Levator Scapulae Pain: How to Knock It Out in 10 Min 90% For Sure with Dry Needling

Many musculoskeletal clinicians use dry needling (DN) to treat myofascial pain syndrome (MSP). Levator scapulae pain (LSP) is one of the most commonly seen MSP.

An Extraordinary Technique

An extraordinary feature of DN, particularly the deep DN, is that it requires extraordinarily strong stabbing to be effective, as the study by one of the founders of DN Lewit K. demonstrated (Lewit, K, 1979).

In many other types of needling such as TCM acupuncture, patients may feel being stabbed only for a short moment of 10 – 30 seconds while the needle being twisted by practitioners. Particularly in Japanese acupuncture, a clinician will treat a patient as if handling a sleeping cat without waking it up: if a patient feels anything, your treatment failed.

But in DN, needles are often inserted deeply with ‘sparrow pecking’ or ‘fast-in & fast-out’ pistoning movement for at least 1-2 minutes, resulting in excruciating immediate pain plus post-needling pain or soreness which may last up to 72 hours (Aitor M.P., 2018).

A "Labor" Intensive Modality

In many cases, DN was accompanied by ischemic compression or post-needling stretching (Manuel R.H et al 2022). According to Mayo Clinic, “Dry needling usually is paired with exercise and other physical therapy techniques to prevent trigger points from reoccurring”.

The Most Painful Thing I’ve Ever Loved

Some time in 2015, a patient talked about her experience with dry needling treatment (AshleyJane Kneeland, 2015):

“After I lie down on a massage table, my physical therapy doctor inserts a thin-filament needle directly into the muscle that is currently tight or spasming. Then she jiggles the needle up and down until my muscle responds with a twitch.

“Dry needling hurts, but for me the hurt is worth it. Because the knots in my shoulders are so severe, I find dry needling extremely painful. I walk out of the office feeling like my nerve endings have been cut and exposed to air. A few hours later, that sensation passes, and my shoulders are noticeably more relaxed. Over time — two appointments a week for six weeks — most of my spasms, and their resulting headaches, fade away.”

The patient's post on the internet titled: “Dry Needling: The Most Painful Thing I’ve Ever Loved”.

It is true that patients will have to “love” the torture anyway. Just like a stomach cancer patient would “love” to have his or her breadbasket resected by 80% or even completely removed.

But a question is: will DN be proportionally more effective than other types of needling corresponding to the intensity of the torture imposed on the already-unfortunate patients? If the answer is yes, then would Japanese needling be worthless because patient will feel nothing when being pricked?

If not, why not discontinue such meaningless torturing?

The Popularity of Dry Needling

The popularity of dry needling among musculoskeletal community is striking. According to Edo Zylstra, the creator of KinetaCore in Michigan, which trains 50-80% of the PTs getting accredited in dry needling across the country: “[among] methods like e-stim, hot packs, ...correctional workout, and lasers …Dry needling permits physiotherapists to be the most reliable in returning clients...”

For many musculoskeletal clinicians, they feel application of DN greatly increased their confidence in their practice. Steve Curtis, a licensed PT for three decades who also became an acupuncturist 18 years ago, says “It’s a great technique. The dry needling is just a tool that blows the doors off any other (muscular-skeletal pain) technique that’s out there.” (Stainton, Lilo H, 2018).

According to Cleveland Clinic, “Dry needling is a safe, minimally painful and often very effective technique for people with certain musculoskeletal conditions. Many people have found the treatment to be a game-changer in improving their quality of life”.

How Effective DN Is for Musculoskeletal Conditions?

Another feature of DN is that it does not always provide consistent outcomes. Its clinical effectiveness appears to be very heterogeneous.

In 2017, a systematic review on the effectiveness of TrP DN for musculoskeletal conditions by physical therapists published on the Journal of Orthopedic Sports Physical Therapy (Eric Gattie et al, 2017) which included 13 trials with 723 participants. The review concluded:

Compared to no treatment or sham dry needling at 6 to 12 months,

1. For pain relief, very low-quality to moderate-quality evidence suggests DN is more effective for a short-term.
2. For function, low-quality evidence suggests DN is more effective for a short-term.
3. For long-term benefit, no evidence exists for a conclusion.

In 2020, a systematic review including 28 trials on the efficacy of DN for neck pain was published in the Journal of Clinical Medicine (Marcos J.N.S. et al, 2020), which reached the similar conclusion:

• Low to moderate evidence suggests that dry needling can be effective for improving pain intensity and pain-related disability in individuals with neck pain symptoms associated with TrPs at the short-term.
• No significant effects on pressure pain sensitivity or cervical range of motion were observed.

Specifically for neck and upper trap pain, a 2015 trial involving 52 patients investigated the efficacy of dry needling on an active MtrP on upper traps for the patients who have neck or shoulder girdle pain (> 3 months) ( Lynn H. Gerber, et al, 2015).

The outcome of this trial is that DN reduced VAS pain score by 74.3% (from 3.5 to 0.9) after 9 sessions of treatment performed in 3 weeks. But DN did not produce significant improvement for BPI and PPT.

Since this trail did not set up a control group for comparison, we are not sure how much effect was truly produced by DN itself and how much was from patient's natural healing.

Assuming patients' natural healing produced 17% pain reduction from the base line (17% is a reasonable number based on literature), it follows that DN in this case produced 57.3% pain reduction after 9 sessions of treatments for neck and upper trap conditions (which includes the levator scapulae muscle). This is a wonderful outcome.

