In the next segment we are going to review the neurofunctional acupunctural blueprints for the treatment of shoulder problems. This is a very complex area and therefore is going to take a little more in-depth review of the neurostructural anatomy to understand the foundation of our blueprint. We use three main blueprints, the first one being the neuroanatomical one consisting of local inputs, axial inputs and extrasegmental inputs that have been defined elsewhere. As a brief reminder, local inputs are any peripheral, segmental structures or nerves related to the problem. Axial inputs are any spinal, segmental levels that are associated with the problem via the posterior primary rami, both at the segmental somatic levels, dermatome, myotomes, sclerotome, and at the segmental autonomic, particularly the reflex vascular sympathetic level.
These two levels can be expanded using blueprints number two and three which we have defined elsewhere as a neurostructural approach and a neuromechanical approach. Neurostructural approach, which is reflected here, is the combination of structures such as joints, articulations, nerve trunks and muscles that participate in the dysfunction. And this neurostructural definition allows us to select a vast array of targets for our acupuncture needles.
At the same time, the definition of the dysfunction in precise segmental terms, dermatomal, myotomal and sclerotomal, allows for the selection of the axial inputs which have two levels, as mentioned before. Segmental somatic, which in the shoulder region goes from C1 to T1, not as much neurologically, as there is no C1 direct supply to the shoulder, but their anatomical structures such as some of the scalenus muscles and the levator scapulae that have their origin at C1. So C1 to T1, or C2 to T1, are the segmental somatic levels. And then the segmental autonomic or reflex vascular sympathetic levels go from T1 to T5, the origin of the preganglionic neurons that supply the vessels of the head, neck and upper extremity.
Therefore, the neurostructural blueprint allows us to select local and axial inputs as well as the neuromechanical analysis of the kinetic chain can help to select distal inputs that will be either neurofunctionally related to the problem by sharing segment, so anything distal to the extremity that is of C7, C8, T1 dimension will have an influence on the shoulder because of the segmental somatic common origin. But also from a biomechanical standpoint, the joints distal to the shoulder have an influence on how the shoulder operates, particularly when they are actions that involve the whole extremity, such as hitting a tennis ball with a racket or doing any other thing with that full extremity. Some of these distal inputs can be deducted or inferred by this neuromechanical analysis, some can be taken from traditional empirical information that has proven to help on the modulation of nociception and sympathetic activity on the whole limb.
And we’ll discuss those insertion sites later on.
Finally, our blueprint number one, our three-level segmentally-related inputs, or non-segmentally-related inputs, extrasegmental inputs is a category that has less value for shoulder problems but can be included when appropriate. Less value because the shoulder is a very structural regional with complex biomechanics and neuromechanics, but the central nervous
system, as in any other condition, chronically can suffer changes and can contribute to the control of the inflammation, to the control of the somatosensory cortex processing of the sensory signals that come from the different structures of the shoulder and therefore there is value in adding something extrasegmental when necessary.
So we’re going to use our model for the demonstration of the selection of the inputs and then the demonstration of a blueprint treatment. This is not a detailed analysis of the neuromechanics of the shoulder. It’s a demonstration of a blueprint that targets the main neurostructures, joints, articulations, nerve trances and muscles that are involved in the normal mechanics of the shoulder. We’ll start with the anterior aspect and we’ll review what are the main components of the blueprint from the articular, muscular and neurological standpoints.
Before that, the end result of the analysis and selection of the insertion site will be supported by the use of electricity. Electricity will be an important part of every treatment and the blueprint for the use of the electricity will consist of four electrodes put across the area that want to influence, something anteriorly, something posteriorly, something proximal, something distal. And then electricity will pass through the affected area and therefore will be a form of stimulation to all the nerve endings involved in the problem, even if we don’t know with precision what these nerve endings are, the value of electricity is that you can treat in a broad manner. And this is what the blueprint is until we proceed to analyze the problem in more detail biomechanical terms, which is beyond the scope of this presentation on blueprints.
So on the [tier] aspect, we have access to some of the most important elements on the neurostructure of the shoulder. We have access to the external clavicular joint, acromialclavicular joint and glenohumeral joint between the scapula and the head of the humerus. These are three joints that need to work in coordinated fashion for the shoulder to have its full function. In addition there are a number of articulations which are not true bone-to-bone connections but they are sliding interfaces, the most important one being the scapulothoracic articulation between the scapula on the back and the rib cage that slides without being connected to the underlying bones. There are other articulations less know or less discussed but equally important.
For instance the subacromial deltoid articulation, the space between the deltoid and above the capsule which is occupied by the subacromial deltoid bursa, can be considered an articulation because if there are adhesions that prevent the sliding of those planes the whole mechanics of the glenohumeral joint will be altered. There are other articulations that I’m not going to discuss, but some authors have mentioned, particularly the coracoacromial ligament complex and the structures underneath. Everything needs to slide properly for the compound movement to allow the positioning of the hand on the space, which is the ultimate function of the shoulder. So a scapular glenohumeral joint, acromioclavicular, sternoclavicular and the other articulations operate in conjunction to allow the extremity to operate properly.
