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The main periosteal needling sites in the shoulder are the coracoid process and the lesser tuberosity of the humerus, both of which are at least latent trigger points. These are most conveniently needled with the patient sitting.

There are also numerous soft-tissue sites in the shoulder muscles. These may lie in the anterior or posterior axillary folds (pectoralis major and minor; subscapularis, teres major, teres minor, infraspinatus). To needle these, the fold is gripped between finger and thumb (pincer action) and the muscles are palpated for trigger points, into which the needle is then inserted.

Yet another useful needling site is the area above the tendon of supraspinatus as it passes over the top of the humerus beneath the acromion. The needle is inserted posterolaterally, between the acromion and the top of the humerus at an angle of about 45 degrees to the sagittal plane; this is much the same approach as that commonly used to inject the shoulder. It is particularly indicated for patients who show the painful arc phenomenon.

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Mann identifies two further sites (Mann, 2000), which he calls Hansen 1 and Hansen 2. (The name refers to a Dr Hansen, from whom he learned these sites.) Hansen 1 is 2 or 3 cm below the medial third of the scapula, in the fibres of trapezius; it approximately corresponds to SI11 but is medial to it. Hansen 2 is the infraglenoid tubercle, to which the long head of the triceps is attached. This point is notably tender in almost everyone (latent trigger point). It is most conveniently needled with the patient lying down, slightly rotated towards the opposite side, and with the fingers of the affected arm touching the opposite shoulder. The point cannot be clearly identified unless the patient is slim; in fatter patients only superficial acupuncture should be attempted.

On the whole, one’s enthusiasm for treating shoulder pain with acupuncture needs to be tempered with caution. Acupuncture may on occasion help with both intrinsic and extrinsic shoulder pain but the success rate is not high; perhaps one-third of those with intrinisic pain will respond. As was pointed out some time ago by H. Berry and others (Berry et al., 1980), similar proportions of patients respond to other available forms of treatment and also to no treatment at all! Even when acupuncture is successful, it generally relieves pain for a time without altering the natural course of the disease, which as noted above is towards recovery within one to two years. However, occasional patients do respond dramatically so acupuncture is always worth trying.

Patients should be advised about preventive measures. Posture may contribute to rotator cuff tendinitis; avoid working above shoulder level, because the supraspinatus tendon is forced under the coraco-acromial arch during elevation of the arm. Reduced blood flow to the tendons due to static muscle contraction may contribute to tendon degeneration. Repetitive movement of the shoulder may cause rotator cuff tendinitis.

Osteoarthritic pain in the shoulder region, arising either from the glenohumeral or acromioclavicular joints, usually does poorly with acupuncture.

Chest pain referred from chest wall muscles

Trigger points in the pectoralis major muscle are relevant to cardiac pain due to angina pectoris. There are tender areas in these muscles in people without angina, but in patients with angina pressure at these sites can produce long-lasting, severe pain. This may be a summation effect, whereby pain information arising from two different structures (pectoralis major and heart muscle) is added together centrally to give rise the conscious experience of pain. It is sometimes possible to relieve angina by needling these trigger points, although the possibility of precipitating a severe anginal attack has to be kept in mind. There is also a question about the desirability of relieving angina in this way, since the cardiac flow rate is presumably not improved. Most doctors, at least in Britain, regard angina as a warning sign telling the patient to stop doing whatever

has brought on the pain, and if this is correct (some cardiologists dispute it), relieving angina by acupuncture would be ill-advised except in those few patients who fail to respond to medical or surgical treatment, for whom it may be useful.

The similarity between chest pain due to trigger points in the muscles and chest pain due to angina can pose a difficult problem in diagnosis. Both types of pain may be brought on by exertion, but skeletal pain may be aggravated by stretching and twisting movements. A therapeutic trial of medication doesn’t distinguish between the two types of pain reliably because there is a considerable placebo response. An electrocardiogram may not give the answer either. In some cases it may be necessary to resort to sophisticated cardiological investigations to make the diagnosis.

A woman had been admitted to hospital on several occasions with suspected cardiac pain but nothing was found to confirm the diagnosis. She had numerous trigger points in her pectoralis major and subscapularis muscles and needling these prevented further episodes of pain.

References

Berry H. et al. (1980) Clinical study comparing acupuncture, physiotherapy, injections and oral anti-inflammatory drugs in shoulder cuff lesions. Current Medical Research

Opinion, 7; 121–6.

Bunker T.D. (1985) Time for a new name for ‘frozen shoulder’. British Medical Journal, 291; 1233.

Camp V. (1986) Acupuncture for shoulder pain. Acupuncture in Medicine, 3; 28–32. Mann F. (2000) Reinventing Acupuncture: a new concept of ancient medicine (second

edition). Butterworth-Heinemann, London.

Tariq M. et al. (2000) Role of acupuncture in thoracic outlet syndrome. Acupuncture in

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