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StuckintheMiddle

Acupuncturetreatmentofpersistentthoracicpain

•  Thereareseveralpresenta=onsofpersistentanddistressingthoracicpainthatareresistanttotreatmentbymanualorpharmacologicaltherapybutrespondwelltoacupuncturetreatment

•  Anysuchcondi=onisworthiden=fyingandexploring

TheThoracicCage

•  12thoracicvertebrae•  12pairsofribs•  Costalcar=lages•  Sternum•  Thoracicmusculature–intercostals,paraspinals

•  Upperlimbmusculature

Costalcar=lages

Sternum

Ribs

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Floa=ngribs–11&12

Manubrium

Body

Xiphoidprocess

Sternalnotch

Sternalangle

Costo-vertebraljoint

Costo-transversejoint

Costo-chondraljoint

Sterno-chondraljointAnterior–Rib8Lateral–Rib10

Posterior–T12

Superiormedialthirdofclavicle

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Thoracicmusculature

•  Intrinsicmusculature:– Paraspinalsincludinglongissimus(innerBl)andiliocostalis(outerBl)

–  Intercostals–partofGBjingjin– Ruledbylegyang

Thoracicmusculature

•  Extrinsicmusculature:– MainlyshouldergirdlemusculaturethataXachestoribcageandspine

– Allruledbyarmmeridians

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Points

•  Huatuojiajipts.–  0.5cunlateralto=pofspinousprocess–  strongeffectonspinal=ssuesatthatsegment

•  Jointsandsegmentalmuscles

- insertperpendicularlydeeptofacetjoint

Points

•  InnerBlpoints–  1.5cunlateralto=pofspinousprocesses–  moregeneralsegmentaleffectthanhuatuopoints–  passthroughlongissimusmuscle–  insertat45degreestowardsspine

Points

•  OuterBlpoints–  3.0cunlateralto=pofspinousprocesses–  justmedialtoanglesoftheribs–  insertveryobliquelytowardsspine–  passthroughfibresofiliocostalisfibres–  usefortrea=ngribproblems

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Iliocostalistendinopathy

•  Verypreciseandpersistentpain

•  Doesnotrespondwelltomassage,manipula=onorothermanualtherapytechniques

•  MaintendernessisatouterBlpt

Costo-chondralorsterno-chondraljts

•  Thesejointsaremorejunc=onsthanpropermobilesynovialjoints.

•  Iftheyseparateforanyreasontheycanrepairslowly

•  Paincomesonwhenthejunc=onisdistorted

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La=ssimusdorsi

•  Latdorsiisanadductorandinternalrotatoroftheshoulder

•  Triggerpointsinthemusclereferpaintomedialtotheinferiorangleofthescapula

•  Thepainseemsnon-mechanical•  Itisodenworseatnight

La=ssimusdorsi

Serratusanterior

•  Notsocommon

•  Itriedseveraltreatmentsinthiscaseoverseveralweeks,whichproducedliXlesustainedrelief–  firstlytrea=ngtheaffectedvertebralsegment,– secondlytrea=ngtheaffectedrib

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Serratusanterior

•  OnthedayIfilmedIspentaliXleextra=metrackingdownthesiteofthemostextremetenderness

•  ThisturnedouttobesomefibresofSerratusanteriorastheyinsertedontotherib

•  Itcouldbethoughtofasatendinopathy

Serratusanterior

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Treatmentofribproblems

•  Thesearecommon,selflimi=ngdisordersofasinglerib

•  Painisaffectedbybreathinginorout– Usuallyfeltatthebackorsides

•  MaintendernessatouterBlpointandatthespine

Costo-vertebraljoint

Costo-transversejoint

Costo-chondraljoint

Sterno-chondraljoint