Tag Archives: Matt Callison – Brian Lau

Callison-LauHD08042021 Thumb

Cluneal Nerve Entrapments: An Often Overlooked Cause of Low Back Pain

 

 

We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain.

Click here to download the transcript.

The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. And thank you very much for coming to the American Acupuncture Council, our sports acupuncture webinar. We’d like to thank the American Acupuncture Council for sponsoring us with this. I’m here with my friend, colleague and partner in the sports medicine acupuncture certification program. Brian Lau.

Hi, nice to be here again,

Brian and I were discussing just the other day about the upcoming module two low back hip and groin webinar that we’re having in the anatomy pop patient cadaver lab. We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain. For example, the superior cluneal nerve entrapment can mimic yarn syndrome pain at the iliac crest, or it could be maybe 30% or 40% of that con contribution to the pain. So something just to routinely check in your cases of low back pain to see if an attraction is contributing to part of it. So I think we could probably just start bouncing right into it. So, Brian, do you want to go ahead and take it away and we’ll just go to the next slide.

Yeah, sure. So, uh, we’ll go, um, pass the title slide here. So into the next slide, and we’re going to start by, um, just giving a quick overview of the clinical nerves. So you have three circles that you see there. Uh, we have the superior cluneal nerve, so that’s that upper circle, uh, that I’m going to cover quite a bit in just a moment. So just for now, yeah. There’s the highlight, uh, showing the superior cluneal nerves now there’s multiple ones. Um, and we’ll, we’ll talk about that in just a moment, but then below that, in that middle circle, we have the middle cluneal nerves. Uh, those mats going to go into a little bit more, we’re both going to discuss some, but, um, he’s going to take that primarily. We’re not going to be discussing the inferior cluneal nerves, that bottom circle, uh, in this particular webinar, just because, um, this one is a little bit more on causes of low back pain and fluid inferior cluneal nerves, or are important.

Maybe another day we’ll cover those, but we’ll focus more superior and middle. Uh, so these nerves are cutaneous. Nerves are sensory nerves. Um, they, uh, then that means they’re going to be primarily innervating the skin. So they’re traveling in the subcutaneous tissue and innovating the skin. Uh, so let’s go ahead and move on and we’ll go right into superior cluneal nerves. So the superior cluneal nerves, uh, come from, they stem from [inaudible] the dorsal ramus. They travel posterior, uh, as they get more inferior penetrate through fibrous tunnels within the thoracolumbar fascia, uh, then they branch over the iliac crest to become subcutaneous where they, uh, innovate the skin and the subcutaneous tissue. Uh, so these are a common site of entrapment. Uh, so this, uh, superior cluneal nerves can becoming trapped in the superficial layer of the thoracolumbar fascia and can contribute to low back and leg pain.

Uh, just the note is that’s a little bit of a shorthand. So when it says that they, they, uh, stem from L one through L three travel posterior, there’s a whole lot of territory, you know, they’re not traveling through empty space at that time period. They’re actually traveling through structures like the, so as they’re traveling sometimes through the quadratus lumborum, but usually between the psoas and the QL, they travel through the para spinal muscles. So there’s a lot of territory, uh, in that region that we might be able to come back to later on in the, in the webinar to differentiate between various types of injuries. Our focus though is going to be on that, uh, area where they Pierce the thoracolumbar fascia, just at the iliac crest region, and then drape over the iliac crest. So maybe more on the other, other areas later, but let’s go with the entrapment site that we’re talking about in this webinar. So that’s the superior cluneal nerves and their site of entrapment.

So in, in terms of, uh, entrapment, there’s a, these are all the superior cluneal nerves, but there’s a middle or medial. Uh, one of those though, you know, the one that’s most medial, uh, then there is a middle or intermediate and then a lateral, uh, superior cluneal nerve. So these are all superior cleaning, the nerves that we’re talking about now, but we’re looking at the multiple nerves. So the medial most the middle and the lateral one, and it’s usually the medial branch that is commonly affected, uh, in terms of, um, becoming and trapped. So they all can be contributors, but this, this medial branch is the one that we’re really, um, gonna focus on, uh, in terms of where it’s, it’s going to become trapped. So, uh, these traveled through a fibrous tunnel, uh, then they go over the iliac crest so they can get in trapped in that fibrous trunk tunnel of the thoracolumbar fascia, or they can get trapped between that and kind of adhering to the iliac crest. So there’s a lot of research out there. You can look into it if you want it to, to check more information about it, but this image really kind of highlights that fibrous tunnel that you can see that those medial branches of the superior cluneal nerves travel through. So it’s just a, just a sort of a fibrous tunnel through the thoracolumbar fascia. All right, so let’s move on next one.

So in a cadaver studies, the researchers found that this medial branch of the superior cluneal nerve was frequently adhered between the fibers tunnel and the thoracolumbar fascia and where the medial branch travels over the iliac crest located just lateral to the PSIS. So there’s a lot of studies on this. Um, why it’s studied in Western literature, uh, is twofold. Uh, they study it of course, because it’s an entrapment site and it can be a pain generator. It’s considered not super common of a pain generator, but it is a pain generator and it’s worth knowing about, uh, that’s one reason that it’s a study. The other reason that it’s studied is when they harvest bone from the iliac crest to use for, um, fusion for lumbar fusions, uh, they want to know, you know, it’s really important that they know where these, uh, cluneal nerves are, so that they don’t damage the cluneal nerves in the process of process of harvesting bone from the iliac crest.

So because of that, there’s a lot of really good research that that kind of gives an average of where these cluneal nerves exit, um, both, you know, the, the medial ones, the intermediate and the lateral ones. So they have it all charted out on various different cadaver studies, measured from the PSIS are measured from the midline. And if we look at this, um, medial branch of the superior cluneal nerve, it’s approximately in the region of Yan, you know, of course they’re measuring it from different criteria. They’re usually usually measuring in millimeters, but the measurement kind of comes to about that same measurement, uh, as Yan, which is three and a half sun from the lower border of L four, just over the iliac crest. So this being a common site of entrapment means that it’s also a contributing factor, or sometimes the factor for Yan syndrome, which is pain at this particular region.

Um, again, we can come back and differentiate this type of pain that’s caused from an entrapment of the superior cluneal nerve versus other things that are in this region. Like the Leo Castelli’s lumborum, which attaches to the iliac crest in that region, or deeper to that, the quadratus lumborum, which attaches to the iliac crest in that region. So being able to differentiate what’s the, the pain generator is important, but in that process of determining what’s the pain generator, we want to make sure that we take into consideration the, uh, the superior cluneal nerves. So those cause pain Ayanna, that pain might radiate down into the buttock region, and you could follow those nerves and see how they drape over the glute medius. And even over the glute Maximus. Matt, do you want to add anything to that kind of just jumped in and covering it, but

That was great. Yeah, that was really good. So, uh, just to reiterate the, the, on, we just published a, an article as well on the sports medicine acupuncture website, and it’s talking about the superior superior cluneal nerve entrapment at the extra point Yon, and also in the Yon region, just something to, for practitioners to consider that there is a cadaver dissection that we did. And we were able to find one of the superior cluneal nerves, which is a difficult dissection to tease out these cutaneous nerves. Um, it’s not just us, that it’s actually in some of the articles, um, that are in the references. Um, they talk about the difficulty of actually trying to tease them out and try to be able to dissect them, to see if they are entrapped or not. Um, Yon syndrome that we call it is also in Western science called iliac crest syndrome is basically the, um, the strain of the soft tissues within that area like Brian was talking about, could be the thoracolumbar fashion, the illiocostalis or the thoracolumbar fascia and the quadratus lumborum.

And this has been treated for thousands of years by acupuncturist, but yet the entrapment side also could be a contributing factor to that. So the patient is complaining of that low back pain. They may also talk about a mild parasthesia you’ll have to dig that out of them. Most people are not going to consider that as a chief complaint. Um, it’s just more of the low back pain in that Yon region. So the entrapment side is something definitely to assess which we’re going to be talking about. The very simple assessment coming up in just a little bit, Brian, should I jump into the next entrapment? Uh, yeah. Yeah.

There’s some other things that we can come back to later on. That’ll be more differentiation. Um, but, uh, just to highlight one real quickly, what you said about why these are so difficult to dissect is that they live in the, at least the process that we’re the part of them that we’re looking for, uh, in terms of where they drape over the iliac crest, those live in the adipose tissue, and you know, this dissection, I mean, this, uh, this image from Netter, they they’re so clear looking. It’s so easy to see, but in dissection and it all looks alike, it’s all the same color. These are little over a millimeter in diameter, so they’re super thin. And just finding them in that adipose can be very challenging and take time to look for. But, um, one highlight from the video that Matt referenced on the blog, um, that in the processing of this video, it’s funny how you listen to things over and over, and you never noticed something. I just noticed today, actually, when I was listening to it, that I say superficial cluneal nerve over and over again, instead of superior cluneal nerve. Um, so, uh, if you listened to that video, if you go to the blog post and you look at that, that dissection video, don’t be confused. It is superficial because we’re looking at it, look, our we’re highlighting and showing it where it would be in the adipose tissue. But I meant to say superior cluneal nerve and not superficial clinical.

Yeah, that’s good. Brian, I think, I think it’s important for people to understand that this is really quite superficial. So if we have the low back, you’ve got the skin, then you’ve got your layer of your subcutaneous tissue. Then it’s just underneath that. So people have been treating the superior and middle cluneal nerve entrapment for a long, long time with techniques with cupping. And guash on with acupuncture. All of those actually have a strong effect on this superficial tissue, which we’ll talk little bit more about Sue

And Matt. It sounds like your chickens are laying eggs in case people are wondering.

Yeah. They just, they, they, they love to interrupt these webinars. They do. All right. I was wondering if you could hear it. All right. So let’s go to the next slide. Thank you. All right. So the middle cluneal nerves, so let’s separate, let’s differentiate this from what Brian was just talking about. The superior cluneal nerves are further broken down to medial, intermediate and lateral. You can see those three nerves as the superior, right? That’s not circled in this particular image. So now, now we’re going to be talking about the middle cluneal nerves that are branches from the [inaudible] dorsal. Ramiah now like the superior cluneal nerves. They also exit through the thoracolumbar fascia. And then the cutaneous area for them to innovate is going to be the lower part of the PSIS medial, buttock and OXA also the coccsyx region. So a patient may be complaining of pain in that area. It could, it could be planning of pain in the SSI joint that at first glance, you’re thinking that it could be a sake really actually problem. Um, but then you further differentiate that possibly the middle cluneal nerves are part of this. And we’ll talk about that. And just a little bit, when we get into our assessment and treatment, let’s just break down the anatomy of it for, for us right now. So let’s go ahead and go to the next slide.

So anatomically here’s an image from Grey’s anatomy, the course of the middle cluneal nerve stems from the sacral nerve roots. So we talked about S one through S3, then it travels posteriorly either under or through the long posterior sacroiliac ligament. Now there’s a number of different references for you guys to be able to check out and through the different anatomy from human to human, the course of the medial cluneal nerve, um, does vary. So sometimes it’s going to be underneath this long posterior sacral ligament, and other times it goes through it. And other times it goes above it with patients that have had the medial cluneal nerve entrapment with the surgeons. What they’re, what they’re saying. And their research is that when the long posterior sacral ligament becomes two tense in certain conditions, it will entrap the medial corneal nerve as it exits from the [inaudible] underneath that ligament, or in some humans, it’ll actually go through that ligament.

So that would be the entrapment site in the ligamentous tissue. However, like we saw in the slide before we saw that, that medial cluneal nerve, as it exits deep in this ligament and then comes superficial cause it’s a cutaneous nerve and it goes through thoracolumbar fascia. So in one of the articles that are in the references, they actually talk about that as being one of the entrapment sites it’s strong and Divya in 1957, they actually talk about how difficult it was to go to find the medial corneal nerves, but they felt that the entrapment side was through that thoracolumbar fascia. And then with further research, I think a decade later is when they actually started seeing the possible trap this side of the long posterior sacral ligament. So there’s two and Travis’ sites for us to be able to consider with the middle cluneal nerves that can mimic or contribute to pain in the SIB joint region. So let’s remember that one.

Hey Matt, can I add something to this, uh, later on, uh, when we talk a little bit more about treatment, it’s worth that noticing the connection between the, um, long posterior sacral, uh, sacroiliac ligament and the sacred tuberous, like a mint, cause that’s all kind of one chain of, of continuous tissue. So the sacred tuberous ligament ligament goes from the issue of tuberosity on the kind of bottom of that image as starting right there and then travels up at an angle towards the sacrum. Um, so we might come back and mention that later. So just, this is a good image to see that. All right, thank you. Um, next slide,

We talked about the neuro travels through the superficial fibers and exits a slightly lateral to you be 32 and 34. So that would be our landmarks. So the entrapment site couldn’t be through that long posterior sacral ligament. That’ll be deep to that region and also through the thoracolumbar fascia as a possibility. All right. So in this very interesting study from, uh, Kono and atta, the middle cluneal nerve is associated with pain involving lower back and buttocks. It can mimic sake, really act joint pain. It creates sciatica likes sensations, which is really quite fascinating. Now, according to our research, the trapping of the middle cluneal nerves is underdiagnosed cause of low back and or lakes symptoms. And if you refer to this research, uh, what they found was in 13% of the cadavers that they dissected, they found that the, uh, middle, middle cluneal nerve was adhered and trapped underneath the long poster sacral ligament.

In fact, they teased out the middle corneal nerves in the middle colonial nerves. If we look at this pin had normal density on one side normal density on the other side, when the attract it was, it was really, really very, very thin. So that patient most likely had low back pain, which was an attribute from the middle cluneal nerve as fascinating. So 13% of the population. So think about how many people are coming into your office with low back pain, like said it’s a good routine thing to check for superior cranial, nerve entrapment, and middle cluneal nerve entrapment on this image. You’ll see, there’s an a, and then there’s a B. And what they did is they measured from the lower border of the PSIS and the posterior, um, the long posterior sacral ligament, which is a mouthful to say where approximately where that attracted is from the lower border of the PSIS. And on average, it was about one centimeter. It was about one centimeter, so that you can see why that entrapment would mimic sacroiliac joint pain because you’re right next door to the lower aspect of the sacroiliac joint. [inaudible]

All right. So Brian, we’ll go ahead and jump into this one together. I’ll start it off. So the Cardinal symptom of chronic low back pain with, or without legs symptoms, you guys, so this remember that it doesn’t always have to be a chief complaint of parasthesia, but it’s a good thing to ask if somebody talks about a little bit of numbness or tingling and they may not even be aware of it because it can be so subtle, um, into the butt off region or maybe down the leg. I’ve of course, if it’s going down the leg, we have to rule out a disc problem with the many different nerve tension test for sciatica. Um, common aggravating activities are going to be walking rising from sitting, standing flection and extension. So a lot of functional examinations are going to be important with this. Uh, patients often find that pushing above the iliac crest with their hand relieves symptoms of the superior cluneal entrapment. So that kind of body language you want to watch for, you can ask the person if they find that if they put pressure on their low back and they push down a little bit, if that helps, that would be a sign as a possible nerve entrapment.

Yeah. They’re kind of decompressing it themselves, right? Yeah,

Exactly, exactly. They’re decompressing and try to open up the, uh, Travis’ side. I mean, people can have this for years because it may be just low back pain of a two or a three, and then sometimes it gets really bad to a four or five. And how many people do you know that just don’t get treated with their low back pain thinking that it’s just an aging thing. So this is something for us to consider when that patient comes in. They’ve had it for chronic low back pain for years, definitely check for these nerve Travis’ sites. In addition to the other things that could be occurring, it could be sacroiliac joint problem. It could end up being a Yon syndrome where there’s a strain within that soft tissues. And we’ll talk about that a little bit more when we get into posture, which I think is in a few more slides, Brian, you want to take it from here?

Let me just, uh, dimension the, uh, leg pain aspects. And, and you can tell me if I’m correct on this map. And my understanding with that, first of all, the cluneal nerves, if you go back to those images, do travel through the gluteal region. Uh, they’re superficial at that point, but they’re traveling in the adipose to, in route to the skin, uh, over glute max glute medius, depending on which, uh, which ones we’re looking at. Um, but the leg symptoms, uh, from my understanding, I think is more of a sensitization and, and a common innervation for other nerves that are traveling peripheral nerves that are traveling down to the legs. So if it’s very, um, severe entrapment, then that can start to irritate the other, other structures in that same innovation zone and, and cause pain in the legs. That’s my understanding of it. Does that match, match your, your, um, understanding of that, the leg symptom, uh, component of it?

Yeah. Cause it makes sense. I mean, it shares the same sciatic nerve distribution of being L four down to S3. Yeah.

Yeah. And especially the middle cluneal nerves, which have a lot of, uh, innovation of the legs. Yeah. So, um, looking at, uh, uh, pelvic imbalances, if there’s an elevated ilium, uh, anterior tilt, uh, is, is often associated too with it because of the shortening that can happen in the thoracolumbar fascia with that, of course a posterior tilt is going to kind of overstretch that, um, that same structure. So it wouldn’t be unheard of to have a posterior tilt of the pelvis, but those are the things to really note and notice with, um, with, uh, uh, cluneal nerve entrapment, regardless if we’re talking about the superior or the middle colonial nerves, just because those, uh, postural imbalances and we’ll look at an image for this to kind of highlight it. Those are gonna put extra tension on, on the ligaments, the, the, uh, posterior, uh, sacred iliac ligament that we’re talking about, the long posterior sacral ligament, um, but also the thoracolumbar fascia and how that tension patterns are then going to relate to a propensity to entrap the nerve.

So when we get to an image on that, we can highlight some of those aspects. Uh, as we both mentioned, this could be the cause, you know, this could be what, uh, is the, the, the main pain generator for a patient. Um, it could be like number one, but you know, it also can be just a component of a series of things that are kind of coalescing in the same area, and that can cause pain. So it doesn’t have to be an all or none type of type of thing. Like Matt mentioned, I think 20 or 30% of it might be coming from the clinical nerve irritation and entrapment. So it’s worth checking for, uh, do you want to talk about assessment mat

With it? I think the next slide we can jump into and kind of get into a little bit more. Yeah, there we go.

Yeah. So here we have that image of somebody with an elevated ilium. So you can look at and see that the person has an elevation on the left. So sometimes we call it a left, elevated ilium. Sometimes we refer to that as a right tilt of the pelvis because the whole pelvic structure is tilting to the right. The top of it’s kind of pointing to the right, but the left side is high. And that’s the main thing to notice. So with that, there’s going to be a lot of shortening and things like the quadratus lumborum iliacus Talis lumborum, those are all, uh, kind of intimately associated with the thoracolumbar fascia. Um, so that’s gonna, uh, tend to, uh, correlate with more of a propensity for entrapment of the, um, cluneal nerves. I would tend to see it more often, see it on the side of the elevation, but again, just those changes are going to change the tension patterns on both sides. Really. So the fact that that, that the tension patterns are changed and disrupting the, uh, the, uh, uh, normal sort of, uh, even balance, uh, in the pelvic and low back region that, that elevation of the Lem could really be a big factor for, for people. Um, of course it’s not the only one.

Yeah. So at the takeaway with this, I believe is to make sure that you are addressing the pelvic imbalances, which will then help with the soft tissue imbalances that are in trapping the cluneal nerves, as well as causing a sick really act joint problems or Yon syndrome, or the other many other causes of low back pain, something of which that we spent a heck of a lot of time in module, two, trying to be able to teach people how to be able to balance these. Because when you think about it, you want to balance that dantien your center of gravity. And then by balancing that pelvic curdle that changes the balance above, and it changes the balance. Yeah.

Now this particular patient, uh, I can’t tell looking at them, especially from the back, uh, if there’s an anterior or posterior tilt, um, sometimes visually you can see that it’s a little easier to get in and palpate, uh, to, to, um, feel landmarks like the PSA. I S N a S I S and look, we have a particular protocol we teach to measure that that’s a little bit more accurate than just glancing. Same with pelvic rotation. That’s a somewhat of a visual assessment, but it’s all, it’s really more of a palpatory assessment, but this particular model, you can definitely see the elevation of the Lem. Cool.

All right. So then now the second to last bullet, did we cover? Yes. So, so the third to last bullet where it says cluneal nerve and trauma can be a contributing factor along with other causes of low back and leg pain. Absolutely. So when you’re diagnosing what is causing that person’s low back and leg pain simply, and this is the assessment. One of the assessments is simply taking your index finger or your middle finger, and just tap firmly, firmly, right over the area of Jalya where the superior cluneal nerves could be in tract. It’s like a tunnel sign. Alright, just tap very thoroughly all around that region, even onto the PSIS, where the traffic could happen, then move down level with you be 32 and you’d be 34, do the same type of tapping. What you’re looking for is the patient have any pain with that is a reproducing, the pain that they’re complaining about, is it reproducing any of the parasthesia that they know about, or maybe they don’t about it? Like if you’re, if you are tapping on there and it’s causing that, parasthesia consider that the nerves are entrapped and they are contributing to part of the clinical picture here. Brian was anything.

Yeah. Even before that, you might not have gotten to the point where you, you think about doing a tunnel sign there, but you’re just palpating. You’re kind of going through the process of figuring out where the cause of the low back pain is and trying to diagnose what the, what the condition is. And you go to palpate, maybe you think it’s an SSI joint, um, uh, it’s SSI, joint pain, and you go to palpate that PSIS region. And even with superficial pressure, you know, you barely, you’re definitely not pressing past the subcutaneous tissue into the deeper muscular structures, but when you start getting that superficial, uh, pain, that’s a little bit more pain than you’d expect at such a superficial level. That’s if I haven’t already been considering cluneal nerve entrapment, that’s a, that’s a point at which I’m definitely starting to think about it because it’s, uh, it’s, they’re, they’re cutaneous nerves. So you don’t have to press particularly hard to elicit pain if they’re irritated and then going from there to the tapping for a Tinel sign might be a consideration that’s, especially the case with the superior ones, you know, with the, the middle ones, the, the entrapment can be a little deeper if it’s at that, uh, ligaments. So that may or may not be quite the case, but if it’s irritated, uh, uh, at a periphery from that entrapment site, you still might get that elicit that, uh, very superficial pain.

All right. Should we go into a couple of needle techniques we could use? Yeah. So these are some images from the sports medicine acupuncture textbook on the left-hand side, you’ll see four arrows. Those are different vectors angles that we’ll use to palpate to affect the, um, iliac joint region. So the needle is going to actually be going into ligamentous tissue and the deep [inaudible], but let’s talk about the arrow that’s on the very bottom. Now that particular direction there, if you remember that direction is going to be very, very close to where the entrapment site of the middle cluneal nerve in the long post of your sacral ligament would be. So you could take your finger underneath that. PSIS approximately one centimeter go directly anterior, and then push upward toward that PSIS but deep angle it toward the sacroiliac joint. Now that’s really very, very tender and maybe even causes some parasthesia again.

Then you could be able to consider an entrapment site, and that would be a needle angle that we could choose. So going in with a three inch needle, or maybe a two-inch needle going into that Oscher point that we just diagnosed through palpation stimulating. Now, what you can do as well is to rotate the tissue around the needle. So turn the needle 180 degrees, 300 6720 degrees in one direction, as long as the patient’s. Okay. And then gently just pull up to loosen up that tissue with the idea, the intention of opening the area of the entrapment site. Of course, always to patient comfort. Uh, patients usually really liked that area because a deep, deep massage really doesn’t get to it, but that acupuncture needle can get to that region. So that’s one needle technique that you can use, but remember, that’s just one spot and this area is associated with the urinary bladder primary channel, and also the sinew channel.

So remember to link points that will address this region. So your adjacent and your distal points as well. Now you’ve got the images on the middle here on this slide and also in the lower right. That’s going to be looking at Yon. So the finger, you can see the middle fingers pointing right toward where that superior cluneal nerve can be entrapped. So that’s really quite tender. You can kneel that with your three inch needle. Um, the lower right-hand side is going to be kneeling in that level. And then as we discussed in the smack program, and this was Brian’s finding that this particular level is going to be more about the urinary bladder, send your channel, and if it would happen to be deeper, it’d be more about deliver channel Brian. You want to take it away? Uh,

Yeah. So this is another one that that needle technique by itself, uh, is great. And, um, I think what Matt was alluding to was if we’re at superficial, uh, pressing into Yon, we might, we’d be pressing into the iliacus Dallas, uh, muscle, which is also a potential, uh, site of pain in and of itself. But, uh, that could be putting excess tension into the thoracolumbar fascia. Um, and that would be more online with this new channel associated with the urinary bladder. So we might link it with, I don’t know, biceps, remoras, motor point, maybe beat channel points. We could try distal points and then go back and palpate that area and see if it reduces pain. If we go a little bit lateral sink in and go deep back to that same point. And we were at the quadratus lumborum attachment quadratus lumborum is on the myofascial plane that is continuous with the iliacus and into the abductors.

So it’s part of the liver send your channel. Uh, liver five would be my go-to point for that, but again, you can try different points and see if, uh, if that helps reduce pain at that site. Um, those, those are, those could potentially be vectors for the muscle pain, but those would also be associated with tension in that region. Um, when I, when I think that there’s, um, cluneal nerve entrapment, sometimes I do one vector like that, uh, just as being shown and I’ll do another vector above and trying to actually touch the iliac crest, kind of like two needles meeting at the same point and do it just what Matt mentioned with the middle Glendale nerve, where I’ll, I’ll, I’ll twist the needle to comfort to get the needle stuck purposely. You know, if you let it sit for awhile, it’ll, it’ll be able to come out, but you want to be able to get it a little bit, uh, wrapped around the tissue so that I can pull both of those needles in opposite directions. You know, one superior the other lateral to help decompress and open that area up. Maybe even a couple needles in, in that, uh, that region might be useful that way, but that would be by patient comfort. And you have to keep in communication with your patient.

Chinese needles are usually the best for that. Some of the, um, the Japanese or Korean Neil’s needles that are coded doesn’t wrap the tissue as well. So, um, our favorite needles for that is watchtowers. And you get the, watch us from LASA RMS. That’s good. Um, we’re about to show you. We’ll be,

Uh, Matt, since I let’s go back just for a second, since we’re mentioning, we both mentioned that, uh, usually you let the needle sit for 10 minutes or however long you’re going to have the treatment. They come right out after that time, but it’s always good to note which way you’re rotating the needle in case there is an issue and you have to D rotate it. Do you want to remember, oh, I did a clockwise. I needed to D rotate a counter-clockwise. So just, uh, to make a note of that is, is useful.

