Dry Needling for Scapular Winging

This week’s article is a guest post from Michael Infantino.  Michael reached out to me on Facebook and sent me the below videos of a patient’s improvement in scapular winging after dry needling the serratus anterior.

I wanted to share the below article that Michael wrote showing the videos, but also talk about how trigger points may be involved.

I’m not sure what to make of these videos, if trigger points are involved, or exactly how dry needling the serratus anterior helped this patient’s winging.  But I am sure that I was impressed with the results.  I wish we knew more about the reasoning and mechanism, but in the meantime I’m happy we can help people feel and move better.

Dry Needling for Scapular Winging

Can we correct scapular winging in a matter of minutes?  This obviously depends on the cause of the scapular winging.

It is well documented that injury to the long thoracic nerve or cervical spine may lead to medial border scapular winging or dyskinesia of the scapula (Meininger, 2011). These are always challenging.  Ruling out neuromuscular cause can be done with a nerve conduction velocity test or EMG.  

But a recent patient of mine, made me think…

Research has continually shown that muscles with trigger points demonstrate the following:

  • Altered muscle activation patterns on EMG (Lucas, 2010; Wadsworth, 1997)
  • Reduced muscle strength (Celik, 2011)
  • Accelerated muscle fatigue (Ge, 2012)
  • Reduced antagonist muscle inhibition (Ibarra, 2011)  
  • Increased number of trigger points on the painful side (Alburquerque-Sendin, 2013; Bron, 2011; Fernandez-de-las-Penas, 2012; Ge, 2006; Ge, 2008)

Appreciating these findings would lead most to conclude that treatment of trigger points could improve scapular mobility and timing. This was my immediate thought when I noticed a significant medial border scapular winging while watching my patient raise and lower his arm.

It wasn’t until I read this research that I began using dry needling to do more than just manage pain. The results seen following dry needling to the serratus anterior were remarkable.

After seeing this amount of scapular winging, I dry needled his serratus anterior muscle.  Note the remarkable improvement:

How Trigger Point Dry Needling May Impact Scapular Winging

It is well documented that appropriate muscle activation patterns (MAP) surrounding the shoulder is necessary for efficient and pain free mobility (Lucas, 2003). Lucas and group actually gauged the effect of trigger point dry needling on MAP in subjects with latent trigger points (LTrP).

“Latent myofascial trigger points (LTrPs) are pain free neuromuscular lesions that are associated with muscle overload and decreased contractile efficiency” (Simons et al., 1999, p. 12). MAP’s of the upper trapezius, serratus anterior, lower trapezius, infraspinatous and middle deltoid were compared in a group with LTrP’s and one without. Following surface EMG, the LTrP’s were treated with trigger point dry needling. Surface EMG was performed after treatment as well.

Findings from this study were as follows:

  • Muscle activation of the upper trapezius in the LTrP group pre-treatment.
  • Early activation of the infraspinatous in the LTrP group pre-treatment.
  • Increased variability of muscle activation in all muscles assessed in the LTrP group pre-treatment compared to the control group.  
  • Altered MAP of distal musculature (infraspinatous and middle deltoid) were consistent with co-contraction, a finding that has been attributed to increased muscle fatigability (Chabran et al., 2002).
  • Improved muscle activation times in the LTrP group following dry needling.
  • Significant decrease in the variability of muscle activation in the LTrP group following dry needling, except for the serratus anterior.
  • The serratus anterior and lower trapezius showed increased variability in both the control and LTrP group, which may be why the results did not reach significance. This is also consistent with the latest research in JOSPT that found dyskinesia to be normal in asymptomatic populations. (Plummer, 2017).

Based on the both my clinical experiences and the research presented in this paper, it would seem highly valuable to focus on the treatment of trigger points to restore muscle activation patterns surrounding the shoulder complex.

Being able to press the “reset button” on a muscle is important for re-establishing normal muscle activation patterns prior to exercise. Inclusion of other manual therapy and exercise techniques is important for optimizing function of the local musculature (range of motion, hypertrophy, strength and endurance).

No research that I am familiar with has compared dry needling to other manual therapy techniques for restoring MAP in muscles adjacent to the shoulder. Future research that compares various trigger point treatments for restoration of normal MAP would be beneficial.

