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Home , Coracobrachialis muscle, Teres minor muscle, Upper limb

The

The shoulder is the upper part of the upper extremity, where our connect with our central axis — the spine and ribcage. The is composed of the and . The shoulder is the gleno-humeral joint.

The is loosely attached to the scapula by the shallow gleno-humeral joint. It is supported and moved by a series of short powerful muscles which have their origin on the scapula. Two larger muscles, and Latissimus dorsi, run from the spine and ribcage, bypassing the scapula to attach to the humerus.

The scapula in turn can move freely over the posterior aspect of the ribcage. It is moved and stabilised by powerful muscles that have their origin on the spine (, Rhomboids, Levator scapulae) and ribcage ( and Serratus anterior).

The clavicle performs the major bracing task, helping keep the shoulder at a useful distance from the midline. It is attached to the scapula at the acromio- clavicular joint and to the sternum at the sterno-clavicular joint.

This combination of a mobile and a scapula that can move into the optimum position gives the humerus enormous flexibility relative to the spine. This helps us get our where we want them so we can feel, manipulate and otherwise interact with the world.

Chinese Medicine Perspective All the meridians cross the shoulder. However, most of the important structures of the shoulder are in the lateral and posterior aspects and are thereby governed by the arm yang meridians - Large Intestine, Sanjiao and Small Intestine. Of the yin meridians, only the most superficial (or least yin), the tai yin meridian of the Lung, plays any significant roll in the shoulder. Palpate your own armpit where the Heart and Pericardium meridians pass and feel how little substance there is there. Notice also that the distance between the Lu and Ht meridians is small relative to that between the LI and SI meridians. Thus the LI, SJ and SI (and to a lesser extent the Lu) are those most involved in shoulder problems.

The author’s perspective on the sinew channels (jinjing) as they cross the shoulder is:

Jingjin Pathway - to /chest

Large Intestine Up lateral intermuscular septum to Deltoid insertion, Deltoid, binds at , Trapezius

Sanjiao Up lateral intermuscular septum (with LI) to lateral tubercle, Supraspinatus, Levator scapula

Small Intestine , Infraspinatus, Teres major and minor, Rhomboids, Serratus posterior superior, contra-lateral Splenius cervicis and capitis

Lung Brachialis and , Coracobrachialis, binds at , Pectoralis minor, subclavius

Pericardium Up medial intermuscular septum to , divides, Subscapularis, Serratus anterior, and Latissimus dorsi, Teres major

Heart Up medial intermuscular septum, Pectoralis major

The arm yang meridians do not seem to have any direct relationship with the organs whose names they bear. They have no points that directly affect those organs, the points that do directly affect them being on other meridians, notably the Bl and St meridians. It is more useful to think of the arm yang meridians as reflecting the yang aspects of the related zang. Therefore, LI meridian relates to yang aspects of Lu SJ “ “ “ “ “ PC SI “ “ “ “ “ Ht

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Points that affect the shoulder The many local points of the shoulder have precise local effects that often depend on precise needling. Choices about direction and depth are particularly important. The anatomy of the target tissue is the main guide. In addition to the meridian points there are several extra points. Even with this many points there are many situations requiring the use of ah shi points. Local points LI15 (Jianyu) Gleno-humeral joint and supraspinatus tendon LI16 (Jugu) Acromio-clavicular joint and supraspinatus SJ 14 (Jianliao) Supraspinatus and infraspinatus tendons SI 9 (Jianzhen) Teres major, Latissimus dorsi SI10 (Naoshu) Infraspinatus SI 11 (Tianzong) Infraspinatus SI 12 (Bingfeng) SI 14 (Jianweishu) Levator scapulae SI 15 (Jianzhongshu) Splenius cervicis SJ 15 (Tianliao) Trapezius Bl 41 (Pohu) Serratus posterior superior Bl 43 (Gohuangshu) Serratus posterior superior Lu 1 (Zhongfu) Pectoralis major and minor

There is little agreement in available texts about the names and locations of extra points around the shoulder. Extra (Jianqian, Taijian, N-UE-11) 1.0 - 1.5 cun anterior to LI 15 below clavicle Gleno-humeral joint Extra (Taijian, Jianshu, N-UE-42) In the hollow below AC jt, lateral to the tip of the coracoid process. Gleno humeral joint Extra (Jianneiling, Jianqian, M-UE-48) With the arm hanging at the side, midway between the end of the anterior axillary crease and LI15 (Jianyu) Anterior deltoid, short head of Biceps, Coracobrachialis Extra (Jubei) 3 cun above anterior axillary fold. Gleno-humeral joint

