A Brief History of Acupuncture

• Acupuncture is one branch of a complete system of medicine known as Oriental

Medicine, which has developed over the course of thousands of years.

• Theories underlying traditional Oriental Medicine are largely based on observing the
natural world.

• Oldest written medical information ~ 168 BCE

• What does Oriental medicine do?
• Traditional Chinese medicine aims to restore the body's balance and
harmony between the natural opposing forces of yin and yang, which can
block qi and cause disease. Traditional Chinese medicine includes
acupuncture, diet, herbal therapy, meditation, physical exercise, and massage.
• Practiced in China for over 4,000 years
• Traditional Chinese medical technique for unblocking chi
• Acupuncture is the insertion of needles in specific points on the body
• These insertion points are believed to correspond with 14 main pathways within the body called meridians
• 1950s - Becomes known as “TCM” (Traditional Chinese Medicine) – taught today in many Western
acupuncture schools.
•Is it chi or qi?
•Both terms have been used to describe this undercurrent force and while they
are technically interchangeable, they vary slightly based on its cultural origin. “[It’s called] qi in
Chinese medicine or prana in ayurvedic, yogic tradition,” says Annie McDonnell, LAc, of New York’s
Joy Alchemy Acupuncture.
•According to the Acupuncture and Massage College in Miami, Florida, it’s best to use qi in the
context of restoring balance since that is the “physical or nourishing portion that makes up the air,
water, and food we take in,” whereas chi refers to the “vital fluids and the energy itself that flows
through our bodies.” Regardless, both have
Maintocomponents
do with working towards
of Traditional feeling a little better day to
Chinese
day. Medicine:
• Herbal medications
• Acupuncture
• Massage (Tui na)
 Meridians

• Energy flow system

• Chi (Qi): energy flow
• AP points on 12 major meridians
• Normal: Energy flow all the time on all the meridians
from one acupuncture point to another

LU->LI->ST->SP->HT->SI->BL->KID->PC->TB->GB->LIV
 What exactly is Chi?
• Chi is an energy that, according to ancient Chinese beliefs,
permeates all things
• Chi must be able to flow freely throughout the body in order for
a person to maintain overall health
• Translated as “life energy” or “vital energy”, a dynamic
construct.
• Qi is responsible for all physiological functioning in the body.
• Qi is derived from three main sources: air we breathe, food we
eat, & inherited.
• Chi flows through the body via channels, or meridians, that
correspond to particular organs or organ systems.
 Meridians/ Acupoints
• Meridians are pathways which qi follows as it flows around the body.
• Analogous to, but not the same as, circulatory, lymphatic, and nervous
systems.
• 12 regular meridians, named for internal organs.
• Meridians contain 365 acupuncture points (originally there were 365
acupuncture points, but through the years this number has increased to over 2,000)
• Points have Chinese names which often relate to their function or
location.
• Acupoints are discrete and specific sites through which the Qi of the
organs communicates with the surface of the body.
 Meridians

• Where there is no free flow, there is pain.

Pathogenic factors

Meridian

No free flow
Pain
 Meridians

• Where there is free flow, there is no pain.

Pain
No free flow
Pathogenic factors

Meridian

Acupuncture Stimulation
Eliminating

Meridian

Normal
 Where do yang and yin fit in?

• Acupuncture needles are inserted in an attempt to balance the opposing

forces of yin and yang
• Yin and yang are balanced when a person is healthy and chi is therefore
able to flow freely
• Injury or illness cause yin and yang to become distressed and
unbalanced.
• Yang: The masculine element and opposing or balancing pole to Yin. Like
brightness, sun, day, summer, hot, fast, sky.
• Yin: The feminine element and one pole within a philosophical concept
of duality in nature. Like dimness, moon, night, winter, cold, slow, earth.
Scientific Evidence ?
 Scientific Bases of Acupuncture

• Neurohumoral
• Morphogenetic
• Nerve Reflex Theory
• The gate control theory of pain
• Endorphin

https://www.wikidoc.org/index.php/
Scientific_theories_regarding_acupuncture#Singular
_points_in_bioelectric_field
Neuro-humoral Approach

• Peripheral nervous system to be crucial in mediating the

acupuncture analgesia.
• Meridian-Cortex-Viscera correlation hypothesis.
• Acupoint-brain-organ
• Acupuncture stimulates to brain cortex and nerve system,
then control the chemical or hormone release to the
disordered organs.
Morphogenetic singularity Theory
-Shang C. China, 1989

