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At Range Of Motion Acupuncture we think it is!

In the past year, we’ve seen many cases of lateral epicondylitis, also known as tennis elbow. This is a painful condition that can last for months without much improvement. There are many devices made to treat tennis elbow. Braces are one and there are rubber sticks that can be used to strengthen the forearm extensors. And many are taking non-steroidal anti-inflammatory (NSAID) medications which all have side-effects and liver toxicity as well as an increased risk of stroke or heart attack.

So what’s our solution? In the past year we have resolved over 90% of all tennis elbow cases in 1-5 treatments and most of the cases were solved in under 3 treatments.

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The tensor fasciae latae is a long name for a small muscle with a really long tendon. The iliotibial band (IT band) is the tendon part of the tensor fasciae latae (TFL) structure. Tensor fasciae latae is Latin for “the muscle that moves that side tendon thingy” or something to that effect. From here on out I’m just calling it the TFL and it’s understood that I’m including the IT band as part of that structure. The fact that this structure has parts with different anatomical names is probably part of the reason issues with the TFL go undiagnosed or are misdiagnosed (i.e. lots of sad people at my gym rolling their sore IT bands with foam rollers to no avail).
The origin of the TFL is at the anterior lateral portion of the iliac crest near the ASIS and the insertions are on the anterior lateral tubercle of the tibia and the lateral femoral condyle and the linea aspera of the lower femur. There are tendinous fibers that cross over the patellar retinaculum. The TFL crosses the greater trochanter on its way down to below the knee.

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The TFL does a few things. It does hip flexion, hip abduction and internal rotation, all in that order of priority. It’s innervated from L4-L5-S1 by the superior gluteal nerve just like the gluteus medius and gluteus minimus. When doing hip flexion it’s assisted by the psoas, rectus femoris and sartorius and when it’s doing abduction it’s working with its superior gluteal nerve siblings glute medius and minimus.
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Martial arts fighters are prone to TFL issues because side kicks are using all three of the functions of the TFL in one move. But people who sit for long periods of time are candidates for TFL muscle shortening which will give the same painful result as the Muay Thai masters with a lot less sweating.
So what happens when the TFL is tight, short and weak? There are a few pain patterns that are common. 1) Sciatic-like pain down the side of the leg (remember the IT band?). 2) Knee pain! 3) Hip pain that is often misdiagnosed as trochanteric bursitis.

