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Pathogenesis and Tuina Treatment of Shoulder
Disorders
East West Healing Center
By Dr. Leon Chen
www.eastwesthealingcenter.net
Review of Tuina History
Warring States Period: from 475 BC to 221 BC. Tuina manipulation has been recorded in the “Huangdi Neijing” or call “Inner Canon of Yellow Emperor” that is a earliest medicine book in China.
Three Kingdoms period, The Jin Dynasty: from 220 A.D to 581 A.D. Tuina technique was improved and Tuina books been appeared, such as “Zhou Hou Fang”.
From Song Dynasty to Qing Dynasty: from 960 to 1911, had a lot of Tuina books been appeared and technique much better.
Since 1958, Tuina has been get comprehensive development, especially to use modern science approach to the study of Tuina.
ZhouHouFang
ZhouHouFang
ZhouHouFang
ZhouHouFang
元代 -危亦林（ 1277-1347 A.D ）《世医得效方》Yuan Dynasty
Counter traction for treatment of back pain
元代 -危亦林（ 1277-1347 A.D ）《世医得效方》Yuan Dynasty
Waist belt for back pain
TuiNa Actions
1)1) To reduceTo reduce the pain. the pain.2) To flow blood to 2) To flow blood to particular area. particular area. 3) To activate the Qi in the channels.3) To activate the Qi in the channels.4) To reduce muscle spasm.4) To reduce muscle spasm.5) 5) To repairTo repair the damaged soft tissue. the damaged soft tissue.6) 6) To adjust joints, To adjust joints, reset bone.reset bone.
How Does Tuina Work?
The tuina can improve the skin and muscle the blood circulation, strengthen the metabolism of tissues and organs, and promote gastrointestinal motility and anti-inflammatory effect.
How Does Tuina Work of Anti-inflammatory?
1) 1) Increase content of Beta- endorphin (END) and Increase content of Beta- endorphin (END) and Catecholamine (CA) in blood to help Catecholamine (CA) in blood to help the painthe pain..
2) Decrease content of 5-hydroxytryptamine (5-2) Decrease content of 5-hydroxytryptamine (5-HT) in blood to reduce HT) in blood to reduce the painthe pain..
TuiNa Methods
1. Single manipulation:
1) Tui: pushing. ①Finger pushing. ②Palm pushing. ③Twin palms pushing.
2) Na: Grasping. ① Fingers. ② Twin palms.3) An: pressing. ① Finger pressing. ② Palm pressing. ③ Elbow
pressing. 4) Mo: Rubbing.5) Rou: Kneading.6) Gun: Rolling. S① ide fist. ② Fist.7) Dou: Shaking.8) Da: Patting and pound.9) YaoHuang: Rotating.
Tui ( pushing): Finger pushing. Palm pushing. Twin palms pushing.① ② ③
Na: Grasping. Fingers. Twin palms.① ②
An (pressing): Finger pressing. Palm pressing. Elbow pressing. ① ② ③
Mo: Rubbing
Gun: Rolling. Side fist. Fist.① ②
Da: Patting and pound.
YaoHuang: Rotating
2. Combined manipulation:
• AnGunRou: Pressing, Rolling and Kneading.
• NaRou: Grasping and Kneading.
• Wave: Grasping, Pushing and Rolling.
• AnMo: Pressing and Rubbing.
3. Manipulation for the Spine or Joints
1)BaShen: Counter traction
①Joints traction.
②Cervical traction.
③ Lumbar traction.
2) Ban: Adjustment spine or joints.
BaShen (Counter traction): Joints traction. Cervical traction. Lumbar traction.
Ban: Adjustment
Ⅰ Local Anatomy 1.The Structure of Shoulder
(1)Bones: Clavicl Humerus Scapula Coracoid process Acromion Glenohumeral joint
Coracoid process
(2) Ligaments:
①Coracoacromial ligament. ②Coracoclavicular ligament. ③Glenohumeral ligament.④Coracohumeral ligament.
(3) Articular capsule
(4) Bursa: Sub-acromial bursa and Sub-deltoid bursa
Deep: Supraspinatus, Infraspinatus, Teres minor and Subscapularis, those are called Rotator cuff.
(5) Muscles
Superficial: Pectoral major, Biceps, Deltoid, Triceps, Trapezius.
