and will link these blog posts together. Again, these conditions are:

• Supraspinatus tendinopathy – an inflammation or irritation with fibrosis (extra fibrous tissue) of the tendon of the supraspinatus (one of the rotator cuff muscles). Tearing (either partial or full) may be present;
• Bicipital tenosynovitis - an inflammation or irritation with fibrosis of the tendon sheath of the biceps brachii muscle;
• Supscapularis myostrain - a pain pattern caused by trigger points affecting the subscapularis muscle (another of the rotator cuff muscles);
• Infraspinatus myostrain - a pain pattern caused by trigger points affecting the infraspinatus muscle (yet another of the rotator cuff muscles).

For all of these conditions, mechanism of injury will be discussed (mechanism of injury describes the underlying causes of the injury), treatment options will be explored, and self-help corrective exercises will be discussed.

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The Four Pillars of Chinese Medicine

Acupuncture is Just One Pillar of Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is a comprehensive medical system from China. While many people are aware of acupuncture, TCM actually incorporates four major avenues or treatment. These are known as “the four pillars” of TCM, and they are: acupuncture; Chinese herbal medicine and dietary therapy; Tuina, which incorporates medical massage and manipulation; and exercise and movement therapy. Your trained Doctor of Oriental Medicine will evaluate your case and prescribe one or several of these treatments depending on what is needed.

Acupuncture involves the use of very thin, single-use, sterilized needles inserted in various locations to regulate body processes. In the West, acupuncture is most often used for pain relief, for which it is very effective. But this is not the full scope of comprehensive acupuncture treatment; it is actually appropriate in a wide range of illnesses.

Chinese herbal medicine is based on a vast array of medicinal formulas, which are therapeutically balanced combinations of herbs used to treat patterns of medical disharmony. TCM looks for clinical signs and symptoms of these patterns and then prescribe specific herbal medicinal formulas to treat these patterns. TCM pattern differentiation and treatment with herbal Medicinals can offer a safe and effective natural treatment for illness or can complement your treatment prescribed by your Western MD, in some cases possibly enabling your Western pharmaceutical prescription to be reduced or helping deal with side effects.

In addition to the prescription of herbal Medicinals, dietary recommendations can also be used as part of the treatment. This can include general assistance with weight loss or maintenance, or specific food choices and preparations designed to help you manage an existing condition.

Tuina is a Chinese system of clinical massage and joint mobilization. Tuina is derived from two words; tui meaning to “to push” and na meaning “to lift and squeeze”. Tuina uses light, moderate, or deep pressure to mobilize the body’s structures and joints and restore normal movement. It is primarily used for musculoskeletal conditions, but it can also be employed for other condition such as respiratory or digestive problems. Generally, Tiuna focuses on particular regions such as the neck, back, legs, etc., and resembles more clinical styles of Western deep tissue massage therapy. Click here to see a previous post about Tiuna.

Finally, Therapeutic Exercises are often prescribed in China to help treat illness and to maintain and improve health. In particular, tai chi (Taiji) and qigong are therapeutic forms of exercise that improve flexibility, circulation and general wellbeing.

When looking for a practitioner of Traditional Chinese Medicine, it is important to understand that many practitioners focus mostly on one or maybe two of these ‘pillars’ listed above, usually based on a practitioner’s specialization. Practitioners focusing on internal medicine might use herbs more extensively while those treating musculoskeletal pain might be inclined to use Tiuna more. In my clinical practice, I specialize in the treatment of sports injuries and orthopedic pain conditions. So, I primarily focus on acupuncture, Tiuna, and corrective exercises to facilitate rehabilitation from injury, and to correct muscle imbalances that contribute to pain conditions. When I prescribe herbal medicine, it is usually a formula (balanced combinations of herbs) to help with the particular pain or injury. Such herbal formulas may help with trauma; they may address how the body deals with inflammation, or they may regulate the nervous system to reduce over-contraction and tightness in the muscles. The herbs basically support the treatment, while the acupuncture, Tiuna and therapeutic exercise prescription specifically target the region of pain and return normal movement to the body.

Another practitioner who specializes in internal medicine might rely much more on herbs, and their acupuncture treatment might be more supplemental. It is important for patients to know what to look for when seeking a practitioner, as not all have equal training and not all have experience that will make them effective in treating all medical problems.

Most TCM practitioners do use these four pillars, but there is no need to be dogmatic about using only techniques that originated in historical China. If a modern or Western-developed treatment protocol is appropriate and compatible with TCM principles, it can be integrated into a Four Pillars-based treatment plan. For instance, to reduce inflammation, I might prescribe a classical herbal formula, but I might also prescribe fish oil supplementation. Also, I frequently use manual massage techniques and mobilization of joints, but much of my training comes from Western bodywork systems such as myofascial release and structural integration (I am certified in both of these via the CORE Institute). On an even deeper level, my acupuncture treatments rely heavily on Western anatomy and Sports Medicine principles. These techniques are taught in AcuSport Seminar Series and the Sports Medicine Acupuncture Certification Program, on whose faculty I serve. My point is that as Chinese medicine becomes more global, it can include insight from many other viewpoints, especially Western medicine, but the heart of the medicine will continue to focus on these four basic pillars of treatment which are designed to return the body to a balanced state of health.

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Dry Needling and Acupuncture

Is Acupunture Dry Needling?

I often get asked if I do dry needling. Many acupuncturists become defensive when asked this, and there is currently some contention in the fields of acupuncture and physical therapy, as PTs either have it in their scope of practice to do dry needling (in some states) or are trying to get it added to their scope (in other states, such as Florida). Many acupuncturists feel that dry needling is just another name for acupuncture and that PTs are trying to add acupuncture to their scope.

So, what is dry needling and why is there any controversy? First off, I want to state that this blog post is not intended to state any profession opinion or get into the politics. Instead, I am going to discuss the technique, goals, and give a brief history of dry needling.

Dry needling as a technique and name grew out of work primarily from Dr. Janet Travell, MD. Dr. Travell, along with her colleague, Dr. David Simons, MD wrote a very influential two-volume book in the field of pain management called Myofascial Pain and Dysfunction: The Trigger Point Manual. In this book, they discussed trigger points (TrPs) which are defined as hypersensitive spots found in taut bands of muscle (click to read more about TrPs). When palpating muscles that are dysfunctional, there are notable taut bands. Following these taut bands, physicians might find a hypersensitive nodule, often in the belly of the muscle along these taut bands. Pressing these yields hypersensitivity and often a characteristic referral pattern is noted, many times quite a distance from the location of the TrP. These two volume books gave a detailed description of the palpation, signs and symptoms, and pain referral zones of these TrPs for each muscle in the body.

In addition to clinical information regarding locating and diagnosing these TrPs, these books also discussed treatment. Many protocols were discussed, but TrP injections were primary treatments outlined in these books. It became increasingly understood that the mechanism that was at play with TrP injections was the mechanical stimulation from the needle. Most often what was injected were substances such as lidocaine which served the purpose of reducing sensation as a relatively thick hypodermic needle probed into a hypersensitive TrP. Dr. Travell did discuss dry needling, differentiating between using a hypodermic needle to inject a substance versus using a hypodermic needle without injecting a substance (which was, therefore, 'dry needling'). Over time, especially as acupuncture was becoming more popular in America, other practitioners determined that the use of a thinner solid filiform acupuncture needle could serve the same purpose.

Actually, in the history of acupuncture in China these same techniques were discussed, and the Chinese referred to these hypersensitive nodules as Ashi points. Ashi means something along the lines of ‘That’s it’. Imagine a physician palpating for the source of a patient’s pain and the patient proclaims ‘Ashi’. The needle technique involves with needling Ashi points is extremely similar to those described in TrP injection and dry needling circles. Notably this involves locating the hypersensitive nodule, inserting a needle, bringing the needle back to the subcutaneous layer and redirecting the needle. Imagine a needle pointing to numbers on a clock and, from the same point, the needle touches 12, 1, 2, 3, etc. This describes the lifting and thrusting technique discussed in the classics of Chinese medicine. When doing these techniques, there is a characteristic muscle twitch or fasciculation that is achieved as the TrP is being deactivated.

This technique can be extremely effective in reducing pain associated with TrPs which is a very common source of pain. Increasingly, TrPs are being understood to be a major contributor to pain. Needling TrPs with an acupuncture needle is one of the most effective tools to treat these. I feel that acupuncturists are best suited to treat TrPs, as we have the greatest amount of training with needle technique, and we have the greatest ability to incorporate this technique into a balanced acupuncture session. However, while all acupuncturists have had some training on needling sensitive points, those who have undergone more continuous training with emphasis on a detailed understanding of anatomy and palpation are going to yield the greatest results. While not all acupuncturists have this understanding, there is growing movement within acupuncture circles to incorporate a more detailed understanding of Western anatomy and utilizing a more integrative approach to treating patients.

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