Shoulder Pain: The Supraspinatous Muscle By Whitfield Reaves, OMD, LAc and Chad Bong, MS, LAc As a practitioner of acupuncture for more than 25 years, there is no single injury I find more rewarding to treat than shoulder pain due to supraspinatous tendonitis. I was fortunate enough to have studied trigger points with Dr. Janet Travell early in my career. Her work on myofascial pain syndromes changed the way I think about acupuncture and Chinese medicine, and has led to many of the treatments and techniques that I use in clinical practice. The supraspinatous muscle is one of the four muscles of the rotator cuff, and the of shoulder tendonitis.1 I would go further to suggest that the supraspinatous is the most common diagnosis in shoulder pain from all causes. Pervasive psql v11 keygen software.
This is probably due to its beneath the boney acromion, between the points LI 16 and LI 15.2 What makes this problematic for the acupuncturist is that pain from the supraspinatous muscle often refers to the deltoid region of the shoulder, and occasionally distally down the arm and forearm. This deltoid region pain leads many practitioners to a diagnosis of Large Intestine ( yang ming) and San Jiao ( shao yang) disorders, resulting in treatments that rarely suffice. The supraspinatous is an abductor, so activities with the arm lifted to the side rely on this muscle. Injury is seen in movements with overhead motions, such as those in racquet sports, swimming, and throwing in baseball and football. But you don't need to be involved in sports to have supraspinatous pathology. Hairdressers, painters, and even those using a computer and keyboard whose arms are in a prolonged state of abduction may develop symptoms.
With an acute strain, the trauma often occurs with heavy lifting, a fall while snowboarding, or an outstretched arm in protection from a cycling crash. But don't be limited to these causes; I had a patient with a tear of the supraspinatous from angrily hitting the ground with her golf club after a bad shot. Illustration by Deborah Kelley The patient complains of shoulder pain, usually in the anterior lateral, lateral and posterior lateral region of the deltoid. It is often dull and diffuse, difficult to locate, and frequently 'comes and goes.' There may be pain at night, especially while sleeping on the affected shoulder. Another characteristic symptom is sharp paroxysms of pain with certain movements involving abduction (lifting the arm to the side).
It is not uncommon to hear that it hurts to put an arm into the sleeve of a coat or reaching to the back seat of a car. This is due to the impingement of the tendon under the boney acromion. Supraspinatous dysfunction with its resulting pain syndrome is due to various pathologies within the muscle-tendon unit.
Lets look at each separately: The belly of the muscle: The of the supraspinatous are in the suprascapular fossa, in the region of the acupuncture point SI 12. Download pinterest. This is the site of the trigger point as well as the motor point.3 In the myofascial explanation of pain, Dr. Travell describes active trigger points in the belly of the muscle at SI 12, contributing to the predictable referred pain pattern in the deltoid region. Palpation of the suprascapular fossa may reproduce pain and reveal taut fascial bands of the muscle. This zone can extend medially to SI 13, as well as 1 to 3 cm lateral to the text location of SI 12.
The sub-acromial portion of the tendon: The muscle-tendon junction is at the lateral aspect of the suprascapular fossa, in the region of the point LI 16. The supraspinatous tendon must pass under the acromion, and this narrow fossa is not particularly forgiving. Many patients with tendonitis in this part of the muscle experience what is termed 'impingement syndrome.'
With those overhead arm movements and other positions of abduction, the swollen tendon gets impinged under the bony acromion, causing the paroxysms of sudden sharp pain. It should be noted that the pain from impingement is difficult to locate with palpation, as it is deep to the bone between LI 16 and LI 15.
The tendinous attachment: The supraspinatous tendon attaches at the greater tubercle of the humerus, in the region of LI 15 and sometimes posterior towards SJ 14. Both inflammation and possible tears can occur to the tendon at this site. If there is localized pain with palpation in this region, suspect supraspinatous strain. The practitioner should also keep in mind that deep to the tendon is the sub-acromial bursa, which, if inflamed, will probably present with tenderness on palpation. While at the lateral shoulder, you should palpate the deltoid region where the patient reports pain. You probably will not be able to find ah shi points that correspond to the symptoms described by the patient. However, be aware that the deltoid, also a muscle of abduction, compensates for the distressed supraspinatous and may present with some tender areas.