One more thing for me now is that after that needle technique, now this is not just an allopathic needle technique. This is going to be a needle technique for decompressing, that nerve entrapment in the region that you leave with that we’ll be communicating with all of the rest of the needles that you’re using during that treatment. So just to be clear, we’re not going in and doing the different needle techniques and then taking the needles out. That’s actually part of the treatment it’s going to be communicating with the channel systems. Just want to make sure that that was clear, uh, before we go to the next one. So we’re going to have two videos right now. These are some myofascial release techniques that are really very useful to use after the needle techniques. These techniques are going to be taught in the assessment of treatment of the channel sinews module two coming up in September. So these are just two of the, uh, mini techniques that we’re going to be teaching in that weekend class. Um, very useful for, uh, low back pain. And also in particular, these nerve entrapments. Brian, can we just go for it? Yeah, sure.

So this is a very simple technique just to spread and, and descend the tissue or the erector spinae as part of the urinary bladder sinew channel. A couple of considerations though, is as we’re spreading down the urinary bladder line, when we get to the iliac crest, we have a couple options. If the patient has an elevated ilium, may hike your Liam up. We might work a long, the iliac crest to be able to descend that tissue, but also to help, uh, push the helium down. In addition to that, a posterior tilt moving from medial to lateral will help sort of put the tissue back into a place. That’ll take them into an anterior tilt. So either posterior tilt or ilium elevation, I can take that tissue then to, from a medial to lateral position, they have an anterior tilt. I might gently come over the ilium, just being sure not to push into the bone and then descend down through the fascia over the sacrum. We’re going to find a good starting place somewhere around the inferior angle of the scapula. I want to be careful not to dig my elbow into the spine, but I’m going to be pretty close to the Lima, but the bulk of the pressure is going to be along the urinary bladder line sink in, and then slowly spreading downward [inaudible]

Patient movement. They can just gently take a nice deep breath and breathe in to the pressure

And exhale [inaudible].

And again, when I get closer to the OEM, that’s when I need to make a decision based on my assessment to either spread along the top of the iliac crest, going medial to lateral or in this case, I think I’m going to be careful not to dig my elbow into the bone. And I’m just going to continue downward to take the pelvis or influence the pelvis into a posterior tilt. Yeah. I can have the patients slowly talk to the pelvis under and relax one more time and track the glitch. Just try to slowly, just a little bit tuck under. Yeah, there you go. And that feels like a good place to exit.

Okay. It’s a very nice technique, especially after Neely needling in that area and helps reduce any kind of needle soreness. And then we have another one coming up, which is in particular really great for the sacrum and middle cluneal nerve. Brian, do I say anything before we jump into it? Nope. I

Think it’s about to start anyways. Or maybe that’s that play? Yeah, I think the video will describe it pretty well.

So it will be well working on the attachments of the glute Maximus, especially the sacral attachments and just that spreading and moving kind of softening the attachments along the sacrum. Very nice technique. Uh, we can adapt the technique to somebody who has a posterior and anterior tilt. This model. We have an anterior tilt, but I’m an exaggerate. The anterior tilt. You can imagine with that, that it’s going to be much more effective if I move that tissue away from the sacrum. Yes. But also downward to help encourage more. Posteriority tip the pelvis. Conversely, if somebody has posterior telecon tuck your pelvis under. Yeah. And in that case, you know, if you were working in that same direction, it’s going to encourage them more into a posterior tilt in the RDR. So it would make more sense to come from a different angle and help lift the tissue to help encourage more anteriority to the pelvis.

So we can adapt that general direction. But in both cases, you’re moving the tissue away from the sacrum, either away and down kind of lateral and down or lateral and up. So we’ll start with lateral and downward. I’m going to set a little bit out at the edge of the table. My side is towards her, so I can gently let my body sink into the tissue, using the elbow. Also a little bit of the proximal, although I’m going to go right to the sacral attachments, think perpendicular and then spread slightly lateral just to distract the tissue away from the sacrum, an inferior. I might have the patient gently and slowly tuck the pelvis under just the small movements, adequate good and relax, move slightly downward, get another area of the tissue sink in, talk under and move. That movement that you’re doing is going to help them talk the pelvis under relax [inaudible] and slowly, gently talk under

[inaudible].

So in some instances you might, especially with an anterior tilt, you might add to the technique I put in the patient into sort of a crawl position. And you can see in this position, that’s going to encourage even more of a posterior tilt of the pelvis. So I can do similar technique here. Again, similar technique with them in this position. And the position itself is going to encourage more of a posterior tilt

[inaudible]

And I might hold a little longer in this particular position.

[inaudible]

Okay. That was great. So with that crawl position, you could see that the long posterior sacral ligament will then be slackened because the attachment sites were brought together closer. The PSIS went into a posterior tilt and his Brian’s elbow was right there. Pretty much level with S two S3 S four region. So what a great technique for sacred iliac joint problems, as well as if you are suspecting any kind of, of middle cluneal nerve entrapment, Brian, anything you want to say before we do our conclusions?

No, I think, uh, I think we’re, we’re good. Um, just the fall assessment really to differentiate what’s causing the pain. Is this a contributor or is this really a sacred iliac joint problem or is this a facet joint problem? Um, thoracolumbar junction syndrome for me is one that’s really tricky to differentiate between just because of those nerves can also be involved in thoracolumbar junction syndrome, but they’re involved, uh, not as they exit the thoracolumbar fascia, but they’re involved, uh, in route to, to that region. So those are, those are a little trickier to differentiate, but looking at all, differentiation for all of those really ruled out which one is, or, you know, figure out which one is really the pain generator is important.

Yeah. A thorough differential diagnosis. Yeah. With through sports medicine assessment, and also through TCM, which is something that we do in sports medicine, acupuncture certification program. So you guys, if you like our education, please come join us at www.sportsmedicineacupuncture.com. You can also reach out to Patricia, which is, uh, through email AQI sport info@gmail.com. Um, I believe that’s going to be wrapping it up for us. You guys thank you so much for staying the extra time. I know that these are only supposed to be a half an hour, so thanks for the extra time and also come back next week. Cause we have Chen Yen coming in. Who’s going to be discussing a lot of great things. So, uh, Brian, it’s always a pleasure. Thank you so much. We want to thank the American Acupuncture Council for having us. Thanks for much you guys. And we’ll see you again soon. Yeah. Have a great day, everyone. All right. Bye

Callison-LauHD07072021 Thumb

Motor Points and Trigger Points: A Compare and Contrast Discussion

 

 

We want to talk about the compare and contrast of what is a motor point, what is a trigger point, which is a very, very common question and also how to use them clinically.

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. Thank you very much for attending our Sports Acupuncture Webinars sponsored by the American Acupuncture Council. My name is Matt Callison. I’m here with my colleague and good friend,

Brian Lau. So

Last month we had Josh Lerner as a guest. I was not able to make it last month, but Brian and Josh talked about trigger points quite a bit, and the pathophysiology and also different clinical uses. We wanted to this month to discuss and build upon last months, a narrative. We want to talk about the compare and contrast of what is a motor point, what is a trigger point, which is a very, very common question and also how to use them clinically. So before we actually start going into, let me talk about Josh a little bit here on the reason why we have him is he’s like Brian, who is, uh, not only just an excellent clinician, but a true academic. So that’s a pretty rare combination to have, uh, Josh graduated from the north west Institute of acupuncture and Oriental medicine in 2001. And he’s currently on faculty of the Seattle Institute of east Asian medicine, or he’s teaching orthopedic medicine trigger point theory, muscle-skeletal amp and also points and channels. Now he’s studied with Tom Bizzio and Frank Butler for quite a while. Starting in 2006, he also started taking trigger point release, uh, acupuncture trigger point release in 2007, and started dry needling classes in 2016, which he has become certified in dry needling in 2019. Now being an overachiever that Josh is, he also took the smack program at the same time and graduated from the sports medicine acupuncture certification program in 2017. So Josh is welcome. Thank you very much for coming Josh and help us out with this podcast webinar. Really appreciate it.

Thanks for having so you appreciate being asked back for this.

Yeah, absolutely. Well fun. All right. So we only have 30 minutes, so let’s jump right into what is the motor point? Well, you didn’t get into the trigger point, then start talking a little bit about case studies and how to be able to use them. Uh, first things first, the motor point when I first started studying them, this would be before I was an acupuncturist when I was going in and, uh, physical education and athletic training school at San Diego state university. I graduated from SDSU in 1986. Now in the training room, we were taught to use one inch by one inch or two inch by two inch could be even four inch by four inch electrical pads to place them over the central aspect of the muscle in order to influence the muscle belly or the motor point region. Now, it was common to be able to use these pads on agonist and antagonist muscles, for example, hamstrings and quadriceps, or even on hamstrings and then to a distal tendon or a proximal tendon in order to influence the electrical energy of that particular muscle.

Now, when I became an acupuncturist graduating from Pacific college Oriental medicine, which is now called Pacific college of health sciences, graduated from Pacific college in 1992, always was curious about the motor point and wondered as an acupuncturist. What would it be like to take a highly conductive electrical material, a stainless steel needle, and put it into this region as defined as having the lowest resistance to electrical conductivity. So therefore we, you have a region that has the lowest resistance to electrical electrical conductivity. That means that there is a enormous amount of cheap potential to manipulate. Now, of course, an acupuncture needle is much thinner than a one by one or a two by two pad. So therefore I started my journey and researching motor points. Where are they located at that time? Nobody was really talking about motor points, trigger points was the big thing.

Um, it was still under a lot of influence of Janet Chevelles and Dr. Simon’s enormous work and trigger point theory and their books as well. Um, and at that time, I, like I was saying, motor points really weren’t discussed very much. They were mentioned in the Shanghai text of acupuncture, which is an interesting read with that. And then going online and trying to find who was actually doing acupuncture on motor points, um, was Dr. Chan Gunn. Now he was up in Canada and he was also researching on motor points, but she’s got some incredible research if you guys wanted to go and check that out on Google scholar, um, being more of the dry dealer, um, he was really staying quite a bit away from traditional Chinese medicine and taking it more toward the dry needling aspect of it. And so we’ll finish that story at another time.

So what I found was taking acupuncture to the Motorpoint region was changing range of motion, changing muscle strength, decreasing pain. And this was really very, very exciting. Um, but trying to find where those motor points are at that time was very difficult because there really weren’t that many maps available. It was more of a line drawing with just like a black dot on it. So gathering a number of different research articles. I think it was in the forties or fifties, and today it’s well over 300 research articles that I have on motor points in their locations. But back then, there wasn’t very much so collecting that information and then also electrocuting a triathlete friend of mine with the surface surface electrode, trying to find exactly where these motor points are. Then I would map them and then locate them according to bony landmarks and acupuncture points for the acupuncturist.

Now this was way back in the early 1990s. And that was when the motor point manual came out, which I even have a copy of that anymore, but also the motor point chart came out and I’ll since then, it’s also has been updated the motor point chart. And this just came out in 2019. The original came out in the year 2000. Also some of the work that I was doing back then in the year 2000, I actually collected a whole lot of notes and started writing quite a bit and then published this treatment of orthopedic disorders manual, which came out, like I said, in the year 2000 or actually 1998, it came out and it’s been used at all three Pacific college campuses since then now in 2007, then my research came out and published the motor point index in 2007. So long story short, my work has been out there for a long, long time and has actually influenced quite a few people over the years.

Um, this has a lot of accountability and a lot of responsibility to it because even as today, Motorpoint locations have changed a little bit. The definition of the motor point has changed. Um, motor points. Now over these last 15 years are talked a lot about you’ll see research articles all over the place. It has infiltrated our field pulled a lot from the work that I have created, but then also what other people are also doing with motor points. So it’s, it’s something that is needing some discussion about what is a trigger point and what is a motor point. Now, the definition of the motor point in the 1940s, fifties, and sixties was basically an umbrella term for where the motor nerve inserts into the muscle belly and where the motor nerve inserts at the intramuscular junction, the neuromuscular junction. So both of those locations, which can actually be far away from one another in a muscle was the umbrella term called motor point.

Now recently, I would say within the last five to seven years, you start to see articles talking about motor entry points. And this is actually a better way of describing where my work has actually been taken is I’ve been looking for the motor point where it goes actually into the muscle belly itself. And the reason why is because it has the largest diameter of the motor nerve, then going into that motor point and has the lowest resistance to electrical conductivity, I’m taking that acupuncture needle and inserting it into that spot is where we can actually change quite a few things within that muscle, not only within the muscle itself, but also how the central nervous system views what’s happening within that muscle.

So the interesting, interesting thing about this is with motor points, like I said, that’s more of an umbrella term for what’s now being clearly defined as a motor entry point or where the motor nerve inserts into the neuromuscular junction would be the intermuscular motor point. So again, as the motor nerve comes in and inserts into the muscle itself has the largest diameter that goes into the motor into the muscle. Then it usually will bifurcate and go into a proximal part of the tissue. And also the distal part of the tissue sometimes close within an inch sometimes far away, six to eight inches, depending on the length of the muscle. So these collateral branches from the motor nerve travel within the muscle tissue and then insert into the actual muscle itself back can be called the intramuscular motor point. So we have motor entry points. We have intermuscular motor points, VM umbrella term would be motor points.

So I hopefully that actually helps. Um, you don’t really see motor entry point too much discussed in our field, but I’m sure it will start to spread over this next five or 10 years. Just, just because that gives us a little bit more clear definition of what exactly we’re trying to be able to treat. Now, the motor entry point is where the green triangles are on the sports medicine, acupuncture textbook, and also on the motor point chart, that’s where the motor entry point is located. Okay. So then now the intramuscular motor points themselves, um, those can actually be turning into trigger points with Josh and Brian and I are going to go ahead and discuss that in just a little bit or a trigger point can also develop, uh, at the location of the motor entry point. So from here, why don’t we now start to compare and contrast with the trigger point? Josh, do you want to take it away or Brian, do you want to add anything?

Yeah, I’ll, uh, I’ll step in here. And so Matt and I have had lots and Brian, Matt and Brian, and I have all had lots of discussions about, um, comparing and contrasting, um, trigger point phenomenon with motor points. And so there are a few different, um, dimensions within which we can kind of talk about these both contrasting differences and comparing areas that are similar. So one of the things to keep in mind, especially once we start talking a little bit more clinically, is that as helpful as it is to really talk about the, the differences between ideas about motor points versus trigger points to a large degree, especially clinically there’s a huge amount of overlap. And it’s a, if you really like Venn diagrams, there’s like a big circle about trigger point phenomenon and a big circle about Motorpoint phenomenon. There’s a huge gray area of overlap between the two of them.

So I’m going to try and keep that in mind as I’m discussing this, but it might sound at times like I’m being a little bit arbitrarily black and white about differences between them when that’s really not the case. So, um, one of the, one of the areas of contrast is that the motor points are basically a, a normal physiological phenomenon. Everybody has motor points. It’s just how the body works. Whereas trigger points are very specifically a pathological phenomenon. I’m not going to talk too much about the details about trigger point physiology, Brian and I spent an hour actually last time talking about a lot of that stuff. And so if you want to brush up on that, you can kind of go watch the previous podcast that Brian and I did. I think there are also going to be some links to some other discussions that Brian and I and a few others have had about trigger point stuff.

So you can refer back to that. Um, so that’s the first contrast is just normal physiology versus a pathological condition, right? Trigger points. Are they form due to some kind of muscle damage, right there, a small contracture in a muscle fiber that is the response to either like an excessive eccentric load or, uh, a low level contraction that goes on a long time and kind of wears out the fiber. Uh, another, another type of contrast between them is that motor points in a lot of ways are more like acupuncture points in that not only everybody has them, but the, the locations tend to be somewhat predictable, even though there can be quite a bit of variety of from person to person, whereas trigger points can really form just about anywhere in a muscle. So when you’re looking to treat trigger points, you really have to palpate the entire length of a muscle.

Whereas when you are treating motor points, um, you’re generally starting from a somewhat relatively defined position. Like it’s, uh, say, you know, in the middle, like the middle part of a muscle, or like in the case of say the rectus femoris, one of the common motor points is going to be halfway between like stomach 31 and hunting, right. You still have to palpate locally and the actual location you’re going to be looking for like a kind of an usher point. It might be, you know, one up to sooner, so away from that point, but you’re starting roughly from [inaudible].

Um, another, another area of contrast, uh, that I think will probably open up interesting discussion because Matt and I have talked about this quite a bit is how you use them clinically and what muscles you choose to treat, whether if you’re thinking about a trigger point versus a, um, a motor point. And so I’ll just kind of talk just very briefly about my take on this and then maybe, uh, Brian and Matt, if you guys want to pop in and, uh, contradict what I’m saying. Awesome, nice and heated, spicy debate going. So motor points in my practice, I tend to use very, uh, very kind of more generally to really overall improve the functioning of the muscle and to treat in the sense of the little skeletal homeostasis, what I’m really focusing a lot on biomechanical issues, where there’s a joint dysfunction in gallons of muscle pull across a joint, or are treating, uh, a muscle in one area of the body.

And I want to treat the entire senior channel. I might need other muscles more display or more proximally in that CGU channel. I’m 10 years motor points is in those locations, more commonly, um, and for trigger points, I tend to overall use the more specifically to treat the referral patterns when there’s pain or some other like parasthesia, that might be part of the referral, but even having said that there’s a huge amount of overlap between them. And so I also very commonly will use trigger points to treat more general biomechanical issues and old very often also use motor points to treat painful conditions. Um, and there’s a more subtle distinction to be made. And how I diagnose personally between the use of those two things. Um, it has to do with the fact that when you have pain, sometimes the pain is coming from a motor point, but you can have pain due to a muscle dysfunction that isn’t sorry, a trigger point.

Um, you can have pain from muscle dysfunction that is not from a trigger point pain, but just you can have pain because the muscle itself isn’t firing correctly, which can send signals to the central nervous system, kind of a warning signal. That just something isn’t right. We’re going to just give you some pain. So you stop using the muscle. Um, so you can have cases of pain that are in a muscle that are not to the trigger point, but they can be helped a lot by motor points. Um, so there are just kind of muddied the whole discussion a little bit with that. So I I’ll, uh, let’s open this up, Matt, Brian, uh, what do you guys want to talk about in terms of that?

Uh, Brian, I’ve got a few things to say, but why don’t you go ahead and start? Uh,

Well, I just say something simple and that’s, uh, you, both of you guys painted an ice clear picture of, uh, a difference between a motor point in a, in a trigger point. But if you look at a lot of the discussion and sometimes even the research out there, it’s not always so clear cut as, as Josh kind of alluded to it, the Venn diagram of how they overlap in terms of, um, comparisons, but even in terms of discussion like Matt was mentioning, sometimes they use the term motor entry points, sometimes motor point to encompass all of that. It’s not always very, um, consistent sometimes there’s discussions of trigger points that talk about, like, I saw several research articles that talked about an anatomical basis for trigger points. And they were basically looking at the motor entry point as the site of where trigger points tend to form.

Um, so the it’s not so clear how we’re going to try to discuss it from a, um, you know, compare and contrast and as if they’re different, but there’s a lot of overlap out there. So if you’ve looked into this at all, sometimes it’s easy to get confused because it’s confusing cause there’s a lot of different, different people saying different things about it that aren’t always consistent. Um, and I know this isn’t the case with the newer edition at Trevell and Simon’s book, but, um, in the previous additions, you know, they had Xs on sort of the frequent location of where a trigger points tend to form. And there was numbers, you know, like trigger point number one, upper traps trigger point number two, and in a different regions and different kinds of common sites. Now, of course, within that common site, you’d have to palpate and find the exact location.

Um, uh, and it’s going to be very variable, but there were sort of go-to sites, so to speak. And, um, if you look at those go-to sites, you’ll see that those go-to sites tend to be at the motor point, the motor, uh, close to the motor entry point location, um, where the muscle is getting the innovation. So, uh, the reality is that motor points are at the location of where common trigger points form, and both of them share one similar thing in their description and their language is that a motor point is the highest concentration of motor in plates. It’s a motor in plates or the cite on muscles that are, uh, have receptors for acetylcholine. So a motor point is the highest concentration of motor end points, a boater, um, in plates. I think that’s more of the classical definition of, of a motor points. Now with motor entry points, that’s more about the entry side of the nerve, but the classic definition going a little farther back as the highest concentration of motor in plates and trigger point in the language is often described as forming at the site of the highest concentration of motor in plates. So there’s a lot of parallel and there’s a lot of overlap and it’s not always clear to differentiate one from the other, my turn.

All right. Thanks Brian. Um, Josh Brian, that was awesome. That was good. Uh, in, in my mind, the motor implants are going to be where the intramuscular motor points are a little kid at, um, where the motor nerve enters into the muscle. There can be collateral branches that go into the motor end plates, but not always. So let’s now take this information and see if we can be able to bring it into some kind of clinical sense, for example, let’s I remember before we get into clinical sense, let’s remember that motor points also can be used as empirical points that will take pain away from a distance site. And that pain from a distance site has nothing to do with the trigger point referrals. Like for example, a flexor carpi ulnaris motor entry point is pre magnificent and taking pain away from the levator scapula attachment.

And that lateral posterior side of the neck or the piriformis motor entry point takes pain away from a urinary bladder 10 region. So there’s a number of different ways of looking at the motor entry point. And also what the trigger point is. Let’s say that tomorrow a patient comes in with sciatica, you use slump tests, you use straight leg, raise tests, a neural tension test, and they’re negative. So it doesn’t seem like it’s true sciatica. So what could be causing the sciatica like sensations? There’s a number of things that can, for example, a Fossette joint can cause referral pain, a sick really act joint can cause referral pain trigger points can cause the sciatica like referral pain. So let’s say that with this patient that you’ve done slump test and straight leg raise, and you’ve ruled out sacred iliacs joint dysfunction or Fossette joint dysfunction.

And you’re palpating along the iliac crest where the gluten minimis attaches and you find with palpation, it reproduces that patient’s sciatica likes sensations. This is just in the hypothetical example. So you’re looking at the glute minimus at its attachment side, or maybe the muscular tenant is junction site that you’re palpating around that area. And it’s a way from the motor point, which would be the muscle belly halfway between the superior border of the greater show canter and the iliac crest. That point definitely needs to be treated because it was causing this person sciatica or sciatic, like sensation definitely needs to be treated and TCM. We look at it as being either as an access or deficient, is it cold? Is it damp? And we are treated according to how we know how to get rid of and resolve damp or treat cold, reduce access, reinforce the deficiency.

It’s all going to be predicated on your palpation. Now, from my experience, if we treated the motor points of the gluteus minimus, first that trigger point that was located two or three inches away would be difficult to find it’s not going to be reproducing that same type of parasthesia. So from my experience, I would like to treat the trigger point. First, what I’ll do clinically is treat the trigger point first because that’s what’s causing it. And they’re like what Josh was talking about before let’s treat the motor entry point, cause that’s going to be then communicating quite a bit, the central nervous system about where that muscle is in space. You guys want to comment on that? Yeah. So

I think, um, another really great aspect to think about motor points is that in that particular case that you’re talking about, the motor points are also going to be incredibly useful to then treat the other muscles that might be involved in why that glute minimus develop trigger points in the first place. Right? So there may be, uh, there may be some, you know, if there’s like a pelvic imbalance where you have to look at the balance between the, the hip, uh, AB doctors like the glute medius and minimus plus with the add doctors plus with like the QL, um, that there may be this larger muscle imbalance issue between keeping the pelvis level in the, in the frontal plane, right? So it could be that treating the motor points of the adductor longus and brevis the quadratus lumborum and even using the motor points more in a TCM sense of looking at excess and deficiency to try and balance.

A lot of that is going to be a really important part of the treatment to keep that one gluteus minimus that’s causing referral pattern to keep that from developing further trigger points, right? Cause the trigger points could just be the end result, like the last symptom of a dysfunction that has been going on from these other areas, right. Um, where you might need to treat motor points, uh, down in the, in the cap for any of the motor points for the muscles that control the foot of the ankle. Cause maybe the glute minimus is developing trigger points because of its being overloaded because of an ankle dysfunction. Right? So I think that’s another aspect to the balance between looking at trigger points versus motor points that can be really helpful clinically. Awesome. Brian, anything you wanna say?

Yeah, I would just add into that some distal channel points do it. Now we have a pretty comprehensive picture. You know, we, we use this one a lot with the glute medius and minimus minimus in this case. Cause it’s clearly on the gallbladder sinew channel ma uh, Josh mentioned the quadratus lumborum and the add doctors, which we on time to go into it now, but the QL is, uh, part of the liver send you a channel as the ad doctors are. So you could also include points, um, to affect the relationship between those channels like sourced and low combination gallbladder, 40 liver five would be a really good combination that we use quite easily in the program. So you do, maybe we have this one point, that’s creating a referral, but it’s linked, uh, functionally with other muscular structures. So glute minimus in this case, linked with quadratus, lumborum add doctors in terms of how they’re in dysfunction together. So we can use motor points and trigger points and combinations of those muscles along with distal channel points. And that’s a to create a good local distal and point combination from a TCM standpoint.

Oh, awesome. Yeah, that’s good. Let’s go farther into that. So remember you guys, Osher points have been treated for thousands of years. So trigger points and tender motor points have been observed and treated with traditional techniques. And in some of the discussions that Josh and Brian have had is that when a trigger point is located in a different location than the motor entry point, it’s really common to find a tight palpable band linking the two. So for example, from the motor entry point, if you cross fibered toward the trigger point, many times you’ll actually find that type palpable ban linking the two, which maybe is why punk’s a needle technique was developed, which is really quite common in myofascial acupuncture by kneeling three or four needles in a row within that tight palpable bag. One of the needles would be at the motor entry point.

One of the needles are two of the needles might be the trigger point. So you’re covering those bases. And then as Brian was talking about linking that particular channel with points that will open up the channels in the collateral Xi, cleft Lubo points and such, and let’s also remember this patient, what’s their internal balance. What’s happening with them? How well can they handle inflammation because it’s on the gallbladder channel. Well, how is their liver and gallbladder functioning in their life? Could the liver and the gallbladder be contributing to part of this clinical picture? Always something for us to be able to consider is people are not just coming in as meat suits. We treat the entire patient. Great discussion. You guys.