Posterior musclesAnterior muscles
Biceps
Pectoral major
(6) Tendons: Supraspinatus Tendon, Bicipital Tendon, Subscapularis Tendon
(7) Blood Vessels and Brachial plexus
Axillary artery
Brachial plexus
Brachial plexus:
• The brachial plexus is composed C5, C6, C7, C8 and T1 spinal nerves.
• Those include a radial nerve, a median nerve, a ulnar nerve.
① The radial nerve: C5-C8,T1 of spinal nerves.② The Ulnar nerve: C8 and T1 of spinal nerves.③ The median nerve: C5-C8,T1 of spinal nerves
Relationship of Cervical Vertebrae and Nerve Roots
Conus medullaris
Cervical vertebraes Nerve roots
Brachial plexus
S2
S1
45
C 34
5 67
8
34
5
C
S2
L1
L2
L3
L4
L5
S1
T1
T1 23
12
4 56
78
910
11
C5
C6C8
C7
C8
C7
C6
S2
L5
L4
L5
L4
L5L4
3
2. Shoulder Movements
Extension:0-60°
Adduction: 0-45°Abduction: 0-90°
Lateral Rotation:0-90°(External Rotation)
Medial Rotation:0-90°(Internal Rotation)
Flexion:0-180°
Ⅱ Differential Diagnosis and Treatment of Shoulder Pain
①Supraspinatus Tendinitis ②Bicipital Tendinitis ③Frozen Shoulder ④Sub-Acromial Bursitis (Sub-deltoid bursitis)⑤Arthritis of the Shoulder⑥Cervical Spondylosis
1 Supraspinatus Tendinitis
• Definition:
The tendinitis is an inflammation of the tendons of the Supraspinatus tendon.
The causes of supraspinatus tendonitis can be chronic impingement and degeneracy of the tendon.
• Symptoms
① Pain associated with arm movement .
② Pain in the shoulder at night, especially when lying on
the affected shoulder .
③ Weakness with raising the arm above the head, or pain with overhead activity.
• Examination Tests
①Trigger point on the acromion.②Lateral of Shoulder pain, or the pain radiate to neck or arm.③Examination test of shoulder abduction: passive abduction the pain eliminated with shoulder in medial rotation. The other way round, active abduction shoulder in medial rotation posture the pain start 60° to 120° ( pain radian), under 60° and above 120° then the pain disappear.
Ossification of Supraspinatus tendon
MRI X-ray
Tuina Treatment
(1) GunRou (Rolling and Kneading) on the Deltoid for 3 minutes.
(2) AnRou (Pressing and Kneading) by thumb on the Supraspinatus tendon for 3 minutes.
(3) YaoHuang (Rotating): passive rotate shoulder for 2 minutes.
(4) Abduction of shoulder by passive associate with Pressing and Kneading for 3 minutes.
(5) Dou (Shaking) the arm for 1 minutes.(6) Using heating pad 2-3 per day.
Acupuncture treatment
• Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.
2 Bicipital Tendinitis
• Definition:
Inflammation of the bicipital tendon which is long head tendon of the biceps . It is often associated with some sort of trauma or overuse, and usually associated with rotator cuff disease.
Symptoms
①Aching shoulder
②Shoulder pain when lifting heavy objects
③Shoulder pain when performing overhead activities
④Tenderness over bicipital groove.
bicipital tendonHumeral bicipital groove
Yergason test
Neer test
Hawkins test
Speed test
Examination Tests
Tuina Treatment
①GunRou: Rolling and Kneading.②An: Finger pressing.③Na: Grasping.④Dou: Shaking.⑤Yao: Rotating.⑥Using heating pad 2-3 per day.
Acupuncture
• Ashi point, IL15, SI10, TE14, LU2, LU3.
3 Frozen Shoulder
• Definition:
causes limitation of motion in the shoulder joint, that also called adhesive capsulitis.
In Chinese medicine, is called Bi Zheng of wind cold, also called “fifty shoulder”.
Etiology of Frozen Shoulder
• Age and gender• Endocrine (hormones) disorders• Shoulder trauma or surgery• Other systemic conditions
Symptoms
• Pain in the should.• Most commonly affects patients between the
ages of 40 to 60 years old, and it is twice as common in women than in men.
• Beginning the shoulder pain, and worse in the night. Later pain less but shoulder movement has been limited.
