Needling

Question 1

FLEXOR HALLUCIS BREVIS

Answer 1

With the patient in a side lying position on the involved side and the area to be needled exposed, the muscle is palpated for in search of active TrPs. A 13mm fine gauge needle is inserted from the medial direction just below the first metatarsal. The local twitch response will often produce flexion movement of the great toe.

Question 2

QUADRATUS PLANTAE

Answer 2

13-30 mm needle.
With the patient prone and the feet hanging off the table the needle is inserted at a 90 degree angle. It is best to use a finer gauge needle for the foot, as it can feel very tender for the patient.

Question 3

Quadratus Lumborum

Answer 3

All TrPs can be needled prone in a caudal medial direction except for the superior deep TrP which can be performed side-lying. Alternatively, all could be needle side-lying if desired.Aim at the posterior aspect of the transverse process for the deep superior TrP.

Question 4

Flexor Hallucis Longus

Answer 4

30-40mm needle.
With the patient prone, the TrP is needled with an anterior and slightly lateral needling direction. The posterior aspect of the fibula is used as an anatomical landmark to assure the proper position of the needle and a sufficient depth of penetration.

Question 5

Lumbar Paraspinals – Iliocostalis Lumborum and Lx and Sx Multifidus

Answer 5

Iliocostalis Lumborum – 30-50mm needle. With patient prone, locate borders of muscle and palpate TrP, due to the ropeyness of the muscle slow longitudinal palpation may help to distinguish the TrP. Needle in an oblique caudal direction.
Multifidus – 20-30mm needle. With patient prone, palpate between the spinous and transverse processes of the lumbar/sacral spine. If able, push the erector spinae musculature out of the way and needle on an oblique medial angle.

Question 6

EXTENSOR DIGITORUM BREVIS

Answer 6

13-30mm needle can be used and angled perpendicular to the skin. The needle may make contact with the underlying bone.

Question 7

ABDUCTOR HALLICIS

Answer 7

With the patient in side lying on the affected side, or in a supine position, a 13-30mm needle is inserter in a lateral direction towards the underlying bone.

Question 8

Flexor Digitorum Longus

Answer 8

The patient lies on the involved side and the limb is positioned as described above. A 30-50mm needle is inserted obliquely with the needle tip directed towards the posterior surface of the tibia in order to avoid the tibial nerve and posterior tibial vessels.

Question 9

Gluteus Maximus

Answer 9

Consider patients tissue quality and levels of subcutaneous fat as strong depression of the needle is often required to reduce the distance from the skin to the muscle.

30-75mm needle at a 90 degree angle.
TrP 1 and 2 can be identified by flat palpation and isolated between two fingers of one hand.
TrP3 can be pincer palpated and needled while grasping firmly or the same technique as for 1 and 2 can be used.

Gentle stretching should follow needling – advise patient of likely post Rx soreness.

Question 10

Gluteus Medius

Answer 10

The patient is side lying or prone and 40-75mm needle is inserted at a 90 degree in the region just inferior to the iliac crest. The insertion depth is dependent on the size of the patient.

Question 11

Gluteus Minimus

Answer 11

50-75mm needle is recommended; however, consider the amount of overlying tissue when choosing.

With the patient side lying or supine the needles are inserted at a 90 degree angle.

The lower posterior border of the gluteus minimus is located by defining the upper limit of the piriformis muscle. Direct the needle above this line in an upward direction to avoid the sciatic nerve as it exits the pelvis through the sciatic foramen.

Question 12

Piriformis

Answer 12

The patient may be lying prone or side-lying and 40 -75mm needles are inserted at a 90 degree angle

Be aware of the patient’s build – in a small, thin person a 30-40mm needle may reach the joint capsule though the skin, gluteus maximus and piriformis.

Deactivation of TrP1 should also reduce symptoms from TrP2.

Question 13

Iliopsoas

Answer 13

Psoas:

Only the distal portion of the psoas is accessible via needling. Please be aware that patients are usually prone to severe local soreness and disability for several days after having this muscle needled.
The psoas musculotendinous junction is accessible to needling within the femoral triangle. The position of the muscle in relation to the femoral vessels must be clearly palpated prior to needling.

The thigh is slightly extended, abducted and laterally rotated. A 40-50mm needle is directed towards the muscle and is angled to avoid the femoral vessels.

Iliacus:

TrPs close to the iliac crest are commonly needled with an abdominal approach. A 50-75mm needle is inserted inside the crest of the ilium and directed towards the TrPs. The needle must travel close to the inner surface of the ilium to avoid penetrating abdominal contents.

Question 14

Tensor Fascia Latae

Answer 14

With the patient supine or side lying insert a 30-40mm needle at a 90 degree angle.

Question 15

Sartorius

Answer 15

With the patient supine, insert a 30mm needle at an oblique angle to the muscle nearly parallel to the skin

Question 16

Rectus Femoris

Answer 16

The patient lies supine with the thigh leg in a relaxed comfortable position. A 30mm needle is inserted at a 90 degree angle into the TrP.