Now, what’s important to know from the pure neurofunctional standpoint, neurostructural, is what is the articular innervation of the joints? We have a simple two-way approach to the treatment of the joints. We can put needles directly into the capsules or ligaments of the joints, such as we will have here. The capsule of the acromioclavicular joint easy to access, or even the
capsule of the - and the ligaments of the sternoclavicular, easy to access. And the glenohumeral on the posterior aspect as well, easy to access. This is one direct approach.
The second approach, the indirect approach to the joint, is to go to the nerves that supply the joint. And for that we go back to our Hilton’s Law that tells us articular branches come from nerves that supply the skin that covers the joint, or and from the motor branches that innervate the muscles that move the joint. Therefore, if we know their cutaneous innovation and we know the prime movers of the joint we know which origin the articular nerves have. And here we’ve represented several important that we need to always consider on the treatment of shoulder problems.
The first one is a set of three branches that come from the cervical plexus at the level of the laryngeal prominence at the posterior border of sternocleidomastoid, we see the exit of several branches of the cervical plexus, the lesser occipital nerve, greater auricular nerve, transverse cervical nerve and the big trance of the supraclavicular nerves, C3, C4 segmental origin, anterior primary rami. Here we have the three distinct branches. The first one, the medial supraclavicular nerves supply the skin over the sternoclavicular joint, therefore providing branches to the sternoclavicular joint. The middle intermediate supraclavicular nerve, has a territory that includes the acromioclavicular joint and the skin over this area. So this is all a C4, the infraclavicular region is a C4 dermatome, and the peripheral nerves that supplies these fibres are the supraclavicular nerves.
And the third nerve is the post-lateral supraclavicular nerve that supplies the area over the angle of the acromion and the top of the shoulder. Then lower down we are going to have, represented here as well, the cutaneous branch of the axillary nerve that supplies this patch of skin. But the whole top of the shoulder is a territory for the supraclavicular nerves. Therefore, this exit here, this insertion site can be used for any problems of the shoulder where we have an involvement of any of the three joints that we mentioned. Therefore in any shoulder problem we can use it. And that coincides with the classical insertion site, the small intestine 16. So once again the level of laryngeal prominence, posterior border of the sternocleidomastoid, and not a very deep insertion because above 1cm we can encounter the nerve trance.
This is a local input even though the needle is not on any of the structures, but it’s on the nerve that supplies the structure and that’s why it’s a neurostructural approach. In addition, we could put needles on the capsules or ligaments of these joints as we mentioned. This would be one important part of the blueprint, the cutaneous nerve.
Let’s represent the small intestine 16 here on the lateral aspect of the neck as our first contribution to the blueprint. It’s not compulsory to use everything that we’re going to mention.
This is just a construction of a treatment that makes sense from the neurostructural standpoint.
Again, regardless of the specific neuromechanics of the problem or the patho-physiological processes that have taken place underneath, such as degeneration of the joints, etc., our approach is targeting the nervous system. It’s not targeting the structure, it’s targeting the vascular system, the sympathetic nervous system as well and the effect on the metabolism of everything in the area. It’s therefore a neurofunctional approach even though we’re using a neurostructural logic to find the best insertion sites to communicate our message to the nervous system.
We have therefore the first level of innervation of the joints, which are the cutaneous nerves that supply the skin that covers the joint. The second level is the motor nerves that innervate the prime movers. So let’s review the main prime movers of the glenohumeral joint in particular because the sternoclavicular and the acromioclavicular joints are here to allow rotation and sliding of the clavicle so that scapula has an anchor when sliding over the ribcage and it doesn’t go off on any tangent and allows therefore the action of the muscles that go from the trance to the humerus, which include the so-called rotator cuff muscles, supraspinatus, infraspinatus, suprascapularis, teres minor and others such as the latisimus dorsi, the teres major, etc. And the big deltoid here represented.
So the glenohumeral joint, which is a universal joint with infinite degrees of movement that can be summarized along with three planes of the space, it has prime movers that include first this big muscle that participates in every direction. It does flexion, it does extension, it does abduction and is the deltoid muscles. The deltoid muscle is innervated by the axillary nerve. The axillary nerve is one of the two branches of the posterial core together with the radial nerve, and it comes from the quadrangular space around the posterior aspect of the glenohumeral region and it wraps around deep to the deltoid, innervating - providing several motor points to the deltoid.
That would be the first nerve to think about when dealing with glenohumeral joint problems.
Then - unless write them down as we discuss them. So we have axillary nerve. We also have a deeper - the nerves that supply those muscles, some of the muscles I mentioned, particularly the important supraspinatus and infraspinatus. The supra and infraspinatus muscles that end up mixing with the fibres of the capsule of the glenohumeral joint are stabilizers that allow the rotation of the humeral head without the humeral head being pushed against the acromial ceiling, and therefore allow for the clearing, part of the mechanism that allows for the clearing of this osseous arch.
