Tag Archives: Sports Acupuncture

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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.

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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.

 

 

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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.”

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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.

 

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Acupuncture Sports Medicine with Whitfield Reaves

 

 

His experience includes the 1984 Los Angeles Olympic games, as well as numerous track and  fields cycling events nationally for the last four decades, Whitfield is the author of the well-known practitioner’s manual, the acupuncture handbook for sports injuries and pain, which one of the few texts integrating traditional Chinese medicine, acupuncture, orthopedics, and sports medicine.

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.

Hi, welcome to this week’s American Acupuncture Council’s Live uh, Facebook podcast show. I’m your host Poney Chiang of neuromeridian.net from Toronto Canada. Joining us today is our special guest Whitfield Reaves who is joining us from the central coast of California and he will be relocating into Santa Fe. I’d like to begin by giving you a biographical description of, uh, uh, Dr. Reaves. Uh, Whitfield Reaves is one of the leading practitioners in the field of acupuncture sports medicine. He began clinical practice in 1981 as specialized in the field of orthopedic and sports acupuncture for 40 years. He is licensed in California and his earned doctorate Oriental medicine degree in 1983, his thesis acupuncture and the treatment of common running injuries demonstrated that TCM could address many clinical issues in sports medicine. His experience includes the 1984 Los Angeles Olympic games, as well as numerous tracking fields cycling, either events nationally of the last four decades, we feel is the author of the well-known practitioners manual, the acupuncture handbook for sports injuries and pain, which one of the few texts integrating traditional Chinese medicine, acupuncture, orthopedics, and sports medicine. He’s also the director of the acupuncturist sports medicine apprenticeship program. Thank you very much for joining me. We feel it is an absolute honor,

And it’s a pleasure for me, Poney. It’s great to see you.

Um, I have, um, uh, some questions for you today and, um, uh, I want to keep it pretty relaxed and casual. Um, mostly wanted to hear about your experience, um, in sports medicine and you know, your clinical experience, especially, I was wondering if, um, you can tell us how you ended up specializing in the field of sports medicine.

Well, I started practice in 1981 in February of 1982. I had a marathon runner out for run run in my office and he had Achilles tendonitis and he asked me, you know, can you, can you help? And I said, of course, and of course I had never treated Achilles tendonitis. I had never had a teacher that taught me how to treat the Achilles tendonitis, but that was, you know, I was new in practice. It seemed like the logical thing to say. So I treated them. I was back from China. So I treated them China style, little bit Wednesday, Thursday, Friday, Saturday. And then on Sunday he ran the mission Bay marathon. He won the race. I had no idea. I didn’t even know him. You know, like, well, how fast do you run your splits? And what’s your personal best? And what are you training on this? I didn’t know any of that stuff, you know? And so that was Sunday and this was 1982. This was two years before the Olympics in San Diego. This was in San Diego, California, San Diego was filled with Olympians training, trying not to be in Los Angeles, but to be close Monday morning, he brought in busloads of athletes, you know,

From, and

Literally I became a sports acupuncturist overnight and it was of that moment. I didn’t choose it. I was always athletic. I love sports. And it just happened. And really looking back, I didn’t know anything as, you know, the education for graduation to be an Lac in 1981, included nothing very precise about sports acupuncture. So what happened? And I had to teach myself while we went.

That’s a fantastic story. So I guess it’s all, all word of mouth from a high-performance athlete from there. Yeah, that was it. Yeah. Um, well, unfortunately it’s sad to say even to this day, there is still not very more sports medicine curriculum, your average Chinese medicine school. Uh, so, uh, so unfortunately that it has changed, but thankfully we have, uh, mentors and masters such as yourself, which can help us pre-state yet. Now I wanna, um, um, uh, kind of put you on the spot a little bit. Um, I want you to tell us what do you find you get the most consistent results and when it comes to sports medicine now, what do you find? It’s one of the more complicated, more difficult, uh, conditions for you to treat

Well? Um, I would say consistent results for me come with the shoulder, come with tendonitis, infraspinatus, uh, the acromioclavicular joint, much of the shoulder. I find that I can just do really well with the techniques that I’ve learned and, and put together over the years that, I mean, unless you have greater than a 50%, all the way up to a full thickness tear of a, of a rotator cuff tendon, you can get great results in better than any other tradition. I know better than anything PTs can do or, or, or exercise signs or anything. Cause we can get into those discover chromium space area effectively with the needle. So I’d say that’s my favorite.