Yeah. Another really interesting aspect to, uh, bringing TCM theory into this is also looking at, uh, general, like we get into TCM basic constitutions, right? There’s I very often find an element of spleen Xi deficiency with certain types of people who tend to develop a lot of trigger points because of the, the spleen’s ability to supply energy to muscles. Right? Cause the trigger point formation is in a sense of problem with energy supply to the muscle after it gets damaged, right? There’s a, there’s a very strong case to be made for looking at the importance of blood status and using herb formulas to treat a lot of blood status. Um, I think I mentioned maybe in a previous discussion that Brian and I had, I’m a big fan of the drew Yutang family of formulas for treating various types of musculoskeletal pain for that, uh, for that purpose. So I think that that’s, that could be a whole other podcast. We could talk about like a TC woman also talking about like postural distortions and TCM constitutional diagnoses, and then talking about muscular relationships between postural distortions and TCM stuffs. That could be a whole other thing we can get. Right, right.

That would be hours and hours and hours or people would just go to the smack program. Right. Well, this has been a great conversation, you guys, and I think there’s a lot of clarity that was added to this. Um, we are right approaching that 30 minute mark right now. Is there any closing comments that you guys want to be able to say?

Uh, I’ll just say, well first, um, Matt and Brian, thanks again for inviting me to do this. I really appreciate it. And uh, I just want to put it out there for everybody listening that the, the, the smack program, the sports medicine acupuncture program was one of the real turning points in my career. It kind of brought together, even though I’ve done a lot of work with trigger points and some orthopedic stuff before then, um, it really brought together, uh, so many different elements of what I was trying to get at when I was doing, um, orthopedic work with my patients that it’s probably saved me 15 or 20 years of studying on my own, trying to do a lot of this together. So I just wanted to say, thank you, Matt and Brian for, uh, giving people this opportunity. Great.

Well, thanks for that, Josh really appreciate that. And that’s good. Um, yeah, it’s always welcome. And no, Josh, you didn’t bug me with your questions during the smack program where you sat down as a no, no, you just have very inquisitive mind. And the thing is, is that kind of dialogue is so welcome to because other people are stimulated by that kind of conversation. So it’s always welcomed. So thank you, Josh, for that also for more, let me finish this one real quick, Brian, for more information about Josh in the comments section, there’s, uh, three different links that, um, he’s talking about trigger points for anybody who’s interested in a motor point chart or motor point book. There’s also, there’s going to be links for that as well. Go for what Brian.

Yeah. On the topic of, uh, messages coming up, there was a question which we could go into a lot of detail and we don’t have time, but it was about osteoarthritis of the hip. Um, and I just want to quickly say that the same discussion we were just having about balancing the pelvis, um, by using motor points, uh, in terms of like, if there’s a, uh, elevated Lem, QL, glute medius, and minimus, and the combination of motor points, plus distal points, that’ll help balance the hip joint would be really a great idea for osteoarthritis, but you could also look at, uh, what trigger point referrals are referring to that region of pain. The hip joint itself can refer pain and can be, can be the pain source. Sure. But since we’re talking about trigger points and motor points, looking at the trigger points that are part of that referral, uh, it could be that the trigger point is causing 20, 30, 40, 50, 60% of that pain. Um, so also treating the, the, uh, looking for trigger points in those, um, regions that could be referring to that area would be a, it would be a good idea to start with

Joshua say something, I’ve got something to add.

Um, uh, the only thing I would add to that is if you’re not used to looking up trigger point referral patterns, it not is going to not just be the muscles locally to the hip, right? One of the muscles that might recreate something like osteoarthritis of the hip could be like the lung just amiss muscles up around the thoracolumbar junction around T 12, right. That can refer pain down to the truck hacker. So there’s a lot that has that a lot of, um, resources out there to allow you to look up for pain in one particular area of the body, what is the list of different muscles that can all refer to that area? And it’s really helpful looking, you can find those online it’s in Trevell um, uh, yeah, very useful resource.

Um, just to add some clarity with this one, cause I don’t know what kind of diagnostics were made with the osteoarthritis. So the patient may actually have confirmed osteoarthritis, but now these comments that we’re making is that, um, there also could be, uh, pain contributors, which would be trigger points. So as we know, uh, trigger points can also live not only in muscle tissue that we’ve been addressing over these last couple of hours is also can live in joint capsules, tendons, ligaments. So needling the joint capsule itself may also help in this particular case as well.

All right. Anything else, gentlemen? I think we, uh, we covered most of the stuff we wanted to cover.

All right. Well thank you very much. Really, really appreciate it. And so stay tuned for next week, come in, check in, check out Jeffrey Grossman for next week. And Brian is, was nice hanging out with you, Josh. Thank you so much. Really, really appreciate it. Thanks you guys. Bye now. Bye-bye

 

Callison-LauHD06012021 Thumb

Clinically Relevant Trigger Points

 

 

So we’re going to talk, uh, about some relevant trigger points. There’s a lot of relevant trigger points, but we tried to narrow it down to ones that are probably the most frequently seen in practice, especially ones that are good to with, for practitioners who maybe don’t use a lot of trigger points or wanting to get into working with trigger points.

Click here to download the transcript.

Click here to download the slides.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Welcome everybody. I’m here with Josh Lerner and I’ll introduce him in just a moment, but I just wanted to give a little heads up. Matt Callison and myself. Uh, co-present uh, frequently on this webinar that the American Acupuncture Council is kind enough to welcome us to. And I, Matt couldn’t make this particular, uh, uh, date and we’re here with Josh Lerner, but the reason I’m mentioning that is the subject matter we’re talking about actually has roots in some conversations we’ve had with Josh over the past couple of years, uh, specifically looking at the difference between motor points and trigger points, difference, comparison, uh, overlap, you know, uh, just a, it’s a, it’s a really great topic and that was going to be our webinar. But, um, the dates didn’t work for Matt. And, uh, we’re going to have this as part one where we’re talking a little bit more specifically about trigger points and then looking at part two on July 7th, Josh will be back with us and we’ll kind of get a little bit more into that difference between difference and again, comparison between trigger points and motor points. So thanks for joining us today, Josh.

Thank you, Brian. I appreciate being invited to do this. It’s always a plan involved with doing that.

Yeah, yeah. It’s great to have you here. So Josh, uh, Josh is up in the Seattle area and the Pacific Northwest has been practicing for 20 years. Um, and teaching at the Seattle Institute of east Asian medicine for 11 years. Uh, is that correct?

Yep, that’s it. Yeah.

And you focus on a lot of things, but uh, particularly in specifically relevant to this, uh, webinar with, uh, orthopedics TuiNa and corrective exercises.

Yeah. That’s a main part of my practice. So I incorporate a lot of the sports medicine, acupuncture protocols, as well as stuff, uh, dealing with trigger points, uh, corrective exercise, you know, movement assessment and lots of manual therapy with, uh, including things like 29.

Yeah. And Josh is also a graduate of the sports medicine acupuncture program. And like myself has a pretty long history in martial art practice, which I think is what gets a lot of us into this work initially, which is interesting. Yeah. Yeah. So there’s definitely, we would like to chat for a bit, but there’s a lot of material to present, so maybe we will go ahead and jump right into the, uh, the presentation and Josh, let me know if there’s anything you want to add before we, uh, go into that. Ready to go. We’re good. All right. So we’re going to talk, uh, about some relevant trigger points. There’s a lot of relevant trigger points, but we tried to narrow it down to ones that are probably the most frequently seen in practice, especially ones that are good to with, for practitioners who maybe don’t use a lot of trigger points or wanting to get into working with trigger points.

Um, this will be a, a chance to kind of go into those specifically though for a short webinar. We’re not going to really get into a lot of needle technique, which takes a little bit more set up. We’re going to try to put it into the context, more of, um, assessment recognizing and when, when to look for these and when to, um, utilize them and maybe even some disappointed channel theory with it. So let’s go to the next slide and we’ll jump right into that. So I’m strictly speaking, uh, myofascial trigger points, uh, or just oftentimes referred to as trigger points are a concept that’s developed in Western neuromuscular medicine. Uh, so there’s a history of it. Um, we’ll probably mostly be talking about the, the work of Dr. Janet Reval and David Simons or David Simmons. Uh, but there’s a history that goes way back, many people involved with it. I guess you could say a history that kind of parallels some, some discussions that happened in Chinese medicine, but it’s a, it’s a Western history. However, if you look closely and you, and you’re versed in both traditions, you will definitely see a lot of overlap. So we’re going to discuss the overlap, but just keep in mind that that overlap is

Not strict

Trigger point in the, you know, if you get travails books, she’s not going to be talking about the large intestine channel. Um, but there’s a lot overlap if you look for it. And just a as one quick example, looking at this picture on the right, we have two pictures actually on the left-hand side of that image, there is a supraspinatus trigger point referral patterns. Superspinatus access in the region of SSI 12 though, it’s attachment at ally 15, my tendonous junction around ally 16. And then you see the referral going down the large intestine, a little bit, the lung channel, but primarily the large intestine channel. So this muscle superspinatus as part of the small intestines sinew channel. However, there’s a link with the large intestine channel. So on the right, many of us are familiar with this Deadman image and you’re looking at that large intestine channel, um, where you see some of that trigger point referral pattern.

But it’s interesting to note that from ally 15 and to ally 16, where you would have access to the superspinatus, the channel then links, uh, intersects at SSI 12. So even the description of the large intestine channel starts showing some relationships to this, uh, um, superspinatus muscle and how there’s a relationship between both the referral pattern and the channel itself. We could talk the whole webinar about relationships between this, this type of thing between the channels and the trigger point referrals. But unfortunately, that’s not the topic though. Fortunately, we had some really great things to say, uh, uh, in addition to that, but Josh, anything you wanted to, uh, add or any thoughts that you have on, on this? I know we talk about this a lot.

Yeah. I’m not a whole lot, but just as a general idea, it’s something that people can really do is if you’re interested in this kind of thing, look at referral patterns and Trevell or other resources, but look not only at the main pathways of channels, but also delve into a lot of the law channels. Um, some of the other less commonly really known, uh, although everyone knows the law channels, but, um, the ones, your, a lot of the connections you’re not normally going to think of very often, you’ll see more connection with the trigger point referral patterns there than if you’re just looking at the main channel pathways. So in some ways you can kind of use this as an opportunity to go back and delve into traditional channel theory and kind of get into some details and start uncovering some connections you might not otherwise have thought about.

Yeah, and to me, it seems kind of obvious that the channel system in Chinese medicine has a pretty long history, a long tradition, many things that added to the development of the channels. But I think a simple one is that people were probably needling areas and node and noting and, uh, seeing the common referral and saying, oh, there’s something about needling at that SSI 12 region that kind of refers, um, down a particular pathway. And that was, you know, that, that, I’m sure I had a big part of the development of the channel system. And in addition to other things

I absolutely, yeah. Alright.

I think we can jump into the next slide. So just to give a definition, a myofascial trigger points are a hyper irritable spot in skeletal muscle that is associated with a hyper-sensitive palpable nodule and a top band. We’re going to break this down and talk a little bit more about it in a second. Uh, the spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. This is the definition in a travail and Simmons book, the trigger-point manual, which is a great resource, a two volume, uh, resource. And you can see some of that play out in the image on the left, which is showing the sternal head of the, uh, um, SCM muscle sternocleidomastoid and the referral to the sort of frontal region occipital region Vertex of the head a little bit into the face when you’re looking at these referral patterns.

Something to take in, uh, into consideration is the darker, the red doesn’t necessarily indicate more pain when there’s referral. It’s more about frequency. You know, that that there’s going to be, uh, the greater frequency of that sort of frontal region for the sternal head occipital region. And these spillover regions are going to be a little less common, but still, still common. Uh, but the intensity of that pain might be, uh, for patient a might be greatest at the Vertex of the head. I would say it tends to be greater at those, those, um, more common sites, but, but that’s what it’s showing is more frequency of referral, uh, with the spillover being less frequent. And Josh, do you want us to actually break down a little bit of this definition? I think,

Uh, well just because one of the things that I teach at, uh, the Seattle Institute of east Asian medicine is a specific class on trigger point theory. And I find that emphasizing really understanding each of the individual words in that, um, in that definition can be really helpful. So, uh, I like the way that I define it, I kind of, you know, the words are shifted around a little bit, but it’s essentially the same definition, but it is first it’s, we’re talking about ones in skeletal muscle. They’re also their trigger point phenomenon that can occur in other tissues, aside from skeletal muscle, a muscle like in periosteum and joint capsules, things like that. But for the majority of what we’re going to be talking about is occurring in skeletal muscle. Um, it is, they occur in a taut band in the skeletal muscle. So whenever you’re looking at trigger points, you’re always going to be trying to palpate for a particular palpable taught band.

Then you will look along in that top band for the, the nodule. Usually it’s some type of thickening or a slightly harder section of that top band, and then you apply some type of manual pressure to it. And you’re looking to see if you can find the most hypersensitive spot in that nodule in that top band. And just understanding that definition itself can help you clinically when you’re trying to start learning this material. And you’re actually going to start looking for trigger points. If you keep all of that in mind, um, it will help with how you’re palpating, um, especially as acupuncturists, we tend not to palpate as deeply for, and as strongly for kind of big gross structures like taut bands and muscles. We tend to be much better palpating for more subtle things like pulses, um, chief lo in channels, whether or not, you know, kind of the spaces between things, the way that a lot of people find acupuncture points instead of big, you know, really obvious structures, uh, which it sounds kind of counterintuitive that that would be harder for acupuncturists to do. But, um, you know, Brian, you have this experience as well. And, uh, Matt and I have talked about this, how acupuncturists it’s, when they’re learning this material, whether it’s looking at motor points or trigger points, there’s always an adjustment period. We have to kind of shift gears perceptually to actually be able to palpate correctly for taught math and muscles compared to focusing on real kind of more subtle things like fascial planes and acupuncture points, things like that. And

You have to know the anatomy quite well, which is something that some acupunctures know really well. But, um, often we hear how that is something that could be a little bit under Todd in school. And I think as a profession, we really need to bring that level of anatomical understanding of

Absolutely.

All right. Well, why don’t we move on to the next slide then? So, uh, just so you have some understanding of some classification of trigger points is they do have classifications, um, a trigger point can be an active versus a latent trigger point. The image here is showing the upper trapezius and the referral pattern active generally would be a little bit larger, probably more contractile tissue, but that’s not the main gist of the definition. It’s really about that. The patient is actively coming in with that complaint. You know, maybe they’re talking about in this case, a cervicogenic type or tension type headaches that are traveling up the neck and, oh, it really hurts, you know, at the temple. So they’re actively feeling that that referral pattern, whereas latent trigger points as any of us have probably noticed we’re in they’re palpating and tissue sometimes. And oh, I didn’t realize I was insensitive.

You know, somebody says that they feel maybe some referral, uh, so it’s late and it’s kind of hidden, you know, maybe it’s a little extra, uh, challenge on a tissue, you know, carrying groceries a little too far, you know, suitcase in the airport or something. Um, and that latent trigger point can start to become an active trigger point. But at this point, Leighton would be that you’re not feeling it until you manually put pressure on it and kind of, kind of, um, highlight it through that pressure. So active trigger points would be, you know, people coming in with that complaint late in you’re kind of finding in the process, a key trigger points, satellite trigger points, I think is a really important thing because, uh, the difference is, is key trigger points. In this case, using the image of the, um, the, the upper trapezius.

You can look at that referral and see that, that cervical region traveling along the gallbladder channel, if we were looking at it from a TCM lens into the temp temporality. So the temporal region, well, you can form satellite trigger points along that pain pattern. It’s like that irritating noxious signal, um, will start to cause satellite trigger points along that referral pattern. So upper traps are, are often a key trigger point that can refer into the head and into the temporal region causing secondary satellite trigger points into the temple region. And it might be that the person coming in is complaining about that pain at the temple. And we go, and maybe a point like Thai Yong or the, um, uh, trigger points, or maybe even the motor point of temporality we use, and that will help. But until we sort of get it at that source, it’s going to be much more likely to come back and be short-lived help, uh, unless we can kind of find those key, uh, trigger points.

So that’s very similar to the channel theory, you know, um, in terms of, uh, us looking at that sort of more of a comprehensive view of, of the, uh, the channel in this case, um, and the muscle within that channel. And then the last classification is central trigger points versus attachment. The previous image of the superspinatus, uh, showed the central trigger points around the SSI 12 region and frequently there’ll be attachment trigger points added this attachment, like an ally 15, let’s say. Um, and generally speaking, the central trigger points have a little bit more, uh, emphasis and trigger point thought, uh, in the sense that if you take care of the trigger at the central region belly of the muscle, then oftentimes the attachment months resolve, or at least, uh, um, it’s more likely to resolve. And maybe, maybe those are the secondary ones that you look at, anything with that Josh,

Uh, yeah, just a little bit about active versus latent because clinically this is one of the areas where people often can run into problems when they really start getting into act, uh, treating trigger points. Um, like, like Brian said, it’s the act of trigger points that actually bring them into the clinic, right? They’re coming in with, um, say pain in the front of their shoulder from like an infraspinatus or a superspinatus trigger point, or maybe trading down the arm and you palpitate. And then you may palpate up around the upper trapezius and find trigger points in the upper trapezius. And even if you palpate them, it may refer up into their head. Um, and you may get distracted because you found this latent trigger point that may have nothing to do directly with the patient’s symptom. Um, but you can actually find latent, trigger points all over your body.

Um, they’re much more numerous than active trigger points. Uh, you, I don’t want to alarm anyone who’s watching this right now, but as you’re sitting there or standing, or hopefully not driving, watching this podcast, uh, your body is riddled with Leighton trigger points. They’re all over there throughout your entire body, but they normally don’t cause problems, but they’re often very easy to find. And so it can be, um, a little bit of a stumbling block because once you get good at palpating trigger points and finding them, you can kind of find them in almost any muscle, not any muscle, but large number of muscles, if you look hard enough. And so that’s where we’ll talk a little bit later about differential diagnosis and how important clinical reasoning is in addition to just palpatory skills. Um, because I, and I’m sure Brian’s done this and anyone else who’s worked with trigger points.

You can spend a lot of, uh, needless energy and time treating muscles that may actually not be helping with their problems. So that’s just one other thing. And also some of the treatments can be, uh, can involve some discomfort for the patient depending on the type of treatment that you’re doing. And so sometimes you’re needlessly causing the patient some soreness afterwards, if you’re doing something like dry needling or mashing on a trigger point manually for a long period of time, when maybe you didn’t need you because the real problem was elsewhere. So that’s just another act, uh, another aspect to active versus latent. That’s helpful to understand clinically.

Yeah, that’s a great point, Josh. I’m glad you brought that up. I see similar things with needling to where, uh, there’s a response, a sensation achieve response. And, um, sometimes that’s not the target tissue that you’ve reached, but instantly, you know, people who are new to this type of work, it’s like, okay, oh, they felt it. I’m going to stop. Now, if it’s painful, you don’t need to keep on barreling through it. But the point is that sometimes that initial sensation you get might be not at the level and the depth that your target is. And it’s not that that shouldn’t be taken note of, but maybe, you know, you’re, you’re wanting to be a little bit different target tissue. That’s going to have a different sensation. And I see that whether it’s trigger points, motor points, tendon periosteum, whatever the target is, is that the target is one thing. Um, and the sensation that you get might be felt at a different region, um, that isn’t your target yet,

Which further strengthens the importance of really understanding the anatomy in three dimensions. If you actually know what it is that you’re, you’re effecting.

Yeah, absolutely. All right. So I think we can get into the next slide and then Josh and myself, we’re kind of bouncing back and forth, but he was going to take it in just a moment from here. So, one thing to consider with that with trigger points is that they’re often, like if you look at travails book, she talks about functional units, um, and this would be a grouping, usually agonist and antagonist muscles. It’s a little broader than just this, but that’s the basic simple definition, um, that they often also share us a spinal reflex. Again, that’s the simple definition, but if you look at our functional units, they often go a little bit beyond just that, but it’s groupings of structures that relate to each other that are functionally working together and often become dysfunctional together. So if there’s a, a pain generator and say the upper trapezius, well maybe also the superspinatus deltoids, maybe even the SCM, those are all kind of, um, uh, dysfunctional together.

And those can, uh, you know, be sort of creating a, uh, problem, uh, in, in terms of how they relate to each other. So needling the, the source of the pain is useful, but also working, um, kind of normalizing the relationship between that functional unit can really give much longer AskPat lasting results. This is something we teach in sports medicine, acupuncture, not necessarily from the trigger point lens, so to speak, but, um, you know, Matt Callison and in his book, um, uh, has, uh, has something called the Watteau arc and something that’s taught in module one. We have module one coming up, um, soon. And, uh, uh, the end of the month, uh, that’ll be on net of knowledge, a webinar for it, and then it’ll be live or accessible after that. But it kind of parallels this idea of a functional unit where you’re working with these groupings of related muscles, but then the Watteau arch, we’re also adding the lotto Jaci points to affect the deep paraspinal muscles for that level.

That’s, innervating those muscles really relevant in a lot of sports injuries, also extremely relevant for patients with spondylosis, where there may be having a reduced neural output to those regions of muscles, like the supraspinatus and infraspinatus, um, that that reduced output and the neural output might not be leading to, um, radicular pain. It might be, you know, preclinical, um, you know, before that radicular level, but that reduced neural output can cause dysfunction in muscles that those muscles then have muscle imbalances that can lead to dysfunction. So including those Watteau Jaci points of that segment can be really useful. We usually do a sets of three. So like say for the rotator cuff muscle, maybe we’re doing C4, C5 and C6 at the lotto judgy points. So that’s a great addition to working with these because you’re also working then with the do channel to some extent, and looking at that relationship between that and the channels, we also get a lot into send you channels in our program. And, um, uh, the way we look at sinew channels and define the sinew channels kind of relates to this functional unit idea too.

So,

Yeah, and I saw, uh, candy justice just asked a question about perpendicular versus, uh, threading needling. I, um, I, I really want to answer that question. It’s a great question. I think given how long we’ve already been talking over just the first few slides, I don’t know if we’re going to get to it. I’ll just say really briefly that the, there are a few answers to that question. One of them is just practical. Some muscles are easier to needle perpendicular versus more, um, threading either with the muscle fibers or sometimes cross fiber. Sometimes it’s a safety issue. If you’re needling some of the muscles over the thorax, for instance, um, you’re going to often be needling more, uh, in a kind of a threading or like a transverse, um, just to avoid going into the pleural space. It’s going to have to do also partly with, uh, in some cases, whether or not you’re going to actually needle with retention versus doing more like a dry needling. So try this, not a very full and, uh, probably satisfying answer, but, um, for the, uh, so we can kind of get on with the rest of the lecture. And I dunno, think we’ll really have time during the lecture to answer any more questions, keep asking them maybe in the, in the conversation after this is posted and like on the Facebook page, whenever we can get to them. But I just wanted to recognize that question and address the aspect of it.

Right. So the next slide.

Okay. All right. So, um, understanding the pathophysiology of trigger points, meaning both the physiology and pathology of them can also be really helpful when you’re thinking clinically. So first just understanding what a trigger point actually is. And for the next few slides, when we talk about physiology, I’m going to try really, really hard to be brief, but this is such a really, really cool and interesting topic that Brian and I, as we were talking, we could probably spend an entire hour long, an hour and a half a lecture just on these first few slides. So I’m going to try and edit myself as much as I can here. So what is a trigger point? A trigger point is essentially a series of small, very localized contractions within a muscle fiber. It is not what is called an electrogenic contraction of the whole muscle. So if you remember back to your anatomy and physiology classes, which all of you took either as part of before acupuncture school, and you remember muscle physiology, normally what happens with a muscle contraction is there’s a signal from the central nervous system sent down along a motor nerve, it’s an electrochemical signal.

And then it reaches the end of the motor nerve to the little, the terminal button. The, uh, the nerve ending then releases a neurotransmitter acetylcholine in the case of neuromuscular junctions, which diffuses across the cleft, comes into contact with the surface of the muscle fiber. Depolarizes the surface of the muscle fiber. And then it causes all the actin and myosin to kind of ratchet past each other and you get a contraction. And that normally happens when you have a nerve signal sent down that happens to an entire motor unit within a muscle. Um, and then the end, it happens to all the motor units in a muscle. What happens with trigger points is because of damage to the muscle. Some of those motor end plates, meaning the areas where the motor nerve is touching and contacting the muscle. Uh, there is a type of dysfunction that has to do with, uh, based on the most recent research I’m aware of, um, an excess spontaneous leakage in a sense of acetylcholine across the claps.

So basically neurotransmitter is spontaneously diffusing towards the muscle fiber to a greater degree than normal. It is actually a normal process. It just starts to happen more commonly in damaged motor end plates. And this causes a small amount of localized depolarization in the muscle fibers. And so you end up getting small little pockets of, of contractile units of the sarcomeres within the muscle that are contracting. So this is happening independent of an actual signal from the central nervous system. So once these little pockets of contraction form, they essentially are kept, they keep occurring because of some feedback loops essentially within the muscle itself, independent of continued input from the motor aspect of the nervous system. Um, and if you look at another interesting thing clinically, that can be helpful to realize with trigger points is if you look at the picture on the right. So we have here a drawing that was actually taken from an actual slide that comes from Trevell.

Um, the top shows a whole muscle with the talk band in it, and then the kind of thick and nodule the middle of the belly, which is the trigger point region. And then if you zoom in and look at the lower portion, you can see each of these muscle fibers kind of running across the picture there, they all have these little vertical lines, which are the individual sarcomeres, right? In, in between each vertical line, there is the contractile unit and the thickened kind of darker areas are where the trigger point contraction is occurring. And you can see that those vertical lines closer together, right? So the, as the sarcomeres contract, they go this way. But also that means that as anything else, if you squeeze it in one direction, it’s going to get thicker in the other direction. And so that thickening of all those sarcomeres with those contractions is what causes the thickened, not in the muscle, but if you look on either side of those knots, right, you’ve got like this, not in the middle, but then you can see the rest of the fiber on either side that the distance between the lines is a lot greater.