• Acupuncture points are singular points in surface bioelectric

field
• The role of electric field in growth control and morphogenesis
• Organizing centers have high electric conductance/low
resistance
• Acupuncture points originate from organizing centers
Nerve Reflex Theory
-Ishikawa and Fujita et al, Japan, 1950s

• Autonomic nervous system extending through the internal

organs
• Viscera-cutaneous reflex
• Cutaneous –Viscera reflex
• Acupuncture utilize these reflexes for restoring the
homeostasis of the body and accelerates the healing
process.
The Gate Control Theory
Drs Melzack and Wall, 1965

• Model for acupuncture pain relief

• Specific nerve fibers that transmit pain to the
spinal cord (substantia gelatinous)
• Balance between Stimulation & inhibitory fibers
• Short term block pain by acupuncture ( did not
explain the prolong effect)
• The "gating of pain" is controlled by the
inhibitory action on the pain pathways. That is,
the perception of pain can be altered (gated on
or off) by a number of means physiologically,
psychologically and pharmacologically.
Endorphin Theory
Dr. Pomeranz, Canada, 1996

• Natural Morphine
• Acupuncture trigger the release of endorphin
into the central nervous system
• Only deal with pain
• Corticoids and Substance P also released along
with endorphin
 Does acupuncture hurt
• People associate needles with pain from Western Medicine.
• Acupuncture needles are not anything like hypodermic needles used to
administer medications in Western Medicine.
• Acupuncture needles are many times smaller in thickness and are solid with
smooth endings.
• People experience acupuncture needles differently and most patients feel
only a minimal sensation as the needles are inserted.
• Some people feel no pain at all and others feel as short quick sensation upon
insertion. Once the needles are in place, people may feel anything from
nothing to a heaviness or lightness feeling.
 How safe is Acupuncture
• Acupuncture is extremely safe. It is an all-natural, drug-free therapy, yielding no side
effects except feelings of relaxation and well-being. There is little danger of infection
as the needles are sterile and used one time and then discarded.
Do I have to believe in this energy thing for this to work?
• Acupuncture is effective whether you believe in it or not. It has been effectively
been used for thousands of years with millions of people. Additionally, acupuncture
has been used on animals such as horses, dogs, and cats with success as well as on
children.
• While you don’t have to believe in it, just have confidence in the system of medicine
which has worked effectively for millions of people over several thousand years.
 What
conditions can
Acupuncture
treat?
 Is
Dry Needling
Acupuncture?
 WESTERN ACUPUNCTURE
• Modern scientific method was established by Galileo in the 17th century when
he introduced systematic verification through planned experiments to the
existing ancient methods of reasoning and deduction (MacLachlan 1999).
• Filshie & Cummings(1999) interpret ‘Western Medical Acupuncture’ as the
scientific application of acupuncture as a therapy following orthodox clinical
diagnosis.
• More recently (White 2009) WMA is defined as a therapeutic modality
involving the insertion of fine needles; it is an adaptation of Chinese
acupuncture using current knowledge of anatomy, physiology and pathology,
and the principles of evidence-based medicine. It is based on the ethical
practice of medicine requires the practitioner to understand and use scientific
method.
 What's the Difference between Dry Needling and Acupuncture?

• Acupuncture and dry needling, while using the same needle types, are two very
different treatments. Traditional Acupuncture is used for the diagnosis and
treatment of pathological conditions including visceral and systemic dysfunction,
while dry needling is used for the assessment and treatment of myofacial pain
syndromes and dysfunction due to myofacial trigger points / tension areas / muscle
spasm / increased tonicity.
 Is
Dry Needling
within
the
Scope
of
Physical Therapy
Practice?
 Dry Needling-Definition

Dry Needling
A skilled intervention performed by a physical therapist that uses
a thin filiform needle to penetrate the skin and stimulate
underlying myofascial trigger points, muscular and connective
tissues for the management of neuromusculoskeletal pain and
movement impairments.
(American Physical Therapy Association Dry Needling Task Force, May, 2012)
 SUPPORT STATEMENT
Dry needling is a neurophysiological evidence-based treatment
technique that requires effective manual assessment of the
neuromuscular system. Physical therapists are well trained to utilize
dry needling in conjunction with manual physical therapy
interventions. Research supports that dry needling improves pain
control, reduces muscle tension, normalizes biochemical and
electrical dysfunction of motor endplates, and facilitates an
accelerated return to active rehabilitation.
October, 2009
This suggests an important concept that “it requires effective
manual assessment. It also emphasizes that it is an adjunct to our
other treatments and that is it supported by research.
 Contraindications to MF therapy with DN

Malignancy: dependent on the type and position of tumor, but treatment

may accelerate spread;
Open wounds: tissue may become aggravated during the application of
therapy or stretching; never needle directly into an open wound;
Severe arteriosclerosis: excessive compression and stretching may
accentuate clot formation;
Aneurysm: if peripheral, TP therapy is contraindicated;
Specific sensory neuropathies; patient can’t feel.
Advanced osteoporosis: relative contraindication. If unsure, communication
with relevant health care practitioner is imperative
 ACUPUNCTURE NEEDLES

• Stainless steel single use needle;

• Guide tube & plastic holder;
• Use disposable needles to limit the spread of AIDS and Hepatitis B virus;
• Use a needle longer than the depth required to avoid inserting the needle up to the
hilt and to prevent the needle from breaking off;
• Needle choice governed by anatomy.
 Needles • Single use needles - pre
sterilised and disposable.

• Guide tube

• Solid shaft with wound metal

A or plastic handle

• Sizes:
B
– diameter or gauge 26
C
(0.22mm) to 34 (0.45mm).
guidetube – length 0.5 (15mm) to 5.0
D
(125mm)
A: handle B: root
C: shaft D: tip
 • Wet (injection)
– Thicker
– Hollow
– Inflexible
– Cutting tip

• Dry (acupuncture)
– Thinner
– Solid
– Flexible
– Pointed tip
 Needles • May be silicone coated
like hypodermic needle
• Tip rounded (pine cone)
rather than tapered
• No cutting edge
• Pushes tissue
• fibres apart
May still puncture blood
vessel / nerve / viscera
White et al (2008). Introduction to Western
Medical Acupuncture. Elsevier
 BASIC NEEDLING PROTOCOL

• Patient always recumbent

• Sterile technique / needles only.
• After needling, passively stretch muscle?
• Apply hot packs (post needling soreness);
• Active range of motion.
 BASIC NEEDLING PROTOCOL

• Localize TP
• Palpation grip – pincer / flat palpation;
• Quick and strong needle tap insertion;
• Hemostasis – ie bleeding stops.
• Needle the TP (probing, flicking, twisting);
• Depth / angle.
 BASIC NEEDLING PROTOCOL

Reasons for failure of treatment

• Needling of latent TP (not primary active);
• Missing the TP (only into band);
• Inadequate hemostasis;
• Not performing active ROM after Rx;
• Omitting regular passive home
stretches.
 COMPLICATIONS OF DRY NEEDLING

• DN is relatively safe provided sterilized needles used;

• risks are minimised with a good knowledge of
anatomy;

• Complications
– Vasovagal attack;
– Convulsions;
– Visceral damage;
– Haemorrhage;
– Pregnancy (relative contra-indication).
 NEEDLE SAFETY

• Disposable needles;
• Sterile technique (sterile needle, skin
disinfection and gloves);
• Correct disposal: needles disposed
straight
into sharps bins and correct disposal of sharps
bins.
Anatomy for Safe Dry Needling
Important Anatomical Considerations

• When needling, we MUST be aware of the

following anatomical positions to avoid
penetrating;

– Nerves
– Arteries
– Visceral structures
– Foramens /
– Fenestrations
Joints
 Nerves
• The following nerves
must be avoided
• Sciatic, femoral, tibial,
posterior tibial, common
peroneal.
• Median, ulnar, radial,
brachial plexus.
• Facial and trigeminal
 Arteries
• The following arties
must be avoided
• Vertebral and Carotid
arteries
• Subclavian
• Brachial
• Femoral, popliteal, tibial,
 Visceral Organs-Lungs

• The lungs usually extend only 2.5 cm above the clavicle

but can extend as high up as 4 or 5 cm above the

clavicle.
• The parietal pleura lies up against the inside of the ribs

at a depth of approx 2-3 cm.

• The lungs extend inferiorly to approx. 10th thoracic

vertebra.
 Visceral Organs-Lungs
• The lungs can be pierced when needling anywhere
around the thoracic cage.
• Upper traps & post scalenes; horizontal needling;
• Intercostal muscles; very superficial;

• Serratus / rhomboids / lats; use the ribs as backstop

• R11 & R12; avoid deep needling upward and inwards.

 Visceral Organs – Kidney
• The kidneys extend from T12
to around L3; they are about
11-12 cm in length.
• Lie anterior to the 12th rib
• sit on the posterior abdominal
wall anterior to the psoas
muscle, QL and the diaphram.
• Retroperitoneal so not
contained in abdominal
cavity.
 Visceral Organs – Abdomen
• No penetration of the
abdominal cavity when needling
obliques, psoas (proximal),
iliacus and QL.
• It is possible to pierce the
bladder and intestines with
deep needling
• One case of a foreign body
(needle) being found in the
kidney on ultrasound is
reported.
 Foramens / Fenestrations

• It is possible to accidently
pierce through a foramen or
fenestration.
• The scapula can have
fenestrations / holes that if
pierced can lead to a
pneumothorax.
• The foramen magnum and
spinal cord can be pierced when
needling the deep sub-occipitals.
 Foramens / Fenestrations

• Needling thru a sternal

foramen (4th IC space) into the
chest cavity can cause cardiac
tamponade.
• Needling to a depth of 15-
20mm can reach the lungs and
cause a pneumothorax
 Joints

• There is no basis for dry

needling into a joint.
• An effusion / haemarthrosis
must be drained under
sterile conditions.
• Needling a joint can;
• Damage intra-articular surfaces
and structures;
• Cause infection;
• Exacerbate patient symptoms;
 DN contraindications & cautions

• Needle phobia / patient is unwilling • Recent joint replacement (local DN)

• Inability to give consent • Aneurysm

• Malignancy • Sensory neuropathy

• Acute medical condition / open • Advanced osteoporosis

wound • Diabetes (peripheral needling)

• Severe arteriosclerosis / CHD Limb • Anticoagulants (DDN)

with lymphedema • Pregnancy (trunk needling)

•
 NEEDLE STICK INJURIES

• Low risk if correct technique used;

• HIV risk is low, other viruses such as Hepatitis
is higher (consider vaccination);
• If exposed:
– Clean area with alcohol and water;
– Rinse thoroughly if mucus membrane;
– Explain to patient if neccesary;
 NEEDLE STICK INJURY
• Exposures that should consider PEP (Post-
exposure prophylaxis):
– Blood contaminated needles;
– Injury with blood contaminated sharp
– instrument;
– Exposure to mucus membranes;
– Blood contamination on broken skin;
• PEPProlonged
should beexposure to blood
started within on normal
hours skin.
to be effective
• Consultation with relevant practitioner is
imperative
 PROFESSIONAL INDEMNITY AND
INFORMED CONSENT
• Practitioners / therapists must ensure that
relevant insurance is in place prior to
performing dry needling on patients.
• Written informed consent is considered good
practice.
• Relevant regulatory guidelines for your
profession must be adhered to.
 Trapezius
• Anatomy; The upper fibres arise from the external occipital Lung apex
protuberance, the medial 1/3 of the superior nuchal line, the beneath first rib
lig nuchae and the spinous process of C7 and inserts into the
posterior border of the latera 1/3 of the clavicle.
• Function; ipsilateral side bending; contralateral rotation of
the head, elevation of the shoulders.
• Nerve supply; Accessory nerve (X1 cranial nerve) and cervical
spinal nerves C3-C4.
• Referred pain; spreads ipsilaterally from posterior-
lateral region of the neck to the temporal area.
• Needling technique; patient in prone or side lying; muscle
needled either pincer grip towards opposite fingers or vertical
Precautions; pneumothorax.
Trapezius
 Beware of pneumothorax!
• Can occur with needles placed;
– parasternal (chest TrP)
– supraclavicular (ST-11/12)
– Infraclavicular (LU-2 / ST- / KD-27)
– 13
– lateral thoracic (SP)
paravertebral
• Lung depth 15-20mm(BL)
• Tissue compression
• Needle of 10mm can reach lungs at
postmortem
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Sterno Cleido Mastoid
• Anatomy: Originates from the mastoid process of the temporal bone.

Sternal head attaches to the anterior surface of the manubrium sterni

and the clavicular head attaches to the superior border and anterior

surface of the medial third of the clavicle.

• Function: Side-bends to the same side and rotates to the opposite side the

head. Also tilts the chin upward (extension of the head)

• Nerve supply: Accesory nerve (XI par cranial), and cervical spinal nerves

C2-C3.

• Referred pain: The sternal division may refer pain to the vertex, to the

occiput, across the cheek, over the eye, to the throat and to the sternum

whereas the clavicular division refers pain to the forehead and deep into
Sternocleidomastoid

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 SCM

• Supine lying, head side flexed towards and

rotated away to slacken muscle.
• Locate carotid pulse.
• Avoid middle 1/3rd of muscle and external
jugular vein if easily seen.
• Pincer grip, towards finger
SCM
Levator Scapulae
 Levator Scapulae
• Anatomy: The muscle originates from the dorsal tubercle of the tranverse processes of C1 to C4

vertebrae and inserts on the superior medial angle and adjacent medial border of the scapula.
• Function: It extends and side-bends the neck. When the head is turned to the opposite side and

forward flexed, it rotates the head toward the midline. The muscle rotates the scapula glenoid fossa

downward when the neck is fixed.

• Nerve supply: Cervical spinal nerves C3-C5, via the dorsal scapular nerve.
• Referred pain: It is projected to the angle of the neck and along the vertebral border of the scapula.
• Precautions: Do not needle towards the rib cage to avoid creating a pneumothorax.
Levator scapulae
• Side lying – either lying on the side of the scap to Levator
be needled (to lift the scap) or on the opposite scapulae
side
• Locate upper portion attaching to TrP of C1, C2.
• Muscle about 0.5cms thick in bands to upper 4
cervical vertebrae (C1-4).
• Needle towards superior angle of scapula for the
lower TrP’s.
• Pincer grip for mid belly.
Rhomboids
 Rhomboids

Anatomy:

Major – The muscle arises from the spinous processes and supraspinous ligaments of the second

to fifth thoracic vertebrae and descends laterally to the medial border od the scapula between the

root of the spine and the inferior angle.

Minor – The muscle runs from the distal ligamentum nuchae and the spines of the seventh

cervical and first thoracic vertebrae to the base of the triangular surface of the medial end of the

scapula spine.

Function: Both muscles retract the medial border of the scapula superiorly and medially.

Nerve supply: Dorsal scapular nerve C4-C5 via the upper trunk of the branchial plexus.

Referred pain: Pain is projected to the medial border of the scapula and superiorly over the supraspinatus
 Rhomboids

• Fingers in rib spaces, trap muscle fold.

• Needle obliquely towards rib

• Side lying (same side) scapular winging, or

arm lock position – needle to scapular border.
Supraspinatus

Suprascapular nerve & artery

through suprascapular notch.
 Supraspinatus
• Anatomy: The muscle originates from the supraspinous fossa of the scapula and inserts at the superior

facet of the greater tubercle of the humerus.

• Function: It assist in abduction and stabilizes the humeral head together with the other rotator cuff

muscles during all movements of the shoulder. The muscle prevents caudal dislocation during carrying of

heavy loads, such as bags and suitcases. Assist Lat. rotation.

•
• Nerve supply: Suprascapular nerve, from the C5 and C6 nerve roots.

• Referred pain: It is projected to the mid-deltoid region, often extending down the lateral aspect of the

arm and forearm, sometimes focusing strongly over the lateral epicondyle of the elbow.

• Precautions: The apex of the lung is in front of the scapula and clinicians should avoid needling in a

ventral direction.
Supraspinatus

• Side lying, (i) needle medially towards root of

scapular spine
• Prone, (ii) needle laterally along suprascapular
fossa.
 Infraspinatus

• Anatomy: The muscle originates from the infraspinous fossa of the scapula and inserts at the
dorso-superior facet of the greater tubercle of the humerus.
• Function: It assist in external rotation and stabilizes the humeral head together with the
other rotator cuff muscles and prevents upwards migration of the humeral head during all
movements.
• Nerve supply: Suprascapular nerve, from the C5 and C6 nerve roots.
• Referred pain: It is projected to the front of the shoulder and the mid-deltoid region,
extending downwards the arm to the ventrolateral aspect of the hand. The referred pain
from this muscle can mimic the symptoms of carpal tunnel syndrome.
• Precautions: In osteoporotic patients, fenestration of the scapula has been reported which
would imply that clinicians should avoid needling through the scapula. In clinical practice,
however, in fenestration has not been an issue.
Infraspinatus

• Referral to mid deltoid region of front of

shoulder
• Side lying with arm in flexion / abduction on
pillow in front
• Prone with arm abducted over couch side
• Needle obliquely (30-45°)
 Infraspinatus

• Anatomical variation of
perforated infraspinous
fossa
• Creates scapular
• foramen
• Angle needle obliquely
Ossified suprascapular
ligament may also close
suprascapular notch
Soni et al (2012) Morphometric Analysis of the Suprascapular
Notch.
The Internet Journal of Biological Anthropology. 5(1).
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Teres Minor
• Anatomy: The
muscle
originates from
the upper one-
third of the
• lateral border
of the dorsal
surface of the
scapula and
•
inserts on the
doral facet of
• the greater
tubercle below
the insertion of
the
• infraspinatus
muscle.
Function: It has the same function as the
infraspinatus muscle, but can also adduct the
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upper arm
Teres Minor

• Same function as infraspinatus

• Referral to posterior aspect of

shoulder and can go to ulnar

aspect of forearm

• Lateral to scapular border

• Pincer grip above T major and

lateral to infraspinatus.

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 Teres minor
Teres
Rhomboid minor
minor
• Teres minor mimics
infraspinatus, Teres major
mimics latissimus dorsi
• Arm abducted
• Pinch grip just below GH
joint Rhomboid
• major
Angle needle towards
finger
of pinch grip or to lateral Teres
major
border of scapula

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 Teres Major Muscle
Anatomy: The tendon of the teres major muscle
fuses with the tendon of the latissimus dorsi muscle
and inserts into the medial lip of the bicipital Groove.

Function: The muscle assists the latissimus dorsi

muscle in extensión, internal rotation and adduction
of the arm.

Nerve supply: Lower subscapularis nerve from the C6

and C7 nerve roots.

Referred pain: The pain is locally projected in the

posterior deltoid, the posterior glenohumeral joint
and over the long head of the tríceps brachii, and
occasionally to the dorsal forearm.

Precautions: There is no danger for injury of the

neurovascular bundle or entering the ribcage, as log
as the needle is directed ventrally and slightly
laterally.

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PECTORALIS MAJOR

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 PECTORALIS MAJOR
• Anatomy: The muscle crosses three joints: Sternoclavicular, acromioclavicular and glenohumeral joint. The
pectoralis major originates from four separate attachments: the clavicular fibers,, the sternal fibers, the costal
fibers and the abdominal fibers. All fibers converge to a flat bilaminar tendon attached to the crest of the greater
tubercle of the humerus along the literal lip of the bicipital groove. The ventral is laminated like playing cards. This
arrangement should be kept in mind when palpating TrPs and eliciting local twich responses.
• Function: It give internal rotation and adduction of the arm and medial flexion across the chest and oblique
upward and forward movement of the arm with the clavicular fibers. The pectoralis muscle is active in forceful
inhalation.
• Nerve supply: The lateral pectoral nerve from the C5-C7 nerve roots and medial pectoral nerve from the C8 and
T1 nerve roots.
• Referred pain: The clavicular section refers pain over the anterior deltoid muscle. The medial sternal section refers
to the sternum, the costal and abdominal fibers cause breast tenderness and nipple hypersensitivity. Left pectoria
major TrPs may mimic angina while a point on the right side in the intercostal space between ribs 5 and 6 just
lateral to the xyphoid process may be linked to cardiac arrhythmias
• Precautions: Care must be taken to prevent penetration into the lung, creating a pneumothorax. A
pneumothorax is much less like to occur when using a solid filament needle than when using a hypodermic
needle. A special precaution to consider is the presence of breast or pectoral implants. Dry needling is
contraindicated in the presence of implants.
PECTORALIS MAJOR

• Protracts shoulder girdle and depresses

scapula
• Sternal & Clavicular fibres
• Referral to chest, anterior shoulder and ulnar
aspect of arm
• Pain may mimic angina
 Pectoralis Major

• Sternal, clavicular, and costal divisions.

• Laterally placed fibres – abduct arm and pincer
grip away from chest wall.
• Medially placed fibres – tangential insertion in
line with chest wall.
• Keep over a rib with fingers within intercostal
spaces.
 Pectoralis Minor
• Anatomy: Pectoralis minor originates from the
coracoid process of the scapular along with the
coracobrachialis and biceps short head muscles
and inserts into 3rd, 4th and 5th ribs near the
costal cartilages.
• Function: pec minor protracts and draws the
scapular forwards, downwards and inwards. It is
also a shoulder girdle stabilizer and depressor
and also an accessory muscle of respiration.
• Nerve supply: medial pectoral nerve from
the
• C8 and T1 nerve roots.
Referred pain: is projected to the ventral aspect
region
of the and the ulnar
shoulder side of the
extending toarm
thetoanterior
the chest
3rd,
4th and 5th fingers. The referred pain is very
similar to that of pec major.
• Precautions: As the pec minor muscle is located
over the ventral surface of the ribcage, be sure
to avoid entering the intercostal space and the
lung. Neurovascualr bundle to the arm also lies
under pec minor and close to the coracoid
process.
All rights
reserved;
SUBSCAPULARIS
• Anatomy: The muscle originates from the upper one-
third of the lateral border of the dorsal surface of the
scapula and inserts on the dorsal facet of the greater
tubercle below the insertion of the infraspinatus muscle

• Function: It is an internal rotator assisted by the pectoral

major muscle. It stabilizes the humeral head together
with the other rotator muscles and prevents upward
migration of the humeral head during all movements.

• Nerve supply: Subscapular nerve from the C5, C6 and C7

nerve roots.

• Referred pain: It is projected to the dorsal aspect of the

shoulder extending to the dorsal aspect of the upper
arm and around the wrist.

• Precautions: As the subscapularis muscle is located

between the ventral surface of the scapula and the
ribcage, the needle has to be directed away from the
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SUBSCAPULARIS

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 Subscapularis
• Axillary approach – supine with arm

abducted and tractioned. Needle

onto lateral border of scapula,

between lat dorsi and chest wall.

Hand against chest wall, needle

Subscapularis
lateral to hand

• Medial approach – prone

hammerlock position. Needle to

medial border aiming at scapula.

Latissimus
dorsi
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SUBSCAPULARIS

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LATISSIMUS DORSI
• Anatomy: The muscle originates from the spinosus processes of
the lower six thoracic vertebrae and all lumbar vertebrae, the
lower 3 or 4 ribs, the iliac crest and lumbar aponeurosis to the
sacrum. It inserts at the medial edge of the intertubercular groove
of the humerus in common with the teres major

• Function: The muscle extends, adducts and internally rotates the

arm. It assits in retraction of the scapula and downward drawing of
the arm. Bilaterally, it assists to extend the spine and
homolaterally.

• Nerve supply: Thoracodorsal nerve, from the C6, C7 and C8 nerve

roots

• Referred pain: The inferior angle of the scapula, and the

surrounding mid-thoracic region, the back of the shoulder down to
the medial aspect of the arm, forearm and hand including the
fourth and fifth fingers. Sometimes the pain refers to the lower
lateral aspect of the trunk above the iliac crest.

• Precautions: All needling is performed in a pincer palpation

towards the fingers to avoid penetrating the chest wall and the
lung. The fingers are positioned between the muscle and the chest
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 Latissimus dorsi

• Supine with hand behind head, or

arm abducted as far as possible
• Prone with arm off couch
• Pincer grip to pull lat away from
chest wall
• Position fingers between muscle
and chest wall
• Needle to finger, angling laterally
away from chest wall

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 LATISSIMUS DORSI

i Lat ssimus dorsi

T1 Teres major
Subscapularis

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BICEPS

• Elbow flexion and supination

• Flexion & stabilization (long head) of
shoulder
• Referral to local muscle area, anterior
deltoid, and antecubital space
BICEPS BRACHII
• Anatomy: The long head attaches to the upper margin of the glenoid
fossa. The tendon passes through the glenohumeral joint over the head
of the humerus. The short head attaches to the coracoid of the scapula.
Both heads join in common tendon to insert at the radial tuberiosity,
facing the ulna in the supinated.
• Function: The long head of the biceps seats the humerus in the glenoid
fossa when the arm is extended and loaded. Both heads assist in flexion
of the arm at the shoulder in the externally rotated arm. The muscle
is one of the three flexors at the elbow and acts most strongly when
the hand is supinated. It also supinates the forearm when the arm is
flexed but not when it is fully extended.
• Nerve supply: Musculotaneous nerve via the lateral cord.
• Referred pain: Refers pain upward over the muscle and over the anterior
deltoid region of the shoulder and occasionnally to the suprascapular
region.
• Precautions: Avoid the radial nerve that lies along the lateral border
of the distal biceps and the brachialis muscles. To avoid needling the
neurovascular bundle of the upper arm – preferred to needle this muscle
only via the lateral approach.
 Biceps
• Radial nerve lateral, Medial nerve medial
(ulnar nerve within groove)
• Radial & median N either side of muscle, Cephalic V
close to bone
• Cephalic vein over lateral border (visible)
• Pincer grip to draw muscle from bone and
lateral approach to avoid medial
neuromuscular bundle
Radial N

