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Dry Needling
Stuart Hinds
Masseter
muscle
Anatomy
The muscle extends from the
inferior aspect of zygomatic
process to the angle and
lateral surface of the
mandible (superficial layer);
the mid portion of the
mandibular ramus (middle
layer); and to the upper
mandibular ramus and the
coronoid process (deep
layer).
Innervation
Reffered Pain
The patient lies in supine. The
muscle is generally needled
with a flat palpation, although
pincer palpation may also be
feasible. The needle is
inserted perpendicular to the
skin toward the muscle belly.
Function
It closes the mouth by elevating
the mandible. The superficial
layer has also a component of
protrusion (forward) of the
mandible whereas the deep layer
has a component of retraction
(backward).
Reffered Pain
The superficial layer refers pain to
the eyebrow, the maxilla, the
anterior aspect of the mandible,
and to the upper or lower molar
teeth; whereas the deep layers
spreads pain deep into the ear
and to the temporomandibular
joint area.
Innervation
None.
Trapezius
muscle:
upper
portion
Anatomy
The superior region
(descending part) of the
muscle arises from the external
occipital protubernance, the
medial third of the superior
nuchal line of the occipital
bone, the ligamentum muchae,
and the spinous process of C7,
and inserts into the posterior
border of the lateral third of
the clavicle.
Innervation
Acessory nerve (XI par
cranial) and cervical spinal
nerves C3-C4.
Needling Technique
The patient is in prone or sidelaying. The muscle is needled with
a pincer palpation. The needle is
inserted perpendicular to the skin
and directed towards the
practitioners finger. The needle is
kept between the fingers in the
shoulder. The needle can be
inserted from anterior to posterior
or posterior to anterior.
Function
When it contracts unilaterally, it
includes ipsilateral side-bending
and contralateral rotation of the
head and also elevation of the
shoulder. When it contracts
bilaterally, it extends the neck.
Reffered Pain
It spreads ispilaterally
from the posterior-lateral
region of the neck, behind
the ear, and to the
temporal region.
Innervation
The most common serious
adverse event is penetrating
the lung, and producing a
pneumothorax. This is
minimised by needling strictly
between the fingers holding
the muscle in a pincer grasp,
and needling directed
towards the practitioners
Levator
scapulae
muscle
Anatomy
The muscle originates
from the dorsal tubercles
of the transverse
processes of C1 to C4
vertebrae, and inserts on
the superior medial angle
and adjacent medial
border of the scapula.
Function
It extends and side-bends the
neck. When the head is turned to
the opposite side and forward
flexed, it rotates the head towards
midline. The muscle rotates the
scapula glenoid fossa downward
when neck is fixed.
Reffered Pain
Needling Technique
Innervation
Precautions
Sternocleidomastoid
Anatomy
muscle
Function
When it contracts unilaterally, it
side-bends to the same side and
rotates to the opposite side of the
head. It also tilts the chin upward,
i.e., extension of the head. When
it contracts bilaterally, it flexes the
neck against gravity.
Reffered Pain
The sternal division may refer
pain to the vertex, to the occiput,
across the cheek, over the eye, to
the throat, and to the sternum,
whereas the clavicular division
refers pain to the forehead and
deep into the ear, inducing frontal
headache and earache.
Needling Technique
Precautions
Splenius
capitis
muscle
Anatomy
Function
Innervation
Reffered Pain
It is projected to the
vertex of the head.
Needling Technique
Precautions
Cervical
multifidi
muscles
Anatomy
The muscle crosses 2 to 4 vertebral levels. The
superior attachment is the posterior processes of
C2 to C5, whereas the inferior attachment is the
articular processes of C2 to C7 vertebrae.
Function
Reffered Pain
It spreads upward to
the suboccipital
region, and
downward over the
neck and upper part
of the shoulder. Pain
is perceived deep
into the cervical
zygapophyseal joint.
Innervation
Needling Technique
Posterior primary
rami of the cervical
nerves at each level.
Precautions
Avoid needling strictly
medially to minimise
the risk of pentrating
the structures within
the spinal canal
(epidural or
subarachnoid space,
Anatomy
The muscle originates from the supraspinous
fossa of the scapula and inserts at the superior
facet of the greater tubercle of the humerous.