This has been great and reassuring to hear because for a lot of practitioners, they are afraid of shoulder. I have an associate in my clinic whenever a shoulder case, just like she gives it to me. So I’m very happy to hear that you, um, at that, that is possible to become really, really good to get great results in the shoulder. Cause I know a lot of people lacking that confidence because sorry to interrupt you, please continue

The worst. The things that I don’t like are places that are hard to needle. I don’t like an inguinal hernia or inguinal strain. I don’t like the groin. I don’t like need doctors and I don’t, and I don’t like the armpits, you know, the awareness, you know, I would prefer to send them out for manual therapy. Uh, and so as I would prefer to send out for manual therapy and those are conditions that I think acupuncture does, you can’t get precise access. Cause my needling is all about precision, you know? And you just can’t be precise, kneeling into an armpit, you know, or what have you. So, uh, that being said, there are people who can needle the subscap pretty effectively. I don’t like I don’t teach it. I don’t like it.

So I see. Yeah. Um, well I, I can relate, um, those places definitely are trickier. And of course you just, sometimes you have a deal with like, uh, you know, body hair and things like that. It’s, uh, it can get a little messy. Um, um, and yeah, I, I have found, uh, you know, growing issues to be, uh, relatively difficult to, you know, I’d rather treat, um, at least tendonitis than deal with the growing street. Um, you shared us with it as a great story.

Okay. I got to tell you that you became my hero.

Well that’s

When, what, when I use this technique of using needling small intestine nine, uh, with three-inch deep, deep, you know, all along the act below the axle and I use it for shoulder joint dysfunction, and I never could understand we’re not really going into the infraspinatus or the Terry’s minor. And I would do a corresponding point on the anterior side and I never really knew why they worked cause we weren’t really going into a muscle. And when I was looking at one of your webinars and you showed that branch of the nerve here that goes into the shoulder capsule, can’t remember if it was the anterior, the posterior or both. I went, that’s why it works. It’s a neural explanation and you became my hero. So,

So that means a lot. It means a lot. Uh, I was not expecting that at all. I mean, you know, I, I, you’re definitely a giant the field and I, you know, I, I studied your work very in depth and uh, so it’s actually a great, tremendous provision for me to, to have you on my show today. And, uh, so I really I’m just floored by your, by your generous words. Thank you very much. Um, no. So you shared it with us a really awesome story about how you got into, uh, the field of sports medicine. Would you mind telling us, um, a recent success story to something that was especially memorable that you can, um, chose, inspire our fellow listeners?

I’ll go back to the shoulder. Uh, I had this boy who had had a pretty severe motor vehicle accident 10 years ago, and she’d had a fracture and humorous, uh, up the proximal end and, and, uh, so they dealt with the fracture and, and, but the opposite shoulder had always heard her and it never got any attention because of the fractured side and the opposite shoulder was, uh, the seatbelt and shoulder. So something had happened in there and I, uh, I evaluated it. She had a positive arc of pain, so it with a D AB duction, she had impingement right into here and she was going and she had weakness on resistant AB duction. She had a weak, uh, turned off, right, inhibited supraspinatus with a positive impingement test. So something was going on inside of here, uh, with the 10 men and what have you.

And it just smoldered for 10 years and nobody had paid attention to it. She was leaving in two weeks to go to the Caribbean, uh, to, to, uh, take, uh, uh, uh, to sail. And she was going to be the captain, you know, ahead of the boat. And she needed to get her arms up like this for the wheel and for the lines and all that. And, and, and I said, well, two weeks, you’ve had this for 10 years. So she said, give me everything you got. So I went in at L I 1645 degrees of bleak, lateral and threaded under into the subacromial space needle and kind of toward [inaudible] superficial to the supraspinatus tendon, deep to the S to the boney, you know, a, a chromium. And I felt it going through these layers of scar tissue. I could just feel the springiness and I pushed through, and we, and we had maybe five mechanical strikes of, of scar tissue and fibrosis underneath here. She aggravated for, for seven, eight, nine days. I couldn’t treat her because it was so aggravated. She came back. Finally, we had three days left ago, she had no positive and, uh, impingement test. And the only thing that was left was that her muscle was still inhibited. We needled small intestine, 12, the motor point of, or the muscle belly of the supraspinatus. And she was seated. I got the needle in, into the muscle and, and within five seconds she turned green and

Yeah, that’s definitely a very memorable story.

Oh my God. Well, so we brought her up and we got her all fixed and then I’ve retested, it turned off five seconds of needle into the supers place. It turned on that muscle and she was 100% fixed for the rest of the time that I knew her, you know, and the second treatment was a five second stimulus to small intestine 12 and it just went, wow. So I didn’t need to put that needle in there for 30 minutes and do all this stuff fixed. So that was good.

