Deep Dry Needling of the Arm and Hand Muscles

Chapter 9

Deep Dry Needling of the Arm and Hand Muscles

César Fernández-de-las-Peñas; Javier González Iglesias; Christian Gröbli; María Palacios-Ceña; José L. Arias-Buría


Arm pain syndromes constitute a complex entity which can arise from a wide range of different conditions. Symptoms in the upper quadrant, including the neck, shoulder, arm, forearm, or hand not related to an acute trauma or underlying systemic diseases, can be provoked by trigger points (TrPs). In fact, there are several neck and shoulder muscles with referred pain pattern perceived throughout the upper extremity, for example, the scalenes, subclavius, pectoralis minor, supraspinatus, infraspinatus, subscapularis, pectoralis major, latissimus dorsi, serratus posterior superior, and serratus anterior muscles (Simons et al., 1999). A combination of referred pain patterns from TrPs in multiple neck, shoulder, and forearm muscles can create a complex clinical pattern of nonspecific arm pain (Fernández-de-las Peñas et al., 2012). Furthermore, TrP referred pain in some muscles can mimic some neuropathic pain conditions. Qerama and colleagues (2009) demonstrated that 49% of individuals with normal electrophysiological findings in the median nerve, but with symptoms mimicking carpal tunnel syndrome, presented with active TrPs in the infraspinatus muscle with paresthesia and referred pain to the arm and fingers. In the same study, patients with mild electrophysiological signs of carpal tunnel syndrome exhibited a significantly higher occurrence of infraspinatus muscle TrPs in the symptomatic arm compared with patients with moderate to severe electrophysiological signs (33% versus 20%). Dry needling (DN) of the shoulder musculature can improve pain, sensitivity, and grip power of individuals presenting with lateral epicondylalgia (Kheradmandi et al., 2015). DN of the neck and shoulder muscles is covered in Chapter 7 (neck) and Chapter 8 (shoulders).

TrP taut bands in the musculature of the upper quadrant can be related to neural or articular dysfunctions. For instance, because the brachial plexus runs anatomically between the anterior and the medial scalene muscles, taut bands and TrPs in the scalene muscles may be related to entrapment of the brachial plexus. Similarly, shortening of the scalene muscles induced by TrP taut bands may be related to first rib dysfunctions (Ferguson & Gerwin, 2005), which means that clinicians should integrate TrP DN within the overall clinical reasoning process and management. In the current chapter we will cover deep DN of TrPs in the arm and hand muscles.

Clinical relevance of trigger points in arm and hand pain syndromes

There are only a few studies demonstrating the relevance of TrPs in the aetiology of different arm pain syndromes. The most commonly described muscle pain syndrome in the arm is probably lateral epicondylalgia (Slater et al., 2003). Fernández-Carnero and colleagues (2007) found that active TrPs in the extensor wrist musculature reproduced the pain symptoms in subjects with lateral epicondylalgia (65% extensor carpi radialis brevis; 55% extensor carpi radialis longus; 50% brachioradialis; 25% extensor digitorum communis muscle). In a subsequent study, Fernández-Carnero and collegues (2008) reported that subjects with unilateral lateral epicondylalgia also exhibited latent TrPs in muscles of the unaffected elbow (88% extensor carpi radialis brevis; 80% extensor carpi radialis longus), which may be related to the development of bilateral symptoms in this patient population. Active TrPs in the extensor carpi radialis brevis were very prevalent (68% right side; 57% left side) in women with fibromyalgia syndrome (Alonso-Blanco et al., 2011). Although these studies support the role of TrPs in arm pain syndromes, particularly in lateral epicondylalgia, further studies are needed (Shmushkevich & Kalichman, 2013). A recent study reported almost excellent agreement on TrP location and classification in the extensor carpi radialis brevis and extensor digitorum communis muscles (Mora-Relucio, et al., 2016). It is also important to consider that when TrPs are present in the brachioradialis (Mekhail et al., 1999) or extensor carpi radialis brevis muscles (Clavert et al., 2009), entrapment of the radial nerve is feasible. The only randomised clinical trial investigating the effectiveness of DN in lateral epicondylalgia observed that TrP DN was more effective than medical drug treatment at 6 months (Uygur et al., 2017).