Tuina Treatment
• GunRou: Rolling and Kneading.• NaRou: Grasping and Kneading.• Flexion and external rotation of the shoulder
associated with pressing and kneading.• Rotating.• Shaking.• Using heating pad 2-3 per day.
Acupuncture
• Ashi point, IL15, SI10, TE14, LU2, IL4.
4 Sub-acromial Bursitis (Sub-deltoid bursitis)
• Definition:
Inflammation of the bursa which is located in the sub-acromial or sub-deltoid. It is most often caused by some sort of trauma or overuse of the shoulder.
Symptoms
• Pain and weakness when the arm is lifted up sideways through a 60 degree arc.
• Pain point at acromion or deltoid. • Active arm movement is often restricted in
abduction only.
Subacromial Bursa
Bursa of the Coracobrachialis
bursa
deltoid
Supraspinatus
X-ray with contrast medium
Tuina Treatment
• GunRou: Rolling and Kneading.• Finger pressing.• Mo: Rubbing.• Passive lifted up arm with Finger pressing and
kneading.• Rotating.• Shaking.• Using heating pad 2-3 per day.
Acupuncture
• Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.
5 Shoulder Arthritis
• Definition:
Osteoarthritis is characterized by progressive wearing away of the cartilage of the glenohumeral joint. Also called wear and tear arthritis or degenerative joint disease.
Diagnosis
• Age: It usually affects people over 50 years of age.
• Physical examination of the arthritic shoulder usually demonstrates limited motion in all directions with pain.
• Crepitus (the crunching sensation inside a joint) is frequently found in shoulder arthritis.
• X-ray demonstrates evaluation of the arthritic shoulder.
glenohumeral joint
Tuina Treatment
• GunRou: Rolling and Kneading.• NaRou: Grasping and Kneading.• Flexion and external rotation of the shoulder
associated with pressing and kneading.• Rotating.• Shaking.• Using heating pad 2-3 per day.
Acupuncture
• Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes.
6 Cervical Spondylosis
• Definition:
that is due to deterioration related wear and tear on the cervical vertebrae (bones) and cartilage or disc of the neck. That affects the brachial plexus lead to nerves pain also.
Symptoms
• Cervical spondylosis typically affects only the neck, causing pain and stiffness. When nerve compression also is present, signs and symptoms of cervical spondylosis may include:
• A stiff, painful neck • Shoulder, arm or chest pain • Tingling and pinprick sensations in the arms, hands.• Numbness and weakness in the arms, hands.
Pathogenesis
1) Intervertebral disc herniation:
① Injury; ② degenerative changes.
2) Degeneration of cervical vertebrae:
① Osteophytosis of the vertebral bodies.
② Hypertrophy of the facets and laminal arches.
3) ligamentous and segmental instability.
Radiation of cervical nerves
Physical Examination
1) Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending 45°; Rotation 60-80°.
2) Tension arm test.
3) Percussion head test.
4) Spurling test.
5) Jackson test.
6) Compression shoulder test.
7) Traction test.
Tension arm test
Percuss head test
Jackson test
Compression shoulder test
Traction test
Imaging
• A spine or neck x-ray shows abnormalities that indicate cervical spondylosis.
• A CT scan or spine MRI confirms the diagnosis. • A myelogram (x-ray or CT scan after injection of dye into
the spinal column) may be recommended to clearly identify the extent of injury.
• An EMG may also be recommended.
Treatment by TCM
1) TuiNa: RouGun (rolling and kneading), NaRou (Grasping and kneading), An (pressing), Ban (adjustment).
2) Acupuncture: GB20 (风池 ) ， GB21 (肩井 ) ， DU14 (大椎 ) ， SI11 (天宗 ) ， LI12 (曲池 ) ， TE 14 (外关 ) ， LI 4 (合谷 ) ， DU20 (百会 ) ， DU (上星 ).
3) Chinese herbs: ① Wind Bi: FangFengTongShenWan,DuHuoJiShengWan.
② Blood stagnation: FuFangDanShengWan. ③ ShenYang deficiency: ShenQiWan,
BuYangHuanWuWan, TanWangBuXinWan.4) Traction.
Ⅲ Cautions or Contraindication
• Acute injury.
• Fracture.
• Tear ligament.
• Ulcer.
• Eczema.
• Hemophilia.