Be cautious, as these may very well lead you away from the primary problem, which is rarely the deltoid. Several tests may confirm what you already may suspect after hearing the patient's symptoms and palpating the shoulder. The 'empty can' test is easy to perform, using resisted abduction to assess the supraspinatous muscle and its tendon. With the patient standing, both arms are raised laterally at 90 degrees of abduction (parallel with the floor). Move the patient's arms about 30 degrees anterior, in a forward direction. Then, place their arms in full internal rotation by pointing the thumbs down.
Think of this as the patient holding an 'empty can' of their favorite drink. Ask the patient to abduct (push in an upward direction) while you apply downward pressure on the forearm just proximal to the wrist. If there is pain and/or weakness, the supraspinatous in likely involved in the injury. Note that there are various other methods to test this muscle that all involve abduction with resistance. Also simple and quick is the 'arc of pain' test.
If it reveals discomfort around 90 degrees of abduction, tendonitis and impingement are probable. Have the patient stand with their arms adducted to the side.
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The patient then slowly abducts the arm of the injured shoulder by raising it laterally. If pain occurs with active abduction during the arc from approximately 70 to 110 degrees, the test is positive.
When the arm is parallel with the floor, it is at 90 degrees of abduction. Pain will occur above and below this level. In summary, shoulder pain due to supraspinatous dysfunction is very common in the clinic. You will see it in athletic community, as well as in many patients more than 50 years old, whether or not they are active. Diagnosis is easy when it is an acute injury from a definitive trauma. Chronic cases due to repetitive stress may seem more difficult to assess, as the causes appear quite benign.
However, most patients present with some, if not all, of these signs and symptoms: dull or diffuse pain in the deltoid region of the shoulder; sudden, sharp pain with certain movements of abduction; pain and taut muscle bands in the belly of the supraspinatous at SI 12; supraspinatous weakness and/or pain with resisted abduction; and a positive arc of pain. Acupuncture treatment is frequently successful, as long as damage to the tendon is not severe. Your treatments need to be precise; the belly of the muscle at SI 12, and the tendon between LI 16 and LI 15, are the usual sites of local needling. Treatment to the adjacent muscle, the infraspinatous, at SI 11, may benefit. Of course, you may need to use one or more distal points to complete the protocol.
If the patient does not respond, don't hesitate to refer them for an orthopedic evaluation. Acupuncture may not be appropriate for some cases where the injury is extensive.
References. Corrigan B, Maitland GD. Butterworth-Heineman, 1989, p 41. McGraw-Hill, 2008, p 601. Simons DG, Travell JG.
Williams & Wilkins, 1983, pp 368-9. Whitfield Reaves, OMD, LAc has a Doctorate of Oriental Medicine degree from SAMRA University of Health Sciences and is a Licensed Acupuncturist. He is also a Professor/Instructor at Southwest Acupuncture College in Boulder, CO. Reaves is also the author of 'The Acupuncture Handbook of Sports Injuries and Pain.' Contact Reaves at wreavesoffice comcast.net. Chad Bong holds a master's degree in Exercise Science.
He is a contributing writer to The Acupuncture Handbook of Sports Injuries and Pain. He combines acupuncture with Western sports medicine and fitness training.
Athletes are high achievers who may seek creative or unconventional methods to improve performance. The literature indicates that athletes are among the heaviest users of complementary and alternative medicine (CAM) and thus may pioneer population trends in CAM use. Unlike non-athletes, athletes may use CAM not just for prevention, treatment or rehabilitation from illness or injuries, but also for performance enhancement. Assuming that athletes' creative use of anything unconventional is aimed at “legally” improving performance, CAM may be used because it is perceived as more “natural” and erroneously assumed as not potentially doping.
This failure to recognise CAMs as pharmacological agents puts athletes at risk of inadvertent doping. The general position of the World Anti-Doping Authority (WADA) is one of strict liability, an application of the legal proposition that ignorance is no excuse and the ultimate responsibility is on the athlete to ensure at all times whatever is swallowed, injected or applied to the athlete is both safe and legal for use.
This means that a violation occurs whether or not the athlete intentionally or unintentionally, knowingly or unknowingly, used a prohibited substance/method or was negligent or otherwise at fault. Athletes are therefore expected to understand not only what is prohibited, but also what might potentially cause an inadvertent doping violation. Yet, as will be discussed, athlete knowledge on doping is deficient and WADA itself sometimes changes its position on prohibited methods or substances. The situation is further confounded by the conflicting stance of anti-doping experts in the media. These highly publicised disagreements may further portray inconsistencies in anti-doping guidelines and suggest to athletes that what is considered doping is dependent on the dominant political zeitgeist. Taken together, athletes may believe that unless a specific and explicit ruling is made, guidelines are open to interpretation.
Therefore doping risk-taking behaviours may occur because of the potential financial, social and performance gains and the optimistically biased interpretation (that trying alternatives is part of the “spirit of sport”) and doping risk-taking behaviours may occur. This discussion paper seeks to situate the reader in a world where elite level sports and CAM intersects. It posits that an understanding of the underlying motivation for CAM use and doping is currently lacking and that anti-doping rules need to be repositioned in the context of the emerging phenomenon and prevalence of CAM use.
Background Western medicine as is practiced in many industrialised countries is generally regarded as conventional, or orthodox, and its use has a long-established history in these societies. Interest and use of complementary and alternative medicine (CAM) has, however, been growing in recent times in Western countries, as reflected by the increasing number of research papers in medical and scientific journals unpublished literature search by the authors.
Interested readers are referred also to the following for further details:., Surveys in many countries have suggested a high use of CAM: in the United States, about a third of adults aged 18 years or older use CAM., Despite this growing interest, the definition of what is complementary or alternative remains very subjective and is certainly not universally accepted. While individual organisations have their own definitions, the perceptions of the general population or the end”users and even the practitioners of the various forms of medicine of what constitutes CAM vary tremendously. In addition, CAM techniques could become co-opted as they enter the mainstream. More physicians are also seeking training in CAM: there is an estimated 3,000 American physicians who integrate acupuncture into their practice and an estimated one-third of homeopaths who are physicians or osteopaths. The confusion of what constitute CAM (and the increasing penetration of CAM in everyday life) – either as a distinct treatment modality that consumers actively choose, or through the integration of CAM into Western medicine - may have serious implications for athletes. Athletes are highly motivated and many seek new methods to improve performance.
The literature indicates that athletes may also be the highest users of CAM and may help pioneer population trends in CAM use. While nonathletes may use CAM for prevention, treatment or rehabilitation from illness/injuries, athletes may possibly also use CAM for performance enhancement.
If links between sport motivation and doping exist, and athletes' sport motivation and CAM use are related, a connection between athletes' CAM use and doping may also occur. This paper seeks to situate the reader in a world where elite level sports and CAM intersects and posits that anti-doping rules need to be repositioned in the context of an emerging phenomena and ubiquitous prevalence of CAM use. This paper discusses the concept of doping, the issue of using natural substances as a doping violation, how acupuncture as a type of CAM works, and how the use of CAM may be related to doping in the formal context of the spirit of sport. It is important to note that most international sports are governed by rules of Western nations and Western culture and philosophies. For example, the rules for competitive swimming and all aquatic sports are governed by Federation Internationale de Natation (FINA), while anti-doping rules in all sports are governed by the World Anti-Doping Agency (WADA). The official languages (and the inherent culture and worldview) of FINA and the WADA rules are English and French and where the interpretations of the rules are in doubt, the English language shall prevail.
With an increase in the participation of non-Westernised countries in international sports, these rules (especially those regarding anti-doping) and their interpretation need to be sensitive to a multi-cultural environment. This paper will also explore how biopsychological evidence in the contexts of CAM use and WADA rules need to be more consistent and better explained to the sporting community. What is doping?
It was mentioned earlier how the WADA is the current international governing body that oversees the issue of doping in all sports. The WADA has defined doping in their World Anti-Doping Code (the “Code”, 22). Genetic manipulation.
This paper discusses the first two factors. Controversy exists as to what are acceptable levels of naturally occurring endogenous compounds and also what is a method that is not considered doping. The interpretation of the Code is a legal one and largely untested.
The broad interpretation of the principles behind the Code would seem to be related to any substance or method that (potentially or actually) enhances sport performance, becomes a health threat to the athlete, or is against the spirit of the sport. If the motivation, and indeed, the imperative, of an athlete is to constantly seek creative ways to improve the sporting performance, what then is the spirit of sport, and what actions are deemed to have violated that spirit? Using a biopsychological perspective, issues of what are acceptable levels of naturally occurring endogenous compounds, what is a method that is not considered doping, and what is the spirit of sport are explored below.
What is unnatural about natural substances? Calf-derived deproteinised haemodialysate, Actovegin (Nycomed Austria), is a component in calves' blood that gained attention when its use by the Australian rugby teams was reported to improve endurance and recovery from injuries. Although the medical research suggests some evidence (i.e. ‘potential’) of efficacy in the treatment of soft tissue injuries, the Australian Sports Anti-Doping Authority (ASADA, as a national representative of the international parent, WADA) said that Actovegin was not then on the WADA's list of prohibited substances. Thus its use as a substance when restricted to intra-muscular injections is therefore not prohibited. However, it is illegal as a method when injected into a vein., Actovegin was initially listed on the banned list by the International Olympic Committee (IOC) (the leading authority in anti-doping prior to the formation of the WADA) in December 2000 because of the concerns about its abuse in cycling. It was, however, removed from the IOC banned list in February 2001 pending further research.
Actovegin is not a prohibited substance in WADA's most current lists, although these lists do have an inclusion statement not present in previous versions: the prohibition of any growth factor(s) affecting muscle, tendon or ligament protein synthesis/degradation, vascularisation, energy utilisation, regenerative capacity or fibre type switching (p. This inclusion statement has, however, created more uncertainty over other therapeutic substances, besides Actovegin, used in sports medicine settings e.g.
Platelet-rich plasma: discussed in more detail by Engebretsen et al. So far, the lawful challenge of using Actovegin as a tendon healing substance has not been made, although this legal issue is evolving at the time of writing. According to the latest 2012 WADA prohibited list, Actovegin is not prohibited in any sports. However, to complicate matters, WADA has issued specific guidance on Actovegin on its website that, according to section M2 of the WADA code, the volume of intravenous injection of any non-prohibited substance must not exceed 50 ml with a simple syringe, and further serial injections must be at least six hours apart. This means that under the latest (2012) interpretation of the Code, Actovegin cannot be administered by intravenous infusion or single intravenous injection with a volume exceeding 50 ml.
Erythropoietin (EPO) is a peptide hormone and another compound that is found in the blood. EPO occurs naturally in the human body. To boost the amount of EPO in the human body with the aim of improving endurance performance or to improve recovery from anaerobic exercise, some athletes (e.g. Cyclists) may use recombinant EPO. Recombinant EPO is prohibited both in and out of competition under the World Anti-Doping Code Prohibited List, although raising endogenous EPO in an athlete's body through the method of high altitude training is not prohibited. Recombinant EPO use, traditionally difficult to detect in the athlete, has recently been successfully tested in athletes as a result of collaboration of WADA and the pharmaceutical companies in uncovering a molecular marker of the drug. This uncovering process helps differentiate naturally occurring EPO and those artificially introduced.
A similar technique to detect Actovegin would not be useful if the artificial introduction into the human body intramuscularly or using less than 50ml volume (no specification of concentration by WADA) intravenously were not prohibited. This means that the detection of doping of Actovegin would depend on catching athletes in the act of performing the banned method (not adhering to the rule of an intravenous injection of less than 50ml or an intramuscular injection of Actovegin) and not simply detecting Actovegin in the athlete's body. The inclusion and subsequent exclusion from the prohibited list, coupled with confusing biological evidence and scientific perspective is not unique to Actovegin: caffeine, considered a performance enhancing substance, was also previously classified as a banned substance by WADA if it was detected in urine above a concentration of 12 micrograms per millilitre. Subsequent scientific evidence suggests that caffeine actually decreases performance above that 12 micrograms per millilitre threshold, and is known to be metabolised at very different rates in individuals.
The Acupuncture Handbook Of Sports Injuries Pain Pdf Readers
Thus the risks of sanctioning athletes for simply consuming social amounts of caffeine common in drinks and food led to the removal of caffeine from WADA's list of banned substance in 2004. The inconsistent stances on substances and methods illustrated above may confuse athletes, particularly when interpreted in the context of the spirit of sport (discussed later). This confusion may be exacerbated by consistent media portrayal of differences on the legalities of using Actovegin and caffeine in sports by anti-doping experts., The next section will discuss various possible ways that acupuncture (as a form of CAM) works physiologically. In the setting of expert debate on acceptable levels of naturally occurring endogenous compounds and what is a method that is not considered doping, it provides a biopsychological basis in the context of doping and spirit of sport. CAM physiology and methods Acupuncture and the field of traditional Chinese medicine (TCM) is arguably an archetype of what is considered CAM in Westernised societies. Acupuncture is also increasingly being integrated into conventional medicine in these communities and is one of the most extensively scientifically studied forms of CAM. While there is still debate on the actual physiological mechanism of how acupuncture works, many scientists believe that several mechanisms are possible.
Because these proposed mechanisms are different from the underlying ethos and philosophy that govern acupuncture and TCM – the presence of the life energy (or “Qi”) flowing through channels (or “meridians”) in the human body – and how disease occur, direct comparisons with the scientific paradigms of biomedicine are not always possible. Also, individuals may use CAM and TCM due to their beliefs in the underlying traditional philosophies rather than any scientific motivation. There are several ways in which acupuncture may work. Local anaesthesia at needle insertion sites may block the analgesic effects of acupuncture which suggests that acupuncture is dependent upon neural innervation.
Acupuncture may also cause the release of endogenous opioids in brain-stem, subcortical, and limbic structures, or induce the secretion of adrenocorticotropic hormone and cortisol from the pituitary gland thereby creating a systemic anti-inflammatory response. Indeed, functional MRI studies in humans show that acupuncture modulates limbic and basal forebrain areas involved in pain processing, while PET (positron-emission tomography) scans have shown that acupuncture is able to increase the opioid binding potential in the brain for several days.
Other proposed mechanisms of how acupuncture works are through its ability to mechanically stimulate connective tissues, release adenosine at the site of needle stimulation, or increase local blood flow. Ahmedov provides a more detailed discussion of the potential ergogenic effects of acupuncture in sport and exercise. As an example, an athlete sustained a ruptured muscle fibre (traditionally requiring prolonged treatment periods) less than three weeks before the 1998 European track and field championship. Treated with acupuncture, the athlete went on to win a silver medal and maintained a high performance level without pain. Evidence-based medicine requires large sample sizes and preferably randomised-controlled trials to provide statistical evidence of significant effects. The issue of doping, however, is as much an interpretation of the law, as it is about the scientific and statistical evidence. The Code states that “.regardless of whether the expectation of performance enhancement is realistic.”.
This is discussed in the next section. Regardless of how acupuncture works, if a CAM modality such as acupuncture that does not involve ingestion of (potentially prohibited) substances but operates via a physical method, is capable of (potentially) increasing an athlete's endorphin levels or increasing the athlete's tissue regenerative capacity and in so doing potentially improves athlete performance, is it acceptable under WADA rules? Or is it against WADA's spirit of sport? Community and solidarity.