The innvervation of these two muscles is through the suprascapular nerve. The suprascapular nerve we will see afterwards when we turn our model around, it ends up in the infraspinatus fossa. So let’s write it down. Suprascapular nerve. These would be the two most important nerves on the articular supply of the glenohumeral joint. Axillary suprascapular, together with the supraclavicular that is the cutaneous branch that covers the area. At the same time, the axillary nerve is also - and both the axillary and the suprascapular are going to contribute to the acromioclavicular joint innervations.
We have of course many other muscles that participate in the movements of the glenohumeral joint. We have the big anterior pectoralis major and underneath, the pectoralis minor, which participate in anything that approaches the humerus to the limb, whether [across] a deduction from this position, from elevation, from the resting position. It’s a little bit of internal rotation from external rotation. Also deep there on the suprascapular fossa, the [suprascapularis] muscle participates in the internal rotation or the recovery from abduction. So these anterior muscles are supplied by branches such as the medial and lateral pectoral nerves, every easy to access here.
And oftentimes the presence of hypertonicity on the shoulder with bad posture that involves hunching forward, anterior forward head and increased kyphosis of the thoracic spine, tightening
of the pec minor is necessary to open up the fascia by treating, relaxing these muscles, treating the trigger points, stimulating these nerves to restore the normal flow of information between these muscles and the central nervous system, the spinal cord. So as part of the blueprint I would recommend always to do something on this quadrant. And that something can combine two of the criteria we just mentioned. We can try to target simultaneously the territory let’s say of the supraclavicular nerves. So we’re going to go through the skin. That’s accomplished by that.
Then deeper, the trance of the suprascapular nerve, which can be found at the infraclavicular fossa, this triangular space between the anterior deltoid border of the deltoid and the lateral fibres of the clavicular fibres of the pectoralis major. So in this triangle, called the intraclavicular fossa, on the depth we have the suprascapular notch that is being closed by the superior transverse scapular ligament, and that serves for the suprascapular nerve to come from anterior to posterior to reach the supraspinous fossa and from there going around the root of the spine of the scapula to innervating infraspinatus on the infraspinous fossa.
So in the depth of this fossa is the suprascapular nerve, and this is one of the inputs that we can include in our blueprint. We can also substitute that by either one of the official acupuncture points such as Line 1 that would target the pectoralis minor, not represented here, from the coracoids to the third, fourth and fifth ribs. And that’s also an excellent anterior anchor for the electrical stimulation. Or we can select a trigger point of the many - on the area clavicular fibres of the pectoralis major, sternum fibres or even anterior deltoid, or even trying to go to the coracobrachialis, now innervated by the musculocutanea.
So something from this area will help to anchor the electrode that will go here. So let’s represent a couple of the insertion sites, here, Line 2, infraclavicular fossa, Line 1 to the pecoralis minor innervated by the lateral and medial pectoral nerves. This would be the best summary of anterior inputs, but we can also, as I mentioned, go to the anterior deltoid or to the coracobrachialis here on this area.
In addition in this region we have a very important muscle that attaches to the inferior aspect of the clavicle and that often - and it goes from there to the first costochondral joint. I’m talking about the subclavius. The subclavius muscle, represented here on our model, going to the first costochondral joint is a stabilizer of the sternoclavicular joint, but at the same time when hypertonic may restrict the free rotation, the free sliding of this joint, particularly after trauma of the shoulder it oftentimes - the clavicle remains restricted. The acromioclavicular joint prevents the proper movement of the scapula and the glenohumeral joint starts complaining because it doesn’t have the freedom to operate properly.
And the symptom appears to be a glenohumeral dysfunction, while in actuality the dysfunction is the mechanics of the clavicle and the subclavius is at the core of it. The subclavius is supplied by a nerve directly from the upper trance C4, C5, C6 levels and is an important nerve because it has consistent connections described by the German anatomist between the phrenic and this nerve.
And therefore, embryologically it has some connections with the important diaphragm, which is an interesting connection, something that is not usually thought in practice that has a connection, the subclavius and the diaphragm.
So if we want to add this as our stimulation, we have the technique described elsewhere very safe when properly done, mid-clavicular line, aiming laterally, superiorly and posteriorly and going about 1, 1 1/2cm, that only takes going through the clavicular fibres of the pectoralis major. And that will, in a few seconds of the stimulation with the monopolar stimulator, will restore the tone and will restore the flow of information between the C4, C6 level and the corresponding spinal segments.
So this is our main general discussion of the anterior aspect. We have also represented the sterno plato mastoid just to point out the connection with the supraclavicular nerve trance. And also we have the trapezius, which will come to the one-third, outer third of the clavicle and then will go to the spine of the scapula as well. So this territory is a spinal accessory nerve territory in addition of being a supraclavicular nerve for the skin. So it is may be a good idea to evaluate whether there is a trigger point associated with this 11th cranial nerve, a spinal accessory nerve,
So this is our main general discussion of the anterior aspect. We have also represented the sterno plato mastoid just to point out the connection with the supraclavicular nerve trance. And also we have the trapezius, which will come to the one-third, outer third of the clavicle and then will go to the spine of the scapula as well. So this territory is a spinal accessory nerve territory in addition of being a supraclavicular nerve for the skin. So it is may be a good idea to evaluate whether there is a trigger point associated with this 11th cranial nerve, a spinal accessory nerve,