Basilic V
BRACHIALIS
 BRACHIALIS

• Anatomy: The muscle originates from the distal two thirds of the humerus and
inserts at the coronoid process of the ulnar tuberosity. This muscle extends
into the anterior part of the joint capsule of the elbow.
• Function: This muscle flexes the forearm at the elbow.
• Nerve supply: Musculocutaneous nerve, via the lateral cord and by spinal
roots C5 and C6.
• Referred pain: It is projected to the base of the thumb and often to the ante-
cubital region of the elbow
• Precautions: The neurovascular bundle should be avoided over the medial
head of the muscle.
 Brachialis

• Elbow flexion

• Anterior arm and antecubital aspect of elbow

• Base of thumb

• Elbow flexed to relax muscle

• Needle from lateral direction to avoid neuromuscular

bundle.

• Between biceps and triceps, push biceps medially out

of the way.
BRACHIORADIALIS MUSCLE
• Anatomy: The muscle starts from the upper two-thirds of the supracondylar

ridge of the humerus and attaches over the distal radius at the styloid process.

• Function: In the neutral position of the forearm, the muscle flexes the forearm at the

elbow.

• Nerve supply: Radial nerve via the posterior cord of the branchial plexus from the

spinal roots C7 and C8,

• Referred pain: It is projected to the lateral epicondyle, the radial aspect of the

forearm, the wrist and the base of the thumb.

• Precautions: This muscle is the most superficial muscle over the lateral elbow.

The radial nerve passes close to it and must be avoided. Clinicians should be

aware of the needling their opposing finger in patient with a very thin
 Triceps

• Extension of elbow and

shoulder

• Referral to posterior

arm, forearm, and

scapula
 TRICEPS
• Anatomy: The long head is the only head
of the triceps muscle that crosses the
shoulder joint, attaching to the scapula
below the glenoid fossa. The three heads of
the triceps muscle attach to the olecranon
process of the ulna via a common tendon.
• Function: Extension and adduction of the arm at the shoulder and rotation
of the scapula to elevate the humeral head towards the acromion.

• Nerve supply: Radial nerve of the posterior cord (C7, C8)

• Referred pain: Posterior arm to posterior shoulder, upper trapezius area

and dorsum of the forearm.

• Precautions: The radial nerve runs caudal to the head of the humerus and
posteriorly to the humerus under the lateral head of the triceps muscle.
 Triceps
Radial N
• Side lying, elbow flexed
45°
• Pincer grip (2 fingers) and needle

from a lateral direction, between

fingers.
Lateral
head
• Pull muscle away from bone to

avoid neuromuscular bundle

• Lower portion & anconeus – prone

with elbow flexed over couch edge

DELTOID

• Abduction, flexion and

medial rotation
• Posterior fibres extend
• Local referral,
sometimes to upper
arm
• Anterior referral more
common.
DELTOID
 DELTOID
• Anatomy: The muscles originates from the lateral
third of the clavicle, the entire lateral border of
the acromion and the lateral half of the spine of
the scapula. The entire muscle inserts on the
deltoid tuberosity which is a rough triangular
area midway the anterolateral border of the
• Function: This thick, multipennate muscle is a prime mover for abduction of the
humerus
upper arm and assists in flexion and internal rotation or extension and external
rotation.

• Nerve supply: Axillary nerve from the C5 and C6 nerve roots

• Referred pain: It is locally projected in the region of the affected part of the
muscle.

• Precautions : No special precautions.

 Deltoid

• Position with arm slightly

abducted on a pillow in

supine or side lying Cephalic

vein
• Perpendicular or oblique
insertion

Circumflex
• Avoid needling to bone humeral A / V

depth at humeral neck