Neck and Rhomboid Pain

I am the author of the blog post on neck and rhomboid pain featured at the Sports Medicine Acupuncture page. Here is the link.

The post discusses dorsal scapular nerve entrapment which is a common cause of neck and periscapular pain. The post also discusses the relationship of this condition to the Large Intestine sinew channel.

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LI 15 (Jianyu) and Channel Relationships: A Point Reached by the Lung sinew channel and the Small Intestine Luo-Connecting Channel

"Jianyu L.I.-15, a meeting point of the Large Intestine channel with the Yang Motility vessel, is also reached by the Lung and Bladder sinew channels, the Large Intestine divergent channel and the Small Intestine luo-connecting channel. Jianyu L.I.-15 is considered the preeminent point for treating the shoulder, and clinically the majority of shoulder disorders affect this region."1 This is a quote from the commentary of LI 15 in A Manual of Acupuncture by Peter Deadman. There is a lot of information in this opening paragraph; a look at the anatomy will help to elucidate it. 

Fig. 1: Image from A Manual of Acupuncture,
by Peter Deadman. Illustrating the
The Lung sinew channel which
"enters the bottom of the armpit"
 but also "connects to the front 
of the shoulder joint"

In this post we will start with the Lung sinew channel and the Small Intestine luo-connecting channel. This will highlight the relationship of LI 15 to shoulder problems. The Lung sinew channel includes the biceps brachii. The Lung sinew channel is continuous, via myofascial connections, from the thenar muscles to the pectoralis minor, subclavius, and intercostal muscles. The biceps brachii are part of this sinew channel and it is specifically the short head of the biceps which blends with the pectoralis minor. However, as described classically and seen in the illustration from A Manual of Acupuncture, the long head of the biceps can be interpreted to be included. The long head has a fascial connection to the supraspinatus.2

Interestingly, the supraspinatus muscle is part of the Small Intestine sinew channel and its muscle belly is accessible at SI 12 (which is the motor point of the supraspinatus).3 However, its musculotendinous junction is reached by LI 16 and its humeral attachment is reached from LI 15.

Fig 2: Note the transverse ligament which is illustrated
as a separate structure. Compare it to Fig 3. where it
does not appear to be a separate structure. In a cadaver
specimen, it is observed to be a continuous sling as describe
in this post.

The long head of the biceps brachii (part of the Lung sinew channel) lies in the bicipital groove where it is held in place by a ligamentous structure called the transverse humeral ligament. While not described this way in anatomy texts, the transverse ligament is actually a fascia sling composed of the superficial fibers of the subscapularis tendon, a muscle of the Heart sinew channel, and longitudinal fibers of the supraspinatus tendon.4,5 Overactivity in the subscapularis muscle can contribute to pain in the long head of the biceps as the additional tension, transmitted through the transverse ligament, compresses the muscle and its tendon sheath and can be an aggravating factor for bicipital tenosynovitis (inflammation of the tendon sheath of the long head of the biceps).

So LI 15 is a fascial meeting point of the supraspinatus (SI sinew channel) and subscapularis (HE sinew channel), and this point is classically described as a meeting point of the Small Intestine luo-connecting channel, a point that would connect the Small Intestine channel with its internally related Heart channel.

Fig. 3: The anterior view of the scapula and humerus with the rib cage removed.  This image is modified from Atlas of Human Anatomy by Frank Netter.  LI 15 is on the anterolateral border of the acromion process of the scapula. When located this way, there is little space felt between the acromion process and the greater tubercle of the humerus. Anatomy illustrations are somewhat misleading and the above illustration seems to put LI 15 much farther inferior to the acromion. This is not the case. If the tip of your finger is on the point, it side should be in contact with the acromion process

Needling at LI 15 accesses the region where the supraspinatus tendon attaches and where the transverse ligament crossed over the biceps tendon. Therefore this point can be used when there is pain from supraspinatus tendinopathy and/or from bicipital tenosynovitis. These are two of the most frequent shoulder conditions, so it can be seen why LI 15 is so useful. Which other points are used in addition will be based on which pathology is being treated, which muscles are overactive and which are inhibited, and, based on this, how well the glenohumeral joint is functioning. Frequently used points include SI 12 (the motor point of the supraspinatus), SI 11 and the motor points of the infraspinatus, SI 9.5 (the motor point of the teres minor and half way between 9 and 10), and HE 1 (the motor point of the subscapularis).6 There are other direct techniques which can be used for specific conditions.

Many practitioners would agree that distal LI channel points are often used for shoulder problems such as supraspinatus tendinopathy and bicipital tenosynovitis. Obviously the LI channel flows through LI 15. But, as mentioned above, LI 16 accesses the myotendinous junction of the supraspinatus and the Large Intestine channel then intersects with SI 12 en route to LI 17.