But with DN, can we do even better in obtaining a more reliable efficacy with less torture to our patients? Yes, we can. Actually, we can transform DN into a magic wand. Here you only need to know the “secrets” how.

The “Secrets” to Obtaining Magic Effectiveness & Reliability

The “Secrets” to obtaining magic effectiveness & reliability are:

1. Forget your beloved TrP (No one is sure about its existence nor its clinical meaning. Even the hardcore advocators of TrP admit it is no more a hypothesis).
2. Forget the muscle or body region where the pain is located.
3. Insert your needles at a location far away from the pain. To treat pain at A, forget A, pain at B, forget B, pain at C, forget C ...don't rub salt to the wound.

Is TrP Necessary? Debate continues about whether the MTrP is necessary for MPS diagnosis and whether it needs to be the target of treatment (Lynn H. Gerber, et al, 2015). The pathogenesis of the MTrP is elusive and current explanations about its relationship to MPS remain incomplete.

When Pain Is at The Insertion of Levator Scapulae

For levator scapulae pain (LSP), the pain may happen at the origin, the insertion, the upper body, the middle body or the lower body of the muscle.

In my experience, the most frequently seen LSP is located at the insertion of the muscle – on or surrounding the superior angle of the scapula.

For LSP surrounding the origin of the muscle, there are countless locations on the body that can be needled to produce a pain relief effect, more or less. Among them, there are at least 10 locations which can produce a miracle effect instantly with 90% success rate, pathology largely regardless. Note, all of these magic locations are far from upper back region.

Among these 10 magic locations, one of the most convenient one for needle insertion is at anterior medial side of the ankle joint surrounding anterior tibiotalar ligament (ATTL) (close to TCM meridian acupoint LR4).

Be A Sharpshooter, No More Guess Work

When the size of the said specific LSP is of a golf ball, you can identify a pea-sized spot at ATTL area which is tender when pressed. The intensity of the tenderness of the spot under pressure is roughly proportional to the intensity of LSP.

Keep your patient in a sitting or supine position. Upon insertion of one or a few 0.18 x 15 to 25 mm needles on or surrounding this tender spot (at the ankle opposite to the LSP), with 3-5 seconds and 90% certainty, your patient while squeezing his or her scapulae toward spine as you instructed, will feel puzzled: Are you a magician?

After the needle insertion, no need to perform any fancy manipulation such as 'sparrow pecking’ or ‘fast-in & fast-out’ in a hope to improve your chance of success.

Attention! For the maximum efficacy, you must careful identify the most painful spot at the ATTL area at the ankle joint. Also, before insert needles, be sure to ask patient “how much pain do you feel right now, on a scale of 1 to 10?” This is for a comparison which will let you know how much your needles worked instantly after the needle insertion.

Five to 10 seconds within the needle insertion, the patient may tell you no pain any more, or much less than before, or 50% better .... Ask patient to rank the pain level again on a scale of 1-10. Leave the needles stay for 20 - 30 minutes while your patient can enjoy a short nap with his or her mind soaked in a soft meditation music.

For minor or moderate conditions, pricking this ankle joint spot at one side (opposite) may be enough: pain could melt away completely in 5-10 seconds while patient is squeezing his or her scapulae.

If the initial pain does not go away completely by the first needle, you can add a few more needles covering the entire opposite ATTL area, or a needle at a tender spot on the same side ATTL area. If some pain still remains, you may add further another needle at a tender spot on the opposite wrist. If still some pain remains, go to the same side wrist. There are many “spare tires” for you to use. Keep going this way, you can erase the LSP surrounding the superior angle of scapulae completely in 10 minutes.

Remember always identify the tender spot before needling. This is the key to get maximum and consistent effectiveness.

Also, usually the instantly relieved pain will come back at a lower intensity in hours or a few days or weeks, depending on how severe or how chronic the initial condition is. The permanent cure of a mild to moderately-severe LSP pain usually needs only 2- 4 treatments at 1 session per week.

If Pain Moves

Often the patient may tell you the pain moved to a different location, for example a little bit going up or down, or going more medially or anteriorly, .... no matter where the pain goes, you can always identify a corresponding tender spot somewhere surrounding or near by the ATTL, once pricked, will take away or relieve the new pain instantly.

Change the Game: No More Shot in The Dark

In modern medicine particularly in musculoskeletal field, we have a lot of “uncertainty” but no “confidence”. All we can do is just “shot in the dark then pray”. Even a simple pain at levator scapulae which can plague every one – both patients and clinicians.

With your transformed dry needling, not only will we become more confident in winning patients' trust, we can change the game, we can change the status-quo world of medicine.

References

Aitor M.P. et al, Post-needling soreness after myofascial trigger point dry needling: Current status and future research, J Bodyw Mov Ther., 2018 Oct;22(4):941-946

AshleyJane Kneeland, Dry Needling: The Most Painful Thing I’ve Ever Loved, 2015, everydayhealth.com

Eric Gattie et al The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther 2017;47(3):133–149

Lewit K: The needle effect in the relief of myofascial pain. Pain 6: 83–90, 1979.

Lynn H. Gerber, et al, Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. PM R. 2015 Jul; 7(7): 711–718.

Marcos Jose Navarro Santana et al, Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis, November 2020, Journal of Clinical Medicine 9(10):3300

Manuel Rodríguez-Huguet et al, Dry Needling in Physical Therapy Treatment of Chronic Neck Pain: Systematic Review. J. Clin. Med. 2022, 11, 2370

Stainton, Lilo H, Physical Therapists Win Latest Battle in Turf War... New Jersy Spotlight News 2018.

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