Rob Satriano, PT, DPT, CMTPT, MLDT
Recently, an old patient of mine reached out with a new problem. She stated, “My doctor said if you can’t get me to feel better in six weeks, I will have surgery.”
She explained that after nearly four years of working from her living room, her employer required her to come to the office full-time. Within two weeks after being back at her old desk, she developed neck pain with numbness and tingling down her right arm and fingers. Her first call was to her primary care physician, who quickly sounded the alarm bells. Over the phone, she was diagnosed with cervical radiculopathy and sent to a local spine surgeon. With an x-ray and brief evaluation, the surgeon confirmed her diagnosis and recommended surgery. When she asked about trying physical therapy, her physician said she could go for six weeks. He doubted her condition would change much and told her his surgical coordinator would be in touch.
As we chatted about her situation, she explained that her computer monitor was located to the right and required her to maintain cervical rotation to the right for hours each day. Unlike in her home office, where she changed locations and body position frequently, she felt stuck at her office desk.
Upon evaluation, I was not surprised to find that her upper traps, SCM’s and posterior cervical muscles were tight and tender. In fact, her entire shoulder girdle was involved and loaded with active and latent trigger points. She tolerated neck pain but was concerned with symptoms in her forearm and fingertips. The specific fingers involved in her case were the index finger and thumb, mimicking a median nerve distribution.
The challenge with a patient like this is deciding where to begin.
After careful consideration, the first place I decided to treat were her anterior and middle scalene muscles. I suspected that their muscle tone and the attachments to the first rib might be contributing to myofascial dysfunction in the region. After implementing skilled dry needling and many twitch responses later, the patient was amazed that the numbness in her index finger was resolved. She quickly regained sensation in her thumb, except for the fingernail. I suggested we work on some upper extremity movements and “nerve flossing.” I recommended to request an ergonomic upgrade from her employer.
A week later, she was thrilled to report that her symptoms had completely resolved. She was surprised how relaxed all her shoulder muscles felt, especially because they had not been needled.
This patient illustrates a common outcome with treatment of the scalene muscle, which often reduces the need for treatment in previously affected muscle groups (especially the distal musculature).
When I learned the myofascial referral pattern for the scalene muscles, I had my doubts. As a novice dry needler, I was intimidated to needle this area and avoided doing so. I am grateful that a colleague helped me regain confidence with these techniques. I quickly learned the profound affects that hypertonic scalene muscles can have on myofascial pain. Moreover, research on myofascial pain of the middle and anterior scalene muscles has been shown to mimic cervical radicular symptoms, cervical spinal stenosis, cervical disc prolapse, and thoracic outlet syndrome [1, 2].
As you continue clinical practice, always remember to stay open-minded and be healthily skeptical of diagnoses assigned without a comprehensive evaluation. You know your patients better than most other clinicians. In many cases, you will be the only clinician to perform a hands-on evaluation! This allows for a unique opportunity to help your patients in a novel and profound way.
When clinically appropriate, I encourage you to include dry needling of the scalene muscles into your treatment plan for similar cases and many others! Good luck!
References:
1. Abd Jalil, N., M.S. Awang, and M. Omar, Scalene myofascial pain syndrome mimicking cervical disc prolapse: a report of two cases. Malays J Med Sci, 2010. 17(1): p. 60-6.
2. Donnelly, J., et al., Travell, Simons & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 3. 2019, Baltimore: Wolters Kluwer.
Dry Needling Course Series
The Dry Needling 1 course is an excellent starting point for learning the fundamentals of dry needling therapy. With a focus on the safe and effective application of dry needling techniques, you will gain a solid understanding of myofascial trigger points, needling techniques, precautions, and how to apply these techniques in clinical practice.
The Dry Needling 2 course is an intermediate-level course that provides in-depth knowledge and hands-on training for dry needling techniques of the extremities, including the upper and lower body. By completing this course, you will expand upon the skills you acquired in the DN-1 course and better understand the application of dry needling for managing musculoskeletal pain and dysfunction.
The Dry Needling 3 course is the final course in the series and the last step before becoming a Certified Myofascial Trigger Point Therapist – Dry Needling (CMTPT/DN). This course offers an in-depth study of advanced dry needling techniques for hand muscles, several lower extremity and foot muscles, the craniofacial and craniomandibular muscles, and more.