So those sarcomeres, uh, that are not part of the little contracture are actually being stretched and usually being overstretched, meaning that the actin and myosin fibers are actually often stretched past each other, which means that not only do you have a knot in this muscle, that is so that part of the muscle is partly pre contracted, which means it’s going to lose strength and a bunch of other motor dysfunctions that’ll happen with the presence of trigger points, but it’s also going to lose strength because some of those fibers are overstretched to the point where they can no longer mechanically produce the same amount of force when they contract. So it’s not just referred pain, that’s going to be the issue with trigger points, but also a disruption of the muscle’s ability to fire normally, and to relax normally, and their whole sorts of other, um, re uh, neurological reflexes that are involved in this. So we can get into some other time, but that’s, uh, something that can be really helpful to realize clinically that it’s not just referred pain out. There is this kind of actual physical dysfunction in the muscle that has other implications. Um, so let’s anything to add to that, Brian?

No, I think that was great. Cool.

So let’s move to the next slide. So when you have this contraction in the muscle, one of the things that happens is there’s this interference with the local blood flow. So as with any type of excess tension in soft tissue like that, it’s going to put pressure on blood vessels and on the lymph system. And so you end up within the actual, not the trigger point itself, a decrease in blood flow, meaning, uh, not just decrease in the nutrients in blood, getting to it, but also a decrease in oxygen. So you end up with local scheming and hypoxia. Interestingly, there’s actually a, essentially a retrograde blood flow outside the trigger point. So as the blood’s trying to get in the knot is keeping blood from getting into that portion of the muscle. So you have the buildup and actually a higher oxygen saturation outside the trigger point with a lower oxygen saturation inside the trigger point.

When you have a lower oxygen concentration, this leads to a drop in the pH in that area of the body. So the area inside the trigger point then becomes much more acidic. And that stimulates the release of a lot of other chemicals that are often pro-inflammatory or allergenic, meaning pain producing. So it releases all sorts of prostoglandin serotonin substance P brainy, canine, um, uh, CGRP bunch of, uh, interleukins, some ones in particular. And so all you get this kind of soup of biochemical signals that are producing some localized inflammation and also stimulating nociceptive nerve fibers. So remember nociceptive nerve fibers, which are often called pain fibers, actually, they’re not, they don’t send pain signals. They send signals of actual or impending tissue damage, right? The pain is something that’s processed and occurs in the, in the brain central nervous system. But what happens with trigger points then is you have this biochemical soup of concentrated, essentially pain producing substances in the area.

When the signal through the nociceptive nerve fibers becomes prolonged enough and strong enough, you know, over a long enough period of time, those signals go up to the spinal cord. And there are actual changes that occur in the spinal cord that are called central sensitization. So that there’s essentially a decrease in the threshold necessary for a lot of those signals, no susceptive or, you know, pain and signals to get to the brain. So there’s an increased chance that any given, uh, no susceptive signal is going to make it up to the brain. Normally our nervous system in a sense is designed to weed out anything below a certain threshold, just so that we’re not flooded with too much information than we can deal with in our central nervous system. Um, but with trigger points and any other kind of chronic pain, the threshold for that information to get up starts to get lowered.

Plus the nervous system in the, in the spinal cord itself starts to wake up old and disused connections between different spinal levels, essentially spinal segmental levels, and actually can form new ones. So it’s a signal say going into the C5 dermatomal myotomal level at the spine, say there’s a trigger point, like an infraspinatus, um, what will happen if that happens over a long enough period of time and is intense enough, is that the signal essentially spills over into adjacent spinal segments, very commonly or more commonly inferior. So the there’s some, maybe some connections that spill over superiorly to like C4, but very commonly will go down. So maybe C6 and C7, those spinal levels are now going to be getting input, no susceptive input or damage or pain input. And what happens for reasons that people aren’t quite sure of is that by the time all those signals get up to the brain, the brain is really interpreting those spillover signals more than the signal coming from the area itself.

It’s really common when you have a trigger point in a muscle with a few exceptions that the area where trigger point is itself, you don’t have any symptoms there it’s pretty far away from the area where the trigger point is, um, especially with some of the muscles like in the hips and the shoulders out into the periphery. So the, the signal of pain that you’re experiencing is actually coming maybe from like the C6 or even the C7 level. And that’s what we call referred pain. So that’s why you can have a, not these trigger points in a muscle, but have the experience of discomfort or pain or numbness or parasthesia happening in what seems like a really distal, uh, area far away. Cool. Anything else for that, Brian?

No, that was great. Great explanation.

Cool. Okay. And so let’s move on to the next slide. All right. So a few other things to think about with trigger points that will also really help you as a practitioner, um, from getting to myopic. Um, so trigger points are a possibility and our component of pain and dysfunction, that’s, uh, an understatement. Um, really some of the research suggests that up to 80% of the cases of pain might involve some type of trigger point phenomenon with any kind of pain. So having said that once you get into trigger point stuff, it can be so effective and it can be so kind of interesting that you can forget to do a differential diagnosis for a lot of the other really important, uh, generators of pain and dysfunction. It might be, you also have to consider joint dysfunctions, other soft tissue, you know, looking at ligaments, you have to look at whether or not someone has other systemic problems that can be contributing to their problem, right?

Nutritional deficiencies, especially things like vitamin D I think iron deficiencies, metabolic disorders. Um, so hypoglycemia and diabetes can be two really big ones that can have caused someone to have a propensity, to, to, um, generate trigger points and also to have more kind of higher levels of pain. Um, basically anything that affects the energy supply to the muscles can be a condition that can lead someone to more easily develop trigger points. If you’re a TCM practitioner, it’s also really important to put these findings into your assessment. And so personally, what I found is when I’m dealing with trigger points and thinking in TCM terms, um, going back to the idea that there is this limitation of blood flow in the area, treating trigger points locally, in one sense, as a form of blood is can be very helpful. And I’m a huge fan of the [inaudible] family of formulas.

I tend to use [inaudible] [inaudible] few herbalists out there a lot or variations of those. Um, but also systemically looking at things like spleen sheet efficiency, especially in terms of how it affects muscle function can be really helpful. So even if you decide to get into this, you’re into this now, and you’re getting really myopic about trigger point stuff, always keep in mind all of the systemic stuff, and don’t give up your as an acupuncturist or as an herbalist and the TCM practitioner. Um, uh, although you probably go through phases where that happens to a greater or lesser degree, I know I did for awhile, but always keep the rest of that in mind. Uh, anything else there, Brian?

Nah, this is just something that Josh and myself have talked about a lot, is that when people just, like you said, start working with something like trigger points, it’s easy to sort of start to, to just see everything as a trigger point and, and kind of throw everything else out the window. Um, and sometimes we learn something new and that’s just the way it goes for a little while, but, but yeah, bringing that full comprehensive, uh, aspect of our medicine back into play is really essential. So, uh, yeah, so let’s kind of go into the next step. So I think we’ve covered a lot of information already in terms of, uh, pain and quality of pain with, uh, trigger points. I think this, uh, next couple of slides, we’ve pretty much covered in the context of the previous slides. So, um, if you’re going back and watching this it’s on the screen, you can reference it, but I think we’ve already really covered an aspect of this. So why don’t we move on even Ms. Josh, is there something you wanted to say about that? Let’s move

On, not on this one, the one after, see what’s the slide right after this one? Uh, yeah, just the fact, just the importance of, um, basically when you’re diagnosing trigger points that you’re looking for them, the aspects you have to take into consideration first or the history of the patient, because often they’re good. There’s going to be some type of traumatic injury or overuse problem or chronic postural disorder. So his, the patient’s history is one thing. Um, the importance of palpation is another thing that you have to actually get into the muscle palpate and look for those sore spots, um, uh, history of palpation and, uh, and assessing, um, you know, movement dysfunction kind of looking at actually doing some, either manual muscle testing, range of motion testing, things like that. Um, but that’s, yeah, we can actually, if you want to kind of just move into the individual muscles, that’s probably a good idea. This is, as we predicted, we’re kind of taking a long time to get from the really cool stuff that we have to be nerds about.

Know we were talking, we can almost do have done a long time just on this, these first parts, but yeah, let’s, let’s move forward. So diagnosis, um, uh, uh, trigger points as Josh was mentioning was really largely based on palpation. Of course, you have to rule out other components of pain and they’re not one or the other, but maybe there’s a facet causing a particular pain. And, um, you have to roll out all of those things. We’re going to focus more on the trigger point aspect, which is going to come down to palpation. And Josh, you wanna kind of go into a little bit of the, the criteria for that.

Uh, yeah. So the, the, the three most important things to understand with trigger points are these things here listed on manual palpation. So first, if you suspect a muscle has trigger points in it that they’re causing problems. And again, actually one of the other things we forgot to mention with diagnosis, the other third thing that I was trying to think of history palpation, but also understanding the referral patterns and a lots of resources online for looking at referral patterns. It’s best. If you look in Trevell or even the most recent version of it, um, by body part. So often you can find lists of if there’s pain in the front of the shoulder, there’s a list of muscles that are the most common muscles that refer to that area. Um, so understanding that, so that, that helps kind of narrow your, your clinical focus down a little bit, but then basically what you’re gonna do is palpate the muscle.

And look for first, the top band, look, you’re looking for these, those stringy or Roby bands in the muscle. And then once you find that, then you’re pressing directly into those top bands moving along the top band, really the entire length of the muscle, the trigger points will often tend to form in certain areas in certain muscles for a number of reasons, more commonly than others, but really you need to check the entire length of the muscle if you can. And then along that tender along that top band, one of those spots is going to be one or two are going to usually be the most exquisitely tender to the touch. Um, often there would be a slight thickening or hardening of the band in that particular location. And if you’re lucky, not lucky, I mean, probably about 60 to 70% of the time, at least, um, if you’re in the right spot, the spot that you press is not only going to be very sore to the touch, but it’s also going to refer pain elsewhere and ideally reproduce the symptom that the patient is coming in for.

So, because someone’s coming in for migraines, you feel the upper trapezius, you squeeze it. Not only is it sore in the upper trapezius, but it actually recreates their symptoms with things like migraines. You have to be careful not to cause it in the clinic cause that’s a whole other topic. But for, um, a lot of patients that recognition of, oh, this practitioner is, uh, knows exactly what’s going on with me, cause they can touch me this other place. And all of a sudden my symptom is occurring. I now trust this practitioner. Um, and maybe they’ve been to two doctors and an osteopath and a chiropractor and two other acupuncturists and massage therapists. And no one has thought to look at that. And you’re the, maybe the first one who’s doing that. So that’s a really common experience, both that I’ve had and I’m sure Brian’s had, and even all the students at the school that I teach, they get that in school of having a patient in the student clinic, tell them you’re the first person that I feel like has actually gotten to where my problem is. So,

Um, yeah, after this, we have a video also this, the video shows a local Twitch response with palpation. Some muscles don’t have a tendency to do this. Some do, and it’s not an essential quality of, um, diagnosing trigger points. But when you do find with palpation this local Twitch response, that it, it’s usually a good sign that you’re at the right spot, especially if they’re feeling that recreation of the symptoms. And I kind of helps you a zoom in on the region where that trigger point formation is. So let’s just look at a quick video that shows for the SCM, you’ll see this. And then for the peroneus longest [inaudible]. So you’ll see this both with the sternal head and the clavicular and especially the Clifford Cuellar head

[inaudible].

So if you look down at the clavicle area with the curricular edge, you’ll see that clavicular head starting to fire just with the cross fiber strumming of the muscle [inaudible] Peroneus longus and apprentice, as long as you don’t see the muscles as much, but look at the foot going into aversion. So when that muscle is under a lot of, uh, uh, strain from metric or point formation just trumping the, the muscle will cause that muscle to fire. So just some things to look for when you’re, when you’re doing assessment. I think we can go to the next slide and, uh, sports medicine,

Muscles, maybe. Yeah, yeah.

I think that’s a good idea. Thanks Josh. Uh, so upper trapezius is one of the most common, uh, acupuncture is very familiar with this one because, uh, uh, oftentimes around the, the region of, uh, gallbladder 21, there’ll be trigger points. Uh, there can be other areas they call bladder 21 happens to be a motor point. We’ll talk about that difference in July, but, uh, this is a extremely common one that comes into practice, especially relevant for tension, muscle, tension, headaches, referring up the back of the neck and then wrapping around usually the gallbladder channel distribution to the temple occasionally to the chin, as you can see kind of the angle of the mandible. Um, most of us, uh, have needled a, this, uh, muscle just cause noodling gallbladder 21. Um, but again, with Josh was mentioning, mentioning with the trigger point palpation, you’re looking not just at one particular region, you have to look through the whole length of the muscle, but that gallbladder 21 or a little bit more medial where the upper trapezius starts to turn the corner are common sites where you start to see those pain generation, um, for trigger points of the upper traps.

And from a channel perspective, a gallbladder channel would be obvious it’s part of the gallbladder sinew channel, but it’s also part of the large intestines and you channel as it comes up the arm into the, uh, the deltoids up into that leading edge of the, of the upper traps. Um, so large intestines and Joel, to some extent, urinary bladder, if you look at the urinary bladder, send you a channel, you’ll see that it, um, has a lateral branch and it covers a whole wide range even coming into the front of the body. But in my interpretation, I see that as including the lower trapezius, upper trapezius, really the whole trapezius muscle, um, and then wrapping around to the SCM muscle. So, uh, the distal points that you can consider with this are along those channels. And one that I find is extremely helpful when people have pain and restriction rotating to the opposite side, as that upper trapezius starts to fire and becomes painful, it can limit motion, gallbladder 39 is my go-to for it, but not actually strict gallbladder 39. I actually do more of an anterior gallbladder 39, particularly at the peroneus Tertius muscle, which would be anterior to the fibula. That’s the one that I find really changes the upper trapezius. And of course I do needle the Udall locally with that too, but that peroneus Tertius motor point, which is kind of an anterior gallbladder 39, uh, is, is really a key one for me.

Yeah. Uh, another, um, distal treatment that I find works really well for this. Uh, if you do Richard tan balanced method stuff, we’re just interested in some of the other more esoteric channel connections, looking at midday, midnight relationships, um, in thinking of this as a primarily gallbladder channel issue, then often looking for Asher points along the heart channel, heart and gallbladder being across the clock from each other and the Chinese clock. Um, if you find a lot, a line of tender points on the forearm and the heart channel, very often needling, those can help quite a bit with upper trapezius stuff because of that heart gallbladder, the David and I relationship. Yeah.

And I think both Josh and myself are in agreement that local needling is also important and we’re not downplaying that, but just for the webinar where we’re not working with people live, we thought we’d focus a little bit more on the symptoms and the distal aspects. The combination is strongest and local distal. Linda Jason is really strongest. Right. Next slide. Uh, so just some things to look for, and then I’ll cue you into the traps. The symptoms that we mentioned are obviously important, but this sort of, um, upward sloping of the clavicle and where it’s kind of making like a V if it’s tense on both sides, uh, shortened on both sides, but that upward sloping and kind of backwards sloping of the clavicle is something that I noticed and kind of start tuning in with, uh, um, over-correct activity in the upper trapezius, particularly also limited range of motion, uh, um, with turning or lateral flection are keys for, um, kind of finding a restriction in the upper trapezius.

Definitely. I think we can go on to the next one. All right. So the SCM can have a similar referral pattern in some ways to the trapezius. Um, and there are actual neurological reasons for that in one sense, the, both the operatory pier or the trapezius and the STM are both innervated by the 11th cranial nerve in addition from like C3 area. And so, uh, they actually start out embryologically as one muscle, the trapezius and the SCM both. And then as you grow as a, as an infant, as child, as your collarbone lengthens, those muscle fibers separate, um, torn. Now there’s actually a gap between the two, but the, the two share a lot of interesting kind of symptomatology and function. Uh, so in terms of symptomatology, you can see in the picture, the SCM in terms of pain or other types of parasthesia causes mostly symptoms in the side of the head, occasionally one SCM will cause symptoms on the opposite side of the head.

Um, but usually it’s centered somewhere around the side of the face, the ear, occasionally the Vertex, um, the occiput, the interesting thing about the STM in particular, and this is one of the few muscles in the body that has this happen is that trigger points can often cause a lot of symptoms that are trigger points, at least in this muscle. It can cause a lot of symptoms that often don’t seem related to muscle function. So muscle symptoms that often seem like they’re more autonomic nervous system phenomenon in terms of the SCM that can include a wide variety of dysfunctions or symptoms of the sense organs. So you can have blurry vision, uh, seeing things like, uh, uh, other, other types of visual disturbances problems with hearing so ringing in the ears. So tinnitus is a common one feeling of pressure in the ears as feeling like fluid in the ears that isn’t from an actual physiological cause.

And it can cause stuffy nose. It can cause excessive, runny nose can cause excessive lacrimation. Um, it can cause dizziness, sometimes some types of vestibular disorders often have a component of SCM or other neck muscle dysfunction. And so it’s also very helpful when you have an understanding of, of what some of the possibilities are for, um, trigger points symptomatology with this muscle, just start recognizing that with some patients. So for instance, for me, commonly, it’s a patient who comes in with maybe sinus or allergy symptoms and they don’t seem to be seasonal or related to anything particular, just kind of there all the time, very commonly, even just palpating the FCM, all of a sudden will cause one of their nostrils to open. And so sometimes treating the SCM for things that can look like allergy symptoms or like hay fever, if it’s seems disconnected from changes in like pollen levels can be something good to look for.

Um, thinking of this, uh, I very commonly end up treating distal points along the stomach channel for this. Um, and also interestingly, the UBI channel, this is not something that if you’re, if you’re only looking at regular channel pathways, you’re going to normally think of, but if you look again at the sinew channel pathways, the UV channel is one of those ones that has pathways that go far away from where the standard kind of channel normally goes. So there’s a, an aspect of the urinary bladder sinew channel that falls up the lat comes across into the Peck and up the neck. And this comes from an aging, just Brian and Matt have actually mapped it onto particular muscles. And so sometimes treating the SCM as a urinary bladder, senior channel muscle can be really helpful. You’ll be 60. I use UV 63 a lot with that sometimes if it happens to be tender or something, or you’ll be 57 or 58. Um, so that’s another fun aspect to that. Uh,

As in young energy, you know, coming up the UV channel. And I, I find when it is, you be an often that has dysfunction associated also with the upper traps, the lower traps, you know, when those are all kind of activating together as that sort of, you know, tension building up the body is where I really see that UV connection.

Absolutely. All right, let’s do the next slide. Um, I I’ll just briefly talk about this before, because we’re not, cause this can muscle can be a little bit harder to examine. Um, partly for safety reasons, because you’re talking about a muscle that is, fascially bundled up with a carotid artery and a lot of other kind of neurovascular structures right near there. Um, most of the time when I treat this, although I do needle it with retention, the way that, um, you will learn in the sports medicine program where essentially needling from stomach nine back towards like small intestine 16 or that area, um, or doing, uh, dry needling, which is a little bit more, requires a little bit more care because your piston and kind of moving the needle in and out, but really learning how to manually release this muscle first, um, and getting really comfortable with the palpation, grabbing the muscle, separating it from the neck and being able to isolate the fibers while you’re pressing on them. Getting very comfortable with that before you start needling, it is a really good idea. Um, anything else kind of in general to say about palpating and treating that muscle that you want to add? Brian,

And then I think I agree with that, uh, um, manual work. If you’ve not used a needle in this muscle, get in, Hey, you’ll get a lot of benefit from, uh, doing the manual work. It’s it’s, um, it’s one that, uh, does well with manual work, but it gets your hands acclimated to that ability to sort of pull the muscle away and feel the, the, how far, how deep that muscle goes and where it is in relationship to other structures. So that’s very important.

Yeah. And I’ll, I’ll say that when I teach this material at school out here in Seattle, uh, the first thing that I have students do for the first year of their education before they do any needling of any of these is they learn manual releases for all of these muscles, because they’re especially as an acupuncturist, if you don’t get a lot of chance to practice specifically palpating muscles, like we’ve talked about, um, it can be very difficult to just start needling them. And so I want to make sure that like my students in particular have of experience with manual palpation and treating the muscles just with their hands first cause then growing into the needling is actually relatively easy.

We’ll say something interesting about the SCM is a two headed muscle, S S C M Sterno and uh, clavicular heads, both attaching to the mastoid process. Um, the channel relationships as the sternal head tends to be more associated with the stomach channel and the [inaudible] had more associated with the sand gel channel. So if you go back and look at the club, vicular had distribution in particular, you’ll see that it does refer deep in the year. And that’s often what people, when you’re working with, it’s like, oh, I feel that in my ear. And that’s the one that has more of a tendency to cause things like, uh, postural vertigo. And, and, um, the point is, is if you look at that clavicular head in particular and then go think about points like San Jo three or sand JAL five, and the relationship of the sand Dow channel to the year, it’s again, one of those areas where you can start to see a little parallel between channel theory and trigger point theory.

Yeah, definitely. Right. Next slide. Yeah. Why don’t we

Get to, I think we’re there. We have Josh and myself knew we had a lot of information and weren’t sure we’re going to get through it all. I don’t want to downplay levator scapula. It’s such an awesome muscle to be familiar with. Um, but let’s go pass this one to, uh, pass this and we’re going to go, I think, to infraspinatus Josh, why don’t you take infraspinatus?

All right. So this is along mean all these muscles. This is going to be true, but the infraspinatus along with like the upper trap and the, um, SCM are ones that if you just build your practice around treating like just this muscle, you would still be incredibly busy and have lots of very, very happy patients. Um, so this is one of the most common areas for trigger points that need to be treated for almost any kind of shoulder joint dysfunction, but also, uh, very commonly for pain in just pain in general in the front of the shoulder, but also down the arm, even all the way down to the thumb fingers of the hand. So the, the most common location for the referral for this one is deep pain in the front of the shoulder. And this can often feel like mean patients will often describe it as like a toothpick kind of sensation around like the large intestine, 15 area.

Um, very commonly they’re going to come in and be told they have bicipital tenor synovitis or bicipital tendonitis because the pain often occurs right over the biceps tendon as it’s going through the, the bicipital groove. Um, this is really a small intestine sinew channel muscle, even though the most common referral pattern is down, essentially the large intestine and partly the lung channel and the best way to treat this distally is usually through small intestine channel points. So a small for can be helpful. Um, most of the time I’m using essentially small intestine three and a half, which is the motor point for the abductor digiti [inaudible], um, kind of right between it’s like the large intestine, four of the small intestine channel, essentially kind of right in the middle of that, of the metacarpal, uh, bone there, where the muscle is. Um, but again, this is one of those muscles that if you get good at palpating, it, uh, for any kind of shoulder problem, this can be really helpful to treat.

And not just because of the referral pattern, another very common issue with any kind of shoulder problem is the biomechanical dysfunction that happens. Even if just someone has mild pain, they start kind of using the shoulder a little bit differently. The, uh, the strain of, of even just raising your arm or whether it’s something like playing tennis or reaching up for a can of tomato sauce in your pantry or something like that. When you have pain from any cause for the shoulder, it starts altering the biomechanics of the scapula. Often the scapula doesn’t move as well, and the rotator cuff muscles, and have to do extra work to kind of stabilize the head of the humerus and to kind of make sure you have the as much arm elevation as you need. So usually the first thing that happens is the rotator cuff muscles of which the infraspinatus is one start developing trigger points or other dysfunction. And so regulating the relationships among all the rotator cuff muscles, which usually involves infraspinatus and also subscap, which we’ll get into in a different discussion, um, can be incredibly helpful, um, for just a wide variety of not just referred pain issues, but also any kind of glenohumeral, biomechanical issue.

Anything to add to that, Brian. Yeah, I see an X on there that I think is an artifact. I might’ve put an X on SSI 11 because that’s such a common area of trigger point formation, even that could be anywhere in the muscle and moving that image around. I think there’s a little artifact there. So don’t go looking for a trigger point in the infraspinatus off of the scapula. That’s an extra price on the top the top. Right.

Okay. Well, you understand that, that be more than that. All right. Uh, next slide. Uh, oh yeah, yeah. As soon as some examination infraspinatus, so often anything that’s going to stretch the infraspinatus, it’s an external rotator. So usually end range of internal rotation or not even end-range of it’s really severe. So reaching behind your back, like to get a wallet out of your pocket, unstrapping a bra, but also having the muscle contract fully can also often cause a pain. So external rotation often that’s going to be like brushing your hair right. Going up into this motion was causing contractually external rotators. Um, so that’s a general rule of thumb with points is that the pain can be brought on either by fully stretching the muscle or by contracting the muscle. So it’s another thing you have to really start to understand work doing this kind of work is what muscle functions are and for any given motion in one part of the body or when joint, which muscles are contracting, which muscles are stretching. So understanding agonist, antagonist relationships, um, can be really helpful in diagnosis, as well as treatment planning in terms of figuring out what spinal levels you want to add to help kind of, uh, normalize muscle function,

Right. Then you can go to the next one. Yeah. And I think we’ll just go through these quick, cause I know, uh, uh, we’ve gone a little past the time that we were hoping for a work around and talk all day, but I know some of you guys probably need to get back to work. Um, so quadratus lumborum is such an important structure. And the referral that you can see is, is kind of generally at that iliac crest region down towards the greater trocanter, uh, deep into the glute area, it’s such an important structure to learn how to needle, especially in a class setting, um, for, uh, uh, to be able to, uh, work on directly, uh, just because it’s so indicated and so many, uh, types of back pain conditions, uh, the work we do in sports medicine acupuncture would probably surprise a lot of people.

If you haven’t heard this already as a, we see this as part of the liver send new channel. Now the liver sinew channel ends at the groin, but if we were to follow that myofascial plane up from the ad doctors going right in that iliac fossa, um, its continuous myofascial plane into the iliac as muscle that would continue right into the quadratus lumborum. So even though you have to get to it through the back, um, it’s really a very deep core structure on the plane of the myofascial, send you a channel of deliver, uh, channel liver network and liver five. And sometimes even adding liver five with liver three as a combo is just a really magical combination for, um, reducing pain in the, um, quadratus lumborum again, a local needle is so important there, but uh, oftentimes just from palpatory pain, liver five and, and um, adding liver three, we’ll reduce it by 50% you go back and palpate afterwards you’ll find that that the pain is reduced by 50% just with those points. And they often, especially liver five becomes very reactive, very tender, very easy to find when the quadrant is some farms under a lot of pressure, a lot of stress.

