The muscle extends from the
inferior aspect of zygomatic
process to the angle and lateral
surface of the mandible
(superficial layer); the mid
portion of the mandibular
ramus (middle layer); and to the
upper mandibular ramus and
the coronoid process (deep
Mandibular branch (V3) of the
tri-geminal nerve (V par cranial).
The patient lies in supine. The
muscle is generally needled
with a flat palpation, although
pincer palpation may also be
feasible. The needle is
inserted perpendicular to the
skin toward the muscle belly.
It closes the mouth by elevating
the mandible. The superficial layer
has also a component of
protrusion (forward) of the
mandible whereas the deep layer
has a component of retraction
The superficial layer refers pain to
the eyebrow, the maxilla, the
anterior aspect of the
mandible, and to the upper or
lower molar teeth; whereas the
deep layers spreads pain deep into
the ear and to the
temporomandibular joint area.
The superior region (descending
part) of the muscle arises from
the external occipital
protubernance, the medial third
of the superior nuchal line of the
occipital bone, the ligamentum
muchae, and the spinous process
of C7, and inserts into the
posterior border of the lateral
third of the clavicle.
When it contracts unilaterally, it
includes ipsilateral side-bending
and contralateral rotation of the
head and also elevation of the
shoulder. When it contracts
bilaterally, it extends the neck.
Acessory nerve (XI par cranial)
and cervical spinal nerves C3-C4.
The patient is in prone or side-laying.
The muscle is needled with a pincer
palpation. The needle is inserted
perpendicular to the skin and
directed towards the practitioner’s
finger. The needle is kept between
the fingers in the shoulder. The
needle can be inserted from anterior
to posterior or posterior to anterior.
It spreads ispilaterally from the
posterior-lateral region of the
neck, behind the ear, and to the
The most common serious adverse
event is penetrating the lung, and
producing a pneumothorax. This is
minimised by needling strictly
between the fingers holding the
muscle in a pincer grasp, and
needling directed towards the
The muscle originates from the
dorsal tubercles of the
transverse processes of C1 to C4
vertebrae, and inserts on the
superior medial angle and
adjacent medial border of the
It extends and side-bends the
neck. When the head is turned to
the opposite side and forward
flexed, it rotates the head towards
midline. The muscle rotates the
scapula glenoid fossa downward
when neck is fixed.
Cervical spinal nerves C3C5, via the dorsal scapular
It is projected to the angle of the
neck and along the vertebral
border of the scapula.
Do not needle towards the rib cage
to avoid creating pneumothorax.
The patient is in lateral decubitus position. The muscle is needled via a pincer
palpation. For superior (cervical) portion, the muscle is felt as a ropy muscle band
of about 5mm diameter in lateral extent, between anterior (ventral) border of the
upper trapezius and the transverse process of C1. The needle is inserted
perpendicular to the skin and directed towards the practitioner’s finger. For the
lower (shoulder) portion, the muscle is identified over the superior medial border
of the scapula. The needle is inserted through the skin at a shallow angle, directed
toward the upper, medial border of the scapula.
The two heads of the muscle
(sternal and clavicular) originate in
the mastoid process of the temporal
bone. The 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.
Accessory nerve (XI par
cranial), and cervical spinal
When it contracts unilaterally, it
side-bends to the same side and
rotates to the opposite side of the
head. It also tilts the chin
upward, i.e., extension of the
head. When it contracts
bilaterally, it flexes the neck
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 the ear, inducing frontal
headache and earache.
The patient is in supine. Both
heads, clavicular and sternal, are
needled by pincer palpation after
identifying the carotid artery. The needle
is then inserted perpendicular to the
skin and directed towards the
practitioner’s finger. The needle can be
inserted from anterior to posterior or
from posterior to anterior.
The carotid artery lies medial to the
sternocleidomastoid muscle, next to the
trachea. Lift the sternocleidomastoid away
from the carotid artery and needle
between the fingers holding the muscle in
a pincer grasp, directing the needle as
described above, to avoid needling the
The muscle arises from the lower
half of the ligamentum nuchae and
from the insets, under cover of the
sternocleidomastoid, into the
mastoid process of the temporal
bone and into the rough surface of
the occipital bone, below the lateral
third of the superior nuchal line.
It extends, side-bends and
rotates the neck to the same
Dorsal rami of the cervical
It is projected to the vertex of
The patient is in lateral decubitus.
One finger is placed on the taut
band. The needle is inserted
through the skin at a shallow angle
in a caudal-medial direction and
directed towards the practitioner’s
When needling above C2, the
needle must be directed towards
the mastoid process. All neddling
must be performed posterior to
the transverse processes in a
The muscle crosses 2 to 4 vertebral levels. The superior
attachment is the posterior processes of C2 to C5, whereas
the inferior attachment is the articular processes of C2 to C7
The main function is
stabilisation of the cervical
spine. They may assist in
extension, and rotation of
the cervical spine to the
It spreads upward to the
suboccipital region, and
downward over the neck
and upper part of the
shoulder. Pain is perceived
deep into the cervical
Posterior primary rami
of the cervical nerves
at each level.
The patient is in prone. Cervical mutlifidi muscles are not directly
palpable; but clinicians can suspect the presence of relevant TrPs when
patients report deep pain into the cervical joints. The needle is inserted
perpendicular to the skin and parallel to the posterior spinous
processes, about 1cm lateral to the spinous process or in a medial caudal
direction towards the lamina of the vertebrae.
Avoid needling strictly
medially to minimise the
risk of pentrating the
structures within the spinal
canal (epidural or
subarachnoid space, spinal
The muscle originates from the supraspinous fossa of the
scapula and inserts at the superior facet of the greater
tubercle of the humerous.
It assists in abduction and stablises 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.
nerve, from the C5 and
C6 nerve roots.
The apex of the lung is in front of
the scapula and clinicians should
avoid needling in a ventral
It is projected to the middeltoid region, often
extending down the lateral
aspect of the arm and
focusing strongly over the
lateral epicondyle of the
The patient lies prone or on the uninvolved side with arm close to the body and relaxed lying
supported by a pillow. The supraspinatus muscle is only accessible through the upper trapezius
muscle and is identified by flat palpation with sufficient pressure. After localisation of the
TrP, the needle is inserted and directed longitudinal to the frontal plane or slightly posterior
towards the base of the supraspinous fossa.
The muscle originates from the infraspinous fossa of the
scapula and inserts at the dorsosuperior facet of the greater
tubercle of the humerous.
It assists in external rotation and stabilises the
humeral head together with the other
rotator cuff muscles and prevents upwards
migration of the humeral head during all
nerve, from C5 and C6
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, fenestration has not
been an issue.
It is projected to the front of the shoulder (intraarticular pain) and the mid-deltoid region, extending
downwards the arm to the ventolateral aspect of the
arm and forearm and the radial aspect of the hand.
The referred pain from this muscle can mimic the
symptoms of carpal tunnel syndrome.
The patient lies prone or on the
uninvolved side with arm slightly abducted
(in side-lying supported by a pillow). The
needle is directed towards the scapula.
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.
It has the same function as the infraspinatus muscle, but can also
adduct the upper arm.
Axillary nerve, from C5 and
C6 nerve roots.
When needling in front of the
scapula, clinician can easily pass through
the intercostal space and enter the pleura
It is projected to the dorsal aspect of the shoulder and TrPs may
cause numbness and/or tingling in the ulnar aspect of the forearm
The patient lies prone with the upper arm 90 degrees abducted. The
TrP is usually located by flat palpation just caudal to the glenohumeral
joint. The needle is directed to the lateral border of the scapula.
The muscle originates from the subscapular fossa and inserts
to the lesser tubercle and reinforces the transverse ligament
that overlies the bicipital sulcus.
It has the same function
as the infraspinatus
muscle, but can also
adduct the upper arm.
It is projected to the dorsal
aspect of the shoulder
extending to the dorsal
aspect of the upper arm
and around the wrist.
from the C5, C6 and C7
Axillary approach: The patient lies supine with arm 90 degrees
abducted and 90 degrees externally rotated. Bringing the scapula
more laterally will optimise access to the muscle. The needle is
directed parallel to the ribcage perpendicular to the scapula.
Medial approach: The patient lies prone with the arm in internal
rotation and the forearm resting on the back at the lumbar level
(Hamerlock position). The muscle can be needled when patient
lies on the involved shoulder.
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
ribcage to avoid entering
the intercostal space.
The muscle originates from the lateral third of the clavicle (ventral
part), the entire lateral border of the acromion (middle part), and
the lateral half of the spine of the scapula (posterior part). The
entire muscle inserts on the deltoid tuberosity, which is a rough
triangular area midway the anterolateral border of the humerus.
This thick, multipennate muscle is a prime mover for abduction of
the upper arm, and assists in flexion and internal rotation (ventral
fibres) or extension and external rotation (dorsal fibres).
Axillary nerve from the C5
and C6 nerve roots
No special precautions.
It is locally projected in the region of the affected part
(anterior, middle or posterior) of the muscle.
The anterior part can be needled in the supine position, the posterior part in prone, and the
middle part can be treated in the prone, supine, or side-laying. In all positions the upper arm
is slightly abducted and supported by a pillow if necessary. The needle is inserted
perpendiculary through the skin directly into the taut band against the humerus.
The muscle originates from the posterior surface of the
inferior angle of the scapula. The tendon of the teres major
muscle fuses with the tendon of the latissimus dorsi muscle
and inserts to the medial lip of the bicipital groove.
This muscle assists the
latissimus dorsi muscle in
rotation and adduction of
The pain is locally
projected in the posterior
deltoid, the posterior
gelnohumeral joint and
over the long head of the
triceps brachii, and
occassionally to the dorsal
nerve from the C6 and
C7 nerve roots
The patient lies prone with the arm slightly abducted. The
muscle is grasped between the thumb and the second and
third fingers and the needle is directed ventral and lateral. It
is also possible to needle this muscle in side-lying, when a
pillow in front of the patient supports the arm.
There is no danger for
injury of the neurovascular
bundle or entering the
ribcage, as long as the
needle is directed ventrally
and slightly laterally.
The muscle originates from the third, fourth and fifth rib near their costal
cartilages and inserts at the coronoid process of the scapula together with the
coracobrachialis muscle and the biceps brachii brevis.
The muscle protracts and draws the scapula forward, downward and inward. It also
depresses the shoulder girdle and stabilises it against forceful upward pressure of the arm.
Downward force of the pectoralis minor causes winging of the scapula. When the scapula is
fixed by the trapezius and levator scapulae muscles, the pectoralis minor is and accessory
Medial pectoral nerve
from the C8 and T1
It is projected to the ventral aspect of the shoulder extending to the
anterior chest region and the ulnar side of the arm to the
third, fourth, and fifth finger. The referred pain is almost the same as
from the referred pain area of the pectoralis major. The pain may mimic
angina pectoris, pain of the tendon of the biceps brachii muscle, and a
The patient lies in a supine position. A woman with ample breasts should be asked to place
her hand over the breast to draw it to the opposite side. The coracoid process should be
identified and subsequently the taut bands of the pectoralis minor muscle should be
identified beneath or through the pectoralis major muscle. The needle is inserted over the
rib cage and directed upwards and slightly lateral towards the coracoid process. The angle of
the needle is shallow, almost tangential to the chest wall. Alternatively, the muscle is grabbed
between the thumb and the fingers in a pincher grip with the tips of the fingers and thumb
against the ribcage to determine the proper needling angle. The needle is now directed
towards the fingers, preventing the needle to enter the thorax.
As the pectoralis muscle is located over the ventral ribcage, clinicians have to be certain to
avoid entering the intercostal space and penetrating the lung. The neurovascular bundle to the
arm lies under the pectoralis minor muscle close to the coracoid process.
The muscle originates from the spinous processes of
the lower six thoracic vertebrae and all lumbar
vertbrae, the lower 3 or 4 ribs, 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.
The muscle extends, adducts and internally rotates
the arm. It assists in retraction of the scapula and
downward drawing of the arm. Bilaterally, it assists
to extend the spine and homolaterally, it causes a
lateral tilt of the pelvis.
Thoracodorsal nerve, from
the C6, C7 and C8 nerve roots
The inferior angle of the scapula, and the surrounding
midthoracic region, the back of the shoulder down to
the medial aspect of the arm, forearm and hand
including the fourth and fifth fingers. Sometimes pain
refers to the lower lateral aspect of the trunk above
the iliac crest.
The patient lies prone with the arm and shoulder off the
table or on the table with the hand under the pillow. The
latissimus dorsi can also be approached in supine with the
arm abducted at shoulder level. It is possible to reach this
muscle in the side-lying position if the arm is supported by
the patient, an assistant or a pillow. The latissimus dorsi is
grasped between the thumb and the index and long fingers.
The taut bands are then palpated and the needle is inserted
perpendicular to the skin into the contraction knot. The
muscle is followed caudally as long as it can be lifted away
from the chest wall.
All needling is performed in a pincher
palpation towards the fingers to avoid
penetrating the chest wall and the lung. The
fingers are positioned between the muscle
and the chest wall.
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 process of the
scapula. Both heads join in a common tendon to insert
at the radial tuberosity, facing the ulna in the
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 and abduction of the arm at the shoulder in
the externally rotated (and supinated) arm. The
muscle is one of three flexors at the elbow (together
with the brachialis and the brachioradialis muscles)
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.
Musculocutaneous nerve via the lateral cord (C7, C8).
TrPs in the biceps brachii refer pain upward over the
muscle and over the anterior deltoid region of the
shoulder and occasionally to the suprascapular region.
TrPs also may initiate another additional pattern of
milder pain downward in the antecubital space.
The patient lies supine with the arm slightly flexed.
The muscle is grasped between the thumb and index
and long fingers. Taut bands are identified. The
muscle should be needled from a lateral approach to
avoid needling the neurovascular bundle at the
medial side. The needle is directed into the taut
bands to elicit local twitch response. The two heads
of the biceps are palpated and treated separately
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, it is preferred to needle this muscle only
via a lateral approach.
The long head is the only head of the triceps muscle that
crosses the shoulder joint, attaching to the scapula below the
glenoid fossa where the long head originates. The three heads
of the triceps muscle attach to the olecranon process of the
ulna via a common tendon.
Adduction of the arm at
the shoulder and rotation
of the scapula to elevate
the humeral head towards
Radial nerve of the
posterior cord (C7,C8).
Posterior arm to posterior
shoulder, upper trapezius
area and dorsum of the
The radial nerve runs
caudal to the head of the
humerus and posteriorly to
the humerus under the
lateral head of the triceps
The patient lies supine, prone or side-lying on the uninvolved shoulder. The forearm is
supinated and the arm abducted to allow the triceps muscle to be held in a pincer grasp to
identify the taut bands. The needle is inserted into the taut bands to elicit local twitch