So today we’re gonna look at some manual techniques that supplement your acupuncture treatment for shoulder injuries, particularly for something like supraspinatus tendinopathy that would be particularly indicated for that, but really a wide range of shoulder injuries.
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Hi, welcome to another American Acupuncture Council webinar. My name is Brian Lau. I’m an instructor with the Sports Medicine Acupuncture Certification Program. I also have a YouTube channel and movement based program called Jing J Movement Training, where we look at channel send you relationships to movements.
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So today we’re gonna look at some manual techniques that supplement your acupuncture treatment for shoulder injuries, particularly for something like supraspinatus tendinopathy that would be particularly indicated for that, but really a wide range of shoulder injuries. We’re gonna look at some manual techniques that can supplement your acupuncture treatment.
So let’s look at a bone model real quick. Get a an idea of what we’re looking at. Oops, we’re Alan, we’re starting with maybe we should start over.
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So let’s look at a bone model first and we’ll get an idea of what our goals are for the treatment. Then we’ll look at some anatomy slides and then we can look at the actual manual techniques. So I have a scapula, so this is looking at it from the front. This is the right scapula. So we’d be looking through the rib cage.
On the front surface, on the ventral surface of the right scapula spine of the scapula’s on the back. So there’s the back view, but we’re looking at the front view. Here’s the coracoid process for reference. I’m gonna put the ERUs in here. So many times with shoulder injuries, especially with patients, as they start getting older, we have a situation where the head of the humerus rides up in the joint and usually a little bit forward.
So it doesn’t get seeded, it doesn’t set in the joint really well, and it rises up. The big problem with that is, as you can see, is when that humerus rises up, the humerus, especially the greater tubercle, tends to bump into the acromion and pinch anything that’s coming underneath there, like the supraspinatus tendon.
So it tends to ride up and a little bit forward. We’re gonna do several techniques on some of the rotator cuff muscles to help mobilize the head of the humerus back into the joint. And create a situation that allows for better healing. So that’s gonna be our goals. We’ll look at that on the the techniques, but let’s look at a little bit more anatomy first.
So we’ll go to the slides.
So this netter image we have from above. We have the rotator cuff muscles. So the trap trapezius, upper trapezius has taken off. We have a couple other images. We’re looking again at the back surface the posterior surface of the scapula and shoulder girdle, and then we’re looking at the anterior surface.
Pretty much what we just saw a second ago. We’re looking at the anterior surface of the shoulder girdle and the rotator cuff musculature. Let’s start with the upper portion. So we have the supraspinatus, and the supraspinous fossa. SI 12 would be going right into the belly of that muscle into a motor entry point of that muscle for reference.
That muscle then continues lateral. We would have LI 16 getting close to the myo tendonous junction. The supraspinatus is going underneath the acromion to attach to the greater tubercle right there. So this is a common area where it’d get impinged in shoulder impingement syndrome. We can start getting a tendonitis or tendinopathy.
Of that supraspinatus tendon very easily because of instability there can’t really see the in infraspinatus and Terry’s minor super well from this perspective, but we can see ’em wrapping around and going to the greater tubercle also. And then from the front we have the subscapularis on the subscapular fossa going to the lesser tubercle.
So from the back surface there’s a better view. We still have supraspinatus, but a better view of the infraspinatus. Looking at the fiber direction, going up and out. Terry’s minor, we’re not gonna look as much as at Terry’s minor in these techniques, but it’ll cover it somewhat. And then subscapularis from the front also going up and out in its fiber direction.
So just a image with some points in, for some reference, we have SI 12 in the supraspinatus. We have SI 13 in the superspinatus. I 16. All of these are very protected. As long as your measurement’s good, very protect is protected by the subscapular fossa, that needle can go straight down and it’s gonna be protected by bone as long as I’m not way forward and diving the needle down through the trapezius higher, farther forward than the supraspinous fossa that could cause a pneumothorax with deep needling there.