A specific distal point commonly used for shoulder problems is LI 11. This point can be threaded to connect with HE 3 (or vice versa) which would help connect the Large Intestine channel (which intersects with SI 12 and the supraspinatus) with the Heart channel (which connects with the subscapularis) and helps balance the relationship of these to important shoulder joint muscles.

References:

^{1. Deadman, Peter, Mazin Al-Khafaji, and Kevin Baker. A Manual of Acupuncture. Hove, East Sussex, England: Journal of Chinese Medicine Publications, 2007. Print.}

2, Myers, Thomas W. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 3rd ed. Edinburgh: Churchill Livingstone, 2014. Print.

3 Lau, Brian. "Anatomy of the Sinew Channels: Head, Neck and Upper Extremities." Sports Medicine Acupuncture Certification: Module 2 Anatomy/Palpation/Cadaver Lab. Pacific College of Oriental Medicine, Chicago. 24 Apr. 2016. Lecture

4, Gleason, P.D. "The Transverse Humeral Ligament: A Separate Anatomical Structure or a Continuation of the Osseus Attachment of the Rotator Cuff?" American Journal of Sports Medicine 34.1 (2005): 72-77. Web.

5, Stecco, Carla, and Warren I. Hammer. Functional Atlas of the Human Fascial System. Edinburgh: Elsevier, 2015. Print.

6. Callison, M. (2007). Motor Point Index: An Acupuncturist's Guide to Locating and Treating Motor Points. San Diego, CA: AcuSport Seminar Series LLC.

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Fascia Fiber Direction, Myofascial Release, and Acupuncture

Fig. 1: Electron microscope view showing
the endomysial layer¹ 

The image to the right (Fig. 1) shows the endomysium, the )fascial compartment that wraps individual muscle fibers. A simplified schematic is shown below (Fig. 2). The cross-linking fiber direction is particularly worth noting, as this can inform clinical strategies. These strategies are especially relevant to tuina (particularly myofascial release), but can also inform acupuncture needle manipulation.2

Beginning with myofascial release, it is important to note what happens to the fibers of the endomysium as a muscle is locked into a lengthened position (locked-long) versus locked into a shortened position (locked-short).3

Fig. 2

When locked-long, the endomysium cross-linked fibers are pulled horizontally, and they become increasingly more parallel to the muscle fiber length. A slow, sustained myofascial release stroke in the direction of the muscle fiber would further move these fascial fibers into this parallel arrangement, which could ultimately be counterproductive for long-term change of the patient.

However, this same slow, sustained myofascial release stroke perpendicular to the fiber direction would result in a positive re-balancing of the fascia, which would enhance the ability of the muscle to return to its normal resting length. So, in effect, this stroke against the muscle fiber direction could be considered a tonification technique.

Fig. 3

For the locked-long muscle to optimally return to its resting length, it is important to also address its antagonist. This frequently involves muscles that are on the internally-externally related sinew channel. For instance, someone with upper cross syndrome would have an overlengthened lower and middle trapezius and rhomboids. These are part of the Large Intestine sinew channel and, in this case, would benefit from the tonification technique described above.4

However, the pectoralis minor, part of the Lung sinew channel, would be in a shortened position (excess) and would benefit from an MFR stroke in a direction with the muscle fibers; a sedating technique.4 This directional stroke would reorganize the fascia and provide the most precise communication to the tissue.

How does acupuncture fit into this? First of all, proper needling to the motor points of both the locked-long and locked-short structures would help reset the dysfunctional muscle-spindle relationship of these muscles, and the myofascial release would help reset the fascia. 

Fig. 4 Image showing collagen fibers
wrapping around the needle6 

Acupuncture needle technique can also involve moving fascia. After needling acupuncture points, the needle can be turned in one direction (just like we were taught NOT to do in acupuncture school) until the needle can no longer turn. Now the needle has wound a considerable amount of collagen fibers around it. Then, the needle can be pulled in the appropriate direction to reroute the fascia. Over time, the fascia will loosen around the needle and the needle can be removed, though it is important that you remember which direction you turned it in case there is difficulty*.5

Imagine a patient with overpronation of the foot. The peroneals are now in an overlengthened position and are pulled up fascially, much like a shirt sleeve that is pulled up on the arm. Needling the motor points of peroneus longus and brevis, winding the needle, and them pulling downward, will help reset the dysfunctional muscle and fascia. Following this with a deep cross-fiber spreading of the tibialis anterior will balance the relationship of the tibialis anterior with the peroneals. This will balance Earth (tibialis anterior/Stomach sinew channel) with Water (peroneals/Urinary Bladder sinew channel).

*This technique is best taught in a classroom setting. Please do not attempt unless you have practiced under supervision first.

References:

1. Purslow, Peter P. "Muscle Fascia and Force Transmission." Journal of Bodywork and Movement Therapies 14.4 (2010): 411-17. Web. 

