THE PROBLEM SHOULDER

Thomas W
Myers
Over 20 muscles are involved in operating
the shoulder & all are vulnerable to strain
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TrPs in the rotator cuff muscles are
the most frequent cause of shoulder
pain, loss of upper arm movement &
clicking and catching within the joint
Specific management of these may
avoid unnecessary surgery, steroid
injections and manipulation
TrP release is also vital for eliminating
pain post surgery

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 ROTATOR CUFF
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
• RC & LHB - correct length – tension, co-activation to supply
compressive forces & resist translation “centering” Lippet
1993
• RC blends into joint capsule...tightens capsular – ligament
complex..acts as dynamic ligaments
• Tendons fuse into 1 continuous band near their insertions... So
contraction of one influences them all.
• Feed forward system local stabilizers

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 A MUSCULAR PARALLEL

“The brain points the arm and the finger as accurately as it points
the eye. In the orbit and at the shoulder, the eye and the humerus
are free to rotate (or swing) in front-to-back and side-to-side
planes, and also around their long axes. And in both cases there is
a precise arrangement of muscles aligned and attached to power
each of these movements.” Frank Wilson in ‘the Hand’

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 Anatomy of the
Shoulder

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 Deltoid

Cephalic Vein

Pectoralis Major
Pectoralis Minor

Coracobrachialis

Axillary Vein
Brachial Artery
Jugular Vein
Brachial Plexus

Subclavian Artery

Subclavian Vein

Brachial Artery
Rotator Cuf

Supraspinatus

Infraspinatus

Terres Minor

Subscapularis

Long Head Biceps

 Upper Trapezius

Infraspinatus

Terres Minor

Terres Major

Latissimus Dorsi

Long Head
Triceps
 Levator Scapulae
Supraspinatus

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 What’s in the fossa?
Dorsal scapular artery
Suprascapular nerve
Suprascapular artery and vein

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 SUPRASPINATUS
REFERRAL & CHARACTERISTICS
• Mimics sub-deltoid
bursitis felt as a deep
mid deltoid ache May
concentrate in the
lateral elbow
Loss of optimal
centering of glenoid
• Activated by carrying
heavy loads with arm at
side – suitcase
• Pulling a dog on a lead
• Lifting an object to or
above the head with the
arm outstretched
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 SUPRASPINATUS
Starting position
TECHNIQUE
Contralateral side lying with hand on pillows in neutral rotation, or just on the hip
Check that scapula is neutral

Insertion: side lying or supine

Palpation landmarks Belly: Margins of the supraspinous fossa

Insertion: Lateral border of acromiom, Light contraction to feel tendon

Possible Needle sizes 0.3x30mm – 0.35x75mm Difficult to know depth of fossa

Insertion: 0.30x30mm

Possible Grip Flat palpation

Direction of insertion Belly:Towards the supraspinous fossa of the scapula Be sure to needle
posterior to the apex of the UFT, and aim toward the inferior angle of the
scapula

Insertion: onto humerus, may use periosteal pecking

Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the symptoms
arise.

Belly: Minimal pecking on periosteum to protect suprascapular nerve and

artery.

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 SUPRASPINATUS
NEEDLING

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 SUPRASPINATUS
NEEDLING

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 SUPRASPINATUS
NEEDLING INSERTION

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 INFRASPINATUS REFERRAL &
CHARACTERISTICS
REFERRAL: Shoulder joint pain…felt
deeply into ant deltoid region and
down arm and intrascapular pain.
Similar referral to scalenes..test hand
behind back to confirm inability to
reach up vertebral column behind back
ACTIVATION:
Overload while reaching backward and
up
Grasping a railing when falling
Recent shoulder trauma
Athletes- throwers tight posterior
capsule

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 INFRASPINATUS TECHNIQUE
Starting position Contralateral side lying with hand on pillows in neutral rotation

Alternate position prone, but check borders of scapula

Palpation landmarks Margins of the infraspinous fossa

Possible Needle sizes 0.25x25mm-0.3x50mm Consider mms bulk

Possible Grip Flat palpation

Direction of insertion Towards the margins of the scapula

There is a very small chance of perforating the scapula in the middle

portion.

Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the
symptoms arise.

