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Medical Ethics Deep Dry Needling of the Shoulder CAREL BRON, JO L.M. FRANSSEN, BETTY T.M. BEERSMA ABSTRACT Illustration and needling instructions of Dry Needling techniques for the following shoulder muscles are provided: This illustrated Dry Needling online course covers: The clinical relevance of myofascial trigger points in shoulder pain syndromes, shoulder pain and movement dysfunction, trigger points and range of motion (ROM) restrictions and trigger points. Supraspinatus muscle Pectoralis minor muscle Infraspinatus muscle Pectoralis major muscle Teres minor muscle Latissimus dorsi muscle Subscapularis muscle Biceps brachii muscle long head Deltoid muscle Triceps brachii muscle long head Teres major muscle Subclavius muscle 1. INTRODUCTION Women are slightly more affected than men and Shoulder pain, shoulder complaints and the frequency of shoulder pain peaks between shoulder disorders are frequently used terms 46 and 64 years of age (Van der Windt et al. and appear synonymous. It is clear from the 1995). definitions that there is a certain overlap between these terms. In this chapter, we will Shoulder pain tends to be persistent or use the term shoulder pain. recurrent despite medical treatment (Ginn & Cohen 2004). The pathophysiological Shoulder pain is a very common mechanisms are poorly understood in spite of a musculoskeletal disorder. In primary care, the growing body of knowledge of shoulder yearly incidence is estimated to be 14.2 per kinematics, shoulder injury mechanisms, and 1000 people. The 1-year prevalence in the the technical improvement of medical imaging, general population is estimated to be 20–50%. including sonography, magnetic resonance The estimates are strongly influenced by the imaging or more conventional techniques such definition of shoulder disorders, including or as X-rays. Most shoulder pains are caused by a excluding criteria, including limited motion, age, small number of relatively common conditions. gender, and anatomical areas. Thus, shoulder pain is widespread and imposes a considerable Although subacromial impingement is often burden on the affected person and on society. suggested to be the most common potential 1 Deep Dry Needling of the Shoulder source of shoulder pain (Neer 1972, Hawkins & diagnosis of shoulder impingement. A recent Hobeika 1983), solid evidence is lacking (Bron study of elite swimmers with shoulder pain 2008). This syndrome includes tendonitis or showed similar findings (Hidalgo-Lozano et al. tendinopathy of the rotator cuff and the long 2011a). head of the biceps brachii muscle, or subacromial or sub-deltoid bursitis. In fact, In an older study, Sola et al. (1955) concluded calcifications, acromion spurs, subacromial fluid, that the supraspinatus muscle was one of the or signs of tendon degeneration are equally least frequently involved shoulder girdle muscles prevalent in healthy subjects and in individuals both in patients and in young healthy adults. with shoulder pain (Milgrom et al. 1995). The supraspinatus muscle is rarely involved by Furthermore, physical examination tests of itself, but usually appears in association with the subacromial impingement are not reliable infraspinatus or upper trapezius muscles (Bron (Hegedus et al. 2007), and the results of et al. 2011b) or the subscapularis muscle imaging diagnostics do not correlate well with (Hidalgo-Lozano et al. 2010), which very pain (Bradley et al. 2005). In addition, commonly harbor TrPs in patients with shoulder interventions targeting subacromial problems pain and dysfunction. In addition, other are, at best, only moderately effective at muscles, such as the levator scapulae, biceps treating patients with shoulder complaints brachii, deltoid, pectoralis minor, and pectoralis (Coghlan et al. 2008, Buchbinder et al. 2009, major, scalene, latissimus dorsi, teres major Dorrestijn et al. 2009). Other less common and minor muscles may also be involved in causes of shoulder pain are tumours, infections, shoulder pain. In fact, two studies demonstrated and nerve related injuries. that TrPs in the latissimus dorsi and pectoralis major muscles reproduced axillary arm pain in 2. CLINICAL RELEVANCE OF MYOFASCIAL women with breast cancer who had undergone TRIGGER POINTS (TRPS) IN SHOULDER PAIN SYNDROMES mastectomies (Fernández-Lao et al. 2010, Torres-Lacomba et al. 2010). Myofascial trigger points (TrPs) in patients with shoulder pain are most prevalent in the Studies investigating the effect of TrP therapy in infraspinatus, upper trapezius and deltoid patients with shoulder pain are sparse. muscles and most of the time, multiple TrPs in Recently, two randomized controlled trials more than one muscle are involved (Hsieh et al. showed promising results of manual TrP therapy 2007, Ge et al. 2008, Bron