That’s very, very cool. Um, and I like the fact that you’re not afraid to share some of these, um, slightly, you know, less than perfect stories. Right. She aggravated her, but sometimes as a healing response, she passed out, but you know, things like that happen. Right. So, um, yeah. So all of them are respect to you for, for, um, sharing these, uh, sort of less than perfect stories. But I think, um, mature practitioners without experience, understand that this part that’s part of the, you know, part of the day-to-day bread and butter, and that is, uh, amazing. Okay. And of course she won the race as well. Right? All your patients in races, right.

And it pricked the boat and they didn’t die. If practitioners will take the point of view that there is no such thing as a wrong needle, you might put a needle in and it might not go to where you want it, but it, but it tells you, okay, I need to direct this over here, or I need to needle it over there. Or I’m not on the band. I didn’t get a [inaudible] or whatever your criteria is. If you, if you, if you, there’s no such thing as a bad needle, there’s just some needles that just guide you to a better placement. Then, then you’re not always feeling like you’re a failure. You use those failures to get you more precise and it’s, it’s a much more positive relationship to the experience. So, yeah.

Yeah. What you’re, you’re, you’re saying is very profound when I have to kind of digest it and reflected about it. I’m sure it’s like, it’s not just going over my head right now. And there’s no such thing as, as a wrong needle. I have to, I have to think about that. Uh, but I appreciate that. Um, now I have the, because I, you know, I’m also interested in neurology, neurology and orthopedic aspects, and I encountered this with, um, you know, uh, new learners quite a bit. And some of them are, uh, hesitant to, to embark on a path to become great, uh, good at treating sports issues. Um, and, and it doesn’t have to be sports. It orthopedic issues right now, but it’s she’s athletes, but everybody, you know, um, everybody is, uh, has some repetitive chronic pain and due to repetitive strain. And so there’s sometimes a lot of overlap between the high-performing athlete and your typical sedentary type of desktop, uh, desk workers. Um, but I encountered some people are afraid to go into the field. I wonder if there’s any advice or words of encouragement. Um, I know you didn’t seek out to go into it, but it has turned out to be very rewarding for you, right? Any, any advice about people that are afraid or hesitant about going into this wonderful field?

Well, I, I think being afraid and hesitant is a really very beneficial emotion to take a look at because, because you’re not going to be very good knowing what you probably know already, uh, Meridian acupuncture is of very little value in treating orthopedics. Zang Fu is of almost no value in treating orthopedic and sports injuries. So you have to learn a new headset, a new way to think, you know, about what you’re doing, but it’s all doable. You can learn this. And there are plenty of teachers and you can, you don’t have to have one teacher. You could do a little bit from a number of places, learn from your neuroanatomy, uh, webinars. Learn from me, learn from that. Talisen, there’s just so many ways to get the information. So the, your fear should only be a guide to tell you you’re going to have to work.

You’re going to have to retrain yourself. You know, I had an occupier, I had a patient that came in and she said, I’ve got Achilles tendonitis. My family general practitioner takes care of all our, our coughs and colds takes care of the kids and all that six times nothing happened. So the patient came in, I said, okay, you have Achilles tendonitis. So when you get up in the morning, your Achilles tendon is stiff. And your first steps are difficult that as we know is a keynote symptom of Achilles tendonitis. It has to act that way to be Achilles tendonitis. And he said, Oh, no, I get up in the morning. And I feel great. It’s at the end of the day, that it’s a problem I want, okay, 99% chance, you don’t have Achilles tendonitis. You got the wrong diagnosis. This guy was a 1500 meter masters runner with the most beautiful body, 1500 meter runners just they’re gorgeous.

Right? They’re just beautiful bodies. You know, they’re not so bolt up as a, as a sprint or they’re not so lean as a marathoner. They’re just like, perfect, beautiful. So, so, uh, I did a pinch test of the Achilles and the pain was all the way down at the attachment at the Achilles bursa. He had Achilles bursitis. So I needled, uh, instead of the tendon, I needle down into the area of the burst. I’ve got some techniques for that. He came back five days later, he was 80, 90% better with one treatment. And the first thing he said to me, he said, there’s a difference between a general practitioner and someone who specializes in sports medicine. He just said that to me. And it made me feel so good because that is what we, that’s what we need to communicate. There is a difference. You know, you don’t go have brain surgery from your, your GP.