 

About the Author

Dr. Michael Infantino, DPT, is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

References

  • Alburquerque-Sendin, F., Camargo, P.R., Vieira, A., Salvini, T.F., 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin. J. Pain 29 (6), 478e486.
  • Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., Oostendorp, R.A., 2011a. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 9, 8.
  • Chabran, E., Maton, B., Fourment, A., 2002. Effects of postural muscle fatigue on the relation between segmental posture and movement. Journal of Electromyography and Kinesiology 12, 67–79.
  • Celik, D., Yeldan, I., 2011. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J. Back Musculoskelet. Rehabil. 24 (4), 251e256.
  • Cummings, T.M., White, A.R., 2001. Needling therapies in the management if myofascial trigger point pain: a systematic review. Archives of Physical and Medicine and Rehabilitation 82, 986–992.
  • Ge, H.Y., Arendt-Nielsen, L., Madeleine, P., 2012. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 13 (7), 957e964.
  • Ge, H.Y., Fernandez-de-las-Penas, C., Arendt-Nielsen, L., 2006. Sympathetic facilitation of hyperalgesia evoked from myofas- cial tender and trigger points in patients with unilateral shoul- der pain. Clin. Neurophysiol. 117 (7), 1545e1550.
  • Ge, H.Y., Fernandez-de-Las-Penas, C., Madeleine, P., Arendt- Nielsen, L., 2008. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur. J. Pain 12 (7), 859e865.
  • Hillary A. Plummer, Jonathan C. Sum, Federico Pozzi, Rini Varghese, Lori A. Michener. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther:1-25.  
  • Ibarra, J.M., Ge, H.Y., Wang, C., Martinez Vizcaino, V., Graven- Nielsen, T., Arendt-Nielsen, L., 2011. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J. Pain 12 (12), 1282e1288.
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Meininger, A.K., Figuerres, B.F., & Goldberg, B.A. (2011). Scapular winging: an update. The journal of The American Academy of Orthopaedic Surgeons, 19(8), 453-462.
  • Simons, D.G., Travell, J.G., Simons, L.S., 1999. The Trigger Point Manual, Vol 1, 2nd Edition. Williams and Wilkins, Baltimore, USA.
  • Wadsworth, D.J.S., Bullock-Saxton, J.E., 1997. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International Journal Sports Medicine 18, 618–624.

 

4 Myths of IASTM

Instrument assisted soft tissue mobilization (IASTM) is really a great manual therapy skill to have in your tool box.  However, there are many myths and misconceptions regarding IASTM that I really believe are holding people back from getting started and seeing the benefits of IASTM in their practice.

In this video, Erson Religioso and I discuss some of the myths of IASTM that led us to develop our online educational program at IASTMtechnique.com to teach people how and why we use IASTM:

4 Myths of IASTM

 

To summarize some of the myths of IASTM discussed in the video:

  • IASTM MythsIASTM does not have to be expensive to learn or perform.  You do not need to spend tons of money on certification courses and crazy expensive tools.  Erson and I have a quick and easy online educational program at IASTMtechnique.com that will get you started right away.  We even talk about how you can get useable tools for as little as $5!
  • IASTM does not have to be complicated to learn.  If you are already performing manual therapy or massage, you know everything you need to know to start using IASTM.
  • IASTM should not make everyone black and blue!  Let me actually rephrase that for emphasis, IASTM is not about being so aggressive that you leave large purple marks and essentially produce superficial capillary hemorrhage.  Some redness and petechia is OK, but the over aggressive black and blue is not ideal.
  • IASTM tools do not provide as much feedback as my hands.  IASTM is a way to compliment your hands, it is not a replacement!  In fact, it gives you a different feel that really helps your palpation skills.

 

 

Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!

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Photo from Wikipedia

How and Why You Need to Learn IASTM

Erson Religioso and I have a nice video for you discussing why and how we both started using instrument assisted soft tissue mobilization (IASTM).  Like many people, I held out initially as I wanted to hear and see more.  However, the more I learned the more interested I became.

IASTM has now become a game changer for me and something I deeply integrate into my manual therapy techniques, and think you should too.  It doesn’t have to be complicated, expensive, or time consuming to start using IASTM.

In this video, Erson and I describe how and why they both started using IASTM, how we integrate IASTM with other manual techniques and exercise, the major benefits of IASTM, and then some brief technique demonstrations.

 

How and Why You Need to Learn IASTM

 

Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!

How to Stabilize the Scapula During Shoulder Elevation

One of the most common compensations we see with people with limited overhead shoulder elevation is lateral winging of the scapula.  Anytime you have limited glenohumeral joint mobility, your scapulothoracic joint is going to try to pick up the slack to raise your arm overhead.

This is common in postoperative patients, but also anyone with limited shoulder elevation.

Stabilizing the scapula during range of motion is often recommended to focus your mobility more on the shoulder than the scapula.  As with everything else, as simple as this seems, there is right way, a wrong way, and a better way to stabilize the scapula during shoulder elevation.

In this video, I demonstrate the correct way to stabilize the scapula, and show some common errors that I often see.

 

How to Stabilize the Scapula During Shoulder Elevation

 

Learn Exactly How I Evaluate and Treat the Shoulder

Interested in learning more?  Join my acclaimed online program teaching you exactly how I evaluate and treat the shoulder.  It’s a comprehensive 8-week online line program that covers everything you need to know about clinical examination, dynamic stability drills, manual therapy techniques, rotator cuff injuries, labral tears, stiff shoulders, and more.
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Integrating Performance Based Physical Therapy

The latest Inner Circle webinar recording on Integrating Performance Based Physical Therapy is now available.