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When the TFL gets short and tight, it becomes weak. The patient doesn’t usually feel anything in the TFL region unless you push on it pretty hard. What they feel is hip pain or pain that radiates down vastus lateralis or the IT band or in the knee or possibly all of them. Those tendinous fibers that cross the patella will pull on the patella and cause tracking issues and pain. A tight IT band rubbing on the greater trochanter can cause hip pain, especially on adduction (think about sleeping with the sore hip on top and the knees touching). If the patient has to sleep with a pillow between their legs to lessen their hip pain, think TFL.
I’ve seen patients who because they described their pain as “radiating down the leg” were told they had sciatica. But when we ask them to show where the pain is and we see that it’s not the back of the leg, but on the side and sometimes down the front of the leg, we have to do some testing on the TFL.
I do some manual muscle testing on the TFL and consider weakness as a positive test. To demonstrate the problem to the patient I will also press on the TFL so they can feel the pain referral pattern as confirmation.
Treating TFL issues with massage and stretching may bring some relief but can be a Sisyphean endeavor. That is especially true if the heat pad, massage and rolling are being done on the IT band, the tendon of the muscle that is really causing the problem. I’m not sure if tendons can be made longer by stretching but since releasing the muscle from spasm or muscle shortening is faster, easier and usually painless, that’s what I would recommend.
What I like to do is motor point needling of GB29. There is another motor point 1-1.5 cun below GB29 as well if you need it.
I will put the patient in a side-lying position with the top leg bent so that their ankle is above the knee. This puts the TFL is a very relaxed state. Easier to needle into when you are expecting that it might be tight, have trigger points or be in spasm.
I measure halfway between the ASIS and the greater trochanter and put a 3” 30 gauge needle straight in perpendicularly to illicit a fasciculation. I always tell my patient in advance what I’m doing and ask them to let me know if they feel the muscle twitch. Most of the time the twitch is visible to me but sometimes it’s not so not only is it the right thing to do to explain in advance what is going to happen but you might need the patient’s feedback to know when you hit the motor point. The motor point of the TFL can be 1.5″-2″ deep.
After getting the motor point, I will usually remove the needle. There are times when longer retention is beneficial and also e-stim might be called for but most of the time the muscle will release within seconds. The patient may be sore the next day so I warn them that it might feel like they had a workout but usually the pain relief is noticeable and the range of motion is improved enough to make up for any muscle soreness. Within 2-3 days the blood will be circulating better and the strength will be coming back and the pain will be mostly or completely alleviated.
There are other considerations of course. If the patient is not new to acupuncture and motor point needling, I will want to look at other agonists and antagonists to see if I need to release them. I will check glute medius and minimus and release them if needed. I will check hip extensors like biceps femoris and glute maximus since they are antagonists to the TFL and hip flexion and could be the primary reason the TFL got tight. So if the antagonists need to be released I’ll do that. These will wait a week if the patient is too needle sensitive. The TFL release is usually a big relief and the rest can be done later.
I don’t want to get in the weeds too much, but as part of my assessment and treatment I’m going to pay close attention to what’s going on in the spine at the same level of innervation (L4-L5-S1). Huatuo Jia Ji needling in the style of Dr. C Chan Gunn with attention to paraspinals and glutes.
For patient self-care, especially martial artists who are going to go right back out and get their TFL in a knot again, I would recommend a little less IT band rolling and a lot more lacrosse ball against the wall. If you put a lacrosse ball against the wall right above the greater trochanter and start rolling toward just above your pants’ front pocket you’ll land on the TFL. The pain is the kind of exquisite pain that is described by Travell and Simons when locating trigger points. I like to roll on those points for about a minute or two at a time and just do that as often as possible throughout the day. (3-5x if possible)

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If the TFL is causing knee pain, one treatment of the TFL is probably not going to be all that needs to happen. Once the body has learned to compensate for knee pain, proprioception need to be retrained.
Releasing the TFL, maybe the vastus lateralis and rectus femoris is a great start. Then light squats will be in order. Just with body weight. The patient may have to modify the squat by externally rotating the hip a little to take some of the pressure off the IT band (keeping knees in line with toes). A wobble board would be in order. The TFL is important in maintaining balance in a standing position. It may need some retraining. There is more to be written about treating and the rehab of knee and hip issues but hopefully this is a good start and hopefully of some interest.
If you like to meet to discuss your unique issues, feel free to contact us and come for a free consultation.

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You can laugh, but it’s a real thing!
Gluteal amnesia is something that can happen when the chain of muscles that are hip extensors are not firing in the right order because of our sedentary lifestyle (we sit on our ass all day)
As we age we are prone to our glutes “forgetting” how to fire properly. They become lazy.
Since the glutes are supposed to be our strongest hip extensors, when they become weak the secondary hip extensors like the hamstrings and the lower back have to take up the slack because the glutes cannot function properly.
And if the glutes have become weak due to lack of exercise you can imagine that something like going up the stairs becomes more difficult because the gluteals aren’t firing or are not firing in the right order so the hamstrings and low back are under more stress so over time we’re likely to have low back pain issues and tight hamstrings. That can then lead to their antagonists (the quads and hip flexors) getting tight.

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Pair your weak glutes with your weak abs (not judging you; just sayin’) and you get something called lower cross syndrome which can cause an anterior pelvic tilt. That’s a different discussion but trust me that it only leads to bad things.
You need to work your glutes!
Glute bridges or kettle bell swings are highly recommended for strengthening the glutes and getting them to start to fire in the right order. It usually takes some practice of consciously squeezing the glutes when going upstairs to begin to get the strength and coordination back that we had when we were younger.
If you consciously make an effort to use your glutes when you’re standing up from a chair or going up the stairs you can get your glutes back in order and very likely if you’re having some sort of low back pain or hamstring issue this can be a big help.
So remember: just because your glutes forgot about you doesn’t mean you get to forget about them!