While these objectives are noble and worthy principles for sport, their abstract nature sometimes creates confusion when applied to the day-to-day realities that athletes face. The Code cites specific issues in the context of the spirit of sport, but these add to the confusion. The WADA states in the Code (9) that the: “ use of genetic transfer technology to dramatically enhance sport performance should be prohibited as contrary to the spirit of sport even if it is not harmful.” and that “ the potentially unhealthy abuse of certain substances without therapeutic justification based on the mistaken belief they enhance performance is certainly contrary to the spirit of sport regardless of whether the expectation of performance enhancement is realistic.” (p.33, italics by this author for emphasis). These seem at prima facie to contradict the guiding principle of ‘excellence in performance’ set out in the characterisation of spirit of sport in the introduction to the Code (p. Athletes dedicate their lives to improving their sporting skills and fitness to be better in their sport. It is acceptable (and logical) to enhance performance by physical training without adding substances to the athlete's body.
The use of varied training programs and orthotic devices by athletes (e.g. Fins for swimming training) during out-of-competition training is standard practice for most sports and one of the fundamentals of training paradigms. Most such performance-enhancing devices are, however, banned during competition. If performance enhancing devices are prohibited during competition, how is the previous acceptance of performance enhancing polyurethane swim suits by the international swimming governing body, FINA, or the recent acceptance of a performance enhancing “swimwear system” for the 2012 Olympics reconciled with WADA's spirit of sport and FINA's own rule of ‘No swimmer shall be permitted to use or wear any device that may aid his speed, buoyancy or endurance during a competition’ (FINA, 54, SW 10.8)? Extending that argument a little further, and in the context of CAM, if a CAM that uses a physical modality is able to enhance performance, regardless of whether the expectation of performance enhancement is realistic, is that deemed acceptable and in the spirit of sport, or does it violate WADA's doping regulations? Should the use of acupuncture, for example, to speed up recovery, improve flexibility and improve performance during a competition be labelled as a prohibited method and/or against the spirit of sport?
The finishing line If the psychological motivation of athletes is to excel in their sport, and there may be a biopsychological basis for using CAM to improve their performance, the implications of CAM use in the context of elite sport must be recognised. Whether using conventional medicine or CAM, athletes utilise any means to maximise their physical potential. So when does a method that increases the athletes' endogenous substance to improve sporting performance become illegal or against the spirit of sport? There is at present an inconsistent application of what are methods that are considered illegal or doping and what the spirit of sport really is. Present day elite sport culture is now less about health, courage, community and solidarity, or even character and education, fun or joy. The majority of athletes presumably believe and strive for ethics, fair play, honesty, and most are mindful of respecting themselves, the other participants, and showing teamwork, and will not knowingly break the rules and the law. While few would disagree that elite athletes epitomise the virtues of dedication and commitment, their ultimate and fundamental motivation is ultimately excellence in sporting performance.
Data from non-athlete patients suggests that ingested CAM substances are not viewed as medications because they are perceived as “natural”. – Thus athletes may use CAM in the belief that it is more natural and, erroneously, not potentially doping (either as a “method” or “substance” under the anti-doping Code). The lack of understanding of various forms of medicine by patients and athletes may result in their not informing doctors (or coaches) about non-conventional treatment use because it is not viewed as important or relevant to their medical management. Patients thus risk complications from CAM drugs and their interaction with prescribed medications.
– The additional consequence from failure to recognise CAMs as pharmacological agents puts athletes at risk of inadvertent doping. PEER REVIEW Not commissioned. Externally peer reviewed CONFLICTS OF INTEREST CONFLICTS OF INTEREST The primary author is a senior editor and peer reviewer of the Australasian Medical Journal. FUNDING The content of this article is an edited version of a paper presented by the primary author at the 4th annual joint University of Liverpool Management School and Keele University Institute for Public Policy and Management Symposium on Current Developments in Ethnographic Research in the Social and Management Sciences, Liverpool, UK. This paper is also part of a greater research project that has previously received funding from the Department of Health and Ageing, Australian Government, research grant. ETHICS COMMITTEE APPROVAL No ethics approval was required for this review paper.
The greater research project was previously approved by the UTS research ethics committee, the Department of Health and Ageing, Australian government, scientific committee, and the New South Wales Institute of Sports research committee. Please cite this paper as: Koh B, Freeman L, Zaslawski C. Alternative medicine and doping in sports. AMJ 2012, 5, 1, 18–25.
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