Yeah. And I would just add, if you treat low back pain, get to know the QL, it’s a, it’s one of the most important muscles along with like the, so as to treat for any kind of low back dysfunction yeah.

Then attaches above into the 12th rib leads right into the diaphragm. So it’s kind of starts to get getting you into that visceral core of the body. Um, so elevated ilium, the next slide is showing, uh, that’s just measuring the helium from the side. We’ve talked about that a lot, various other, um, myself and various other webinars. Um, it’s on our sports medicine, acupuncture, uh, blogs, you’ll see blogs on Anjana syndrome and stuff like that. And it’ll go into that in a little bit more depth if you want to reference those. So let’s look then at the glute medius and minimus, we’ll skip this one, so right. And to medias, why don’t you finish these up Josh? We could probably even look at them as a pair.

Yeah. So this is another one of those long with the QL and the other ones. This is one of the really important points to treat, um, this in the minimus, uh, really for low back pain in addition to hip dysfunctions. So in Trevell often she talks about the referral pattern for the glute medius, which is the larger, more superficial lateral hip muscle primarily. Um, Ady ducts the hip. Uh, the referral pattern generally tends to be somewhere around the sacrum and the iliac crest and a little bit around the gluteal area itself. And then if you go to the next slide that the minimis, which is deeper, kind of underneath the, uh, the glute medius kind of closer to the ilium, um, slightly smaller in scope that the minimus tends to refer down the leg and can really mimic sciatica or any other kind of an L five radiculopathy in practice.

I’ve found that it seems like the glute medias can also refer down the leg like this. Um, I’ve had, I’ve had treated some patients where I know I’m treating the glute medius cause I’m nowhere near deep enough or I’m like right at the iliac crest and they still get the referred pain down the leg. So basically the, really the significance of this muscle or this pair of muscles to me is really this particular referral pattern. And aside from, um, the biomechanical aspects of it as an add doctor, one of the, it’s the really important muscle for stabilizing the pelvis. Every time you walk and take a step, right? If you understand a little bit about orthopedic medicine, you know, the Trendelenburg sign, have someone pick up one foot and look to see if like, if they’re standing on their right foot, if the, if the left side of their pelvis drops, when they stand, they kind of like sag a little bit that’s culture and Ellenberg sign, it’s a sign of dysfunction and, and not a lack of firing of the gluteus medius and minimus.

Uh, and that has repercussions for postural and movement function throughout the rest of the body, along with the QL and muscles in the neck. Um, but aside from those structural issues, the pain referral pattern for this, if you learn to recognize it and then to treat it by treating these muscles up around between like gallbladder 29 and gallbladder 30 in that area, uh, this can mean potentially even have some patients, you know, keep them from getting unnecessary surgeries. I’ve had patients who have been told they had, they needed like a spinal fusion, things like that because they have pain radiating down the leg. We treat the glute medius and minimus and their pain goes away. Right? Cause it’s really, really common for trigger points in muscles for number of reasons that I can have an entire lecture on that. Even in Western medicine circles, they get ignored.

And for some of the muscles like this, where the implications of not realizing that it’s a muscular issue are the implications when there’s something like getting a surgery to fix the problem, uh, that can become a really big issue. That can be very important to the patient. So learning to recognize these, uh, you will, if you start treating this type of thing, have the experience of having, uh, the patient, um, realize they maybe don’t need this very invasive surgery that is that they’re planning to have. Um, just because they’ve been told by one person like an orthopedic surgeon that you need to have like a spinal fusion. So that’s one of the, this was one of the really important muscles that I find for that issue in particular. Right?

Yeah. And it’s also becomes dysfunctional with, uh, frequently with the quadratus lumborum. So even needling, sometimes QL will refer down the leg because of that stimulation from QL into its referrals zone at the glute medius minimus region, and then stimulate, you know, it’s almost like a transfer through that. So, um, but, but those are very, um, very often in dysfunction together. And lo and behold, we have a liver and gallbladder relationship then. So a consideration yeah. Consideration of liver five, uh, and gallbladder 40 source point to help, uh, kind of build energy. And the gallbladder’s a new channel for these muscles that tend to be inhibited and pain generators when there’s inhibition, not always, but that’s the tendency and, uh, liver five to help with that more overactive, uh, add doctors. But we talk more about the quadratus lumborum so QL and add doctors on the liver test and new channels. So something to consider with that really a great combination. All right. Well, I think that, uh, thanks for bearing with us already. We took a little time with that, but, um, it was a pleasure working with Josh and tune in next week for, uh, Jeffrey Grossman’s, uh, presentation. Uh, and thanks again for everybody for coming. Thank you, Josh.

 

 

Callison-LauHD05052021 Thumb

Tibial Stress Syndromes (Shin Splints) – Callison/Lau

 

 

“…we’re from ACU Sport Education and the Sports Medicine Acupuncture Certification Program. Um, we’re going to talk today about tibial stress syndrome.”

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. Welcome to our sports acupuncture webinar. My name is Matt Callison. I am Brian Lau. We want to thank the American Acupuncture Council for sponsoring our, our sport, our sports acupuncture webinar here. Uh, we’re from ACU Sport Education and the Sports Medicine Acupuncture Certification Program. Um, we’re going to talk today about tibial stress syndrome. So let’s go to the first slide please.

So since spring has sprung and we’re quickly approaching summer, we’ll start to see patients that are coming in with a tibial stress syndrome or the layman term for this being shin splints. Uh, people are trying to be able to get in shape. And so this is a common, very common overuse injury. So, uh, Brian, we’re chatting just last week. We, uh, we just published our module three lower extremity online recordings through net of knowledge. And we were talking about what we could actually grab from that since it’s so fresh in our minds and tibial stress syndrome was, was the first thing that we thought about. And so this is actually a, uh, it’s a fun topic because it is something that most of us most acupuncturist to see clinically. And there are some techniques that we have found work extremely well for this. So, uh, before we jump into the first slide there, Brian, do you want to say anything or do you want to go right into medial stress syndrome?

Uh, I’ll say something simple and that is, uh, this particular topic is one that I’ve dealt with, uh, not for a long time, but when I was in high school, I was a wrestler and we used to do a lot of drills on a hard floor running drills and these wrestling shoes that had zero support. Um, they’re not, you know, they’re designed to be on a mat, right? Not on, uh, not for running shoes, but sometimes being young and stupid. We were lazy and just wore the same shoes as we went out and did running drills and exercises and sass. I remember at the high school, this was, uh, something that I didn’t have horribly, or it stopped me that it was quite painful. So I know this one personally, uh, fortunately I haven’t dealt with it for, uh, most of my adult life

Mm

Midnight. And then that I’m ready to roll. All right. So should we go to the next slide and Brian, you want to take it away?

Sure.

As Matt mentioned, that student’s lens is kind of the layman term, uh, for medial and anterior tibial stress syndrome, I’m going to start the discussion talking about medial tibial stress syndrome. So that’ll affect the, the sort of medial side of the tibia, and we’ll look at the anatomy and kind of mechanism of injury for that. Um, and then, uh, I think Matt will take it, uh, from anterior

Tibial stress syndrome, but collectively people refer to these as shin splints. Um, it’s an overuse injury inflammatory condition that involves micro tears and either the myofascial origin. So the tibialis anterior that would be for the anterior tibial stress syndrome or the tibialis posterior for the medial tibial stress syndrome. Uh, those muscles are along the shaft of the tibia. So let’s, uh, go to the next slide and we’ll jump into medial tibial stress syndrome. So immediate tibial stress syndrome, uh, the pain and tenderness is found on the medial really at the posterior medial aspect of the tibia, you know, on the sort of the yin channel side of the leg. Um, so on the medial portion of the tibia, just really on that most posterior aspect. So that would be along the liver channel. Um, and we’ll talk a little bit about the channels on this slide, but, um, it’ll be usually the pain is, is level with the area between spleen eight and spleen six.

That can be a little less than that. It can go beyond those boundaries, but that’s the typical region that it covers. Uh, so that’s the area that people will tend to have pain that they’ll, um, they’ll be complaining about, um, in terms of channels. When we get later in the presentation, we’re going to be looking at a myofascial release technique. We’re gonna be looking at an acupuncture, of course, but then we’ll also look at the myofascia release technique. And in that, uh, particular associated technique, it will be in reference to the spleen, send you a channel. So this injury and the pain is a long that distribution of the liver channel, but the channels, aren’t just a line along the body. You know, they’re not only on the surface, so to speak, you know, we’re taking a needle or we’re penetrating the skin and where that needle goes can be, they’re either more deep or superficial.

So if we were just to glance at this image from mats, a text, a sports medicine acupuncture, um, and look at the arrows, the arrows are pointing to the tibialis posterior muscle, which is what attaches to the posterior surface of the tibia. And that’s, what’s going to pull excessively, or when it does pull excessively on the tibia and you create little micro tears there, that’s going to be what contributes to the medial tibial stress syndrome. But if we look at where those arrowheads sit, not what they’re pointing to, they’re pointing to tibialis posterior, but where do they sit? There’d be another muscle there. Um, that’s not shown in this illustration because it’s, it’s highlighting the relevant anatomy of the tibialis posterior, but that muscle that’s just medial to the tibial. The tibialis posterior would be the flexor digitorum longest. And then if we go lateral on the other side and the lateral side of tibialis posterior, it would have flexor hallucis longest.

But if we come back to that medial side where those arrow had CIT, uh, that would be flexor digitorum longest, that’s actually part of, as we define it in sports medicine, acupuncture, part of liver sinew channel, whereas the tibialis posterior a little bit more anterior, um, and a little bit more in the middle part of the tibia, you know, lateral to the flexor digitorum longest is the tibialis posterior as part of the spleen sinew channel. So depending on the depth that the needle is reaching, uh, we’ll also determine really which at least from a sinew channel perspective, what, uh, uh, channels being, uh, affected. Uh, so we’ll look at, at that aspect as we’re doing the myofascial release technique and we’ll discuss it, um, also, uh, in terms of the channels when we get to the acupuncture portion, but just a heads up, and I’ll re refresh that when we get back to the myofascial release techniques, but this one’s talking about the anatomy and that’s the tibialis posterior, that’s what the arrows are pointing to note that the tibialis posterior comes down, the leg becomes a little bit more medial around spleen six, and then look at how it attaches onto the foot and how much of a support mechanism it creates on the arch of the foot.

It’s really the Keystone muscle for that. Uh, at least from an extrinsic, from the muscles that are in the leg for creating arts apart in the foot. Uh, so I kind of think about the aspect of how the spleen can lift and this a spleen sinew channel muscle is really a prime lifter of the medial arch. And I, I see that as one of the spleen functions to have lifting, you know, in this case of the foot. So if we can go onto the next slide

[inaudible]

So a medial tibial stress syndrome, like we said, involves the tibialis posterior muscle commonly occurs, uh, occurs in individuals who are moderately to severely over pronated. Um, because of that line, Nepal, that we were just looking at how much that, um, tibialis posterior influences the lifting of the arch, when you’re going to the weight bearing and the foot hits the ground, there’s a normal pronation, you know, the foot, the arch is going to drop and that tibialis posterior is going to be elongated, but there’s normal. And then there’s, overpronation where it’s just like a flat tire. And that Tim posterior, it gets pulled really excessively long, probably a little bit in a more of a charring standpoint. So it doesn’t have that normal elongation where there’s a little tone there and it kind of checks, it keeps that, that, um, pronation and check, it keeps it from going too far out of the boundaries in this case, it just flattens.

So if you were to look at these images here and just glance at the runners, if we can see from the waist down, uh, notice which one of those, you know, they’re not all hitting, they’re not all in the, in the weight-bearing part of the gate, but some of them are which ones do you notice, or which one do you notice that really highlights that collapse of the medial arch? I’ll give you a second just to glance at that, but you can look at the front person, you know, th the, the weights falling to the medial arch that’s normal probation, but if you look at the person just behind him, right in the middle of the shot, um, it looks like I can’t tell what the number is 71 possibly, uh, with delusional shorts on yeah. Blue shorts. Um, you can see how much farther that person’s going into pronation and imagine that dropping of the medial arch and how accessibly that would be pulling on the tibialis posterior. Um, so people with foot overpronation is going to be a really key thing that you’re going to notice. That’s going to affect things like a medial tibial stress syndrome. Um, it’s very common with runners that accounts for approximately 13 to 17% of all running related injuries. So it’s a pretty big one. You’ll see it as the prime complaint, or at least a secondary complaint in your practice. Um, you know, frequently, if you haven’t already anything you wanted to add to this format.

Yeah. Brian, I just want to reiterate what you’re talking about with the spleen function being, lifting the tibialis posterior, or this is something that we talked about in December webinars through the American acupuncture council. It will be spoken about it has planets and the number of different injuries that can actually occur from that. And we actually spent a bit of time asking practitioners to look for, um, any time of earth signs and symptoms, spleen and stomach that may be actually contributing to some of the musculoskeletal pain, because with any muscle skeletal injury, there’s always going to be some kind of [inaudible] component, either that the organ and the channel has directly effected that or that the organ systems are deficient and not controlling inflammation very well. So there’s always some kind of [inaudible] component for the TCM practitioner to take a look at that. So that was the December, uh, webinars, something that you, you guys may want to check out on PEs planus, uh, Brian talk right now, but the tibialis post here. But if we look at that person with the blue shorts as well with the tibialis anterior, that will also end up being elongated with overpronation. So we’ll talk about the tibialis anterior, just a little bit, Brian, back to you.

Yeah. Yeah. And just the foreshadow that that’s going to be the stomach Cindia channel. So now we’re talking about spleen stomach and, and often how those correlate again, from a Zong Fu perspective, how frequently those, those two organs are so integrated, you know, that compared to other internal, external parents, those two are just like really functioned quite often together. And their disharmonies are often associated, um, both from a musculoskeletal, but even from his own food perspective. So I’m curious Matt, about the, the, um, long food perspective. I feel, you know, doing Chicano practice Tai Chi can be really any physical activity. If you take time to strengthen the arch in my mind, I feel like, and I see this to some extent play out though. It’s a little hard to, to test for, but, um, but I feel like you’re strengthening this lean channel. Sure. You know, at least the component that’s related to the foot, but I feel like that’s, that’s strengthening and calling on extra blood flow to that area, more communication with the nervous that that starts to be, you know, at least a component of, of strengthening tone to find the spleen. So even from his own food perspective, that, that, um, improvement of health for the floods can also have a, um, uh, regulatory effect on the whole system.

Yeah. And that’s through any channel, right? I mean, if you have a, um, excess gallbladder or excess excess liver and deficiency in gallbladder by exercising, the hip AB doctors and 80 doctors, it does help to balance that particular aspect. In fact, you can, you can feel the pulse prior to the exercises and feel maybe a sharp edge to a pulse. Some people would call that a winery recalls and then have the person do hip AB duction, 80, the options, and it softens the pulse. And that’s just one example. We could also talk about subscapularis and Terry’s minor, you know, again, but, but Brian’s point here is that how important it is to be able to prescribe exercises to your patient. And these are more webinars, isn’t it actually, how important is to prescribe exercises to be able to compliment your acupuncture treatment based on your differential diagnosis for TCM differential diagnosis? Sorry, Brian,

That’s good. Yeah, I think we’re ready to jump ahead. Next slide. All right. So some differentiation, because there’s more than one thing, uh, you know, fortunately, or unfortunately, fortunately, because it makes us put our detective hats on and makes life more interesting. Uh, there’s more than one thing that can cause pain in this region. Um, so if anytime, somebody comes in with pain and we just like, ah, medial tibial stress syndrome, uh, we’ll get it sometimes. And we’ll miss it other times because sometimes it’s not medial tibial stress syndrome and a common very, very close. I mean, you know, within probably less than an inch, uh, of, uh, uh, posterior to this where there’s going to be pain would be a solely a strain. So just off, you know, not up against the bone, but just off the, uh, the bone just posterior, um, there’s going to be a, uh, painful when there’s a solely a strain cause the soleus is a pretty wide muscle and it covers a lot more territory, both medial and lateral than the gastrocnemius.

So this would be, again, this is, uh, channels are a little odd in the, in the leg compared to the rest of the body because it’s along the spleen channel, but the soleus, again, as we have it defined and, and a sports medicine acupuncture would be part of the kidneys in new channel, but we’re on, you know, in this case, the pain that often is going to be apparent is really pretty close to that. Um, kind of most medial edge of the solely, as you know, this only has covers that whole posterior portion of the leg. So it’s a big muscle. And, uh, the bulk of that solely is really, it would be the kidney sinew channel, but the distribution of the pain is going to be really along more of this spleen channel, just posterior to the, um, often again in that region of spleen eight, but that through spleen seven, it’s probably not going to go down as low as spleen six. Um, so something to be aware of, you know, if you’re palpating to help confirm the pain and not so painful right up against the bone, but you back off, uh, what would you say Matt, about half an inch, an inch at the most? Yeah, yeah.

A quarter of an inch sometimes.

Yeah. And then that’s where, Oh, you know, that’s where the pain is. That’s you, you have your fingers right on it. That starts indicating more of a soleus, uh, uh, strain. And, um, it’s pretty close, pretty close in terms of their description of where it’s going to be. So something to look for, uh, uh, that can help differentiate the pain and that’s going to be a different channel correspondence. It’s going to be different, uh, uh, treatment. We’re going to stay with medial tibial stress syndrome for today, but it’s good to differentiate. Can I add something to that, right? Absolutely. Please. Yeah.

So we can use, this is something that we’ve talked about in the past before where we talk about it quite a bit actually is, um, acupuncture as an assessment. This would be when you’re in your assessment. Uh, part of the, um, treat of the clinic, uh, patient visits are for the patient visit and you’re trying to figure out, okay, this is a solely extreme, it seems like it’s going to be more painful. And it’s bound up in that mild fascial tissue about a quarter of an inch away from the bone. Um, we’re saying that it’s more of the kidney, mild fascial gene, Jen, but it’s also the spleen primary channel. Okay. So where’s the stagnation. Is it in the primary channel or is it in the soleus, mild fascial tissue? Um, in the kidney, what we could do is maybe needle kidney three, we can needle maybe kidney four as part of the assessment, and then go back to that soleus and feel if it’s quite a bit softer, is there less pain without patient to the patient?

If not, maybe we could needle spleen three and spleen four and see if that moves cheat within this plain channel and go back and out pate. That solely is, um, from my experience, it’s usually going to end up being kidney three, kidney four, and sometimes even kidney five that starts to take pain away from that solely us. But it’s nice to be able to at least put your detective hat on as Brian was saying and figure out actually, where is that stagnation? Is it more in the spleen primary channel or is it in the kidney gene, Jen?

Yeah, maybe we could just throw in an ashy point, uh, or if you’re a little more, have a little more finesse, maybe a motor point if you know the location for the soleus motor point and you’re going to get resolved, but you’re going to increase those results. If you link it with the channel and it start building a comprehensive picture and Madden this image, you can actually kind of see it. You know, we, we highlight this in our cadaver, um, classes, uh, uh, we look at it on a, on a cadaver specimen and you can really see that. Um, but this even just in the image here, you can see it quite well because if you follow the soleus through the Achilles tendon and look at its attachment on the Achilles tendon, um, I can tell you that the solely as partial portion has a much stronger connection into the medial side of the calcaneum attendant onto the calcaneus.

But then, uh, in this particular model, you can see how that links through the fascia of the calcaneus and right into the abductor hallucis, which we dropped straight down from, uh, could be six. There’s a pretty prominent abductor hallucis muscle. That’s, that’s visible, um, here. So, you know, that whole chain is, is really, uh, um, all part of the same myofascial plane of tissue. And, and as Matt was saying, like, give me five, such a strong point. Other other kidney points might be the ones that are really, um, indicated kidney two is the motor point for the abductor hallucis. So there was a lot of pronation that might be willing to consider too. Yeah. A lot of good choices for this, but that’s kind of deviating from the topic of the, of the day. So anything else,

Because we go in a lot more detail on that module three in the anatomy cadaver lab, and talking about that with different slides such and how I’m really how important that is, and trying to be able to balance out that calcaneus with any kind of, of ankle injuries or these technology and such are going to keep moving and we’re going to take all day. Yeah.

Uh, so the second differentiation to, to consider is a tibial stress fracture. It’s it’s, um, often as a gradual onset, it’s a progression of tibial stress syndrome. So, um, uh, the, the, um, when the tibia is excessively pulling and you’re getting these micro tears, especially if the person’s really powering through it and controlling it with then sets is, uh, um, is that a common dynamic, um, to kind of deal with the pain and they keep on working with it that can progress into a tibial stress syndrome where there’s a lot of, uh, starting with a lot of extra osteoblast, the plastic cellular activity, um, that can sometimes show up on a x-ray, uh, frequently can show up on an x-ray. And, um, you can kind of see that little cloudy area where the arrows are pointing to, and that can progress into a tibial stress fracture.

So with that, there’s going to be a really exquisite tenderness at a point specific region on the tibia. So if it’s not responding to treatment there, that that area is, um, exquisitely tender, where you’re palpating, um, even sometimes a very light pressure. This is something to consider and getting some imaging would be the way to go. And I think the next slide shows a little bit more on this map, but if you want to add anything here before we move on, maybe after the next slide. Yeah. Okay. So the next slide. Yep. So that doesn’t always show up on the x-ray because some of that osteoblastic activity is maybe a relatively new, and it hasn’t reached the level where it’s going to show up on an x-ray. So you can’t really rule it out with a negative x-ray MRI will show a little bit more. Um, but, uh, it, again, it’s really, I, I, we, I see it as if it’s not responding and there’s that, you know, points specific exquisite tenderness, that’s the indications that I’d be looking for, uh, that you would want to consider this to be real, uh, stress fracture method. You are going to add something. I think, uh, the GDV, but I think is another good one. Yeah, go ahead. Yep.

Both of these x-rays were from a patients of mine. Um, and when you are suspecting an osteopath increase osteoblastic activity, or even as it progresses into even a cortical stress fracture, um, like Brian was saying, it is exquisitely tender as you’re palpating along the tibia, and you find that spot, there’ll be a fluid within the tissue. We call that chia DEMA. Um, and it just the gentlest of pressure for the patient. It hurts quite a bit. Um, so just know this is trying to go and get some imaging. If it doesn’t show up on an x-ray, then you want to request a bone scan or even an MRI, but a bone scan is usually the gold standard for that kind of thing. If it’s not going to show up on an x-ray, you want to catch that you want to be the acupuncturist that catches this. Um, and, and because this will come into an acupuncturist office, if you are treating musculoskeletal injuries, uh, it’s just something to be able to make sure that you’re aware of anything else be. Nope. All right.

Okay. So now we’re going into a anterior tibial stress syndrome. So this is going to be affecting the tibialis anterior, which is responsible for 80% of dorsi flection. And it’s an incredibly strong decelerator for plantar flection. So you can see this runner, who’s running down an incline, he’s got heel strike. And so his foot is going into plantar flection. So that tibialis anterior is slowing down the ankle and the foot. So it’s, ecentric CLI lengthening. It’s a contraction. So therefore with overused, just like the tibialis posterior, it can have micro tearing some of the fascial attachments or the muscle fibers microscopically can start to tear away a little bit from that bone thing causing pain. Now the pain just like tibials poster syndrome is going to be on the bone. So you want to palpate medial to the stomach channel on the aspect of where the tibialis anterior attaches to the tibia bone.

That area will be tender if it’s going to end up being a shin splints of involving the tibialis anterior. So let’s go to the next slide and you’ll see the common areas to pop it for. This is usually around stomach 37, generally speaking. I don’t think I’ve ever seen it go all the way up to stomach 36 reasons. It’s usually more toward the muscle belly of it. Um, uh, stomach 37 and even just below stomach 39. So again, I just want to reiterate, it’s not on the stomach channel. That’s a different injury. That would be a tibialis anterior strain. So if you palpated on the stomach channel and you feel a fast cycle of tissue, that’s really quite hardened and that’s causing more pain than when you palpate on the edge of the bone where the tibialis anterior, it comes close to, right? So then therefore it’s going to be more of a tibialis, anterior strain.

Why is it important? It’s going to be different needle techniques, same channel that you’re working with, same channel correspondences that you can work with. But yet if it’s the tibialis anterior strain, we’re going to be needling the motor points. Um, and not necessarily the, um, the technique that we’re going to be showing you for shin splints. Now there’s something that we should all be aware of. And maybe you already know about this, but if not, make sure that if the person is talk is, is complaining about anterior pain when running it gets worse during activity, and then starts to go away. When you look at the front of the leg, that anterior, there may be a certain shine to the tissue, let’s go to the next slide.

It could be chronic exertional compartment syndrome. Now this is a pretty serious condition that often requires surgery. Um, I’ve seen this quite a few times at UCS D the treatments that we applied helped with the person, but as soon as they actually started going back into activity, it came right back. Surgery is in my mind, the better way of going with this, uh, chronic exertional compartment syndrome is usually occurring with people that are increasing their training or they’re changing their running terrain. Something of that nature could also usually be brand new shoes, but they’re starting to develop shin splints, anterior shin splints, but yet the pain is going to be more in the tibialis. Anterior is going to be a long, the bone. It’s going to be a accompany, usually with a burning or an aching or a pressure sensation. And a big note here, it’s often bilateral 70 to 80% of the time you’ll have this as bilateral.

So remember that one, that’s a key. All right. And then also with this burning aching and pressure and possible numbness as well, is that it usually will start to go away 30 minutes, 15 minutes or 30 minutes after they actually stopped their activity. What happens is that the muscle tissue starts to hypertrophy from the increased training or from changing the random terrain and at a very rapid rate. And so the fascia tightens quite a bit, and with that increased pressure within that answer your compartment. And now this kind of chronic exertional compartment syndrome can happen to any compartment of the lower leg, but it’s most common in the anterior compartment. So this is why I can kind of mimic this tibialis anterior stress syndrome or the shins anterior shin splints. Is that the, so like I was saying is that muscle will start to hypertrophy.