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Distal points LI 11 (Quchi) The best general point for mechanical shoulder problems Lu 7 (Lieque) Anterior shoulder. Combines well with Lu 2 Lu 5 (Chize) Anterior shoulder pain and qi stagnation Lu 9 (Taiyuan) Bilateral shoulder pain Extra point The most tender point between St 36 and St 38 about two width from the edge of the tibia. Needled and manipulated while patient moves their shoulder around. To increase range of movement of stiff shoulder

Examination of the shoulder A thorough examination of the shoulder is almost always productive

Patient sitting Look: from the front for asymmetry, swelling etc.

Move: Test passive and active resisted movements Passive movements: These test the quality and range of joint movement. You are looking for: • differences between the ranges of movement of the two . Restricted shoulder movement can be caused by tight muscles, contracted or joint capsules, or bony deformity. • an altered quality of the end feel and pain at the end of the (passive) range. In general tight muscles produce little pain at the end of the passive movement and the endfeel is springy. Contracted joint capsules and ligaments, on the other are often painful at the end of range and have a more sudden endfeel. A single reduced range of movement is usually a sign of a trigger point in a muscle that performs the opposite action to the restricted movement. For instance, restricted internal rotation can indicate a trigger point in infraspinatus, a major external rotator.

Several restricted ranges of movement, on the other hand, usually indicate a disorder of the gleno-humeral joint. Active resisted movements - test a muscle’s integrity and strength.

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Pain indicates some sort of inflammation or damage to the musculo tendinous structures responsible for the movement being tested. For instance, painful shoulder abduction can indicate disorder of Supraspinatus, a major abductor. Weakness is more difficult to interpret as it can be caused by neurological phenomena or atrophy from lack of use.

Stand behind patient with one hand on the shoulder and the other holding the arm to move or resist. Test flexion & extension abduction & adduction internal & external rotation Feel: Diagnosis of shoulder dysfunction is greatly aided by the accessibility of all the major structures. By palpating these, suspicions derived from the movement tests can be confirmed and areas of dysfunction that produced no positive movement signs can be uncovered. During the palpation the operator tests each structure with appropriate pressure and the patient reports any tenderness elicited. The operator tries to feel the dysfunction Stand behind patient and examine both sides at once. • sterno - clavicular joint • the clavicle (signs of previous fracture) • coracoid process (mainly as a landmark) • coraco-clavicular ligaments (conoid and trapezoid) • head of the humerus (tenderness - capsule tightness/ inflammation) • pectoralis minor (muscle belly for trigger points) • pectoralis major (muscle belly for trigger points) • coracobrachialis (muscle belly for trigger points) • anterior deltoid (muscle belly for trigger points) • acromion process, acromio-clavicular joint • (for bicipital tendinopathy and as a landmark) • supraspinatus tendon (for tendinopathy) • infraspinatus / teres minor tendons (for tendinopathy) • infraspinatus / bellies (muscle belly for trigger points) • medial to medial scapula border (upper , serratus post. sup.)

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• levator scapula and upper trapezius (muscle belly for trigger points) • subscapularis (muscle belly for trigger points)

Note: If you cannot elicit or aggravate pain in the shoulder region by testing the active and passive movements of the shoulder then the most likely cause of the pain is referred pain from the neck &/or the upper back. Check this by testing neck movements.

On the following page I have reproduced a list of the muscles responsible for the various shoulder movements. Keep a copy in your clinic to assist your examination.

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Muscles of the Shoulder

Movement Primary movers Secondary movers

Flexion Anterior Deltoid Pectoralis major Coracobrachialis Biceps brachialis

Extension Latissimus dorsi Teres minor Teres major Triceps (long head) Posterior deltoid

Abduction Deltoid - middle Deltoid - rest Supraspinatus Serratus anterior

Adduction Pectoralis major Teres major Latissimus dorsi

External Rotation Infraspinatus Posterior deltoid Teres minor

Internal Rotation Subscapularis Anterior deltoid Pectoralis major Latissimus dorsi Teres major

Scapular Elevation Trapezius Rhomboids Levator scapulae

Scapular Depression Latissimus Dorsi Pectoralis minor

Scapular Retraction Rhomboids Trapezius

Scapular Protraction Serratus anterior

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Myofascial Trigger Points The simplest form of somatic dysfunction in the shoulder is the formation of trigger points. All the muscles of the shoulder can be overloaded through sudden unaccustomed use, chronicoveruse, postural strain, and trigger points are a common consequence of overload. Although mild in terms of pathology, trigger points can cause discomfort equal to that from more serious problems. In addition they can be secondary to more serious disorder but still an important source of symptoms.