Function
It assists in abduction and stablises 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 Reffered
suitcases.
Pain
Innervation
It is projected to the
mid-deltoid region,
often extending down
the lateral aspect of
Precautions
the arm and forearm,
The apex of the lung is in
sometimes focusing
front of the scapula and
strongly over the
clinicians should avoid
lateral epicondyle of
needling in a ventral
Needling Technique
direction.
elbow.
The patient lies prone or on the uninvolved side with arm closethe
to the
body and
Supraspinatus
muscle
Suprascapular nerve,
from the C5 and C6
nerve roots.
Anatomy
The muscle originates from the infraspinous fossa
of the scapula and inserts at the dorsosuperior
facet of the greater tubercle of the humerous.
Function
It assists in external rotation and stabilises
the humeral head together with the other
rotator cuff muscles and prevents upwards
migration of the humeral head during all
movements.
Infraspinatus
muscle
Innervation
Precautions
Suprascapular nerve,
from C5 and C6 nerve
roots
In osteoporotic patients
fenestration of the scapula has
been reported, which would imply
that clinicians should avoid
needling through the scapula. In
clinical practice, however,
fenestration has not been an
issue.
Reffered Pain
It is projected to the front of the shoulder
(intra-articular pain) and the mid-deltoid
region, extending downwards the arm to
the ventolateral aspect of the arm and
forearm and the radial aspect of the hand.
The referred pain from this muscle can
Needling Technique
Teres
minor
muscle
Anatomy
The muscle originates from the upper one-third of the lateral border
of the dorsal surface of the scapula and inserts on the dorsal facet of
the greater tubercle below the insertion of the infraspinatus muscle.
Function
It has the same function as the infraspinatus muscle,
but can also adduct the upper arm.
Innervation
Precautions
Reffered Pain
Needling Technique
The patient lies prone with the upper arm 90 degrees
abducted. The TrP is usually located by flat palpation just
caudal to the glenohumeral joint. The needle is directed
to the lateral border of the scapula.
Anatomy
Subscapularis
muscle
Function
Reffered Pain
It is projected to the
dorsal aspect of the
shoulder extending to
the dorsal aspect of
the upper arm and
around the wrist.
Innervation
Subscapular nerve
from the C5, C6 and
C7 nerve roots.
Needling Technique
Axillary approach: The patient lies supine with arm 90 degrees
abducted and 90 degrees externally rotated. Bringing the scapula
more laterally will optimise access to the muscle. The needle is
directed parallel to the ribcage perpendicular to the scapula.
Medial approach: The patient lies prone with the arm in internal
rotation and the forearm resting on the back at the lumbar level
(Hamerlock position). The muscle can be needled when patient
lies on the involved shoulder.
Precautions
As the subscapularis
muscle is located
between the ventral
surface of the scapula
and the ribcage, the
needle has to be
directed away from
the ribcage to avoid
entering the
intercostal space.
Deltoid
Muscle
Anatomy
The muscle originates from the lateral third of the clavicle
(ventral part), the entire lateral border of the acromion (middle
part), and the lateral half of the spine of the scapula (posterior
part). The entire muscle inserts on the deltoid tuberosity,
which is a rough triangular area midway the anterolateral
border of the humerus.
Function
Innervation
Precautions
No special precautions.
Reffered Pain
It is locally projected in the region of the affected part
(anterior, middle or posterior) of the muscle.
Needling Technique
The anterior part can be needled in the supine position, the posterior part in prone,
and the middle part can be treated in the prone, supine, or side-laying. In all positions
the upper arm is slightly abducted and supported by a pillow if necessary. The needle
is inserted perpendiculary through the skin directly into the taut band against the
humerus.
Teres major
muscle
Anatomy
The muscle originates from the posterior surface
of the inferior angle of the scapula. The tendon of
the teres major muscle fuses with the tendon of
the latissimus dorsi muscle and inserts to the
medial lip of the bicipital groove.
Function
Reffered Pain
Innervation
Needling Technique
Lower subscapularis
nerve from the C6 and
C7 nerve roots
Precautions
Pectoralis
minor muscle
Anatomy
The muscle originates from the third, fourth and fifth rib near their
costal cartilages and inserts at the coronoid process of the scapula
together with the coracobrachialis muscle and the biceps brachii
brevis.