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Plantar fasciitis, heel pain and Achilles tendonitis are conditions I have seen and treated several times successfully using acupuncture. These are conditions that can be very challenging and common for dancers and runners but anyone can suffer from them. They are frequently treated with NSAIDs (non-steroidal anti-inflammatory drugs), braces, shoe inserts and painful cortisone injections. When the tools of choice are drugs and surgery, is there any surprise that relief can be elusive?
I’ve heard that one can treat plantar fasciitis by putting a tennis ball in a shoe box and rolling it around on the plantar fascia. That’s the part of the foot that hurts so it makes sense that people want to treat it.
It’s certainly possible to imagine that the plantar fascia alone could somehow become irritated and in that instance this technique might completely relieve the issue.
Heel pain and Achilles tendonitis are a little trickier because there’s not much to massage and the part that hurts is not going to feel better with pressure!
As it turns out, treating the site of pain is only part of the equation. One needs to look for the source of the problem. Typically it’s further up the posterior chain in the gastrocs and soleus (calf muscles) and even in the hamstrings. Research shows that a high percentage of subjects with plantar fasciitis also had tension in the hamstrings and calves.
Drs. Travell and Simons say in their book Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 2 that pain in the plantar fascia is typically a referred pain from trigger points in the gastrocnemius muscles, especially the medial one. The problem is really in the calves.
For heel and Achilles tendonitis I always look at the soleus for the source of pain. When the soleus is tight it pulls the Achilles tendon and the connective tissue that crosses the calcaneus (heel bone) and can add tension to the plantar fascia as well.
The posterior chain needs to be examined for tension. When the hamstrings and calves are working properly there should be no extra tension on the Achilles tendon and the heel and plantar fascia.

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For the acupuncturists: I like to release the gastrocs with their motor points. The lateral gastroc can be released with a point 3-4 cun inferior to BL39 and the medial gastroc motor point is 3-4 cun inferior to KD10. The soleus can be released at a point halfway between SP7 and SP8 or a point 3 cun inferior to the head of the fibula (behind the fibula).
For chronic tension, I’m probably going to choose to use electric stimulation on the soleus for 20 minutes to get as much relaxation as possible. Patients will typically feel more range of motion on the day of the treatment and relief from pain within 48 hours.
I have found that these conditions can be successfully treated with only 1 or 2 treatments when the problem has been discovered and treated with acupuncture.
An excellent self-treatment option would be to sit on the floor with a yoga block in front. Place a lacrosse ball on the yoga block and rest the calf on the ball. Allow the weight of the leg to do the work. Find tight and sore spots and allow the trigger points to “melt”. This may take some vigilance. 5-10 minutes a couple times a day should pay off in a few days.

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NOTE: While this blog post was written for an audience of acupuncturists, I hope others will read it and apply the information to their own self-care routine (i.e. yoga, stretching, massage) or will seek an acupuncturist who is open to this approach.

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Can your muscles be stressing you out without you knowing it?
There seems to be quite a good amount of research that would support the idea that stress, anxiety and depression can be caused or at least perpetuated by tight muscles (primarily upper traps, neck and upper back, but also glutes and adductors).
The Institute of Psychiatry at the University of London did neurological tests that showed a correlation between mental stress and muscle tension in the trapezius. They believed that a combination of mental and physical work stress interacted and led to “trapezius myalgia problems”. More interestingly they said “This seems to be a vicious cycle of psychological stress, bodily reactions and pain symptoms”. A vicious cycle. So it’s hard to say which one is causing the other?
The Journal of Occupational Health Psychology published a study called “Psychophysiological Stress Responses, Muscle Tension, and Neck and Shoulder Pain Among Supermarket Cashiers” where they state:
“..it seems probable that some of the bodily symptoms in anxiety may be attributed to muscular over-activity, the latter being part of the physiological changes accompanying anxiety. Since patients who report feelings of tension have an increased muscular innervation, it is suggested that the feelings of irritability and restlessness of which they often complain may, in fact, be consequences of the massive bombardment of the central nervous system by proprioceptive stimuli arising from the widespread contraction of the voluntary muscles.”
Aha! The occupational health psychologists are willing to hypothesize that the muscles are causing the irritability and restlessness!
An Italian study from the International Association for the Study of Pain looked for correlations between headache types and their relationship to anxiety and depression.
“The main finding of the present study is a positive relationship between muscle tenderness and psychiatric disorders in patients with EM (Episodic Migraine). In the EM group, muscle tenderness scored consistently higher in patients with anxiety or anxiety and depression as compared to those without such disorders”.
Their study was looking for a connection between headache and anxiety and depression but in their attempts to qualify what types of headaches they were seeing they tested for tenderness of cervical, occipital and pericranial muscles. So there was a clear connection between tight muscles and anxiety and depression.
In his book The Gunn Approach to the Treatment of Chronic Pain, Dr. C. Chan Gunn, MD says the following about anxiety and pain:
Anxiety nearly always accompanies pain: body tone is frequently increased, and groups of muscles become tensed and shortened in a characteristic pattern. In chronic pain with anxiety, even when symptoms are localized to one region, many latent points of tenderness, usually symmetrical, may be found throughout the body, i.e. “fibromyalgia” or “diffuse myofascial pain syndrome”. These conditions cannot be satisfactorily treated unless anxiety is also controlled. In anxiety, all tender “stress” muscles (those that are called into action in “fight or flight” or protection situations) require treatment.
Some important stress muscles are:

  • trapezius

  • sternocleidomastoid

  • masseter

  • prime extensors of the vertebral column

  • infraspinatus

  • gluteus maximus and medius

  • adductor magnus and longus

  • pectineus.

Release of stress
Treatment of these muscles, especially the trapezius, can lead to a state of general somatic relaxation (see Dorsal back). Anxiety may be allayed, and medications can usually be discontinued. Following treatment of these “stress” points, patients may experience a feeling of emotional unshackling that they find difficult to describe. Patients may break into unbridled tears of relief, crying without check for many minutes, sometimes up to an hour. In some chronic pain conditions, e.g. headache, low back pain, “fibrositis”, and temporomandibular joint pain, there can be a strong psychosomatic component. Such conditions cannot respond to treatment unless the “stress” muscles (especially the trapezius and adductors) are also treated.
Dr. Gunn uses acupuncture to release these “stress muscles” and will also certainly use Huatuo JiaJi points along the vertebral column as part of this treatment since that is always a part of his protocols.
Traditional Chinese acupuncture using a TCM diagnosis can do wonders for stress and anxiety. This is one of the true strengths of acupuncture that is hard to dispute by most who have received acupuncture.
However, when we see patients that feel great right after their treatment and then the next day start to slip into their old pattern of anxiety or depression, perhaps we can take a look at what clinical research tells us about the muscular component to anxiety and depression.
For treatment we don’t need to re-invent the wheel. Dr. Gunn has been treating pain and anxiety with acupuncture since the 1970s with great success.
If tight muscles can perpetuate or even create a sense of anxiety, of always being in “fight or flight”, maybe we should add some motor point techniques to our TCM treatment.
Many of what Dr. Gunn calls “stress muscles” are on the Liver, Gallbladder, and Bladder Channels so it’s not hard to see how releasing adductors on the Liver Channel or relaxing upper trapezius at GB21 can fit perfectly in a treatment for stress and anxiety.
And let’s not forget the emotional power of the back shu points that lie on the Bladder Channel which also goes to the neck (BL10 also connects to the KD divergent), the extensors of the back and glute medius and maximus.
I have personally seen treatment and motor point release of tight levator scapula, rhomboids and upper trapezius bring an end to panic attacks and palpitations. And incidentally, during the treatment the patient did feel such a great release that she wept a little.
It was that patient’s response to an orthopedic approach to muscle tension and her anxiety that led me to investigate this further.
I hope there are more such stories to come!

Works Cited
Lundberg, U., Melin, B., Ekstrom, M., Dohns, I. E., & Sandsjo, L. (1999). Psychophysiological Stress Responses, Muscle Tension, and Nec kand Shoulder Pain Among Supermarket Cashiers. Journal of Occupational Health Psychology, 245-255.
SYMPTOMS OF ANXIETY AND TENSION AND THE ACCOMPANYING PHYSIOLOGICAL CHANGES IN THE MUSCULAR SYSTEM. (1954). J. Neurol. Neurosurg. Psychiat., 17, 216-224.
Gunn, C. C. (1996). The Gunn Approach to the Treatment of Chronic Pain. New York: Churchill Livingstone.
Mongini, F., Ciccone, G., Deregibus, A., Ferrero, L., & Mongini, T. (2004). Muscle tenderness in different headache types and its relation. International Association for the Study of Pain, 112, 59-64.