You’ll get the fascia starting to type, it starts to compress. You’ll have a decrease of the venous return. So therefore there’ll be increase of the interstitial fluid. That’s going to put pressure on the neurovascular structures. Um, it starts to get a lot of compression within that region. Again, you’re going to start pressing against the anterior tibial nerve and the deep peroneal nerve, um, getting the signs and symptoms of burning aching pressure numbness. If you do have a patient with that, you want to refer them out, continue to treat them because you’re going to, you can still help them, but refer them out for further diagnostics with this. Now it can be a very serious condition if you’re going to be decreasing the amount of blood to the area, uh, let’s go to the next slide. This is something that I think is really quite viable valuables to feel the dorsal Punal pulse, which is right next to stomach 42, right?

So this is going to be a collateral branch off of the anterior tibial artery. So if you go just lateral to the extensor, hallucis longus tendon, and just medial to the extensor, digitorum, longus tendon, you want to feel for that pulse, right? So it’s pretty common. Make sure you compare sides, even if you feel the pulse on the same side of the possible exertional syndrome, if it is decreased compared to the opposite side, we think of that as being a symptom, right? So as a pop, sorry, as a possible sign here. So, um, feel the dorsal pudo pulse in these kinds of cases, it’s going to be pretty valuable information for you. All right. So what else do we have? Let’s go next.

Can I say something real quickly about that? Matt is, um, some people, some folks are aware of both of these, uh, situation, uh, conditions, but, um, uh, maybe not. So it’s worth mentioning, you know, compartment syndrome, uh, for those who might be aware of like more of an, uh, traumatic compartment syndrome, where you have something call on your legs, some kind of a weight or something like that, you know, an earthquakes and stuff like that. You’ll see these with people. That’s a much more trauma-based, uh, uh, condition where you get that swelling and that can be an emergency, a really severe emergency condition. Um, this is like that it has the same components in that it’s, it’s, um, it’s, uh, restricting and putting pressure on those neurovascular bundles, but it’s not from, you know, impact like a trauma, like something falling on the leg or something like that. But a lot of people are aware of, of compartment syndrome, and this is notice the difference of chronic exertional compartment syndrome. So just that,

Well, there won’t be blood vessel rupturing or bruising with case. Cool. All right. Thanks, Pete. All right. So let’s, um, start to get into the treatment techniques with this. Um, at UCS, I started an externship for Pacific college of Oriental medicine, which is now called Pacific college of health sciences. Um, this was, gosh, I’ve been doing this for 20 years now and it still is ongoing. So we take the interns from Pacific college and we treat the UCF athletes and, uh, shin splints is extremely common, um, there, so we have plenty of experience, uh, to, to practice a number of different techniques to see what works and what actually doesn’t work. And so, um, I developed the study and it’s, again, it was just a very small study. It was only a three week study. We only had 45 people in the pool. Um, there was three groups in the study.

One was an acupuncture, only study. One was a sports medicine only group. And then there was also a group that was a combination between acupuncture and sports medicine. Now, the protocols for sports medicine was ice stretching and strengthening, and also ultrasound. They were using actually both ultrasound and ice in this case, depending on the patient. So they were doing it using those four things. Then the sports medicine group, um, with the acupuncture sports medicine, we applied the techniques that were about to go over the accuracy techniques in addition to the sports medicine protocols. And then we also had the acupuncture group of suggest acupuncture in that sense. Um, so what we found was that at the end of the three weeks, Oh, there’s one important note is that almost each one of these athletes were taking a lot of assets and they’re taking it, um, during and before, and also after the events, because they really need to be able to compete or they’re going to lose their position on that team.

So, um, and says was, was gobbled down like candy. And so one of the questions that we had with this particular study was that they could go ahead and decrease the amount of end sets if they wanted to voluntary voluntarily. So, um, this was something that we found in the study that, that in the acupuncture group, people were actually not taking the sets and just coming in twice a week for the acupuncture, which was not statistically significant in the other two groups. Uh, so in this article, uh, printed in the journal, Chinese medicine, 2002, so way back when, um, it does show that the acupuncture group was actually far superior and the other two groups, um, really didn’t match up very well as far as getting results. Now, again, this was only a three week study. There was only 45 participants in this. If we made it an eight or a 10 week study, I would think that the other two groups would actually start coming up. But I think there was actually enough evidence to show that these needle techniques that we’re about to get into, um, actually work pretty darn well. Um, and this is something that, um, I continue to use and have been teaching in the SPAC program Ford smack program for a good 20 years now. And, um, so we’re getting a lot of good results with it. So let’s take a look at the next slide.

All right. So the key with this with medial tibial stress syndrome is to palpate where the top of the pain is on the tibia. And then also where’s the lower range, the lower end on the tibia. So you’re going to start your needling at the top, just above the painful area. And you’re going to thread a number of different needles could be eight, could be 12. It could be more depending on how long the area of pain is. So each needle will

Actually,

And we’ll go in and the other one we’ll actually go right on top of it. So there’ll be continuous needles all along that edge. Now it’s going to be shallow needling, right? And that’s going to be very important. You don’t want to go deep when we did go deep. It actually aggravated the condition. So it’s a transverse needle technique, no more than 15 degrees, right? You want to thread that needle right along the edge of the tip yet, as if it is scraping the tibia, you don’t want it to go too much into the soft tissue. You want it in the crevice, just off of the edge and on that edge of that bone, right along that liver channel, just like on liver five, how we try to be able to scrape the bone fat, think about that with these particular needles, uh, you don’t want the needle at 30 degrees.

You wanted at 15 degrees, 10 to 15 degrees, and then thread that. So they overlap all the way down to low the area of pain. Now match this needle technique with your constitutional treatment. You can also go ahead and treat other points with this. For example, we were talking, um, spleen points because the tibialis posterior is associated with the spleen gene, Jen. So we want to treat spleen points in this case, of course, we want to probably treat stomach 36 for the patient, which is also nice. Cause that’s the motor point, one of the motor points for the tibialis anterior. So to reiterate this needle technique is not the only thing that we do, but this is a successful needle technique for helping to decrease pain. When you are helping to treat this patient now for the anterior tibial stress syndrome, which is the next slide.

It’s the same type of needle technique is the exact same idea. And, but you’re threading in different areas, obviously. So it’s right on the edge of that tibia and medial to the tibialis anterior in this case. So again, this is going to be something that you want to go ahead and treat the person constitutionally with it. And also you want to apply the myofascial techniques that we’re going to be getting into just next, I believe. Um, one important note, if the patient does have foot overpronation that this, these needle techniques will help decrease the pain, but the foot overpronation will need to be corrected or helped. And one way or another through exercises treatment, maybe, maybe the foot is prone is so much that you actually need to be able to get inserts. And that’s something that we actually talked about in that webinar in December. So the foot overpronation does need to be addressed for long-term clinical success. Brian was saying, um, no, I think it’s good. All right. You want to get into the mob passionate techniques? Yeah, sure.

So, um, I guess we go to the next slide. So we have, uh, one, one slide and a video for, um, demand terrier. And for tip posterior, we’ll start with tip posterior. Uh, we have videos for these because as Matt mentioned, um, we pick the subjects that we’ve recently presented on it, and it’s now live on the Neta knowledge, uh, for some of our classes, for the sports medicine acupuncture program. Um, and we recorded, uh, some acupuncture, more distal points for treatment of things in the assessment and treatment of the sinew channel class. But we have a lot of myofascial release techniques in those classes. So we have videos for them, for presenting at the webinars, um, uh, just cause we had better camera angles. We can, we can plan it a little bit better. Unfortunately, we don’t have videos for the acupuncture part cause we we’re, we’re reserving those classes for live classes, just so there’s more oversight.

Um, especially certain techniques require a little bit more oversight where there might be. Um, it might cause damage if people aren’t doing them correctly, we’ve, we’ve reserved those for post COVID, um, to do a in-person. Um, but some of the other classes, we were able to do a online webinar form during this time of COVID. So unfortunately that videos for them, it’s not to say that these are more important than the acupuncture. It just happens that we have videos for them. So let’s use them. Um, so this one, uh, we’re going to be working just sinking deep, uh, behind the tibia. And the goal is to kind of move the tissue posterior to soften those connections of the tibialis posterior, uh, from the tibia, uh, with the caveat that if there’s extreme discomfort for this, you have to use less pressure or maybe start using this technique as the, um, a few sessions in, as the acupuncture starts improving the condition.

So if the person is retreating from you on the table, either soften the pressure or uh, hold this one in reserve for down the road, but it’s usually, uh, able, you’re usually able to do it. It’s a slow technique you’re giving the time, uh, the tissue time to sort of soften and melt a little bit and connected tissue to sort of, um, become a little bit more soluble to go from that more gelatinous, hard state to a more soluble state. So it’s, it’s often applicable, but, um, you might have to modify pressure, especially on this medial surface that could be quite tender. So you’re going be sinking, a soft fingers sink in, take your time. And then slowly moving the tissue posterior as the person does a range of motion with the foot, if it’s too much of a range of motion that can push you out. So, so it has to be a small plantar flection, dorsal flection, very slowly. You’ll see that on the video. So let’s go ahead and look at the video and it’ll highlight that

This is a compliment to the tibialis, anterior myofascial release the technique. Again, it could be one that’s done along with that one, or it can be done separately. There’s various clinical reasons why you might do one or the other. Um, but the same idea exists is I want to move the tissue from the deep posterior compartment from lower down around spleen six in particular, it’ll be over tibialis posterior. I want to move that tissue away from the tibia. And I want to angle my direction down into that deep posterior compartment, multiple muscles there. But my goal is thinking about influencing the tibialis posterior and moving that most anterior most muscle away from the bone and giving more space along the spleen channel and spleen send you a channel. So I’m going to enter in just posterior to the tibia. Spleen six would be a really good starting point to consider.

So we’ll go in the region of spleen six, angling posterior, I’m going to have the patient’s door selection and plantar flection. This one, especially as I get higher up, it might be a smaller if I can get away with a little bit more, well, that might get to the point where it feels like his musculature is pushing you out out of that little Valley, which has all minimize the movement. Reposition slightly superior, six strays towards the table, and then ankle dorsiflexion thinkers. It could be the flat of the failings, same thing. As I dropped behind the tibia, I sink down towards the table and a slide traction, posterior, they’re going to do it ankle doors to flection. That’s almost pushing me out, but I’m going to do it to see if I can open up that tissue a little bit and relax, good up singing down traction, posterior slightly, just enough to give a drag on the tissue call for movement. Could you even consider using the flat on my elbow, but I’d have to be very mindful of depth because this tissue can be very sensitive.

One more

Sink down, traction, posterior call for movement. That’s enough right there. Yep. Too much. And we’ll push you out. So you might have to minimize the movement. Let’s do one final pass. Might be a little bit more on the solely as two, but that’s okay. It’s still opening up that same space behind the tibia. All right. An excellent technique for tibialis posterior syndrome. As the other technique on the stomach channel would be for tibialis anterior syndrome. It’s excellent to open up the ankle dorsi, flection and working on any condition that would be affecting the foot, uh, especially PEs planus. And we can look at a modified technique for past planters specifically.

I think we can probably move on, uh, to the next slide. Uh, that one I think was most relevant for tibialis posterior stress syndrome. Um, and I know we have not unlimited time. So, uh, this is a similar technique and we’re on the stomach. I send you a channel on the tibialis, anterior, very similar idea. I’m going to sink into the tissue. There’s a little bit more meat of the tissue to sink into. We have such a narrow space for tip posterior. You’re buying the tibia to get to that deep posterior compartment, but the anterior compartment we’re really having a little bit more direct access to. And another difference with this one is the tin posterior. I’m just kind of angling and stretching away, but I’m not gliding through the tissue so much because then I would just be gliding through the soleus. So it’s, it’s more of a traction. Whereas this one I’m going to actually glide through the tip anterior, but at the same goal to help soften those connections to the tibia. So let’s go ahead and look at this one.

We’re looking at a specific myofascial release technique for the tibialis anterior muscle and especially cases and especially useful in cases where it feels like the tibialis anterior. Is it here to the tibia and another condition where you might feel a little bit of a loss of a ballet dance, rigid, tibialis, anterior, and glued and stuck to the tibia. So we’re going to come in with a fist loose fist. My knuckles are going to be right up against the tibia and not driving into the tibia tibial crest, but right up against the tibia as close as I can get to it, I’m going to angle directly down. I’m going to go planning through the muscle, but I don’t want to think about it as a round technique where it pulls the leg into external rotation. I want to think that I’m going straight down to the table and it’ll actually squeeze the leg, push it a little bit into medial rotation, or at least it will influence it towards medial direction.

So again, this way around the leg will pull it into lateral rotation this way, straight down into the table, we’ll push it into medial rotation. So I’m going to contact sync perpendicular into the tissue, ask the patient to do some divorce, deflection toe extension plantar, flection to reflection. Sometimes it’s a little bit faster of a technique, but this tissue feels very stuck here. So I’m going to take my time and let it soften and melt and back out. It’s not uncommon to see some little tracks where your fingers, where it’s a little finger tracks. I can move down a fist length. I can sing stray towards the table, ask for movement and falling at that flood into dorsiflexion and plantar reflection. Again, even if I take my hand away, it actually pushes the leg more into medial rotation because my intention is just straight down. One more pass. You don’t want to go too far down because it can get a little nervy at about mid leg is good. It’s a one Margo plantar flection, and I’m going to do one more pass on the coming back up. You don’t have to do it this way every time, but this tissue felt particularly congested, uh, ankle, Doris deflection, total extension, and then down.

All right, that’s great. So, um, just to reiterate on some of the first technique for the medial side, if the patient is experiencing what you are thinking of osteoblastic activity, where there’s a dime-sized spot that is exquisitely tender, you can perform the technique above and below. It just let pain be your guide. I mean, these techniques are actually very, very useful after the acupuncture technique, um, to help free up that area and increase the circulation. Uh, Brian, anything you want to say before we jump into the exercise now, I think, uh, we’re ready for that. So with the exercise, this is ankle rotation. This is coming from our postural assessment and corrective exercise class in module three. This is a go-to exercise for shin splints. This is something that’s always going to be in. The protocol will be the only exercise. It all depends on the patient’s posture.

Like for example, if they do have food, overpronation, there’ll be a number of different exercises that we teach to be able to, um, use with that. But this would be one exercise we would throw into that protocol because it does exercise all of this in new channels, the yin and the yang sinew new channels with the lower leg. Um, this is an exercise that actually requires quite a bit of concentration. Those because people start to kind of have it, their mind is wandering or the dog comes and licks the patient’s face because they’re on the floor. You know, you have to really concentrate with this exercise. Now in this photo, what you’re seeing is the model, bring the hip into 90 degrees of hip flection, and then supporting that leg so that the tib and the fib are going to pair be parallel with the table.

I’m parallel with the floor. Then you go into ankle dorsi, flection from ankle dorsi flection. You’re going to ask the person to make a full range of motion as if you’re drawing. And Oh, you do that 10 or 15 times in one direction. And then you do 10 or 15 times in the opposite direction. Now to work the opposite side, you’ll notice that the model has Dorsey flection. So this is going to be an exercise that you want to work on both sides. You know, the person’s going to be having shin splints on one side exercise, both sides because there is going to be a crossover neurologically and also with the channels. So this is a really great exercise to really, um, before running and also after running helps really loosen up that lower leg quite a bit, um, before the run. And it helps to, uh, loosen up the leg quite a bit after the run as well. Brian, anything you want to add to that? Yeah.

Yeah. You know, when they’re doing the exercise, I know this is my hand. So you just have to use a little imagination here, but if the person has e-version and they’re already, you know, you can look at the, the video, uh, the webinar we did on PEs planus, we go into it a little bit more than I have time here, but if there are any version of their ankle and foot position is such that it’s going to encourage that, that turning out, um, whether they’re pointing the foot down in the planet reflection or up into door selection, and they have a much harder time going up and in or down and in, which is going to engage, tip anterior and tip posterior. Um, when they do this, they sometimes cheat a little bit, or they’re like a little, uh, a little iffy on the both, uh, down and in and up and end portion of it. But they’re very strong on the up and out, down and out portion of it. You really have to coach them to make sure they’re there fully getting that foot turned in, in both directions, whether they’re going clockwise or counterclockwise. So don’t let them just kind of like, you know, bully it into one direction. It kind of like, eh, not quite there at the other direction, you have to give them a little bit of incentive or kind of bring that to their attention

At least. Yeah. That’s a good point watching your patient, perform the exercise before they go home and do it. And a lot of concentration each time, making sure they’re going into the complete range of motion. If the mind starts to wander, it’s going to be really easy just to kind of flap it around a little bit, which is not really doing very much. It’s not really exercising this. Um, this is also called shin burners. And after doing it 10 or 15 times yourself, you’ll understand why it’s also called shin burners. It’s a difficult exercise. It’s a fantastic exercise, especially for shin splints. Anything else there, Brian? No, I think we are good. All right. So here’s some contact information. You guys, um, uh, thank you so much for attending. It looks like we really went over time with this. And so for you guys that hung out the whole time, thank you very much. Uh, we wanted to thank the American Acupuncture Council again for having us with this sports acupuncture webinar. Um, Brian, it’s always a pleasure hanging out with you and we should say, Oh yes, next week, make sure that you are back for Lorne Brown. He’s going to be discussing some topics, whatever Lorne is going to be talking about. It’s always excellent. He’s got that unique ability to be an amazing clinician and a real, quite an academic as well. So, um, Lauren is a great guy and somebody to be able to listen to.

All right. Thanks. You guys very much. Appreciate it. Yeah. Thank you.

 

AACTTPCallison-Lay03032021

Introduction to the San Jiao Channel Sinew (Jingjin)

 

 

So we are going to discuss a St Joe’s sinew channel today, a little bit of the typography, a little bit more of the anatomies to start off with, and then we’ll, um, have a chance to talk about a representative injury of the channel. So that’ll give you a little preview of what’s to come in the next 20 minutes or so,

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello, everyone. Welcome to the American Acupuncture Council podcast. My name is Matt Callison. Hi, I’m Brian Lau. We’re from Accu sport education and the sports medicine acupuncture certification program. Uh, we want to chat with you today about the San Jiao channel. So can we get into that first slide please? Alright, so go ahead, Brian. Yeah.

So we are going to discuss a St Joe’s sinew channel today, a little bit of the typography, a little bit more of the anatomies to start off with, and then we’ll, um, have a chance to talk about a representative injury of the channel. So that’ll give you a little preview of what’s to come in the next 20 minutes or so,

Matt, were you going to say something? I was just going to introduce that you did a great job.

All right. So this’ll actually also give a flavor of what we teach in the sports medicine, acupuncture certification, each module, we haven’t anatomy, palpation cadaver lab. Uh, so there’ll be some elements of the anatomy that we’re going to be teaching and actually have a class you’re watching this live there. We’re going to be starting tomorrow, uh, for the upper extremity. So the San Jo channel will be one of the many channels that we’re looking at, obviously for the upper extremities. Um, and, uh, some opportunity to look at some, uh, dissection that we’ve done, that we’ll be presenting in our class. Uh, so we’ll remind about this, but if you are watching this around other people, we’ll give you a heads up before the dissection stuff comes on and give a couple thoughts on that, but you just want to make sure that there’s nobody, uh, around you that might be, um, you know, it might be disturbing for some people, if they’re not medical providers and they’re not used to seeing cadaver images. So we’ll give ample warning before those videos come on.

All right. So let’s go to the next slide and we’ll start looking at some of the entry, uh, anatomy for the channel sinew of the Sanjay channel. So this is from a translation of Vietnamese scholar Vanji, uh, from, from the link Shu chapter 13. And if you kind of glance through it, uh, you can see that it gives a description of the typography. It’s kind of vague, you know, the, uh, very open to interpretation and, and vague some of the anatomy descriptions and the link shoe from chapter 13 for the channel send news channel, send sinews have maybe been a little bit less, um, explored than the primary channels and some of the other secondary channels, like low connecting, et cetera. So the channel send you is probably in the history of Chinese medicine. Haven’t been explored as thoroughly, and we’ve been doing a lot of work within the sports medicine acupuncture program to, um, further define and be a little bit more specific on the anatomy of each channel, uh, including which structures are involved with, with channels, how they link with other channels in terms, um, parents, you know, like internal, external related channels, how they communicate and work with those, how they work mid David died, et cetera.

So just to be a little bit more, um, specific with the anatomy and a little bit more specific with some of the functional anatomy in particular, so you can kind of glance through and see some, some aspects of the original description at least translate in English and this translation. So anything dad, Matt? Yeah,

This is good. Let’s go into the next slide there.

Yeah. So yeah, here we have, uh, our interpretation of the, um, San Jo send you channels. Sometimes we referred to them as sinew channels, channel sinews, DJing, Jenn musculotendinous channel, a lot of different translations DJing. Jen would be the, um, the opinion version from the Chinese. So here’s our interpretation of that. The sand shout send new channels a little bit, um, harder to interpret as it gets higher up into the traps and starts, uh, including some of the, um, the cervical fascia. And we’ll go over that when we get to it. But if you just glance through the list, that’s pretty channel like we have the fingers, finger extensors on the back of the, uh, kind of posterior surface of the forearm. Uh, deep to that, uh, included is the super Nader. Uh, then the medial head of the triceps, the triceps are three muscles, but there’s two that are superficial belong had in the lateral head are more superficial.

And then deep to that is a shorter tricep muscle, which is in a different sort of compartment. I’m still a tricep, but it’s a deeper one and that’s the medial head. And that’s part of the San Josten new channel, the more superficial as part of the small intestines, any channel then as that travels up and connects with the lateral intermuscular septum that goes into the deltoids into the superficial deep cervical fascia, superficial layer, upper trapezius, SCM dye, gastric, and up into the scalp. We’ll go through that in a little bit more detail in the next several slides and that you were going to add something to this also.

Yeah, I think it’s important for us to remember that each one of these muscles in these tissues are all interconnected. So this is why when we can treat something, put an acupuncture in distal, how it can signal along that model of fascial chain and soften or change pain at a proximal area. For example, if somebody has pain in the SCM, how we can treat some of these different tissues, a distal from the SCM and start working towards softening that SCM. And is that, uh, the bottom line here is that each one of these tissues are fascially connected and they can be able to carry signals. So I think that’s, that’s good. So we’ll move on to the next slide.

Yeah, sure. Yeah. That’s a good point, Matt, because then that includes, um, both channel points that can regulate tension in the sinew channels, but also, uh, points that are off channel and maybe include, uh, she points or muscle motor points and et cetera. Yeah, let’s go onto the next.

Yeah. Good. Okay, good.

So if we kind of look at the forearm, we have a more superficial layer of the San Angeles and new channel. And like I kind of already alluded to that. Is it going to start at the, uh, the hand with the tendons of the extensor digitorum commuting as muscle? So that’ll travel then up the posterior part of the forearm, and it’s going to attach to the lateral epicondyle, uh, that fascial linkage. And that was referring to then from the lateral epicondyle goes right into the lateral intermuscular septum. A lot of people might not be familiar with the lateral intermuscular septum. It’s highlighted in green in this image that I, we put the highlights in, but the image itself is from an anatomy Atlas from a German author Tillman. So you can see that little thin green line, just, just between the biceps and the triceps.

So this lateral intermuscular septum is the kind of fascial September wall between the biceps and the triceps, and it can transmit force. And in this case for the San jab sinew channel, it’ll transmit force up into the deltoids, particularly into the middle head of the deltoids. So that’s a more of an overview of that superficial aspect. Um, but also, uh, the medial head of the triceps can put tension into the lateral intermuscular septum. So there’s a lot of communication between the medial head of the triceps lateral intermuscular septum, uh, extensor digitorum communis. So those are all facially linked.

Good. All right.

So I guess we can go on to the next one

Next slide.

All right. So we have two more images from the same Atlas. So the first one on the left, we have, you can kind of see the little tools that are there to move apart. Um, and we’re going to see this on that cadaver video that we did. So in any of these types of things, everything’s so facially connected that you’d have to have a scalpel to kind of tease the way that fascia so that you can then come and move away those compartments, and then see deep, uh, below in this case, the extensors, the wrist extensors, especially extensor digitorum communis. And what you’re seeing is the super Nader, which then on the image on the right is a much cleaner image, cause it has all of that other stuff taken off. So you can see kind of the relationship on the picture of the left and then the deeper structure of the super Nader, uh, on the picture, on the right, also part of the sand Jassen you channel, and it especially links, you know, everything has a fascial linkage. This one has a fascial linkage that has a name, uh, into the lateral intermuscular septum. And that’s a radial collateral ligament. So you can see the image on the right really nicely shows that radial collateral ligament that has splashes spreading over the super Nader and then up above it, into that lateral inner muscular septum.

Yeah. Excellent. So let’s go back. Let’s say somebody

Has that sternocleidomastoid pain just to be able to keep it consistent. We could create the supernate or we could treat the lateral intermuscular septum. We could also treat San Jo one. We could treat the extensor digitorum communis and all of those points would end up affecting that part of the SEM that is affected by the sand Jobson channel.

Yeah. Yeah. That’s the hems is interesting too because, uh, the San Justin channel particularly seems to affect the GLA vicular head and then there’s any trigger point people, uh, listening and you might know, Oh yeah, the curricular had kind of refers oftentimes pain into the ear. It can be a headachy, uh, pain into the forehead and different places, but it often refers into the ear and can cause, um, positional vertigo. So then, you know, for me, I started thinking, well, geez, what, what would that make sense for the sand Dow channel to have some kind of effect in the ear and any, and any acupuncturist here? Of course they, yeah, of course you have John three, Sandra five, there’s a lot of, uh, relationships, the points on the San job channel with the, uh, with the ear. So that’s one that has, has an interesting correlation, but it, you know, like Matt, the sand supinate or other ones could be really involved.

I was just thinking San Joe seven, also being the sheet cleft point of that channel is the motor point for the extensor and dices. So that would be another point there too. Yeah.

And that one’s in the channel. We have that one listed in the list above, but it should be

All right.

We’re ready to move on to the next slide.

Sure. All right. So from the

Deltoids and especially the sand Dow channel has a relationship to the middle deltoids that then, uh, deltoids then go to the spine of the scapula and the chromium. And they pick up the, uh, superficial layer of the deep cervical fascia. Because if you look at the trajectory of the Sanjenis in your channel, it kind of comes from the back and it goes up the neck and then binds to the jaw. There’s really no muscle that has that trajectory that way, I guess the [inaudible] more superficial might, but it’s, it doesn’t seem to make sense for the San Joslin new channel. But if you look at this fascial layer of this superficial layer of the deep cervical fascia, it does have that trajectory and binds and connects them to the mandible, to the sort of angle of the mandible and then, um, ramus or the body of the mandible.