If I’m measured correctly and I’m, relatively close to the spine of the scapula, very safe points. Sometimes people even thread from Ally 16 underneath the acromion towards Ally 15. So it’s an interesting aspect is that we have ally channel points more at the tendon aspect. We have si 12, si 13 much more related to the belly of the muscle.
You can go back and review and recall that the Ally channel intersects. The small intestine channel at SI 12, and you can see that there is quite a relationship there. From the back we have SI 11, 10 and nine, wrapping around the Terrys minor. So you can see the SI channel really relates quite a bit to the the rotator cuff musculature.
And then from a, from the front, we have heart one, an opposing muscle group in the sense that it does similar. Activity that it stabilizes the head of the humerus, but it does internal rotation versus these si channel muscles which do external rotation. So the heart Sinu channel has a slight different capacity in its in its actions, but there’s heart one would go deep into that.
Subscapularis, we can see it almost better from this top image where we would be going through the axilla. The arm wouldn’t be going through the anterior deltoids like this. So the arm would be up, it’d be going into the axilla parallel with the rib cage deep needling into heart. One would access the subscapularis a good technique to really learn in class if you’ve never done it because there is a pneumothorax thorax risk if it’s not done properly.
But we’ll look at a manual technique, which is great practice for this needling technique. And it’s actually a very effective technique in and of its own. So one last image. So this is gonna be our basic goal is we’re gonna. Sink down into the supraspinous fossa for the supraspinatus, and we’re going to slowly spread posterior to anterior.
We’ll do several passes covering the length of the muscle. My goal is gonna be to reduce tension, in the supraspinatus, but particularly that sinking down. I wanna notice that muscle attaches to the greater tubercle. So I want to do the technique in such a way that’s gonna drop descend the head of the humerus.
Same thing with the infraspinatus. I’m gonna sink in and slowly spread cross fiber through the infraspinatus muscle and using that muscle as a lever. I wanna pull down the head of the humerus. So we’re gonna be using the myofascia to move the humerus down so the slow spreading over infraspinatus, slow spreading over supraspinatus.
We’ll have that goal. Descending the head of the humerus. We can almost think about these as ification techniques because these muscles tend to get inhibited and they don’t properly seat the head of the humerus into the joint, into the glenoid cavity. And then the final technique we’ll look at will be face up, will be coming deep in the heart, one pinning the tissue, and as the patient does movement, there’ll be an influence down also to help descend the head of the humerus.
But this will be more of a pin and stretch technique, and it’ll be more of a sedating technique. So very frequently we have a situation where this muscle is in excess, this muscle is overactive, the bully. And it tends to create a little internal rotation, pulls the joint forward, but collectively those rotator cuff muscles are failing to seat the head of the humerus into the joint.
And that sets the situation up for the. Bone to rise up and pinch that supraspinatus tendon. This is something we work with quite a bit in our upper extremity class in sports medicine, acupuncture. So this is something we go through quite extensively in our upper extremity class, in sports medicine, acupuncture.
We go through a lot of the dynamics of this, but we’ll get a flavor of this through the videos that are coming up. So let’s go ahead and watch the first video on supraspinatus and we’ll come back and review some of what I just said with the infraspinatus to set up that next video. Look at some rotator cuff techniques.
First of all, just a little bit of cocoa butter. You can see on my finger, not a whole lot. I’m not even gonna put it on patient, just get it on my hands. So just a little bit of lubrication, but I want it to be mostly grab on the connective tissue. So more shearing type techniques. So not too much lubrication.
For the first one on supraspinatus, I’m gonna have the arm up on the table. There’s the spine of the scapula. I’m gonna move this technique. I’m not gonna use my finger like this. I’ll show the full technique in a second, but I’m gonna move the trap slightly out of the way so I can sink down into the supra spinous fossa.
And my target will be on the supraspinatus, but I wanna see the head of the humerus drop down. So this is primarily a technique to drop the head of the humerus down in the glenoid cavity. Using the supraspinatus as a lever. So I’m gonna come at the head of the table, hands on the spine of the scapula, move the traps out of the way, sink down into the spine.