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If you ever have low back pain that is worse when you first stand up after sitting for a long time and then it gets better as you walk around, you probably have a tight psoas. Other signs would be worse pain when lying flat on your back that is somewhat relieved by sleeping on your side in a fetal position.
This pain can be crippling when the psoas is very tight. It can be very painful just to try to walk a short distance and anti-inflammatory meds don’t do much to relieve the pain. The problem isn’t inflammation; it’s muscle shortening and the resulting tension. Tension on the lumbar spine!
A tight psoas causes lumbar pain and an increased lordosis (arch) in the low back. It will make you feel like you are walking like a duck with your butt sticking back.
You might be thinking, “How can tight hip flexors make my low back hurt?”.
To understand this we have to look at the origin and insertion of the psoas. Its origin is on the vertebral bodies of from T12 to L5 and that includes the intervertebral disks. The psoas travels down to the iliac fossa of the pelvis where it interdigitates with the iliacus (which is why the muscle is often called the iliopsoas) before attaching to the lesser trochanter of the femur.
The iliopsoas is the strongest hip flexor on the body and it stays in a shortened/flexed postion when we sit. So it’s not hard to imagine how people who sit all day at work then sit in their car and then sit on their sofa at night for a few hours are good candidates for some psoas shortening.
If we take a look at the iliopsoas it’s easier to understand what I’m talking about. The muscle goes from the back of the body to the front. It’s a pretty interesting design really.

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How many people are putting heating pads on their low back or getting massages of their lower backs and bending over to touch their toes to try to stretch that tight low back out when really the problem is in the front?!

From an acupuncture perspective there are different approaches I’ve heard of and tried. One way to treat a tight psoas is from the front at GB27. I like to put a 2-3” needle in a lateral direction into the iliacus muscle and stimulate the iliacus to get a sensation in the psoas. This may cause some twitching of the psoas if it’s highly reactive from being tight. A gentler approach would be to use some e-stim on the same needle at GB27. That can be paired with TFL at GB29 (another hip flexor that can get pathologically tight) or to another point on the Dai Mai, GB28 or something on the thigh or leg. Update: My new favorite way to release the psoas is from BL24 with a 3″ needle. The motor point can be reached this way and is very effective in releasing a tight psoas.
The innervation of the iliopsoas is from the femoral nerve. TFL is innervated by the superior gluteal nerve and points on the quads (leg extensors) will be femoral nerve so you can choose your treatment based on whether you want to stick with the pathway of the femoral nerve or if you want to get both femoral and the superior gluteal nerve pathways in the treatment. From a TCM perspective you could stay on the Gallbladder meridian with GB27, GB29, GB31 or GB34 or include the Stomach meridian with ST31 ST32 or ST36 .
A quick Google search on “psoas stretch” or “psoas self-massage” will point readers to good resources for self-treatment of a tight psoas. A psoas stretch can give quick relief. When a tight psoas is the source of low back pain, the first time stretching it will usually increase the pain a little. But that’s how you know you are on the right track. Pulling on a tight muscle will naturally increase the tension temporarily. It’s worth being persistent on these stretches. It will pay off in hours or days.

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The levator scapulae has been nicknamed the stiff neck muscle for good reason. When it’s tight it can be painful to turn the head to the same side and if the levator on the opposite side is tight you will have to fight against that tension as well.
When levator scapulae tension or muscle shortening is chronic it can lead to upper back tension, tension headaches, regional pain and sometimes shortness of breath. The regional pain can go down the medial (vertebral side) of the scapula or across the back of the shoulder and also up to the neck.
I’ve seen anecdotally that it can even causing dizziness and vomiting. I have to guess that that patient had some vagus nerve or brain stem encroachment due to cervical compression caused by muscle shortening. What I do know is that release of the levator scapulae muscles on both sides stopped the other symptoms.
The levator scapulae has its origin at the transverse processes of the cervical vertebrae (C1-C4) and goes down past the turn of the neck, goes deep to the upper trapezius and attaches on the anterior side of the scapula at the superior medial corner.
In short, it goes from the neck at the base of the skull down to the upper shoulder blade.
This is the most common cause I have seen for neck pain and upper back pain. And when it’s chronic it can be very uncomfortable even when the muscle is not in use. Some might say that the upper traps (around GB21) are the most common cause of upper back pain but I would say that the upper traps are usually becoming “bunched up” because the levator is keeping the shoulder in a slightly hunched position so if you don’t release the levator, the upper traps will continue to get tight. The upper traps are a secondary problem that is caused by the levator so I’m still saying levator is the number one cause.
This is one pain pattern that doesn’t have unusual referral patterns. The pain is typically in and around the muscle.