Doesn’t do brain surgery on you. You go to a brain neurosurgeon, you know, so the specialty is a beautiful, wonderful specialty. And if you’re drawn to it, you got to learn that you got to learn the language and you have to understand there’s orthopedics, but the next step over is their sports acupuncture. When you’re getting into sports medicine, you have to learn about the psyche of the patient, of the athlete. You have to have more, more attention to how they think and feel, and of course how they train, whereas with the PDX, you can get away without knowing a lot of that stuff. But there are similar the basis of orthopedic and sports acupuncture. The basis is similar with that emphasis of really trying to figure out what makes them do this and why are they doing this? And so, but it’s a wonderful field and it’s totally open. There’s no obstructions, there’s no barriers to entering. You can, you can, you can do fantastically in this field. So you’re welcome to come and join.

Thank you very much for that. Um, just to finish off with our interview session today, I was wondering if you can share with us your favorite acupuncture point, if there is possible to identify one of your favorite, one of your favorite points and how would you, uh, how do you recommend that we use it? Well, I think, you know what I’m going to say.

My favorite point, if I had only one point to do would be the extraordinary point. Jen claw, J I a N qua qua, uh, the claw, the is the, is the thigh and the glutes, the lower mid section five of the bodies, not just the thigh, but it’s, you know, probably includes the, the gluteus Maximus and all of that gen means strengthened. So the translation is strengthened the thigh or strengthened the block. Uh, this is in the muscle belly of the gluteus, medius it from the greater trocanter halfway, but from the greater toe canter to the iliac crest, along the shallow young line, take the mid axillary line, go straight on down to the Raider trow candor halfway between there and the iliac crest is Jen qua it’s post Steria to gallbladder 29. And it’s right on the, in the muscle belly of the gluteus medius, gluteus medius is what stabilizes the pelvis to keep that tilt from going and is crucial to establishing order in the lumbar vertebral segments of the body.

So that when I treat low back pain, I don’t treat Thai young. I treat shaliach. I go in from the side and treat the gluteus medius and deeper, of course, it’s the gluteus minimus. So you have two muscles with differing functions to get, bring about stability in the pelvis, so that the rest of the pair of spinal muscles have some consistency in their experience. They don’t have to be compensating because everything is moving because the gluteus medius inhibits from prolonged sitting. And we all sit too long for reflection along city, the gluteus medius, no matter how big and health, how well, you know, function, this is inhibits. And that big muscle just turns off and all you gotta do is needle it, turn it back on everything changes. So that’s my absolute favorite point that would, that would go up and affect everything up to the shoulder, posture, the neck, it wouldn’t go down and affect heel strike. And, and your whole cadence as a Walker or runner could theoretically correct everything from, from plantar fasciitis up to, you know, neck and head pain. I don’t know.

Wonderful. I didn’t know. I knew it was one of your favorite points, but I didn’t know it was such bright applications for it and the entire spine as well. And it makes a lot of sense that it, the smile has to compensate, you know, that you can have bad problems, they problems, right. And that all comes from having a nice stable, um, pelvis, pelvic bone. Cause after all the, where does the vertebrae sit on this, this other sacrum, which is rooted in the pelvis. Right. Wonderful. Um, so unfortunately this is, um, uh, we’re coming to the end to our, about our interview here. I was wondering if, um, people wanted to learn more about your curriculum or learn or study with you, um, are there some resources or some new information, a website or something that they can do to get in touch, get in touch with you?

Probably the easiest thing to do is go to my website, which is my name, Whitfield Reaves, not com. You got to make sure you spell it right. Wood field.com. There you can order my book there. You can see the links to my most current webinar program called mastering the treatment of injury and pain. It’s 40 hours. I just completed this right before the lockdown last year of all, it’s just all of my work put in 40 hours of webinars. Uh, and we also have some three hour modules of little special segments or portions of the body that we’re teaching still during this COVID era. Uh, and we’re actually starting to schedule some live stuff in the fall. So you can find all of that on my website, on the calendar page. Um, and, uh, and you can email me if you’ve got questions, email me, there’s a contact button. I’m happy to, to give you advice if you need some advice on how to proceed. So, yeah.

Okay. Thank you so much with, um, unfortunately I wish we have more time. I’m sure we can just talk on for hours and I can just, I mean, for me, I guess I can just listen to your stories for hours. Okay. Um, but, uh, I’ve always, that’s all the time you have today. So I thank you very much for joining, joining us. I think all the listeners for joining with joining us today, and don’t forget to join us next week posted next week is Chen Yen. And I’m sure she’ll have some wonderful information to share with everybody. Thank you and have a lovely rest of the weekend

Seal. Thanks for listening.

 

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.

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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?

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