 

Integrating Performance Based Physical Therapy

Integrating Performance Based Physical TherapyThis month’s Inner Circle webinar is on Integrating Performance Based Physical Therapy.  This presentation is actually my talk from the recent Champion Bridging the Gap From Rehab to Performance Seminar that we conducted in Boston last month.  

I wanted to share this with Inner Circle members as I feel the topic is important as performance based therapy is definitely the future of our professions.  Performance therapy is something that is performed to help people optimize themselves and improve performance, no matter what performance means to you.  You don’t need to be injured to benefit from performance therapy.  This is a lot of what we do at Champion and something that I really wanted to share.

We are actually going to be releasing an online version of the Champion Bridging the Gap From Rehab to Performance Seminar, which will include this presentation, plus others from Lenny Macrina, Dave Tilley, Rob Sutton, and Kiefer Lammi.  

Inner Circle members can access my talk now, and get early access to purchase the seminar.  Everyone else will have to wait until the official launch next week!  Plus, if you’d like to purchase the seminar, I also have a $10 off coupon just for Inner Circle members.  All the links will be in the Inner Circle Dashboard.

This webinar will cover:

  • What is “performance therapy”
  • The need for a paradigm shift in what we do
  • What I look for in my movement assessments
  • The components of manual therapy I perform
  • How to integrate and maximize your outcomes with corrective exercises

 

To access this webinar:

 

An Easy Drill to Enhance Thoracic Extension

Thoracic mobility drills are commonly given to people to enhance mobility.  I have shown some common thoracic mobility drills in the past, and recently showed a newer muscle energy technique I have been using.  If you haven’t seen these yet, you should check them out:

 

One of my big principles of rehabilitation and corrective exercises is that you follow up mobility drills with some sort of activation or strengthening drill.  You want to use the body in this newly gained mobility.

For some reason, I feel like this is often ignored with thoracic mobility.

I would actually argue that a very common reason for having limited thoracic mobility is poor endurance into thoracic extension.  The muscles can’t maintain an extended posture and resort to the path of least resistance, a slouched posture.

If you are going to spend time working on thoracic extension mobility, you should follow that up by working on thoracic extension endurance.

In the video below I show an extremely easy way to start working on thoracic extension endurance.  Certainly not groundbreaking, but an important drill that is often overlooked.

 

An Easy Drill to Enhance Thoracic Extension

 

Learn How I Enhance Thoracic Mobility

If you want to learn more about how I enhance thoracic mobility, I have a presentation on Enhancing Thoracic Mobility.  I review some of the self mobility and manual therapy techniques I use to enhance thoracic mobility. This webinar will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

To access this presentation:

 

 

Enhancing Thoracic Mobility

enhancing thoracic mobilityLimited mobility of the thoracic spine is a common finding and something that tends to get worse over time.  To me, it’s one of those “use it or lose it” types of mobility in the body.  Several issues can occur from limited thoracic mobility, such as shoulder, neck, and even low back pain.

Thoracic mobility drills are common, but only part of the puzzle.  I have a new presentation where I’ll be reviewing some of the self mobility, manual therapy techniques, and corrective exercises I use to enhance thoracic mobility.

 

Enhancing Thoracic Mobility

This presentation will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

 

Access the Presentation

You can purchase access to this presentation for only $10, or join my online Inner Circle Mentorship program for only $10/month and gain access to this and ALL my past presentations, product discounts, exclusive content, member only forum, and more!

 

 

Thoracic Mobility Muscle Energy Technique

Have you ever worked with someone that never seemed to improve their thoracic mobility, especially thoracic rotation?

I work with the occasional person that doesn’t respond to many of the common thoracic mobility drills.  Sometimes their daily posture, especially if working a desk job for years, needs more than the simple drills.  Sometimes I feel that thoracic mobility limitations can be true mobility restrictions, but other times I also feel there may be some tone or guarding involved.

A common technique that can be used to enhance mobility drills, especially when tone is involved, is muscle energy technique, or MET.  Muscle energy is commonly used to enhance mobility in other areas of the body, like the shoulder or hamstring, but less frequently used for thoracic mobility for some reason.

In the video below I show a very easy muscle energy technique that you can use to enhance thoracic mobility into rotation.  This is very easy to perform on your own too.

Give it a try and let me know what you think, I’ve been pretty amazed at how much more mobility I can achieve in a short amount of time using this muscle energy technique, especially for those stubborn thoracic mobility limitations.

 

Thoracic Mobility Muscle Energy Technique

 

Learn How I Enhance Thoracic Mobility

If you want to learn more about how I enhance thoracic mobility, I have a presentation on Enhancing Thoracic Mobility.  I review some of the self mobility and manual therapy techniques I use to enhance thoracic mobility. This webinar will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

To access this presentation: