Abdominal Muscles and Back Pain

Abdominal trigger points can refer to the low back

Many people are aware that the abdominal muscles have something to do with back pain and this awareness is centered around 'core' support and the role of these abdominal muscles in back support. While this is certainly the case, my patients are less aware that the abdominal muscles can be directly tied to the back pain they experience. The rectus abdominis specifically can harbor trigger points, or sensitive contractile knots, that can cause pain not necessarily in the abdomen, but can instead refer pain to the back.

Regardless if you have a developed rectus abdominis or not, this is the muscle that people refer to when the discuss a 'six pack' ab. Technically, there are four grouping of muscles on either side, and each of these compartment are bordered by a tendinous intersection. The upper compartment is lies over the lower ribcage and this compartment is less visible when people do have 'six pack abs', so you are really seeing the lower three compartments on either side.

The rectus abdominis attaches from the pubic bone to the lower ribcage and sternum. The muscle is involved with flexion of the trunk, forced exhale and compression of the abdominal organs.

While it is actively involved in forced expiration or exhale, when the muscle becomes rigid and restricted, it can reduce the ability to take a good, deep inhale and this is most frequently the case when this muscle becomes a component of low back pain.

There is a characteristic referral pattern when this muscle is contributing to back pain which can be seen on the image to the right. The low back portion of the refer specifically usually is associated with trigger points in the umbilical region, in my opinion, and they can frequently even occur in the tendinous intersection in this region. This image to the right shows and X at the pubic bone attachment which can also occur, but I still find this occurs more frequently at the umbilical region. The mid back pain referral is more often at the region just below the lower ribcage and close to the xiphoid process which is the lowest part of the sternum or breastbone.

Many people with low back pain will look at the referral that travels across the low back/upper pelvic region and say, 'That describes my back pain!" It could be the case, then that the rectus abdominis is a contributor. It is the case, thought, that there are other frequently causes of this horizontal distribution of low back pain. Specifically, the joints of the lower spine, referred to as facet joints, can become irritated and cause a similar pain distribution. Below is and image that illustrates this referral pattern and you can see that there is some overlap.

It can be a combination of causes, all contributing to the pain that brings people in to see me. Palpation can be used to see if this muscle is referring pain, but there are also other clues. Urinary problems, digestive disturbances, and dysmenorrhea (painful periods) can all be associated with trigger points in the rectus abdominis. Clinically, it is worth investigating if this important muscle is contributing to the back pain and other problems, and then adding protocols to treat it into the mix. Acupuncture, dry needling, manual therapy and specific corrective exercises are all helpful and tools I use for this trigger points in this muscle and for back pain in general.

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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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Muscles of Mastication

Muscles of Mastication (Chewing) and Their Relationship to TMJ Disorder, Headaches, and Sinus Pain

There are three muscles of mastication (chewing) which can be involved with a host of symptoms. Most notably, these muscles are often involved with TMJ disorder (also referred to as temporomandibular joint disorder, or TMD), but also can be a strong contributing factor to headaches, tooth pain and sensitivity, and sinus pain. In the case of tooth pain and sinus pain, painful trigger points in these muscles can often go undiagnosed and can lead to unnecessary dental or sinus surgery, as the muscles are rarely considered with pain in the teeth or sinuses. In the majority of the cases of dysfunction, patients present with a head forward posture (discussed in a previous blog post) and this should be addressed for long term relief of pain associated with these muscles.

Acupuncture/Traditional Chinese Medicine is one of the best treatments for a host of problems that derive from dysfunction in one or several of these muscles. It can directly target the site of pain and dysfunction while also examining why these muscles are dysfunctional. Beyond that, it can add a different perspective for problems that cause a host of problems for patients.

Fig. 1: The Masseter muscle and commonly used acupuncture points
used to treat pain and dysfunction with this muscle.

The masseter muscle is one of these muscles of the jaw.  The masseter consists of a superficial and deep layer. Both can be palpated (pressed) directly and both are easily accessible with an acupuncture needle (Fig. 1). Trigger points frequently form in this muscle, and they can refer to the teeth (causing pain that is mistaken for problems with the teeth), the eye (contributing to headaches), the ear (contributing to tinnitus or ear ringing).

Fig 2: Masseter Trigger Points with their pain referral patterns. Image from Travell and Simons'
Myofascial Pain and Dysfunction: The Trigger Point Manual. The red indicates where pain is felt
when hypersensitive nodules or trigger points develop in this muscle.