Question 17

Vastus Lateralis

Answer 17

With the patient supine or side-lying a 30-40mm needle is inserted at a 90 degree angle.

Question 18

Vastus Medialis

Answer 18

30-40mm needle. Position the patient with the leg well supported with the thigh flexed and abducted, and the knee flexed to 90 degrees. The needle is inserted at a 90 degree angle.

Question 19

Biceps Femoris

Answer 19

A 30-40mm needle is used.
Needles are inserted close to the midline of the thigh and directed laterally away from the tibial nerve and major neurovascular structures. This approach also avoids the peroneal branch of the sciatic nerve unless the most distal portion of the muscle belly is needled.

Question 20

Semitendinosus

Answer 20

40-75mm needle.
With the patient in the prone position, place a pillow or a bolster under their ankles. Insert the needle perpendicularly to the muscle surface directly into the MTrP.
Alternatively have patient supine with knee flexed to 90 degrees & the hip abducted. Pincer grip the muscle & direct needle medially to lateral in an anterior to posterior direction.

Question 21

Semimembranosus

Answer 21

40-75mm needle.
With the patient in the prone position, place a pillow or a bolster under their ankles. Insert the needle perpendicularly to the muscle surface directly into the TrP.
Alternatively have patient supine with knee flexed to 90 degrees & the hip abducted. Pincer grip the muscle & direct needle medially to lateral in an anterior to posterior direction.

Question 22

Adductor Longus & Brevis

Answer 22

The patient is supine, the hip externally rotated and the knee is flexed and supported by a pillow. Grasp the muscle belly and insert a 30mm needle anterior to posterior perpendicular to the muscle surface. Direct needle away from the femoral triangle.

Question 23

Adductor Magnus

Answer 23

50-75mm needle.
The muscle is commonly needled in the supine position with the knee flexed and hip externally rotated. The needle is inserted perpendicular to the muscle surface directly into the TrP.
Alternatively, side lying on affected side with top leg bent to 90 degrees at hip. Insert medial to lateral with ant/post or post/ant direction depending on path of femoral artery.

Question 24

Pectineus

Answer 24

30-40mm. Have the patient supine and the involved hip abducted, externally rotated, and slightly flexed. When needling this trigger point it is important for the practitioner to first isolate the femoral artery by palpating for its pulsations. The needle is then inserted medially away from the artery. On removing the needle, be sure to apply firm pressure with a cotton wool ball for 30 seconds. Travell & Simons (1993) recommend the inactivation of adductor magnus trigger points prior to treatment of those in the pectineus.

Question 25

Gracilis

Answer 25

The patient is supine with slight hip external rotation. A 30-40mm needle is inserted perpendicular to the muscle surface directly into the MTrP.
Needle may also be inserted obliquely with the fibre direction.

Question 26

Gastrocnemius

Answer 26

30 – 40mm needles
The gastrocnemius is more prone to post-injection soreness – the medial head more so than the lateral head.

The patient lies prone with the knee slightly flexed and the leg supported by a pillow.

For TrPs in the central part of the medial head, a pincer palpation is used to locate and fix the TrP and the needle is then angled medially.

For TrPs in the central part of the lateral head, a flat palpation is commonly used to locate the TrP. The needle is then directed perpendicular to the skin aiming in a posterior to anterior direction with a slight lateral angulation.

For TrPs in the proximal part of both heads, the needle is inserted towards the TrP in a posterior to anterior direction with the needle angled away from the popliteal fossa.

Question 27

Soleus

Answer 27

30-40mm needle for most people.

When needling soleus TrP1 the patient is sidelying (or prone) on the involved side and a 30-40mm needle is inserted at a 90degree angle from the medial side distal to the gastrocnemius lower fibres.

TrP 2 is needled from laterally as the patient lies on the opposite side (or prone). The needle is inserted at 90degrees and directed towards the fibula.

TrP 3 is also needled with the patient lying on the opposite side (or prone) and a 30mm needle is inserted at a 90degree angle from the lateral side.

Question 28

Peroneus Longus

Answer 28

30 mm needle.

With the patient side lying or supine insert the needle at a 90 degree angle towards the fibula

Question 29

Peroneus Brevis

Answer 29

30 mm needle.

With the patient side lying or supine insert the needle at a 90 degree angle towards the fibula

Question 30

Tibialis Anterior

Answer 30

30-40mm needles are inserted at a 45degree angle directing the needle tip towards the tibia from the lateral side thus avoiding deeper vessels. The supine patient may be more comfortable if the knee is slightly flexed and supported by a pillow/towel/bolster.

Question 31

Extensor Hallucis Longus

Answer 31

13 – 30 mm
If needling is to be used, insert the needle close to the lateral border of tibialis anterior and angle the needle towards the fibula. The angle should be deep enough to reach the TrPs but superficial enough to avoid the underlying deep peroneal nerve and anterior tibial vessels