Um, so it sort of follows that trajectory and it wraps around the trapezius and wraps around the sternocleidomastoid. So it’s very intimately involved with both the upper trapezius and the sternocleidomastoid the digastric is in this region also. Uh, so if you think about the channel as being more of that cervical fascia, um, it might cross and include muscles that aren’t going in the, in the trajectory, in the pathway of the channel, but still has tensional relationships with the SCM seems like particularly the clavicular head of the SCM and then the upper trapezius and upper trapezius is a big muscle. Uh, I would say that particularly relevant are those fibers of the, uh, upper trapezius that go from the, a chromium to C seven, which are what you would be needling if you needle the motor point, uh, in maths book book, the motor point index it’s referred to as the part two fibers that many people needle from sand gel, 15 kind of angling upwards into gallbladder, uh, 20, 21, excuse me

Now, which is nice, that new technique is safe. It’s you, you’re not going to create a pneumothorax with that and linking the shower Yom channels, which is nice. Something that we take the teach in the smack program is acupuncture as an assessment. And this is going back, let’s go back to the SCM clavicular pain, so to speak, maybe somebody who’s having a cervicogenic headache is going to the side of the head in the sand jaw channel. We’ve provided already a list of different points that we could use that would help to say change range of motion, or start to decrease that headache. So acupuncture is an assessment. If somebody has that type of headache and maybe they have limited range of motion, they have a forward head posture. If we put the acupuncture needle into the extensor digitorum communis motor entry point, and then had the purse move to see if that actually changed the cheat within that San Jo myofascia channel, or we could use of course, San Jo one San gel seven, the lateral intermuscular septum. So we’re providing a number of different tissues that you can use for either a proximal injury or a distal injury using acupuncture as assessments. Really nice because it’s just giving you some ideas of what points actually make the greatest effect on that orthopedic evaluation on that range of motion on that pain, then you would take that needle out. And then when you’re actually going to be needling, the patient you’ll include that needle back in as part of the point prescription. Okay. Hope that was clear.

You already saw immediately that it had an effect on the dysfunction. Yes. CSS.

Yep. All right. So do we now go into the next conversation about the cervical fascia?

So this is a image that’s put together from this, uh, professional softwares. I go body, uh, they don’t have that little lines that are drawn. I, I painstakingly put them through, uh, through a illustrator like program, but, um, but cause I wanted to show the fascia because these programs, these 3d programs are very clunky and not as a muscle like the deltoids and traps and they’re like putting Legos on, um, which is not how the body is when you see the cadaver dissection. Obviously you’ll see this very clearly. So I put those white lines on the sort of show the fascia coming up from the middle deltoids, sweeping through the, uh, upper trapezius going across the SCM I say across, but it actually both the, um, STM and the traps are embedded kind of surrounded in that superficial layer of the deep cervical fascia. So it goes on both sides of the SCM and then goes to the mandible and links up with some of the fascia and the jaw and up into the temporality, uh, fascia, which would include the temporalis muscle.

In that case, you can also see those little, uh, your muscles that move, uh, and stabilize that region of the, uh, of the ear. Um, but the temporary, temporary Alice fashion, uh, the temporary, temporary Alice muscles. Interesting because that’s another point. And I think Maddie, you have the send the motor index as, as having, you can treat the motor point for headaches and various reasons, but this one has a, um, empirical use of, of, uh, reducing tension in the upper trapezius ipsilateral is another. Yeah. And you can see through the fascia, how that would be, be very much linked and help communicate that, that the attentional relationships between the two. So, you know, the take home, there’s a lot of things that are surrounded by this fascia, but really clinically the upper trapezius, especially those fibers that are kind of horizontal connecting to C7 as part two fibers and the [inaudible] head of the SCM that you haven’t, you can access from the motor point kind of in the region of stomach nine and angling through the muscle, but you can also get really good access to it through sand gel 16 and angling from Sanjay 16 cross Valley into the posterior portion of the SCM and, and, uh, um, connecting into that clavicular head.

We have a video on, um, the YouTube channel sports medicine, acupuncture, YouTube channel that shows both of those, um, both, uh, both the needle directions for the motor point and through that Sanjay 16.

All right. So the next slide is going to be, sorry, Brian, go ahead.

I said, I think that’s the, a it for the intro. Yeah. And I think we’re getting ready for the cadaver. Why don’t you set this up that? Sure. Yeah. So let’s just make sure that again, some people, if they do see this, um, passing by your computer or sec are really not going to enjoy it very much. It can actually really affect them deeply. So let’s be really careful of where we’re observing the following video, which is going to be of a cadaver dissection. Um, let’s make sure that there’s no screenshots, no sharing of the recordings and no downloading, please with this, we don’t want to share this kind of information. This is just for us medical professionals to be able to learn from. So then can we now see the video please? And then I believe there’s,

So we’re look at the sand house in your channel, starting with the forearm. We have the extensor digitorum communis exposed extensor digitorum, communis in a different fascial compartment. Then the extensor indices, so different fascial compartment than the extensor indices. Here we go. And a different fascia compartment. Then the extensor digit I minimized. So indices digitized minimize. So we’ll put those back into place so we can see them in relationship extensor, digitorum communis comes up. The arm attaches to the lateral epicondyle it also communicates into the lateral intermuscular septum, but has a communication into the medial medial head of the triceps, which there’s a little part of it on the lateral aspect there, medial aspect of the triceps also puts tension into that lateral intermuscular septum. So San Jo has more to do with the medial head of the triceps all the way up communicating with the deltoids. We feel that that communicates more through the middle fibers of the deltoids and then into that portion of the upper trapezius that attaches to C7. So those part two fibers of the upper trapezius and another point we’ll be able to do a little bit more dissection and start to look underneath these structures to see the, a super Nadir, which we’re starting to see a little bit of the super Nader right there, part of the sand gel channel.

All right, great. So let’s get to the next slide. All right. So some of the common injuries associated with this particular manufacturer, Jean Jim will be distal the EDC tenure synovitis. So the, on the wrist itself, the tendon that is going to be in the middle of San John for an extra point zone Tron. This is a common area for risk tenure, synovitis of the extensor digitorum communis and also super Nader syndrome. So the super Nader being deep to large intestine nine, and we’re going to actually talk quite a bit about the SuperNet. We’re going to highlight it in this podcast because it’s a great mimic for lateral epicondylitis. Um, this particular podcast also, um, will parallel the blog that we have on the sports medicine, acupuncture website, sports medicine, acupuncture.com, where we discuss supinate or syndrome. And we’ve got a couple of videos also, including a mild fascia release technique.

That’s very effective for helping to release the Supernanny. And we’ll talk about that in a little bit more. So another injury that you can get in the Sandra Jean Jean will be lateral epicondylitis in particular, when the extensor digitorum communis is involved, which it commonly is. However, with lateral epicondylitis, we also have the extensor carpi radialis longus and brevis, and those will be more in the large sinew channel. So the lateral epicondylitis will be the EDC or the extensor digitorum communis involvement. Then we have our tricep strain, which can occur around San Jo 10 and actually go all the way, even the lateral, following that Sanjay channel toward the Antonius, the medial head of the triceps, which is involved or categorize within the San jar. Gene gin is one of the more frequent muscles out of the three triceps that become strained. That can cause, um, a tendinopathy there around San Jo 10. Then of course, as we discussed earlier, any kind of muscle tension headaches, they might be contributed from that cervical fascia and also the, um, um, looking at the clivia head, the SCM. So let’s, let’s focus a little bit more now on the super Nader syndrome. Like I said, which it can, it can mimic lateral epicondylitis because it does attach to the lateral epicondyle. So let’s go to the next slide, please.

So the supernate or being in the deep layer that you saw in Tillman’s images. So if we took the extensors off on this image, you’re going to see that supinate or that you also saw on the cadaver dissection. So the radial nerve, as it comes down from C5, C6, C6, C7 follows along the sand job channel around large intestine 11 region. It actually bifurcates. So the superficial radial nerve travels along the large intestine channel. And then the other bifurcation is the deep branch of the radial nerve. It’s also called the poster interosseous nerve. So deep radial nerve and post interosseous nerve is synonymous that posterior interosseous nerve dives down through the supinate or through this fibers canal card that called the arcade of fros. Now with overuse in the super Nader, either being in a lock long or a lock short position, it can entrap that poster interosseous nerve and cause a parasthesia along that sand jaw channel, but it can also mimic lateral epicondylitis. So lateral epicondyle can actually be a little bit tender in that region, but most of the pain is going to be around large intestine nine region. Let’s go to the next

Slide.

So this is from a previous dissection that we’ve had. You can see that the radial nerve is there on the left, the, the blue ribbon there, which is actually a surgical glove, just cut up tied around. So you can see that bifurcation. So the elbow is going to be where that blue glove, that blue little ribbon there that’s the bifurcation. So you can see that post interosseous nerve traveling through the super Nader muscle and then exits and follows along the sand jaw channel. If that muscle, like I said, from overuse and traps, that nerve, and that can cause a parasthesia within that region within the sand jog channel will cause pain, raw, large intestine, large intestine, nine large intestine, 10 deep, but it can also cause around lateral epicondyle. So it could mimic lateral epicondylitis. So a differential diagnosis is going to be needed. Lateral epicondylitis will not have a parasthesia if there is pain at the lateral epicondyle and there is a parasthesia, especially traveling in the super Nader region, San Angelo channel, then you think super Nader syndrome probably want to say anything about that, or should we jump right into assessment

Simple. And it’s not as relevant for super Nadir syndrome, but that a superficial branch of the radial nerve then travels down the ally channel. As Matt said, it goes deep to the brachioradialis. So you can kind of see on that left edge of the slide, you can kind of see the brachioradialis pulled off to the side. So then that, that, uh, branch of the nerve goes deep to the brachioradialis. Just that that’s all just to add that in.

Okay. Cool. All right, let’s go to the next slide. Let’s talk about some assessment. So when a patient comes in with lateral elbow pain with possible parasthesia into the lateral forearm, along the course of the San Angelo channel, you’re starting to think more supinate or syndrome than true lateral epicondylitis. Now palpation of the supernatural muscle will be very tender and possibly listed parasthesia. You want to compare symptoms to the supernatural muscle on the opposite side, that’s always going to be very important. The supinate or manual muscle tests repeated four to six times will often create pain in the large attest nine region Garcia, Tencent 10 region, maybe even lung five. And it might extend along to the lateral epicondyle as well. So we’re going to actually go over that manual muscle test, a mills test and cousins tests. Those tests are for lateral epicondylitis. So therefore if you use mills tests and cousins tests and they do elicit pain at the lateral epicondyle then possibly there is some extensor involvement as well. However, if there’s parasthesia please think about the [inaudible].

Now the patient may also report that the forearm and hand feel weak, heavy, or also uncoordinated because of this nerve entrapment. It can cause muscle weakness. So let’s go to the next slide if we would please. All right. So cousins tests and mills tests, most people already know what those are. If not, it’s very simple to be able to YouTube that Google it. Um, it’s, they’re, they’re common tests. Now, the supinate or manual muscle test is not so common by putting the patient into this particular position. And you’re going from a supinated position. You’re going to try to break them out of super nation and going into nation. Now, if you do this four to six times, if the person does have supinate or syndrome, many times, it it’ll become sore in the large intestine and larger test 10 region. And it may also start to elicit that parasthesia so you can use this manual muscle test as confirmation.

All right. So let’s talk about where the actual motor entry points are, the radial nerve into the supernatant. Next let’s go to the next slide. Okay. So there’s two, one’s going to be approximately one to one and a half soon distal, and one soon, our half a soon radio to lung five. So if you take your finger and put it on a lung five, please, in that cubital crease, you’re going to be on the radial side of the biceps tendon in the elbow crease lung five. Now move about one to one and a half soon distal toward the wrist. Now go half assume to the radial side, deep to this region here is going to be one of the motor entry points onto the SuperNet or which we’re going to have a video. That’s going to describe this a bit more in detail. Now, if you can go too deep to larger test and nine, so large intestine nine is going to be three soon down from large intestine 11.

All right. So we’re going to separate the breaker radiologists and the extensor digitorum, uh, uh, extensor digitorum readouts, longest separate those tissues to large intestine nine press against the radial bone, which is usually a great sensation. And that will cause quite a bit of sensate caught quite a bit of pain in that area. That’s going to be another motor entry point for the super Nader. So let’s take a look at the next video, which is going to describe location and then also the needle technique. And then after that, we can take any questions that you guys may have, or we can have some, uh, closing comments,

The supernate or muscle has two motor points. One’s going to end up being distal from lung five on the other. One’s going to actually be located a large intestine nine. So let’s take a look here. So from lung five, we know that’s going to be in the cubital crease here on the radial side of the bicipital tendon. If we drop inferior one to one and a half. So, and just depending on the size of the patient, and then we go to the radio side one soon. Now, palpating you’ll feel the break your radiologists, when that break your radiologists at this location, you’ll divide the brachioradialis and you’ll fall right into a space. Now from this space here, we just keep massaging that tissue, keep massaging that tissue. Okay. Separating the brachioradialis. Okay. Now I can have the patient who, which is in supine. He’s in super nation right now.

He’s going to go into pronation and now going into superannuation, and I can feel that tissue popping up. I’m going to adjust my finger. I feel a little bit more here from super nation now into pronation. There we go. Okay. So then the needle technique would be looking at the supernatant from this location, which is one, one and a half and a half soon lateral separating the space between, between the brachioradialis and opening that tissue up toward that bone. So you’re going to be kneeling perpendicular, and you saw how I found that super near by going to pronation and supination to the skin directly toward that radius. Now let’s be mindful that the brachial artery is going to be traveling along that pericardium channel. So I want to make sure that we’re not kneeling deep in the pericardium channel in this region. So the needle technique for this particular point, be right toward that radius.

Now we can also need the supernate are based on large intestine, nine large intestine nine. We find large intestine 11, which is going to be at the end of the transverse cubital crease to large intestine five. We know that this is going to be 12 soon. So large intestine nine is going to be three soon inferior because the space between 11 and 10 is too soon. So from large destined five to large intestine 11 let’s divide that in half. There’s our six Mark. All right. So then now if we divide 11 and the halfway point and half, that will be three soon, which will be large test and nine large destined nine, three soon down from large intestine 11. So again, let’s feel for that break here, radiologists, I can quickly do a little manual muscle test or resistance test for the breaker radiologists. I’m going to have the patient just press up against me here and that break your radiologists a little bit harder, buddy. And that break your radius pops right up here. All right. So then now I’m just going to separate between the brachioradialis and the extensor carpi radialis longest and press right into that radial bone, which is going to be pretty darn tender for him. And I can feel that re the supernatural muscles start to pop up. When he goes into super nation, pronation is lengthening super nation. There it is right there. I’m going to needle here, large intestine nine directly toward that radius.

So we’ve located large intestine 11, we’ve located large, large intestine nine, which is three down from 11 we’ve identified where the brachioradialis is. Now we’re going to just slide our finger right into that crevice between the brachioradialis and the extensor carpi, radialis longest separate that tissue there, separate the tissue, and I can feel that radius. All right. So then now moving into superannuation, I feel the muscle popup pronation. I feel it sliding. I feel the muscle pop-up into super nation. All right. So the needle technique is going large intestine nine directly towards

The radius. And then we propagate

This muscle is innervated by the poster interosseous nerve or the deep radial nerve, which is a branch. The superficial nerve goes to the large intestine channel and the deep branch comes down to the posterior interosseous nerve or deep radios synonymous, which then goes into the arcade or fros for the super Nader syndrome. And that’s a lecture that we have in this particular program and this particular module, this is going to be super Nader at large test nine. Let’s take a look at how we’re going to needle the super Nader from the, uh, lung channel.

[inaudible]

Lung five, we dropped down one and a half. We moved to the radio side a half, maybe three quarters of sun. Sometimes it’s one soon, depending on the size of the patient, feel for the radius, that’s going to be your key. Now we’re going to separate the brachioradialis here. All right. So on this side of the brachioradialis Okay. And I can have the patient pronate and supinate, and I can fill the muscle pop-up with super nation. We insert directly toward the radius

[inaudible] and propagate.

Okay. So the two motor points for the SuperNet, and that’s how we would treat that. But of course, that’s just treating the supernatural. We’d have to include more points to be able to soften that, that Sanchez senior channel, and also look at the person’s posture as well. Um, those were just two points to be able to be the super Nader. Again, we can go into extensively SCORM communis [inaudible] St. John for lateral intermuscular septum, the medial head going into the curricular head of the SCM to help, to connect to the entire San Jiao channel with that. Then of course, giving exercises that will help with the pronator, Terese and opera off in the supernatural. Many times the pronator chairs will be in a locked short position. I need to be stretched and the supernatural will be strengthened, but of course there’s never an always with all of this.

So it has to be assessed properly with that. And the pronoun Terry is part of the pericardium sinew channel. So it makes sense to treat that for both reasons. Yeah. Good. So internally and externally related of course. Awesome. Well, that’s it for our sand job channel quick question. Just cause I think other people might have it too. Um, and I think you said it you’re treating both of those points or is there a clinically a reason why you treat one or the other of them? Um, or is it really both for supinate or syndrome? I like to treat both of them because it is such a, a long muscle with a number of different attachments to it. So usually I’ll try to be able to get both because if I miss one, then I’ll probably get the other yeah. Got it. Yeah. Good question. Thanks for saying that.

All right. Well, Brian, was there anything else that you want to close this out with? No, no. As usual, of course, thanks to American Acupuncture Council, having the opportunity, do these webinars. Yeah. Thank you everybody for attending. We really, really appreciate this. And also, Oh, you just see that coming up. Lauren Brown is going to end up being here next week. If you have not heard Lauren speak before, he’s very energetic. He’s very knowledgeable. He’s a great person as well. So that’s going to be a good show for next week. Um, Brian, thank you very much. It’s always a fun time with you and thanks everybody. Really appreciate it. Have a great one. Bye-bye

[inaudible].

 

Forward Head and Shoulder Posture Issues

A Problematic Postural Position: Forward Head and Forward Shoulder

 

So forward shoulder, um, it’s a, it’s a posture that it seems like it’s becoming more and more common with sitting in front of the computer a lot more than we used to, especially during this COVID time. Um, the propensity for this, for the weight of the head to go forward and the shoulders to go forward is really quite great. And the more that we sit in one position, we know that the muscles and the myofascial tissues are going to adapt to that position.

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

The American Acupuncture Council for having us really appreciate that. I’m excited to get into this information. There’s a lot of great things with, uh, let’s go ahead and get into the first slide please.

Or the next slide. There we go. All right. Thank you. So forward shoulder, um, it’s a, it’s a posture that it seems like it’s becoming more and more common with sitting in front of the computer a lot more than we used to, especially during this COVID time. Um, the propensity for this, for the weight of the head to go forward and the shoulders to go forward is really quite great. And the more that we sit in one position, we know that the muscles and the myofascial tissues are going to adapt to that position. So it’s a lot easier to get into that forward head and for shoulder position. If we maintain that position for hours and hours throughout the day, now it’s usually predicated from what’s happening in the pelvis. So this is the reason why that, that we’re saying this is just one piece of the whole. So, I mean, you have to look at the whole body with this to help afford heading for shoulder, but we want to give you some nuggets that have helped us clinically quite a bit, um, to help alleviate some pain. Uh, Brian, do you want to, uh, say anything before we get in the next slide now? I think jump right into the next slide. All right.

All right. So the Ford had an imbalance in his posture, cannot counteract the forces of gravity, thereby increasing the stress on the muscle skeletal system and perpetuating the aging process. So you can see that red arrow that’d be the force of gravity as the head is going forward of the plum line. Let’s back up a little bit. The plumb line will be measured from the foot going up to the head. You want the plumb line to be in line with gallbladder 40 at the foot, the middle of the knee, the greater truck enter the middle of the hip joint. Then going up spleen 21 region into the chromium, the large intestine 15 region, and then the auditory meatus or the small attest in 19 region. So in this case, you can see that this patient’s head is forward by probably a good two and a half inches.

So for every inch for posture, there’s an increase of the weight by 10 pounds. Imagine what’s happening to the upper thoracic region and the lower cervical region and being elongated and polling quite a bit, trying to be able to maintain their proper positioning. But in this case, they’re really struggling because there’s so much weight pulling forward. This can increase the aging process significantly the longer that it ends up lasting. I mean, there’s a host of injuries that can occur from Ford head for shoulder. Brian, let’s go ahead and think about this. We’ve got thoracic outlet syndrome. You’ve got lower cervical spondylosis in the 40 plus age group. That’s increasing, um, nerve impingement. What else? Brian, with the sport headaches would be a big one. Yeah, that’s true. Brutal scapular nerve and traffic could be a big one there. Gosh, a chromatically vicular joint strain is something sternoclavicular joint strength is there, uh, with the pectoralis minor being a shortened position and the anterior scalings being in a shortened position. There’s your nerve entrapment sites for thoracic outlet syndrome. So, you know, with this for shoulder, it goes down the upper extremity chain, the head of the humerus. Sorry, go ahead.

Oh, go ahead. Yeah. The one worth mentioning also is the, uh, uh, when we’re going to be covering more in detail later is a lot of shoulder injuries, especially tendinopathies.

Yeah. So with this, we’re going to talk quite a bit about the functional anatomy of the Ford headed for shoulder, and then flip hats, put a different hat on blending, the two hats actually, and get into this new channels. So again, back to this Ford head and Ford shoulder, this is just one segment of what’s happening with the body. You’ve got humoral internal rotation, and then it’s going to affect the radio ulnar joint proximal, and also distal. So there’s a lot of things to be able to look at. So we’re just, again, just talking about one piece of the whole hair. Can we get to the next slide

While you’re doing that? Matt it’s worth mentioning that the head itself is 10 to 12 pounds. So an additional 10 pounds for every inch forward is pretty significant in terms of the amount of load that puts on the upper back and shoulder girdle and all that.

Yeah, absolutely. Absolutely. So Fort headed for shoulder is one component of something called upper cross syndrome, which Dr. Vladimir Yonda was the one that coined that term. Um, he noticed that a lot of patients in this particular posture, he would document the muscle imbalances that are, that are contributing and holding that posture as well. Now in the 1960s, this was a Latin Marianna in the 1960s, but also Dr. George Goodheart, who was another pioneer in posture and also muscle imbalances, both these guys actually in the 1960s. Talk a lot about the different types of Muslim balances, not only in the upper cross syndrome, but also in lower cross syndrome in the upper extremity and also the lower extremity. These two pioneers are, or actually the, um, major contributors to where we actually have a lot of manual muscle testing today. And manual muscle testing is becoming much more popular than it was in the 1960 seventies, or when I first became an acupuncturist in the 1990s, um, is becoming much more popular and these guys influenced that substantially.

So it was really quite interesting too, when you look at this paragraph here, that Dr. Vladimir Yonda, he thought of it as actually being more of the deficient muscle, the lengthened muscle that was perpetuating a lacrosse syndrome and the muscle bounces and Dr. George Goodheart was actually considering that be more of the shortened muscle is what’s causing the upper cross syndrome. So interesting glamor Yana thought it was more as the deficiency that, that made the excess and the Dr. Goodheart thinks it’s the excess that’s creating the deficiency, both work mean that these are both great pioneers, both actually work quite well. All right, so let’s go to the next slide. So your upper cross syndrome, uh, you’ve got with a Ford head and the Ford shoulder, if you look at the box on the upper left shorten overactive cervical extensor. So that means the upper extensors are really the biggest ones that are going to be shortened and active.

The suboccipital triangle, hence the reason for causing nerve entrapment of the lesser occipital nerve or the third occipital nerve, uh, developing trigger points when the suboccipital muscles causing muscle tension type headaches, um, a whole host of different injuries can, can occur in that area. And then below that you’ve got lengthened inhibit rom boys’ middle and lower trapezius. So those would be in a locked long position, a stretched out position, and you can see how the back shoe points of the heart and the lung here are going to be greatly affected the pericardium as well. So that’s going to be an elongated position, putting stress on those back shoe points. Then on the other side, you’ve got your shortened and overactive pectoral. So that pectoralis minor is going to be pulling excessively on the core court process, inhibiting the muscles on the other side, which are the wrong boys in the middle and the lower trapezius. Then you’ve got your LinkedIn inhibited, deep neck flexors, including the middle and anterior scaling. Hence the reason why you get thoracic outlet syndrome many times or many times, you see thoracic outlet syndrome with people with postures like this. Brian, do you want to say anything?

Yeah, sometimes the, um, the, the neck flexors, I would also include, uh, the longest call lion and longest capitus the deepest, deepest cervical flexors, which are, um, create neck flection, but they are, they’re a big stabilizer and we’ll get, this is a little foreshadowing, but, uh, from a Cindia channel perspective, those would be part of the kid decent new channel. So, um, kind of speaks a little bit to the kidney cheat and how that sort of loss of kidney cheese starts to cause that the, that depression and that, um, dropping of the head in the forwardness of the head.

Yeah. Good point. Yeah. Excellent.

Excellent. All right, let’s go to the next slide. So we’ve talked about this slide before.

This is some research that I did it starting in 2010, um, and presented it, I think in 2011 Pacific symposium, and also 2019, it’s looking at different types of posture and their relation to Zong, uh, uh, TCM patterns. So what I noticed is that with looking at, from the lateral view, certain postures would come in and they would have certain types of Azzam signs and symptoms. For example, the guy on the left, you’ve got spleen lung and kidney deficiency, and you can see how the lungs in this type of position in this position are having a difficult time expanding the diaphragm’s going to be constricted. I mentioned earlier that the tissues around the bladder, I’m sorry, the lung and the heart back shoe points will be elongated and struggling. Um, let’s see what else we’ve got compression caged is going to be affecting this and also the liver, and it is positioned the thoracolumbar fascia. The deep layers around the renal fascia will also be restricted inhibiting some of the kidneys, the kidney, but these people themselves will often come in with spleen, lung and kidney type of deficiencies. Brian, do you want to add anything to that?