Function
The muscle protracts and draws the scapula forward, downward and
inward. It also depresses the shoulder girdle and stabilises it against
forceful upward pressure of the arm. Downward force of the pectoralis
minor causes winging of the scapula. When the scapula is fixed by the
trapezius and levator scapulae muscles, the pectoralis minor is and
accessory respiratory muscle.
Innervation
Reffered Pain
Pectoralis
minor muscle
Needling Technique
The patient lies in a supine position. A woman with ample breasts should
be asked to place her hand over the breast to draw it to the opposite side.
The coracoid process should be identified and subsequently the taut bands
of the pectoralis minor muscle should be identified beneath or through the
pectoralis major muscle. The needle is inserted over the rib cage and
directed upwards and slightly lateral towards the coracoid process. The
angle of the needle is shallow, almost tangential to the chest wall.
Alternatively, the muscle is grabbed between the thumb and the fingers in
a pincher grip with the tips of the fingers and thumb against the ribcage to
determine the proper needling angle. The needle is now directed towards
the fingers, preventing the needle to enter the thorax.
As the pectoralis muscle is located over the ventral ribcage, clinicians have
to be certain to avoid entering the intercostal space and penetrating the
lung. The neurovascular bundle to the arm lies under the pectoralis minor
muscle close to the coracoid process.
Precautions
Latissimus
dorsi muscle
Anatomy
The muscle originates from the spinous
processes of the lower six thoracic
vertebrae and all lumbar vertbrae, the lower
3 or 4 ribs, iliac crest and lumbar
aponeurosis to the sacrum. It inserts at the
medial edge of the intertubercular groove of
the humerus in common with the teres
major.
Function
The muscle extends, adducts and
internally rotates the arm. It assists in
retraction of the scapula and downward
drawing of the arm. Bilaterally, it assists to
extend the spine and homolaterally, it
causes a lateral tilt of the pelvis.
Reffered Pain
Innervation
Thoracodorsal nerve, from the
C6, C7 and C8 nerve roots
Latissimus
dorsi muscle
Needling Technique
The patient lies prone with the arm and shoulder
off the table or on the table with the hand under
the pillow. The latissimus dorsi can also be
approached in supine with the arm abducted at
shoulder level. It is possible to reach this muscle
in the side-lying position if the arm is supported
by the patient, an assistant or a pillow. The
latissimus dorsi is grasped between the thumb
and the index and long fingers. The taut bands
are then palpated and the needle is inserted
perpendicular to the skin into the contraction
knot. The muscle is followed caudally as long as
it can be lifted away from the chest wall.
Precautions
Biceps brachii
muscle long
head
Anatomy
The long head attaches to the upper margin
of the glenoid fossa. The tendon passes
through the glenohumeral joint over the
head of the humerus. The short head
attaches to the coracoid process of the
scapula. Both heads join in a common
tendon to insert at the radial tuberosity,
facing the ulna in the supinated forearm.
Function
Innervation
Biceps brachii
muscle long
head
Reffered Pain
TrPs in the biceps brachii refer pain upward
over the muscle and over the anterior
deltoid region of the shoulder and
occasionally to the suprascapular region.
TrPs also may initiate another additional
pattern of milder pain downward in the
Needling
Technique
antecubital space.
The patient lies supine with the arm
slightly flexed. The muscle is grasped
between the thumb and index and long
fingers. Taut bands are identified. The
muscle should be needled from a lateral
approach to avoid needling the
neurovascular bundle at the medial side.
The needle is directed into the taut bands
to elicit local twitch response. The two
Precautions
heads of the biceps are palpated and
treated
Avoid
theseparately
radial nerve that lies along the lateral
border of the distal biceps and the brachialis
muscles. To avoid needling the neurovascular
bundle of the upper arm, it is preferred to
needle this muscle only via a lateral approach.
Triceps brachii
muscle long
head
Anatomy
The long head is the only head of the triceps
muscle that crosses the shoulder joint, attaching
to the scapula below the glenoid fossa where the
long head originates. The three heads of the
triceps muscle attach to the olecranon process of
the ulna via a common tendon.
Function
Innervation
Reffered Pain
Posterior arm to
posterior shoulder,
upper trapezius area
and dorsum of the
forearm.
Precautions