et al. 2011b). Ingber in patients with shoulder pain (Hains et al. (2000) successfully treated the subscapularis 2010, Bron et al. 2011a). More studies are in muscle, which was thought to be the main cause progress (Perez-Palomares et al. 2009). A of shoulder pain in three overhead athletes. multiple case study supported the idea that TrP Hidalgo-Lozano et al. (2010) found that the dry needling may be effective in reducing muscles most affected by active TrPs were the shoulder pain and improving shoulder supraspinatus, infraspinatus and subscapularis functioning in elite female volleyball players in patients with shoulder pain with a medical (Osborne & Gatt 2010). One study investigated 2 Deep Dry Needling of the Shoulder the effects of TrP dry needling in patients with may also cause muscle inhibition and post-stroke shoulder pain and reported that disturbances of motor activation patterns. In patients in the intervention group reduced their fact, Lucas et al. (2010) demonstrated that even analgesic medication use, improved their sleep latent TrPs disturb motor activation patterns. and mood, and more effectively prepared them for their rehabilitation program than those in the 2.2 TRIGGER POINTS (TRPS) AND RANGE OF MOTION (ROM) RESTRICTIONS control group (DiLorenzo 2004). Finally, a case Adhesive capsulitis, also referred to as primary series of patients with a diagnosis of shoulder frozen shoulder, is the most common cause of impingement found that inactivation of TrPs in severely restricted shoulder joint mobility. the shoulder musculature decreased shoulder Based on clinical experience of the authors of pain and sensitization (Hidalgo-Lozano et al. this chapter, inactivation of TrP in shoulder 2011b) muscles, particularly the subscapularis muscle, frequently reduces patients’ symptoms, 2.1 SHOULDER PAIN AND MOVEMENT DYSFUNCTION including pain and restricted mobility, which Shoulder pain and disturbed movement patterns may lead to an early and proper recovery within are closely related. A disturbed movement weeks. However, there is no scientific evidence pattern of the scapular musculature, such as the from the literature to support this clinical upper or lower trapezius, and anterior serratus experience. In a multiple case study of five muscles may cause subacromial impingement patients with primary frozen shoulders, all and deep shoulder pain (Cools et al. 2003, patients improved after a subscapular nerve Kibler 2006). block and subscapularis muscle injections (Jankovic & van Zundert 2006). On the other hand there is evidence that muscle pain can create a different motor activation 2.3 TRIGGER POINTS (TRPS) AND STABILITY Another enigmatic shoulder disorder is referred to pattern. Falla et al. (2007) demonstrated that as minor, subtle, occult or functional instability, an injection with hypertonic saline reduced the which is often associated with shoulder pain and electromyographic (EMG) activity in the painful diagnosed as secondary shoulder impingement. (injected) muscle and led to hyperactivity of the Patients with this disorder complain of a feeling of muscles in the ipsi and contralateral shoulder. instability in the absence of true instability, con- firmed by physical examination tests such as the These findings are consistent with the pain apprehension test. Although not mentioned in the adaptation model of Lund et al. (1991), which literature, these patients often respond well to dry maintains that muscle pain causes a decrease of needling of the adductor muscles of the shoulder, EMG activity in the agonist muscle, while it including the teres major, latissimus dorsi, and causes an increase of EMG activity in the subscapularis muscles. antagonists, finally leading to motor control changes. As active TrPs cause muscle pain, they 3 Deep Dry Needling of the Shoulder longitudinal to the frontal plane or 3. DRY NEEDLING OF THE SHOULDER slightly posterior towards the base of MUSCLES the supraspinous fossa. 3.1 SUPRASPINATUS MUSCLE Precautions: The apex of the lung is in front of the scapula and clinicians Anatomy: The muscle originates from should avoid needling in a ventral the supraspinous fossa of the scapula direction. and inserts at the superior facet of the greater tubercle of the humerus.* Function: It assists in abduction and stabilizes the humeral head together with the other rotator cuff muscles during all movements of the shoulder. The muscle prevents caudal dislocation during carrying of heavy loads, such as bags and suitcases. Innervation: Suprascapular nerve, from the C5 and C6 nerve roots. Figure 1: Dry needling of the supraspinatus muscle in prone. Referred pain: It is projected to the mid-deltoid region, often extending 3.2 INFRASPINATUS MUSCLE down the lateral aspect of the arm and
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