Uh, no. I think you gave a good summary how it’s not just the muscle imbalance, but how it’s also affecting the internal organs and the space for the internal organs to do their proper function.

Hmm. So which ones out of, out of these spots,

Figures, Brian, which ones can you see have that forward head and forward shoulder type Fox?

Sure. Yeah. So the type one, the first one is the most obvious. And especially with the plumb line, as Matt was mentioning with the plumb line, going through GB 40, coming up through the greater trocanter, um, through the acromion, you can start seeing the shoulder going forward and you can really see the head going forward and the type one, the type two is there, but it’s a little, uh, um, maybe obvious it’s obvious if you look at it, but with the plumb line, there’s a little bit of a trick to it. And you notice how forward the greater trocanter is from the plum line. You know, this, uh, this patient and the type two. And for that matter of the type four posture have an anterior hip shift. So there’s, the hip is as moved forward and then their rib cage is starting to tilt back posterior.

So in some ways their, their head looks a little bit more aligned according to the plumb line and their shoulder looks a little bit more aligned according to the plumb line. But if you were to kind of imagine tilting the rib cage back into position, you know, to, to kind of line the rib cage up in, in a straight line, you would start to see with that, you know, uh, if you did that, how much the shoulder and that hadn’t been forward in relationship to the rib cage. So, um, there’s a definitely a big relationship between the pelvis and the head and shoulder position for those, those type two and type four ones in particular. But it’s, it’s a, if you adjusted, you definitely see the forward head in the forward shoulder, though. It’s a little different flavor from the type one. Yeah.

That’s interesting because if you do end up changing one segment of that, of that disparity, the compensation comes out somewhere it’s like Brian was saying, if you tilted that ribcage here for you brought those hips back to the plumb line, actually physically did that. You would see the compensation above and the forehead and for children. It’s great. Now an increase to type twos. You look at type four and you can see that the greatest rural Cantor is even farther forward, which is causing more of a poster tilt to the rib cage. And the shoulder is posterior to the plumb line, but it’s the same thing. If we brought those hips back, you would see a really far forward head and also afford shoulder. So somebody like this could be coming in with thoracic outlet syndrome or, or such, um, from the muscle imbalances within forehead and for shoulder in upper cross syndrome, the slide three and a type three and type five. I don’t see it as much, possibly type five. What do you think?

Yeah, they’re not as obvious. I mean, the head is forward on type three, but it’s really, that whole body is shooting forward. So it’s not, um, as much of the obvious head and shoulder forward. Yeah. Yeah. Okay.

Excellent. All right. So then, uh, what’s the next I Brian, you want to take?

Yeah, yeah. And Matt, uh, I will nevermind. Um, your audio is a little distorted. You might want to turn your phone off to have a little extra bandwidth, but I’ll be chatting here for a second and give you a moment anyways. So, um, we kind of alluded to this in the previous, uh, the previous slide where we have multiple examples of a forward head and forward shoulder, but I kind of used the term flavor, you know, that, that the farthest one on the left, the type one posture had us at quote unquote different flavor than the type two, which had that obvious posterior tilt to the rib cage and, um, had a different interaction of how things related to each other, but both, ultimately they both had a forward, um, shoulder and forward head. So if we wanted to kind of start assessing that variation from patient to patient, one way we can start to look at is the, um, is the position of the scapula, uh, and notice, uh, that it varies from patient to patient with this forward shoulder.

So a blanket term would be scapular protraction. Um, so scapular protraction, the shoulder blades are going wider and they’re usually tilting forward. Um, but when you start breaking down from patient to patient, you can start to see that there’s variation on tilts shifts and rotations. Um, so just to give a quick terminology, if the shoulder blade itself moves away from the spine, we might call that protraction. It’s an element of protraction, but we can be more specific and call it a lateral shift. You know, it’s shifted lateral retraction. It might shift medial and come closer to the spine. Um, if it tilts forward, we would call that an anterior tilt. So in that case, the top of the shoulder blade, the, um, SSI 12 region is facing forward. Um, it could also rotate around the rib cage. So we might call that a medial rotation cause the, the shoulder blade spacing more medial. So just, uh, based on where it’s moving, if it’s moving medial, moving lateral up down, et cetera, we can, uh, call based on shifts and tilts. So we’ll see an example of this on the next slide. So let’s go ahead and go to the next slide.

So this patient, we have, we could again call it a scapular protraction on the right side, but it’s different than some other people might manifest with scapular retraction. So if you look at the medial border and you were to kind of draw a line along that medial border, you’ll see that the medial border comes closer to the spine, uh, as it goes inferior on the right side in particular notice, the right side is what I’m talking about. So the whole scapula is in, we could call it downward rotation, but if we were to use this terminology of tilts and shifts, it’s a lateral tilt. The top of the, the scapulas facing lateral and the scapula is also moved a little bit away from the spine. So it’s a lateral shift. We’d have to look from the side, um, to see about if it’s tilting forward. It probably is. So it’s a likely anterior tilt, but that, uh, from this, this perspective is a little harder to see, but I think we will see that in the next, uh, slide. We’ll get another view for a different patient.

Hey Brian, can you go back? I’m sorry, can you go back to the last slide please? Um, just to keep in context, what we had with the previous slide. So this would also be immediate rotation of a scaffold, correct?

Medial rotation yet the immediate rotation. Uh, if it’s going around the rib cage, we can say that’s a lateral shift, cause it’s definitely moving away from the spine, but the scapula will start following the rib cage. So you could also describe that component of a medial rotation for sure, because you can kind of picture it the more it goes lateral. The more of the scapula is following the sort of, uh, border of the rib cage. It’s going to start turning and facing inward facing medial. So yeah, I would agree a lateral shift and a medial rotation.

So the anterior aspect of the scapulas is facing immediately. Okay, great. Yeah. Thanks Matt.

All right. So now to the next slide, and again, we could call this a younger, uh, gentlemen here, we could refer to this as a scapular protraction, but it’s a little different, a little different that, um, look than the previous patient. And really what you see is the strong anterior tilt. You can kind of notice that with the inferior border of the scapula, which is poking out in relationship to the top of the scapula. So it’s a, um, kind of highlights a little bit more of the shortening of the pectoralis minor muscle in the whole scapula tilting forward. We’d have to look at him from the back. He might have a little bit of a, um, a lateral shift to the scapula. I don’t recall from seeing previous images. Um, we don’t have it in this PowerPoint, but he didn’t this particular patient didn’t have a really obvious lateral shift. If I remember Matt, do you remember that

It was more of the superior shift in Andrew scapular tilt was more, but he did have scapular protraction on this right here.

Yeah. Yeah. But it’s manifesting a little bit more, is that, is that anterior tilt that anterior tilt component is, um, a little bit more prominent, but why is this important? What’s, what’s the importance of it. It starts to set a picture for which tissues are involved. And, um, if, if you look at it from which, which muscles in which structures are shortened, uh, and which ones are lengthened, it starts to also paint a picture, which send you a channels are involved. So, um, anything else on this one, Matt, before we, yeah,

Yeah, I think, um, for those people that don’t really know the muscles very well as if this is the pectoralis minor image, that’s on the right. So you can see if those fibers shorten their attachment sites, how it’s going to be pulling on that core court process, creating that anterior tilt now with an anterior tilt, the superior medial border of the scapula also raises up a little bit. So in that case, if you thought about what possible injury could be taking place here, the levator scapula, um, and that where it attaches to the superior medial border, as we know, has a lot of mild fascial adhesions in that tissue Guber is basically, I mean, it just feels so very, very rough and some people actually complain of pain in that region. So we could needle that section and that would give good relief for a little bit, but until we actually start working on that enter shift and the Petraeus minor shortening, we won’t be able to help out the elevator scapula and have it be pain-free

[inaudible] treating the effects, not the cause necessarily. Yeah. So we can go ahead and go to the next slide. So this is a little bit of a summary. So we have, uh, some, uh, scapular protraction that have more emphasis on that anterior tilt and that pec minor shortening. So we’ll give you a heads up that the pectoralis minor is part of the lung sinew channel. Um, also we have shortening in the upper fibers of the serratus anterior, also part of that lung sinew channel. And then that’s kind of counterbalanced, especially by the lower trapezius, also the middle trapezius and rhomboids, but we’ll, uh, kind of focus on the lower trapezius, which is there to stabilize against that sort of, um, pull from the pectoralis minor. That’s going to pull the scapula into an anterior tilt. The lower traps are there to sort of stabilize and hold the scapula in place and keep it from being pulled forward from the pectoralis minor.

So this is a very common muscle imbalance between these two, uh, internally and externally related channels, send new channels and muscles where the pectoralis minor gets overactive lock short into a shortened position, holds the scapula into an anterior tilt, uh, tends to pull it a little bit more into, uh, a lateral tilt. So kind of downwardly rotating the scapula, whereas the lower trapezius becomes inhibited and fails to counteract that. So we have an imbalance between these two related channels of the lung and the large intestine channel. So that’s important for local treatment, but of course, important for distal treatment also.

Yeah, that’s great. So the distal treatment, because the Petraeus monitor is going to be, fascially connected to all of the mild fascial tissue on that lung sinew channel all the way down to the wrist. We can use many acupuncture points or to change that mild fascial tension. So not just treating locally, but also adjacent and distal to signal the myofascial gene June, what we’re trying to do. So by treating the TCM, bialy internal and external relationships here, um, it’s just, it’s pretty amazing what can happen when you soften tissues so far away and signal while you’re trying to be able to do when our founding, our founding forefathers were just absolutely brilliant to be able to come up with such associations. And, and we’re just talking about it in a different way. This is great. We will be going over acupuncture points in a little bit.

Yeah. All right. So next slide. So then this particular, uh, example, now we have a little bit more of the emphasis on the lateral shift, you know, the movement of the scapula away from the spine. And, uh, with that, you’re going to see a little less, sometimes a little less of that anterior tilt. So it speaks a little bit more to a different set of tissues, the serratus, anterior, especially the middle and lower fibers of the straightest anterior and the rom points. So those become imbalanced. And in the system that we teach in sports medicine, acupuncture, this is part of the pericardium send new channel. The serratus anterior, um, is, is a big part of that, but the straightest anterior, it goes. And if you kind of notice in this illustration, it becomes a little bit faded because it’s going underneath the scapula. So it goes underneath, uh, it should say anterior to the scapula between the scapula and the rib cage.

And it attaches to the medial border of the scapula, right at the place that the rhomboids attach. So they really create one continuous, uh, myofascial sling. It’s almost like it seemed if you can kind of picture that, that sling that has like a seam along that medial word of the scapula. So it’s, it’s, it’s kind of anchored at that medial border of the scapula, but it’s a continuous sling. Um, and sometimes that’s referred to as the Rambo’s rate of sling, uh, for those who’ve paid attention to, uh, anatomy trains in the work of Tom Myers, he uses that terminology of thrombosis rate of slang. And we see that as a part of the pericardium sinew channel. So it’s a little bit more of that influence of that channel versus the lung and large intestine as a new channel and balance.

Yeah. [inaudible]

Of the scapula.

Oh, I’m sorry for, I’m sorry for interrupting Brian, go ahead and finish what you’re saying. No, that’s it. I finished. Okay. Here’s my audio better now? Yeah, much better. Okay, good. Uh, what was I saying? Yeah. On the cadaver, it’s fascinating to see the thrombosis rate is sling how the straightest anterior and the rom Boyd fibers just interdigitate. It is really one tissue, like so many other tissues in the body, but it’s keeping context of what we’re talking about now. It’s amazing to see how it’s just one line of Paul on that. Yeah. Fantastic. Oh, also something else now, even though we’re putting the pericardium channel or the pair of, even though we’re putting the serratus anterior into pericardium and also lung there’s a gray area with that in smack, we will often demonstrate that by needling the motor innervation points of the straightest, anterior, for example, ribs three through seven or so, you can even do four through six we’ll change a lung pulse.

So it is influencing the internal Oregon. For sure. If you have a patient that’s coming in that has asthma, common cold, a C D something like that, feel the pulse. If you would treat the motor entry points of this rate, anterior that pulse will definitely get better and change. So you are influencing what’s happening with those lungs. Just something to think about when you do have a patient like that. Yeah. It’s going to help the lungs to expand the rib cage, to expand by getting any kind of tension or lack of proprioception within us. Right. Of center. Sorry, Brian, go ahead. We’re going to say, yeah,

I was just, just commenting on what you’re saying that this radius anterior definitely when it’s, uh, restricted we’ll we’ll stop breathing well, we’ll prevent a really good solid fall inhale.

Yeah. Yeah. And it’s fun how fast it changes the pulse, you know, intuitively the body is all right. We can just keep going on this. We better get going. We only have one minute pink. Okay.

Yeah. So, so the, this was kind of painting a picture. You know, it’s a little bit of a simplification because things can be both, you know, you can have both that anterior tilt and the lateral shift, but, but generally when you look at patients one’s predominant or oftentimes at least one’s more predominant. And if we go back to those, uh, the, the, um, TCM patterns and postures, the type two person that we see kind of replicated here on the right with the posterior tilted ribcage. Again, if you were to tilt that rib cage back, you’d notice how much of an anterior tilt of the scapula we have here. You can see that from the illustration, she kind of resembles more of that, right. Illustration where the rib cage is tilting back. The pelvis is shifted forward. The scapula is almost straight up and down, but if we were to adjust the, um, the rib cage, you’d see in relationship to the rib cage in relationship to those tissues that are holding it in into a particular balance, that it’s a pretty strong anterior tilt of the scapula that tends to correspond much more with, uh, kidney deficient, postures, um, and kind of a lack of stability from, uh, the kidney channel sort of holding and stabilizing the body.

That’s a whole nother topic, but, um, but there’s this, there’s a strong correlation with this type of posture with various types of kidney deficiency that you saw from the five fosters that Matt was highlighting earlier. So there’s a relationship between the lung and the kidney channel and this type of posture you saw with the boy, even who had that little bit of a posterior tilt to the rib cage, very, uh, versus, uh, I’m ready to go on, unless you wanted to say something else about that, Matt.

Um, I think maybe just a little bit like another demonstration that we do in smack to see how the pelvis and his position is related to kidney cha. Um, we have, uh, people go ahead and stand up and partner up and feel each other’s, uh, kidney pulses on the right and left hand side. And the kidney pulse is going to be the weakest, the patient, or the practitioner will slowly go ahead and just do anterior poster, pelvic tilts, not enough to get the heart rate up. So it’s going to change that Paul’s, but just very slowly going to an anterior and posterior pelvic tilt, changing the fashion and the position of where the kidneys are. So then by doing that eight, 10, 12 times the kidney pulse actually starts to come up, which is pretty amazing. And it’s so significant. It happens almost every single time, but this demonstration, we, we do frequently in the smack program. And also, I think I did a civics symposium one time. It’s pretty amazing to be able to see that. So what’s the next slide.

So same idea with channel relationships, that more lateral shift of the scapula, um, oftentimes with a little bit of an upward rotation, um, but when you start seeing more of a lateral shift and that sort of rounding of the arms, uh, that often goes in corresponds with, uh, multiple things, but especially spleen channel deficiency. And you can see with this type one posture, as Matt mentioned, how that’s kind of compressing the spleen and, um, the organ itself is being compressed, but the posture and the tissues associated with that posture, um, the tissues associated that sinew channel are involved with the pericardium and spleen relationship. So, you know, you might consider distal points, multiple things, but something like splitting for pericardium six might be a component of the, um, the treatment protocol for this doesn’t have to be, but that’s something that comes to my mind. Whereas the previous one, you might consider something like lung seven, kidney six, or, you know, other other kidney and the lung channel points for the previous, uh, person versus a spleen and pericardium channel point for this one. So we’re going to talk more about points, but just kind of think that, you know, start, start making those connections now. And when we’ll get into that at some point in combinations,

This is great. All right. So with the pericardium and spleen, and also the kidney, the lung, the lung and large test in relationships, the straightest anterior with the pericardium and lung, these imbalances can create a numerous amount of injuries. And we’ve already talked about a few, let’s go to the next slide and see what actually happens to the children.

Yeah. So, um, as much as we can have a whole bunch of injuries that we could focus on, uh, we talked about muscle tension, headaches and spondylosis, and a whole, whole bunch of things. But, um, but we’re gonna kind of give an example related to the, um, the shoulder position, shoulder movement and, uh, tendinopathies. So Matt, do you want to talk about this one?

Sure. What scaffolding humor, rhythm,

The, the humorous,

And also the scab will have a rhythm as the person’s going into shoulder abduction. So when you have process of proper muscle balancing, then that scapula will go ahead into a rotation as the head of the humerus is coming up. Now, if there’s going to be imbalanced with that scapula, if the lung large intestine that roof or the chromium right here is going to not be as strong, it will end up actually coming down into a downward rotation, a budding the head of the humerus, that particular scenario is probably, you probably see that more times than not with shoulder problems is the inability for the, for the scapula to upwardly rotate and allow the head of the humorous to move freely within that joint. It’s the abutting of the head of the humerus against the chromium impinging, the superspinatus tendon, the capsule of bicipital long head tendon making insertional type of strains. Um, there’s, there’s so many different types of injuries that can occur with us. So balancing these muscles and the sinew channels is going to be really imperative, followed by some kind of exercise prescription, which, um, I believe it was last month or the month before that, that Brian and I have a podcast, right. That we talked about this.

Yeah. I said both. We talked about fab lab last two, two webinars, I believe. Hm, Hm. Yeah. You know, it’s interesting

Too, with this cause we don’t have there much time left is that we talked about mostly what’s happening with the scapula, but the head of the humerus with a forward shoulder position. In fact, you can just do this yourself. If you sit up and you have your shoulder go forward, your human starts to internally rotate. And that’s just the way that it starts to move, causing more muscle imbalance within the rotator cuff between the heart and the small intestine Jean chin. So it just keeps on going. We just don’t have enough time in this 30 minutes to be able to talk about that. So let’s go to the Brian D anything else go for the next slide? No, no, I think that’s good.

This is a severe case of shoulder impingement spinner, but you can see in this x-ray as the person going to the shoulder abduction, the rotator cuff muscles are not pulling that head of the humerus down into the joint. And it looks like the scapula stabilizers, the lung and larger tests and Jean, Jen, and also the pericardia are not lifting ASCAP properly into upper rotation. The greater tubercle that humorous is hitting the chromium and the fact that it looks like it’s been doing it for an awfully long time. Cause you can see it, the superior aspect of the humerus, like a rough mountain range edge there. I don’t know if you can see that I don’t have a cursor without I can be able to do this, but at the very top of that humorous in the black, you see a very rough edge and it looks like that’s probably from necrotic tissue or a lot of overused banging into their chromium. This person was in some pain for quite a long time. Let’s talk about some acupuncture points that we can use for forehead and for shoulder Brian. Yep. Sounds good. Next slide please.

All right, go ahead, Brian, go ahead. Well, the points are going to be based on the particular injury, obviously. So is it going to be periscapular pain? Is it going to be levator scapula insertional pain? Will it end up being super spine Natus tendinopathy or maybe bicipital tendinopathies. So depending on which injury is going to predicate, what local points that you have or the adjacent points we want to needle the Watteau G points bilaterally, that’s going to be level with the innervated tissue. So, um, kneeling a C4 through C6, which the C is not on there. My bad, sorry guys. So the Watchers Joshy points of C4 through C6 needling, the pectoralis minor motor point motor entry point, which would be best if you were actually shown how to be able to do that. So we don’t create a pneumothorax if you’ve never done it before. Um, the rhomboids, the middle and the lower trapezius motor entry points would be good to get that communication between the Petraeus minor and the trapezius. And of course the straightest, anterior ribs, three through seven, another muscle that would be best shown how to be able to do those motor entry points. Because if you obvious reasons, if you don’t actually need all that muscle and go to the intercostal space, you could cause some damage with that. So if you’re unfamiliar with anatomy very well, you don’t want to needle these motor entry points.

Yeah. I mean, it just, it’s not three through seven. Like all of them, you wouldn’t necessarily, wouldn’t be needling. Serratus. Anterior is read three, four, five. So you’re picking the more restricted one or two, uh, um, regions, you know, slips of this radius. Anterior, that’d be a lot of needling for, um, you know, for all, all of those, those lips. True.

But we are immediately two to three, sometimes four, depending on the case

And the persons that you want to cover, the distal points Bryant. Yeah. So, um, flexor carpi radialis motor point is a really, uh, excellent, um, uh, motor quieter motor entry point that will soften the pectoralis minor. So in combination is great, but if you’re not comfortable with needling, the pectoralis minor, it is, it is good to learn that in a classroom setting. Uh, just so you do it safely and don’t cause damage to people, but the flexor carpi radialis is a little bit easier of a tissue to, um, to work with if you haven’t been trained to do pec minor. So it’s going to have an effect on pec minor for sure. Uh, other points along the lung and large intestine channel would be, uh, indicated, uh, L I six would be the sheet cleft wine of the large intestine channel would be a really useful long seven would be an excellent point.

Brachioradialis is, uh, brachioradialis is kind of associated with both lung and large intestine, but, but it’s, um, but it’s definitely a, uh, large intestine channel point. That’s going to influence that portion of the channel. Um, protonate or Terry’s Motorpoint would be more for, um, pericardium sinew channel. So if it has more of that lateral shift and again, serratus, anterior is difficult to needle for some people, if they haven’t been trained for inner Terese would be a really excellent, uh, in, in addition or, or just a needle in that one as part of a comprehensive treatment would be good. And then P six, um, for obviously for the pericardium channel. Yeah.

It doesn’t have to be all of these points. You guys, it’s just, we’re just giving you some points to be able to choose from, um, the brachial radialis motor entry points. We could do large intestine, 11 that’s that could connect large intestine lung that’s the upper point. And then lung six, the sheet cleft point is also going to be a motor entry point for the brachioradialis. So points that you can be able to use to be able to communicate upper into the gene gin. Um, just to kick out a little bit more when you were talking about the flexor carpi radialis my mind went to that, um, cadaver dissection that we did on that last specimen. So thank you very much for this donor, continuing to help us learn quite a bit, um, how you showed the really strong connection between the biceps and the flexor carpi radialis and for that lungs in you. That was fantastic. It was great.

Um, the, um, sorry, I don’t have time to go into it, but the connection is the muscle itself attaches flexor carpi ulnaris, uh, flexor flexing carpi flexor carpi radialis attaches to the medial. Epicondyle definitely not on the lung channel distribution, but it has a fibrotic structure from the biceps called the last fibrosis. Sometimes it’s called the bite sip app and neurosis that links the flexor carpi ulnaris with the biceps, which is part of the lungs, then you channel. And then from there short head into the pectoralis minor, and it’s a really strong link. So we talked about how the rhombus rate is slinging on the rhomboids will, will interdigitate also here with the straightest anterior. When you look at the cadaver specimen, you’ll see the pectoralis minor come up to the court court process and just factually bind right with that bicep. Also the, uh, the biceps short head.

So it’s just one continuous tissue onto that coracoid process is fascinating to see the connections at the same layers anyway. So we’re kicking geeking out on that, um, which is crazy. So should we get into a video? You want to introduce the video Brian or the myofascial release, what we’re doing here? So this is a, uh, a pectoralis minor stretch. It’s pretty simple technique. You can do it with the person in a prone position and the video will walk you through it really good to do after treatment. I guess you could make an argument if you’re doing facedown treatment and then turning the person over and doing face up treatment that you might do it in the, uh, after you take the needles out, um, from the face down position and before you turn them over. But generally speaking, we teach these to do after treatment. So the video should run through everything. So we’ll go ahead and go into the next slide.

So this technique, it’s a passive stretch of the pectoralis minor. You’re going to use both hands, one hand, covering the scapula, especially covering the inferior angle of the scapula. The other hand reaches underneath and hooks around the coracoid process. So you have to have contact with the coracoid process and you’re falling to the inferior border of the coracoid process. So with the one hand pushing down, kind of in a direction following the lower trapezius, it’s almost like you want your hands to be the lower trapezius in terms of function, by pushing the scapula inferior angle down and lifting at the coracoid process to give a stretch to the pectoralis minor. When I say lifting, I’m not lifting straight up, that’s going to lock the scapula and kind of limit movement. But lifting is really more in some ways, following the angle of the lower trapezius and lifting headboard, cranial and slightly towards the ceiling, while you press the other hand down and you want to picture the fibers of the pectoralis minor are getting longer and you can hold for however long you feel is appropriate and changing angles slightly to get different fibers. Pec minor has a third, fourth, and fifth rib attachments. So different angles we’ll get different fibers of the pec minor.

So the video is longer than the technique needs to be just because it was showing the setup. It’s kind of a subtle technique. You don’t have the right line of Paul. You don’t get as much benefit from it. Yeah. And feels so good when that technique is applied. That technique is great at, in a combination of acupuncture, myofascial work, and then doing the stretch. It really helps with the four shoulder quiet, big buckets that Ford shoulder’s gonna go right back into place. If the person goes back to their desk and doesn’t do their exercises, do the opposite movement and a host of different movements that can be able to help open up that chest. Well, Brian, is there anything else that you want to say we’ve gone over our time again, thank you very much for hanging in there, guys. I hope this was useful for you, Brian. Anything else that you want to be able to say? Um, no. No. Uh, I think, uh, the technique is you’ll, you’ll see if you wanted to reference that in recordings, that is going to be at one of the techniques that we’re going to have in a class upcoming class. That’ll be a webinar in March. So we’ll have a lot of different techniques like that and kind of combining some myofascial release with acupuncture.

Awesome. Awesome. Cool. So I want to thank American Acupuncture Council again. Thank you, Brian. It’s always nice hanging out and doing these things with you. Next week, Sam Collins is coming in to be able to discuss the billing and coding for insurance. He’s always great for, uh, providing the latest updates, which is really important in these ever-changing times. Um, so thanks again, everybody really appreciate it. And, uh, we’ll see you again next month, right?

Please subscribe to our YouTube Channel (http://www.youtube.com/c/Acupuncturecouncil )

Follow us on
Instagram (https://www.instagram.com/acupuncturecouncil/),

LinkedIn (https://www.linkedin.com/company/american-acupuncture-council-information-network/)

Periscope (https://www.pscp.tv/TopAcupuncture).

Twitter (https://twitter.com/TopAcupuncture)

If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: https://acupuncturecouncil.com/acupuncture-malpractice-quick-quote/.