All trigger points, whether latent or active, will restrict joint movement which can contribute to any of the syndromes described in the following sections. Significant latent trigger points should be found and treated.

Active trigger points will produce characteristic patterns of pain distribution which can be recognised; the diagnosis confirmed when the point is located and successfully treated.

Trigger points in the shoulder are most commonly found in the following muscles – note how many refer pain to the front of the shoulder:

Infraspinatus Refers pain to the front of the shoulder joint Pushing the hand across the back is usually restricted

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Anterior deltoid Refers pain to the front of the shoulder joint

Coraco brachialis Refers pain to the front of the shoulder jt.

Pectoralis minor Refers pain to the front of the shoulder

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Pectoralis major Refers pain to the front of the shoulder

Subscapularis in cases of frozen shoulder – pain behind shoulder

Supraspinatus usually in association with tendinopathy In addition to muscles attaching to the scapula or humerus in the shoulder, several muscles of the trunk refer pain to the shoulder and arm. Chief among these are serratus posterior superior and the scalene muscles.

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Supraspinatus tendinopathy ( disorder)

The rotator cuff is a group of flat tendons which fuse together and surround the front, back, and top of the shoulder joint like a cuff on a shirt sleeve. These tendons are connected individually to short muscles that originate from the scapula. These muscles help rotate the shoulder and help hold the shoulder joint together. Their names and positions in the cuff are: Supraspinatus (superior) Infraspinatus (posterior) Teres minor (posterior) Subscapularis (anterior)

Perhaps the most common presenting shoulder problem is a tendinopathy of the supraspinatus tendon. While there are several different causes, the presentation and the core treatment is similar for most cases.

The tendon of supraspinatus can be squashed or impinged as it passes under the acromion process (or the coraco-acromial ) and it contains a less vascular area near its attachment. Both these weaknesses make it vulnerable to gross and micro trauma in this area. Repeated microtrauma leads to degenerative changes in the tendon (tendinosis) which can result in symptom production (tendinopathy).

Anything that puts pressure on either of these weaknesses can contribute to the deterioration of the tendon. Examples are: Repeated or extreme overhead activity, the shape of the the tunnel that the tendon has to pass through (especially if there are irregularities on the underside of the acromion process), weakness of the scapular stabilizers (allowing humeral head to move forward and upwards), nutritional weakness, reflex changes from the neck, hormonal changes (esp. menopausal).

There are several pathways involved in producing symptoms and a patient can present with one or any combination of the three: 1. Direct trauma of impingement – can be a single episode or from repeated episodes. 2. Calcium salts being deposited in areas of degeneration caused by microtrauma. Can be very acute and last a few days or can present as a chronic condition

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3. The tendon tears, usually in an area of degenerative change caused by repeated microtrauma. The tears can be partial or full thickness. The more degenerative changes that are present, the less serious the impingement or needs to be to tear the tendon.

Signs and symptoms: Patients will usually present with a history of pain of weeks, months or, occasionally, years. The episode may have been triggered by a specific incident. • Pain - over the deltoid area - worse for abduction - possible painful arc between 80 and 120 degrees of active abduction - often worse at night when patient lies on either side. • Weakness – a sign of severity. Resistance testing of the supraspinatus is performed with the arms abducted 90° in the scapular plane (30° anterior to the coronal plane of the body) and internally rotated so that the point toward the floor. The examiner applies a downward force, while the patient attempts to maintain the arms parallel to the floor. Inability to resist the examiner's downward force demonstrates isolated supraspinatus weakness.

• Usually there is a full passive range of movement

• Tenderness over the tendon near its insertion onto the .

Examination: Tenderness over the tendon near its insertion is the most constant feature. Weakness and pain on resisted abduction may also be present. Look for associated dysfunction – this can be the difference between success and failure in treatment. Check the following: • coraco-clavicular ligs • coracobrachialis near the point Jianneiling • pectoralis major • the a-c joint • the neck and upper back

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Treatment • The simple acupuncture treatment is to use a three point combination that has a strong effect on the tendon and muscle. The three points are Jianyu (LI15), Jugu (LI 16) and Bingfeng (SI 12) . The patient lies prone ( down) with the arms hanging off the side of the table or with the hands under the . These positions allow a needle placed in Jianyu (LI 15) to lie alongside the tendon. When in place, the three needles should form a straight line. • Treat any associated dysfunction • Cupping over the tendon can be helpful after the needles have been removed • Techniques of sedation and the choice of appropriate distal points depend on the particulars of the patient’s condition. LI 11 is a common choice.