Supraspinous, fossa, and descend the head of the humerus.
Pushed down. I wanna see that head of the humerus drop down. My thumbs are in contact with the supinate and I’m just gently spreading over it.
Spine of the scapula. The head of the humerus push down
spine of the scapula decent. The head of the humerus push down
and I’m just covering the range of it. So right at SI 12, slightly medial to SI 12. Going closer to SI 13. Moving lateral to the region of Ally 16, and I’m just covering as much of the s spine as fossa as I can my last pass.
Alright, so infraspinatus, just the review, I’m gonna be spreading, sinking in kind of at the spine of the scapula. I’m gonna be spreading down and out going across the fibers, but with that emphasis on pulling downward to help descend the head of the humerus. So it’ll be a down and out slow spread myofascial release type technique through the infraspinatus.
Let’s go ahead and look at that technique. So for infraspinatus, I wanna bring the arm off the table. About 90 degrees, unless the patient has some pain. With that, you can make it a smaller angle, but my preference is to be 90 degrees. I’m gonna come back to the head of the table infraspinatus. The fibers are going up and out, so towards the greater tubercle.
So up and out, I’m gonna do a pass across the fibers of it. Again, it’s like I wanna pull through that muscle to drop the head of the humerus down. This one I often use a knuckle, maybe two knuckles. I turn my ulnar side away. That way my bones are lined up. I can start at that spine of the scapula, sink down into the tissue, move the tissue down and out, and I’m gonna start to slowly spread through the infraspinatus.
So just a slow stroke, waiting for the tissue to soften, not trying to rush through the tissue,
getting small fasciculations along the way. And there we go. So same thing, I’m gonna go slightly medial or lateral. I went medial in this case, sink down into the tissue to the depth of tension and shear down and out.
I’m just covering the infraspinatus, so I’m at the lats now. I’m gonna stop there.
Move slightly lateral down and out.
So one more pass. I can add patient movement with this. So the infraspinatus is an external rotator. I can have them do slight external rotation. Then slight internal rotation as if they’re bringing the arm back onto the table. So just the comfort just to get a little movement as they’re doing it. Go and relax there for a moment.
So I’m gonna sink in first, drop into the tissue, and go ahead and do that slight motion now. External rotation, I’m just holding that barrier. That’s good right there. Internal rotation, go back the other way, and this way it’s gonna start to stretch through that tissue. That might be a little more challenging for the patient.
External rotation, so the hand comes up and hand back.
Good. Do one more. Pass there. Hand up. And then hand back. As he starts going that way, I’m gonna really spread through the tissue.
And there we go. That’s good. Alright, so last video and last technique we’ll look at will be for the subscapularis. Again, this is a really good technique if you’ve never done deep needling into heart, one, not only can you get a lot of results and improvement with patient’s conditions by doing this technique.
Maybe that’s all you ever do, but it also does set up the palpation and the sort of kinesthetic awareness of doing a deep needling technique there. So we’ll look at a manual technique for the subscapularis. I’ll hold off on the needling technique because I think this is best left for classroom in person instruction.
If you’ve not needle the subscapularis deep in the heart, one. It’s a safe technique. If you’re taught properly, you’re pretty close to the rib cage, you’re following parallel to the rib cage and you’re going straight down into the subscapular fossa. So if you don’t have the palpation down, the needle could advance into the between the ribs and into the pleura and causing pneumothorax.
So it’s definitely a technique to learn in person with guidance if you’ve never done it before. This manual technique, however, will be very useful to get the palpation down. And the manual technique is extremely effective in and of itself. So I’m gonna do, just like I would do with the needle technique, I’m gonna reach under the scapula, move the scapula out just a little bit.
It doesn’t move it out much, but it gives you a little bit of extra space. I have the lats peck, I have this little triangle right in there. I’m just gonna come in. A couple tricks with this is I don’t want to grab too much skin. ’cause as I advance down, you can feel how that’s pulling skin and it stops me from going too far down, doesn’t feel great on his end, and then it stops me from doing the technique.
So I need to get the skin out of the way. By that I mean I need to lift it a little bit, move my fingers around, kinda get to where I’m gonna go advance down into that subscapular fossa without pulling a lot of excess skin. So I’m gonna now angle straight down. I can feel the ribs on my fingernail side, and I’m gonna angle straight down into that subscapular fossa cross fiber feeling for bands of that subscapularis muscle.
It’s almost like I’m going to si 11 on the front of the scapula, so this would be deep in the heart one. So once I’m there. One of the things I can do is I can have the patient move their elbow down following the angle of the arm. So they’re making their arm long. That might be enough, but but if they can, then I’m gonna have them start to bring their arm up, keeping the elbow out.
There you go. Keeping that elbow out, bringing the fists slowly over the chest, reaching the elbow out. I really wanna. Push the subscapularis down while they reach the elbow out. Decompress the shoulder joint so as much as they can bring you in by bringing the arm up, the better. So they’re gonna get the hand up.
And now external rotation.
To about there, and then if they can bring the fist down towards the table.
There we go. All right. So JT has pretty good range of motion, so that makes it look a certain way that is not necessarily achievable for somebody who, has limited range of motion and this technique would be too much for ’em. So sometimes you can’t even get the arm up to 90 degrees.
It’s okay to back it off a little bit. I don’t wanna put them in an unstable position. I definitely don’t want that humorous. Can you kinda shrug your shoulders as I do this? I don’t want, yeah, I don’t want that arm to shrug up as I bring their arm to 90 degrees. I’m working at counter purposes, so I need that head of the humerus down.
Maybe I can only get ’em up a certain amount. I can definitely get them to reach the elbow out and decompress, pull the head of the humerus down as I’m pushing the subscapularis medial and freeing the subscapularis. That would be enough for some people. Maybe they can lift their arm up a little bit, so you just have to work with where they are.
But the starting position would be to get into the muscles. Okay, if I do this again, so to get down into the muscle. Feel that subscapularis, I’m cross fiber in it right now. Get on that band. I wanna almost bend that band and just gently reach the arm out, decompressing the head of the humerus.
They could also go into external rotation here, but I like them to be able to bring me in by going into horizontal a deduction to bring me more into the muscle. Maybe that’s as far as they could go. JT can go farther, but I’m just saying maybe a patient you’re working with that’s their end point.
No problem. I can work there, have them reach free. Maybe next week we’ll come back and see if we can go a little farther.
Alright. Very good. Thank you for taking the time to watch those. You can see those techniques take a little bit of time, but not particularly much. A lot of that was me explaining and setting up the techniques. You could easily do this if you had the face down portion. You could take the needles out, do these techniques, spending a couple minutes going through the superspinatus and the infraspinatus to help descend that head of the humerus.
It wakes up the muscles. It helps give them proprioceptive awareness so that they can more appropriately pull down. Head of the ERUs and seat, the head of the humerus in the joint. If you do a second round of treatment and you do whatever on the front, maybe even including the needling for subscapularis, you could follow up with this technique on subscapularis.
Or maybe you don’t do the needling on subscap. This is a really great manual technique to cover that that range of the muscle. Something to consider. My last thought on this is point combinations. Is if there is this excess in subscap and more inhibition sort of deficiency in the small intestine channel muscles.
Infraspinatus, supraspinatus, te minor. A combination I use quite frequently is the source point on the SI channel SI four and the low connecting point on the heart channel heart five. So a source low connecting combination. Feel free to comment. I’d love to hear some other point combinations you guys do that might, you find, give good results and good responses for these types of conditions, or if you use that that low source point combination. Tell me if if you feel like that’s been a useful point, combination for you. Always nice to learn from each other, so I’ll be checking out the comments and maybe we can have a little bit of a conversation about that.
Thanks again for taking the time out and watching this, and thanks to American Acupuncture Council for having me. So it’s always great to be able to do these webinars and I appreciate the opportunity. Hope to see you guys next time.