Fig. 3: Lateral and Medial Pterygoids. Image from
Netter's Atlas of Anatomy

The pterygoids are also jaw muscles and consist of the medial and the lateral pterygoids. These muscles cannot directly be pressed except from inside the mouth. Occasionally I release these muscles by putting on surgical gloves and accessing them in just this way. They can also be reached with an acupuncture needle which, due to its thinness, can reach places that a hand cannot. In this case, the needle does not need to access these muscles through the mouth to reach them but can be inserted on the outside and advanced through spaces between two bones to reach painful trigger points (Fig. 3).

The medial pterygoid refers pain deep to the ear and to the throat. This can interfere with swallowing and contribute to soreness in the throat. This muscle also has an interesting relationship to a muscle called the tensor veli palatini, which, when you yawn or open your mouth, pulls the eustachian tube open and allows drainage and pressure normalization of the middle ear. Tightness of the medial pterygoid can block this function and can be a major contributor to ear stuffiness (barohypoacusis) and can contribute to otitis media.

Fig. 4: Lateral pterygoid TrP referral pattern.
Image from Travell and Simons' Myofascial
Pain and Dysfunction: The Trigger Point Manual

The lateral pterygoids refer pain deep into the maxillary sinus and to the TMJ. Pain in this muscle is frequently a contributing factor to sinus pain and/or TMJ dysfunction.

The final muscle involved with chewing is the temporalis muscle which, as the name implies, is in the temple region. Like the masseter, this muscle can be directly pressed and easily accessed with an acupuncture needle. This muscle frequently contributes to headaches.

Fig 5: Temporalis TrP referral pattern. Image from Travell and Simons' Myofascial
Pain and Dysfunction: The Trigger Point Manual 

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Head Forward Posture

The Head Forward Posture and Health Ramifications

One of the most common postural disparities I see is a head-forward posture. In The Physiology of Joints, Volume III, French surgeon and anatomist Adalbert I. Kapandji states that for every inch the head goes forward it gains an additional ten pounds of weight in terms of strain on the posterior neck and upper back muscles. The average weight of the head is about 4.5-5 kg (10-11 pounds) and, in a balanced posture, it is supported evenly amid the muscles of the neck. With a head-forward posture, this balanced support is disrupted, and the posterior neck and upper back muscles then become increasingly more overloaded (and painful) with every additional degree of head-forward posture. With the head an inch forward (neutral is considered as consisting of the ear aligning over the acromion process which is the highest point of the shoulder) this means that the posterior neck and upper back muscles have to support about 20 pounds of weight all day. At 2 inches forward, this becomes about 30 pounds. With Americans spending more and more time behind the wheel, in front of computer screens, glued to cell phones and tablets, and performing other activities which lend themselves to this already common posture, it is not surprising that we frequently see so many problems attributed to this posture.

The following are common complaints that involve a head-forward posture:

Generalized neck pain and shoulder pain caused from muscle overuse: As stated above, for every inch the head moves forward, it gains an additional 10 pounds of weight in terms of strain on the posterior neck and upper back muscles. What this means is that the muscles of the posterior cervical spine are working overtime, day in and day out, and for a prolonged time. It is just a matter of time before they start to cry out for some attention and that usually comes in the form of aches and pain. Specifically, the upper trapezius, levator scapula, and splenius cervicis are frequent muscular contributors to neck discomfort; they not only produce pain, but reduce range of motion and can contribute to stiffness, including stiffness which makes it difficult to turn the neck. Generally, restriction in the upper trapezius manifests in reduced range of motion and discomfort towards the end of the range of motion when looking in the opposite direction, while restriction in the levator scapula often causes pain when looking to the same direction. However, sometimes all three of these muscles can become spasmed, making it very difficult to turn the neck in any direction without considerable pain.

And it is not just the muscles which are involved with neck pain from a head-forward posture. The strain in the posterior neck from the additional load signals fibroblasts to produce more extracellular matrix to support this area. Fibroblasts are specialized cells that produce the building blocks of fibrous connective tissue, such as collagen fibers and a sticky, syrupy substance called proteoglycans (a protein-carbohydrate based molecular structure). Prolonged strain (such as years of bracing against the extra weight of having the head forward) stimulates production of this extra material which can be easily felt as dense, ropy, fibrous bands in the upper back and neck region. It is the body’s attempt to add more support to a region that has additional demands placed on it. Local massage, acupuncture, or other treatments applied directly to the painful tissue may temporarily help make this dense, stagnant tissue feel better, but the posture as a whole needs to be addressed if there is to be any hope of long-lasting relief.