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Acromio-clavicular sprain / arthritis

The joint can be sprained by falling onto an outstretched arm, pushing the acromion process up and away from the clavicle, from carrying heavy loads on the shoulder or from weight training. The acromio - clavicular ligaments and joint capsule are torn, triggering an acute inflammation. If the sprain is more severe the ligaments between the clavicle and the coracoid process (the conoid and trapezoid ligs.) also become sprained.

Excessive use such as persistent carrying of loads on shoulder, or poorly healed previous trauma can cause the degenerative and inflammatory changes of osteoarthritis. This condition is also common in older women although without an obvious cause. The symptoms can be much the same as in a mild sprain and the local treatment is also similar

Signs and symptoms: Pain - over the distal end of the clavicle worse for passive elevation of the shoulder Extreme tenderness over the acromio-clavicular joint Tenderness above the coracoid process if coraco-clavicular ligs. are damaged

Treatment Bandage or tape to restrict mobility - esp. elevation (sprain only) Acupuncture Ah shi pt. in front or on top of joint (If not too acute). Slide the needle along the groove found under the inferior margins of the anterior acromion and the clavicle. Local pts. Jugu (LI 16) Jianyu (LI 15) Distal pts. Quchi (LI 11)

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Frozen shoulder / Adhesive capsulitis

As the name implies the main symptom of a frozen shoulder is severe restriction of gleno-humeral mobility. It is often painful, particularly in the early stages, at night and when moved forcefully to the end of range. Severely restricted shoulder movement. The patient will hold their arm in a position of internal rotation and adduction. External rotation and abduction are the most restricted movements.

This phenomenon does not occur in any other joint in the body.It affects more women than men usually between ages 40 and 65. Approximately 10% to 20% of diabetics are affected. Other predisposing factors include: - A period of enforced immobility (e.g. after shoulder surgery or a fracture of the arm), hyperthyroidism, cardiovascular disease, clinical depression, Parkinson’s disease. It is not normally associated with calcium deposits or rotator cuff injuries, and often x-rays are completely normal.

The cause of frozen shoulder is unknown, but it probably involves an underlying inflammatory process. The capsule surrounding the shoulder joint thickens and contracts. This leaves less space for the humerus to move around. Adhesions can form between the humeral head and the capsule. Movement is further restricted by tightness of most of the surrounding muscles, especially subscapularis. Usually only one shoulder is affected, although in about one- third of cases, motion may be limited in both arms.

Frozen shoulder develops slowly, and in three stages. • Stage One: The freezing phase - Pain increases with movement and is often worse at night. There is a progressive loss of motion with increasing pain. This stage lasts approximately 2 to 9 months.

• Stage Two: The frozen phase - Pain begins to diminish, and the arm is more comfortable. However, the range of motion is now much more limited, as much as 50 percent less than in the other arm. This stage may last 4 to 12 months.

• Stage Three: The thawing phase - The condition begins to resolve. Most patients experience a gradual restoration of motion over the next 12 to 42 months; surgery may be required to restore motion for some patients

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It is very rare for the disorder to recur. Surprisingly, the non dominant shoulder is affected more than the dominant one

This is a very difficult condition to treat. Acupuncture does offer some improvement and persistent treatment will reduce the duration of the condition. However most will spontaneously recover within 12 months and if progress is slow patients might decide to wait rather than go through an extended treatment program.

Acupuncture treatment A combination of two local points form the core of my frozen shoulder treatment: • Ah shi pt: Needle subscapularis by using a 3 inch needle though the back of the axilla into the belly of the muscle. This is the single best treatment to reduce the ache and to allow a little extra movement. • Jubei (Extra) – 3 cun above the anterior axillary fold. Needle through the fibres of the capsule of the joint – superior to inferior • A series of short insertion/manipulation/withdrawal techniques at the areas of maximum stagnation around the scapula

Distal pts. Quchi (LI 11) + Extra point – tendermost point posterior and inferior to St 36 on the opposite

Treat associated stagnation (see notes on supraspinatus).