In clinical practice an association between TrPs in the wrist flexor muscles and medial epicondylalgia is commonly seen, particularly in individuals with high muscular demands in the forearm (i.e., climbers) (González-Iglesias et al., 2011), or with low but repetitive loading (i.e., manual or office workers) (Fernández-de-las Peñas et al., 2012). Again, TrPs in the wrist flexor musculature can be also related to different nerve entrapments. For instance, as the pronator teres muscle is a common place for median nerve entrapment, commonly referred to as pronator syndrome (Lee & LaStayo, 2004), tension induced by TrP taut bands may be relevant for symptoms associated with median nerve compression (Simons et al., 1999). Similarly, the median nerve can be entrapped by TrPs in the flexor digitorum profundus and superficialis muscles, whereas the ulnar nerve can be entrapped by TrPs in the flexor carpi ulnaris and flexor digitorum profundus (Chaitow & Delany, 2008). Therefore clinicians should consider muscle–nerve interrelations in their daily practice even though no scientific study has confirmed the clinical observations.

Finally, TrPs within the intrinsic muscles of the hand, that is, the interossei and lumbricals, can also be clinically relevant for unspecific wrist–hand pain. For instance, manual laborers or boxers who have suffered a traumatic event over the wrist or the hand frequently develop TrPs in these muscles. There is clinical evidence that TrP DN of the intrinsic hand muscles such as the dorsal interossei is highly effective in these patients. TrPs in the thenar muscles are commonly seen in complaints of presumed arthritic changes in the joints of the thumb. DN of TrPs in the abductor pollicis brevis may relieve the pain associated with these joint problems (Villafañe & Herrero, 2016). Again, no scientific study has been published confirming these clinical observations.

It is important for clinicians to combine scientific and empirical evidence, as often there is no scientific evidence yet for several approaches that clinically are found to be effective. In this chapter we cover DN of TrPs in the arm and hand musculature based on clinical and scientific reasoning.

Dry needling of the arm and hand muscles

Coracobrachialis Muscle

Fig. 9.1
Fig. 9.1 Dry needling of the coracobrachialis muscle (proximal).

Fig. 9.2
Fig. 9.2 Dry needling of the coracobrachialis muscle (distal).

  •   Precautions: In the proximal part of the coracobrachialis muscle, the neurovascular bundle, which includes the median nerve, the musculocutaneous nerve, the ulnar nerve, and the brachial artery, is located underneath the muscle. In the distal part, it is dorsal and medial to the muscle. The musculocutaneous nerve passes through the muscle underneath the pectoralis muscle.

Biceps Brachii Muscle

Fig. 9.3
Fig. 9.3 Dry needling of the biceps brachii muscle.

  •   Precautions: The neurovascular bundle, which includes the median nerve, the musculocutaneous nerve, the ulnar nerve, and the brachial artery, is located medially to the biceps brachii muscle and must be avoided. In addition, avoid the radial nerve that lies along the lateral border of the distal biceps and the brachialis muscles.

Triceps Brachii Muscle

Fig. 9.4
Fig. 9.4 Dry needling of the triceps brachii muscle.

  •   Precautions: The radial nerve runs deep to the lateral head of the triceps muscle (Rezzouk et al., 2002) and must be avoided. A recent case report showed that needling the radial nerve could cause major complications (McManus & Cleary, 2018).

Anconeus Muscle

Fig. 9.5
Fig. 9.5 Dry needling of the anconeus muscle.

  •   Precautions: None

Brachialis Muscle

Fig. 9.6
Fig. 9.6 Dry needling of the brachialis muscle.

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Oct 7, 2019 | Posted by in RHEUMATOLOGY | Comments Off on Deep Dry Needling of the Arm and Hand Muscles

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