Cervical facet joint referral patterns.
Image from: Osteoarthritis of the Spine:
The Facet Joints, Gellhorn, A.C. et al
Nature Reviews Rheumatology 9, April 2013

Facet joint syndrome: This involves a degeneration of the vertebral facet joints, which is usually secondary to degeneration of the intervertebral discs. Cervical disc degeneration is usually exaggerated whenever there is long term hypomobility (limited movement) of cervical spine. While the outer part of the intervertebral disc has a blood supply, the inner part does not and requires nutrition and fluids via diffusion from the outside. So, with any limited movement patterns that persist for a long time, the discs suffer. As one of my tai chi instructor states, “Motion is Lotion,” and this is definitely true for the spine. In addition to the discs, the synovial, freely moveable (at least they should be) joints of the spine can become degenerative and lead to pain, which can affect the neck but can also refer to the head and, even more commonly, between the shoulder blades. This is a commonly overlooked source of pain and patients with a head-forward posture are much more predisposed to it.

Facets joints are the synovial joints between adjacent vertebrae. They can become degenerative and painful with osteoarthritis of the spine. In a head forward posture, the upper cervical facets are often in a closed position while the lower facets are in an open unstable position. Both situations can aggravate the joints and lead to referred pain. This image is from Kapandji's Physiology of Joints.

Splenius capitis (close to GB-20) and splenius cervicis
(at extrapoint Bailao) TrP referral patterns.
Image from Travell and Simons' Myofascial Pain and
Dyfunction: A Trigger Point Manual.

Tension headaches: With cervical (neck) flexion and capital (head) extension, the posterior cervical muscles are in a shortened position, especially the muscles referred to as the suboccipitals. These four deep upper cervical muscles are very common causes of referred pain into the head, contributing to tension headaches. With the movement of the head forward, the eyes would be looking toward the ground if not for these muscles tightening to lift the head, placing the occiput into an extended position relative to the top of the cervical spine. Other muscles, such as the upper trapezius, splenius capitis, splenius cervicis, and sternocleidomastoid (SCM) are also negatively impacted and common contributors to tension headaches.

Nerve impingements and entrapments: Since disc health is affected by head-forward posture, it can play a role in spinal nerve impingement. In addition, thoracic outlet syndrome (another type of entrapment of neural structures) is often seen with a head-forward posture. Both of these can radiate pain into the upper extremities and be causes of pain in the arms, elbows, forearms or hands.

Thoracic outlet syndrome involves an entrapment of the brachial plexus, which is the bundle of nerves that exit from the neck and travel to the arms. The brachial plexus can be entrapped as it travels between the anterior and middle scalene muscles (two anterior neck muscles which are shortened in a forward-head posture), between the clavicle and ribcage, and between the pectoralis minor muscle and the ribcage. The head-forward posture is often a contributing factor to all of these, especially as the entire shoulder girdle is involved (more on this in the next post).

Jaw tension: a head-forward posture places the mandible (lower jaw bone) in a position which stresses and tightens the muscles of the jaw. The position of the head places anterior neck muscles such as the suprahyoids and infrahyoids in an overstretched position. These muscles attach to the mandible and pull down on the lower jaw bone. The muscles of mastication (chewing), such as the masseter, reflexively tighten to hold the jaw close. They then develop trigger points which put pressure on the temporomandibular joint (TMJ).

Shoulder and other problems: Part 2 of this post will discuss the relationship of the balance of the cervical spine to the shoulder girdle. Because these are so intimately tied to each other, shoulder dysfunction such as supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus and subscapularis myostrain, and other conditions are often made worse by the strain of a head-forward posture. As we explore the sinew channel relationship described in Chinese medicine, this neck-shoulder girdle relationship will become even more apparent.