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The Elbow

The elbow is the joint between our arm and . The obvious elbow movements are flexion and extension but pronation and supination of the hands are also essentially movements of the elbow joint. Anatomically there is only one joint - there being only one joint capsule and one joint space. Within that joint however, there are three articulations that have distinct functions: humero-ulnar - enables flexion / extension humero-radial - enables flexion extension and supination / pronation radio-ulnar - enables supination / pronation

Fig π. The elbow joint - articulations and landmarks The muscles largely responsible for flexion (biceps brachii and brachialis) and extension (triceps) make up the bulk of the arm and insert just below the elbowon the and . Many of the forearm muscles (the long muscles that flex and extend the and fingers) have their origin on the humerus and also cross the elbow. Many of these share two peculiar muscle origins. The following muscles have at least part of their origin on the lateral epicondyle of the humerus, forming a common extensor origin: extensor carpi radialis brevis extensor digitorum extensor carpi ulnaris supinator Likewise, the following muscles share a common origin on the medial epicondyle : pronator teres flexor carpi radialis palmaris longus part of flexor digitorum superficialis flexor carpi ulnaris

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Tennis Elbow

Tennis elbow is a painful condition affecting the lateral epicondyle of the elbow. Medically it is often termed Lateral Epicondylitis. The tissues most involved are the tendons that converge to form the common extensor origin. These are the tendons of the wrist and extensors and supinator.

Strictly, tennis elbow is a tendinopathy (painful degenerative changes in a tendon) rather than a tendinitis (inflammation in a tendon). Thus the label ‘epicondylitis’ is a misnomer.

It is most commonly caused by small trauma to the tendon, usually a result of overuse. Repeated trauma or failed healing, leads to hemorrhaging and the formation of rough, granulated tissue and calcium deposits within the surrounding tissues. Collagen, a protein, leaks out from around the injured areas. The tendon of Extensor Carpi Radialis Brevis (ECRB) is the most commonly involved.

Women and patients who report symptoms are more likely to experience a poorer short-term outcome. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women.

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It is important to be aware that there are other causes of lateral elbow pain, including referred pain from the neck, the shoulder, and trigger points in ECRL, Supinator and the medial head of triceps. Always check for these.

Signs and symptoms • Pain - on lateral aspect of the elbow - worse with and after use - occurs when holding objects at arms length - opening drawers, pouring tea, opening windows etc. • Tenderness - on or around the lateral epicondyle of the humerus - and/or near tendon of ECRB near LI 10. • There is usually a full range of passive movement

• It commonly occurs between 35 and 50 years.

Treatment

The primary goal of nonsurgical treatment is to revitalize the unhealthy tissue that produces pain. Generally a LI jingjin treatment.

If main tenderness is on the lateral epicondyle: • Thread a needle on either side of the most tender point on the common extensor origin. Get as close as possible to the epicondyle. These two ah shi points can be further reduced with electro-stimulation. • Needle any trigger points in the forearm that might be contributing.

If the main tenderness is over the tendon of ECRB: • The main needle in this case should be inserted across the fibres of this muscle with an oblique insertion at or near Shousanli. This can be combined with another point for electro-stimulation.

• Trigger points in extensor carpi radialis brevis should be treated in addition to any found in the muscles mentioned above.

Distal points: Quchi (LI 11) can be combined with Zusanli (St 36) on the contra- lateral leg. Find most tender points on St from St 35 down.

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Arthritis of the Elbow joint

Trauma to the elbow, often involving a collateral ligament, can damage the capsule and result in an acute arthritis. A long history of percussive overuse such as occurs in the boilermaking trade or in boxing or damage from an acute injury can cause an osteoarthritis of the joint.

Symptoms and signs • Pain - in the elbow - worse for passive flexion and extension - worse after activity or prolonged rest (osteoarthritis) • Limited passive flexion and extension

Treatment • Ah shi pts Small painful pts on the joint line • Local pts - Quchi (LI 11) Shousanli (LI 10) • Distal pt. - Hegu (LI 4) Contralateral leg St 35 down. Or over fibula • Moxa - if chronic.

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The Forearm, Wrist and Hand

The most common problems in this region are predominantly trigger point phenomena. This includes most finger, and wrist pain.

The more serious and difficult problems involve the tendons, retinacula and .

As a general rule look for trigger points in any muscle that has a pain referral zone that matches the patient’s pain pattern and needle any that you judge sufficiently reactive — no matter what the diagnosis. E.g. there will usually be a palmaris longus trigger in most cases of (or carpal tunnel-like) syndrome, brachialis will often have triggers in problems with the thumb tendons.