 2. Spina, Andreo A. "The 'Direction' of Fascia." Web log post. Functional Anatomy Blog. 10 Mar. 2011. Web. 16 Feb. 2016. 

3. Myers, Thomas. "Lengthening Fascial Tissue: Working with the Grain." Web log post. Anatomy Trains. 25 June 2014. Web. 16 Feb. 2016. 

4. Lau, Brian S. "Anatomy of the Sinew Channels Module 2: Head, Neck, and Upper Extremities." Sports Medicine Acupuncture Certification: Anatomy, Palpation, and Cadaver Lab. Pacific College of Oriental Medicine, San Diego. Lecture. 

5. Callison, Matt. "Assessment and Treatment of Lower Extremity Injuries." Sports Medicine Acupuncture Certification. Marina Village, San Diego. 17 Oct. 2015. Presentation.

6. Langevin, Helene M. "The Science of Stretch." The Scientist Magazine. 1 May 2013. Web. 16 Feb. 2016. 

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Osteoarthritis of the Hand and the Large Intestine Sinew Channel

 This post will discuss hand and finger pain, especially along the Large Intestine channel distribution. This will be relevant to pain associated with osteoarthritis and/or pain associated with myofascial trigger points referrals. We will also look at how certain muscle referral patterns can overlap and combine to increase the amount of pain in a particular region. In this case, we will examine pain in the LI-4 – LI-1 region, which can be associated with the first interosseous muscle, the extensor carpi radialis longus, the brachioradialis, the anterior scalenes, and often a combination of these muscles.

The dorsal interossei originate from the two adjacent metacarpal bones and insert at the proximal phalanx into the tendinous expansion, which is a fibrous branching of the extensor digitorum tendon.^1,2 These intrinsic hand muscles flex the MCP joint, extend the interphalangeal joint, and abduct the phalanges. Heberden's nodules at the distal interphalangeal joint, often identified with osteoarthritis, may be associated with trigger points in the interossei muscles.³ The nodules are sometimes caused by contracture and enlargement of the soft tissue associated with the tendinous expansion on the posterior aspect of the phalanges.² There are some indications that trigger point activity in the muscles attaching to this tendinous expansion, especially the dorsal interossei, contribute to the progression and pain associated with Heberden's nodules.³

Diagram of the finger tendons and ligaments
extracted from Alexander2

Regardless of whether Heberden's nodules are present, each dorsal interosseous muscle refers pain primarily to that side of the finger to which the interosseous muscle attaches.³ In particular, the first interosseous muscle can be a significant generator of pain, primarily to the radial side of the second phalanx, but also deeply into the dorsum and palm of the hand. This muscle is best accessed from its motor point location, which is located at the extrapoint M-UE-50 (Shangbaxie) approximately in the region of LI-3. All of the dorsal interossei motor points are located at the Shangbaxie.⁴

Needle technique for the first interosseous muscle involves locating the head of the second metacarpal and palpating along the bone in a proximal direction until a node is felt (this is fairly close to the head of the metatarsal). This node is the muscle belly of the first interosseous. The guide tube can be placed immediately distal to this node and the needle can be advanced in a proximal and medial direction into the belly of the first dorsal interosseus muscle. A strong da qi sensation will be felt, and often a muscle fasciculation will be illicited once the needle makes contact with the point. This is seen at the end of the video below as the finger suddenly abducts.

Fig. 3

Since the brachioradialis, extensor carpi radialis longus, and anterior scalenes refer pain to the hand in the region of LI-4 – LI1, these muscles should also be checked. The pain referral from these muscles can contribute to the overall pain of this region and can further aggravate the first dorsal interosseous muscle, causing a return of pain even if the local needling of the first dorsal interosseous is successful. All of these muscles are part of the Large Intestine sinew channel and can be accessed at their motor point locations at LI-11 and LU-6 (brachioradialis), LI-10 (extensor carpi radialis longus), and extrapoint jingbi (anterior scalenes)*. ⁴

* Jingbi should only be needled by those with appropriate clinical training and experience, due to its proximity to the pleural dome and the risk of a pneumothorax.

References:

1. Chaitow, L., DeLany, J., & Chaitow, L. (2008). Shoulder, arm, and hand. In Clinical application of neuromuscular techniques: Volume 1 (2nd ed., pp. 529-530). Philadelphia, PA: Churchill Livingstone Elsevier.

2. Alexander, C. J. (1999). Heberden's and Bouchard's nodes. Annals of the Rheumatic Diseases, 58(11), 675-678.

3. Simons, D. G., Travell, J. G., Simons, L. S., & Travell, J. G. (1999). Interosseous muscles of the hand, lumbricals, and abductor digiti minimi. In Travell & Simons' myofascial pain and dysfunction: The trigger point manual (2nd ed., pp. 786-793). Baltimore: Williams & Wilkins.

4. Callison, M. (2007). Wrist and fingers. In Motor point index: An acupuncturist's guide to locating and treating motor points (p. 90). San Diego, CA: AcuSport Seminar Series LLC.

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