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 INFRASPINATUS
NEEDLING

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 INFRASPINATUS
NEEDLING

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 Teres Minor
“Silver Dollar Pain”
Pain referred to
lower posterior
deltoid area
Usually active with
Infraspinatus TrPs
Overload while
reaching out and
behind the shoulder

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 TERES MINOR
 Tight post capsule changes arthrokinematics to
ant translation of humeral head

 With findings of impingement with loss internal

rotation, think Teres Minor and Infraspinatus
trigger points

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 TERES MINOR TECHNIQUE
THE LITTLE BROTHER OF INFRASPINATUS
Starting position Contralateral side lying with hand on pillows in neutral rotation

Alternative prone

Palpation landmarks Posterior “seam” of axilla. Lateral border of the scapula, long head of
triceps laterally.

Possible Needle sizes 0.3x30-0.30x40mm

Don’t be confused by the adipose layer here – be sure to accurately locate

the muscle.

Possible Grip Pincer

Place your target finger deep in axilla between the two Teres muscles.

Direction of insertion Towards your finger between the two Teres muscles, in the line of the
posterior axillary “seam”

Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the
symptoms arise.

Do not needle into the high axilla.

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 TERES MINOR NEEDLING

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 SUBSCAPULARIS MUSCLE
“FROZEN SHOULDER”
REFERRAL & CHARACTERISTICS

Pain referred to
posterior deltoid, may
extend to scapula,
posterior arm and
wrist.
Progressive painful
restriction of
abduction and lateral
• Unusual repetitive exertionrotation
using forceful
of theint
arm
rotation– swimming unfit
• Repeated forceful overhead lifting
• Sudden stress overload reaching backward to
stop a fall
• With fracture of/or immobilisation of arm
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 SUBSCAPULARIS TECHNIQUE

Starting position Supine with as much abduction of humerus as possible. Place your non-
dominant hand on the vertebral border of the scapula and passively abduct the
scapula such that the anterior surface of the scapula/belly of the subscapularis is
lateral to the ribcage

Palpation landmarks Ribcage, medial and lateral borders of the scapula

Possible Needle sizes 0.3x50mm – 0.35x75mm

Possible Grip Flat palpation

Direction of insertion Towards the edge of the scapula. Aim posterior and slightly medially, which
should approximate your palpating hand’s MCP joints, thumb in contact with ribs
as a guide.

Be sure to needle toward your hand, not the ribcage.

Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the symptoms
arise.

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 SUBSCAPULARIS
NEEDLING

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 LATISSIMUS DORSI
Pain inferior angle of
scapula and radiates down
back of Shoulder to forearm
Fascial attachments
may give low back pain
Often thought to be
intrathoracic disease

Repetitive reaching upwards and forwards

Unfit patients exercising in a gym
Sporting – swimming , rowing , exs involving hammering, power
striking
Overactive / short lats: scap abducted beyond chest wall in full
elevation.
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 LATISSIMUS DORSI
TECHNIQUE
Starting position Supine, prone or sidelying

Palpation landmarks Ribcage, lateral border of the scapula

Differentiate between Teres major and Latissimus dorsi

Possible Needle sizes 0.25x25mm – 0.35x50mm

Possible Grip Pincer grip for the free border, flat palpation and rib
blocking for the part that overlies the thorax
Direction of insertion Aim at your palpating finger if in pincer grip, or at the rib
between your fingers blocking the intercostal spaces.
Special precautions Beware pleura. Patient must be advised of additional
risk of pneumothorax injury and be advised what to
do in case the symptoms arise.

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 LATISSIMUS DORSI
NEEDLING

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 LATISSIMUS DORSI
NEEDLING

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 TERES MAJOR
REFERRAL & CHARACTERISTICS
Pain penetrates
posterior deltoid and
is present with lat
dorsi TrPS

Repetitive lifting of
weights over head - -
packing shelves
Unfit – working out at
a gym

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 TERES MAJOR TECHNIQUE
Starting position Supine, prone or sidelying

Palpation landmarks Ribcage, lateral border of the scapula

Differentiate between teres major and latissimus dorsi

Possible Needle sizes 0.25x25mm – 0.35x50mm

Possible Grip Pincer grip

Direction of insertion Aim at your palpating finger in the axilla

Insertion toward the lateral border of the scapula medially
Special precautions Beware pleura. Patient must be advised of additional risk
of pneumothorax injury and be advised what to do in case
the symptoms arise.

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 TERES MAJOR NEEDLING
SCAPULAR INSERTION

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 TERES MAJOR ANTERIOR
GRIP

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 TERES MAJOR NEEDLING
ANTERIOR

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