These triggers can often be needled briefly (30-60 secs) and superficially. Check for effectiveness then look for others in the region and treat again.

The Wrist joint Acute wrist pain is likely to be a result of sporting injury: • Forearm trigger points • Ligament sprain – wrist joint or intercarpal ligs • Lunate dislocation • Fracture of the scaphoid • Tear of the triangular fibro-cartilage

Chronic wrist pain has many causes, all of them uncommon. Use accurate palpation to identify the tissue most involved and your texts to identify the problem. I have found that most wrist disorder responds well to acupuncture treatment, including RA between flare ups • Local points seem to work well: SI 5, SJ 4, LI 5, P7

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Osteoarthritis of the 1st Carpo-metacarpal joint Usually occurs in older people as the result of a long history of overuse. • Needle trigger points in muscles that refer to the area: snuffbox muscles, flexor pollicis longus • Needle ah shi point into capsular fibres on the palmar aspect of the joint • LI 4

Tenosynovitis Tenosynovitis is an inflammation of the lining of the sheath that surrounds a tendon. It can affect any tendon in the body but is possibly most commonly seen in the wrist and hand. In the wrist it is called De Quervain’s tenosynovitis and the affected tendons are the abductor pollicis longus and the extensor pollicis brevis as they pass the .

It is usually considered to be an overuse or cumulative trauma disorder, often associated with keyboard work. Symptoms can last for weeks, months or even years.

S&S Active and passive movements of the thumb are painful Tenderness and swelling over and around the inflamed tendon and tendon sheath. Sometimes the area is warmer or hotter than the surrounding skin. Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist (Finkelstein test)

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Treatment • Needle triggers in appropriate muscles – those with the appropriate reference zones and those of the muscle affected. LI jingjin • Use either local points on either side of the stagnation in the tendon or subcutaneous threading (fine needles) on either side of the tendon. Can use electro if not too sensitive

Stenosing Tenosynovitis (Trigger finger or thumb) This is another variation of tenosynovitis. In this case, the irritation from repetitive friction thickens or dries out the tendon. Nodules can form in the tendon entrance to the tendon sheath, much as thread may bunch with repeated attempts to pass it through a small eye of a needle. The thickened tendon nodule may "pop" in or out of the tunnel. This can be painful. At times, the finger "locks," and it is necessary to straighten the finger with the other hand. When the irregularity becomes too large to pass beneath the pulley or ligament, motion ceases, usually with a locked in a bent position. This can cause a (inability to fully extend or straighten the finger) of the finger.

Dupytren's contracture In this condition, one of the tough fibrous layers of the hand that lies beneath the skin (the palmar ) becomes thickened and contracts and so curls the fingers into the palm. Usually the ring and the are most affected, but any of the fingers and even the thumb can be affected.

The condition is more common in middle aged to elderly men although Margaret Thatcher is a famous sufferer. People who have epilepsy, affected relatives with Dupytren's, chronic lung disease and alcoholics are more likely to suffer from this condition. There is a definite genetic component to the disease and 10% of sufferers have an affected parent/close relative. The condition affects more men than women and people with ancestors from Northern Europe and Scandinavia are at increased risk. You may also get thickening of the knuckle pads and can get a similar condition in the feet and the penis!

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www.monmouth.com/ ~gpess/dupytren.htm

Symptoms Most people only seek help when they notice that they can no longer straighten certain fingers due to a thick tight band in the skin. The condition is fairly late already at this stage. Initially you may see or feel some thick cords or bands in the palm and even pits in the skin. This first stage may even be painful, but this is usually only temporary. The condition normally progresses in most people and the bands tighten to cause more and more deformity of the fingers.

Treatment In early cases a good result is possible. In more long standing cases the best that can be hoped from acupuncture is some increased movement in the affected fingers. • Deep massage around contracture • Ah shi points on either side of contracture. Can be electro-stimulated • Pericardium jingjin. Needle Trigger points in the finger flexors and palmaris longus • P 7 Try points 1 & 2 of the Five Tigers (Tung points)

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Carpal tunnel Syndrome • A combination Pericardium jingjin and main meridian treatment. P8 (needled from dorsum of hand), P. 7 , P 6 and a palmaris longus trigger is the simple core treatment. If any of the attachments of the retinaculum are very tender, they can be needled too. • Treat the neck and upper back if necessary • Distal pts - use Liver or St points near opposite

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