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It can be confirmed by decreased range of motion on head rotation and/or firm pressure on the levator just superior medial to the scapular attachment area. This is the sore spot that feels so good to have massaged when getting a back rub in a chair.
The levator scapulae muscles can be hard and grueling to work out with massage. Massage or ART (Active Release Technique) tends to give some relief but often without fully releasing the muscles. The only thing I have seen that gives fast (10-15 minutes) painless relief for chronic levator scapulae tension is acupuncture. A tight neck from sleeping with head turned to the side in front of the air conditioner is more likely to respond well to some massage and heat

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So, how and why does the levator get so chronically tight?”, you ask.
Well, the levator muscles assist the upper trapezius muscles in a shrug motion which is what’s going on when we carry heavy shoulder bags. A heavy purse or messenger bag could be enough. Also, sitting in a cold air conditioned office with a chair that has arm rests that are too high and cause the shoulders to be in a slightly shrugged position could be a culprit. Maybe you’ve got some emotional stress or anxiety on top of that and that’s a perfect storm for some levator tension. (I personally believe that releasing tight upper back muscles has a very positive effect on a patient’s perceived level of stress and anxiety, but that’s a future blog post!)

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Since the levator scapulae also plays a role in side-to-side head rotation, you can imagine that repeated motion could cause tension. This repeated head rotation happens when playing tennis or when swimming. Or maybe you got really great front row seats to the US Open and you get “spectator neck” from looking left and right so much. (A bit more of an acute situation than chronic, but you get the point.)
So this is one of the most gratifying treatments to give a patient because the results are immediate. The range of motion side-to-side is increased and the tension is noticeably reduced. And it continues to improve for a few days, usually to complete resolution after only one treatment.
While the treatment is completely safe when done by a licensed acupuncturist who knows their anatomy, I hesitate to explain the technique in too much detail here because of the risks if done by someone who learned it from a blog post. (perhaps mine!)
So I’m going to explain what I do and ask that you not do this unless it has been demonstrated for you in person. Perhaps I’ll post a video of it sometime.
There’s an extra point called Dijia that is the motor point of the levator scapulae. It is located 1 cun posterior and .5 cun superior from SI16. It is very important to palpate to be sure the needle is going into the space posterior to the transverse processes of the cervical vertebrae and thus into the levator motor point. (Don’t try this at home, kids!)
Then the other locations I’ll treat will be at the superior medial border of the scapula (between SI13 and SI14). Again, not to be done without seeing a demo. You need to grab the muscle and lift it above the plane of the body so you can get into the muscle without risk of a pneumothorax. On a thin person this is especially important. This is a very oblique insertion going cross-fiber.
When done by someone who is trained the procedure is very safe.
The levator will usually twitch on all of the points. The motor point at Dijia will fasciculate of course and the lower points near the scapular attachment will often twitch because they have become highly reactive from trigger points or muscle shortening. If the issue is chronic I like to add some e-stim to the points near the scapula for about 10 minutes. They usually melt like butter.
In a Dr. C Chan Gunn treatment there would likely be Huatoujiaji needling at the dermatomal level that is most relevant for the levator scapulae (C3-C5). Points in the neck don’t get e-stim of course.
The release can be done without retaining needles but if there is some chronic tension, it’s good to retain them for 10-15 minutes and with e-stim is even better.

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For self-treatment and stretching ideas I would recommend looking on YouTube for PNF stretches for the levator scapulae. There are many good stretches that will certainly give palliative relief.
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