Image from Startle as a Paradigm
for Malposture, by Pierce, F. et al
Perceptual and Motor Skills, 1964
A) Patient standing upright
B) Door closes loudly and startles patient. Notice the shortening along the front of the body

In addition to shoulder dysfunction, head-forward posture can contribute to other problems elsewhere in the body. This could become a very complex analysis, so I will not give a complete list. However, I will mention some interesting research that explored hamstring flexibility in relation to the suboccipital muscles (which extend the joint between the occiput and top of the cervical spine). This research measured hamstring flexibility and then split the subjects into two groups. Members of one group performed hamstring stretches; members of the other performed stretching to the suboccipital muscles. Surprisingly, the group that received stretching for the suboccipitals alone had a greater increase in hamstring flexibility (13%) than the group receiving hamstring stretches alone (9%). The reason likely has to do with the high concentration of muscle spindles present in the suboccipital muscles and, due to this, the fact that they have such a strong influence on tone throughout the musculature of the back, especially at the hip joint. Consider what happens when someone is startled, and the typical startle response observed. The firing of the suboccipitals might be reflexively tied to the firing of the hamstrings which assists in extending the hip joint. This, along with the shortening in the front of the body, would effectively protect the vulnerable organs.

For acupuncturists, it is worth reexamining the Urinary Bladder sinew channel and noting that it does bind to the occiput, and, therefore would include the suboccipital muscles. Looking for a head-forward posture and addressing shortened suboccipitals would be a worthwhile strategy, not only when treating local dysfunction, but with any strain pattern affecting the Urinary Bladder sinew channel. Addressing this pattern would help focus the selection of effective points to treat according to the principle of “selecting points above to treat below.”

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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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Trigger Points and Pain

Common Musculoskeletal Pain Patterns and Treating with Trigger Point Dry Needling

In upcoming blog posts, I am going to describe common trigger points (often abbreviated as TrPs), discuss their clinical presentation (when it hurts, during which movements, how patients describe the pain, etc.) and pain patterns (where the pain refers to and is experienced by the patient). My goal is to educate patients on common pain patterns and give a few tips on how to prevent and alleviate this pain.

A trigger point is defined by Drs. Janet Travell, M.D., and David Simons, M.D., as a hyperirritable spot in a skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band (a “taut band” is a tight area in a muscle). The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. This definition is from their excellent two-volume book Myofascial Pain and Dysfunction: The Trigger Point Manual.

Fig.1 Strumming across the fibers of a muscle
to feel taut bands and following it to locate
the TrP. From Travell and Simon's,
Myofascial Pain and Dysfunction

What this definition states is that a TrP in a muscle will be associated with a taut band within this muscle. If TrPs are present in a muscle and you or a practitioner strums across the fiber direction of that muscle, there will be a taut, ropy band that is present. Somewhere within this taut band, usually towards the central belly of the muscle, there will be a palpable nodule which is often exquisitely tender, especially with pressure applied (Fig.1). Usually, a minimal amount of pressure will elicit this discomfort, if indeed it is not actively painful with no pressure. In fact, it might be this active pain that brings a patient in for evaluation.

The interesting thing about TrPs is that they have characteristic referral patterns which are where the patient experiences the pain (Fig. 2), either with pressure on the TrP, or, when very active, without. While this pain is sometimes in the vicinity of the TrP, many times it can be quite a distance away. This makes assessment and diagnosis somewhat tricky.

Fig.2 Gluteus Minimus TrP referral pattern which mimics
pain from neural compression causing sciatica.
This is sometimes referred to as pseudosciatica

Motor dysfunction caused by trigger points often involves how this muscle relates to its opposing muscle group (agonist-antagonist). Many times, the presence of TrPs can cause a muscle to become inhibited and it will not be able to perform its job effectively. This might be the case when this muscle, along with certain movements, also helps stabilize a joint.

The last part of the definition refers to autonomic dysfunction. Some TrPs can cause sweating, goosebumps, they can contribute to digestive disturbances, and can even contribute to positional vertigo.

It is important to note that TrPs appear as a result of muscle dysfunction and are not a precise anatomical aspect of a muscle. What I mean by this is that in a healthy muscle, there will be no signs of TrPs. When a muscle is overloaded due to repetitive use, injury, postural tension, stress, and other reasons, TrPs can form. Many times, these TrPs can then become a chronic cause of pain.

Finally, while TrPs are very common, there are many other sources of orthopedic pain which can also refer. Spinal nerve impingement, vertebral joint syndromes, tendinopathies and many other conditions need to be taken into account whenever evaluating pain experienced by a patient.

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