Napich Boonyakiat 7214207

Case Report

In Summary & Discussion

On Speciaty Development (CL840)

Case 1: Left side Rhomboid Pain

A 65 y o male with 4 months pain start at rhomboid area by the shoulder blade, radiate to neck
and deltoid mainly on the left side, the pain is fixed location, stabbing and aggravated after
waking up, alleviated by moving. The pain began slowly due to working as an auto body
mechanic, repetitive use. This patient came to see acupuncturist directly, never seen by other
physicians before for this condition. His symptoms had never fully resolved, sleep was disturbed
(3-4 times per night) and everyday function was greatly limited. He takes ibuprofen sometime
when the pain is severe.

Examination: Lt Rhomboid Trigger Point positive

 (*picture show the Rt side but the patient has left side pain)

Western Diagnosis: Rhomboid muscle pain (base on symptom presented)

TCM Diagnosis: Bi syndrome due to Qi and blood stagnation and underly Sp Qi def.

Treatment Principal: Unblocked the channels and promote the circulation of Qi and Blood.
Relieve pain and tonify Sp Qi def

Plan of treatment: Acupuncture 1x per week for 4-6 weeks. Yellow oilment topical use rub
between the pain areas. The next step if the applied treatment is not effective, cupping,
electroacupuncture with herbal prescription can be suggested.

Herbal Formula Suggestion: Shen Tong Zhu Yu Tang

Pharmaceutical
Pin Yin Dosage Actions
Latin

Rx. Gentianae Qin Jiao 3-9g Dispels Wind-Dampness and relaxes the sinews.
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Rx. Chuanxiong Chuan 6-9g Invigorates the Blood and promotes the movement of Qi, expels Wind
Xiong and alleviates pain. 
With  Dang Gui, for pain, numbness and paralysis from Wind-Dampness
and Stagnant Qi blocking the Blood channels preventing nourishment
from reaching the sinews.

Sm. Persicae Tao Ren 6-9g Breaks up Blood Stasis and invigorates Blood circulation.
With Dang Gui and Hong Hua  for pain associated with Blood Stasis. 
With Hong Hua, invigorates the Blood for all types of Blood Stagnation
such as dysmenorrhea, amenorrhea with abdominal pain, clotting and
scanty flow, swollen painful sores, chest pain due to Blood Stasis and
Rheumatoid arthritis.

Flos Carthami Hong 6-9g Invigorates Blood, dispels Blood Stasis and alleviates pain. 
Hua With Tao Ren,  Invigorates the Blood for all types of Blood Stagnation
such as dysmenorrhea, amenorrhea, swollen painful sores and chest
and abdominal pain. 
With Tao Ren and Dang Gui, for pain associated with Blood Stasis. 
With Chuan Xiong,  for chest and abdominal pain due to Qi and Blood
Stasis.

Rx. Glycyrrhizae Gan Cao 3-6g Moderates spasms, alleviates pain and harmonizes.

Rz. & Rx. Qiang 3-6g Expels Wind-Cold-Dampness, unblocks painful obstruction, alleviates
Notopterygii Huo pain and guides Qi to the Tai Yang and Du channels. 
With Chuan Xiong,  for headache and generalized body aches and pains
associated with the common cold or painful obstruction.

Myrrh Mo Yao 3-6g Invigorates Blood, dispels Stagnation, reduces swelling and alleviates
pain. 
With Hong Hua, for chest and abdominal pain, amenorrhea and
dysmenorrhea due to Blood Stasis.

Rx. Angelicae Dang 6-9g Invigorates and harmonizes the Blood, disperses Cold and stops pain
Sinensis Gui due to Blood Stasis. 
With  Chuan Xiong for pain , numbness and paralysis from Wind-
Dampness and Stagnant Qi blocking the Blood channels preventing
nourishment from reaching the sinews. 
With Tao Ren and Hong Hua for pain associated with Blood Stasis. 
With Gan Cao,  moderates spasms and relieves abdominal pain.

Excr. Trogopteri Wu Ling 3-6g Invigorates the Blood, disperses Blood Stasis and alleviates pain.
Zhi With Xiang Fu for epigastric pain.
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Rz. Cyperi Xiang 1-3g Spreads and regulates Liver Qi  and alleviates pain. 
Fu With Wu Ling Zhi for epigastric pain. 
With Chuan Xiong,  for Qi Stagnation combined with Blood Stasis.

Rx. Cyathulae Chuan 6-9g Expels Wind, invigorates the channels and Blood for pain due to
Niu Xi Wind-Dampness.

Pheretima Di Long 3-6g Drains Heat and stops spasms and convulsions and unblocks and
promotes movement in the channels and collaterals.

Modification: add Bai Zhu 10g and Fu Ling 12g to strengthen stomach and Sp, promote
production of Qi.

Treatment outcome: After having 2 treatments with acupuncture, the rhomboid pain is less
notice, now the pain is mostly at deltoid area left side,
After 4 treatments, the pain at rhomboid and deltoid is substantially relieved. Recommend to
do stretching exercise at home.

Lower neck and upper back (rhomboid) stretch

1. Stretch your arms out in front of your body. Clasp one hand on top of your other hand.
2. Gently reach out so that you feel your shoulder blades stretching away from each other.
3. Gently bend your head forward.
4. Hold for 15 to 30 seconds.
5. Repeat 2 to 4 times.
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Resisted rows

Note: For this exercise, you will need elastic exercise material, such as surgical tubing or Thera-Band.

1. Put the band around a solid object, such as a bedpost, at about waist level. Stand facing where
you have placed the band. Hold equal lengths of the band in each hand.
2. Start with your arms held out in front of you.
3. Pull the bands back, and move your shoulder blades together. As you finish, your elbows should
be at your side and bent at 90 degrees (like the angle of the letter "L").
4. Return to the starting position.
5. Repeat 8 to 12 times.

Neck stretches

1. Look straight ahead, and tip your right ear to your right shoulder. Do not let your left shoulder
rise as you tip your head to the right.
2. Hold for 15 to 30 seconds.
3. Tilt your head to the left. Do not let your right shoulder rise as you tip your head to the left.
4. Hold for 15 to 30 seconds.
5. Repeat 2 to 4 times to each side.
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Neck rotation

1. Sit in a firm chair, or stand up straight.

2. Keeping your chin level, turn your head to the right, and hold for 15 to 30 seconds.
3. Turn your head to the left, and hold for 15 to 30 seconds.
4. Repeat 2 to 4 times to each side

Differential Diagnosis Related Disorders: The following disorders should be included in

the differential diagnosis.

• Thoracic Vertebral Articular Dysfunction:

A fixation of the spinal facet joints in the upper thoracic spine may also produce
symptoms that are similar to those of rhomboid pain. Typically the upper thoracic spine
will be unusually flat and not flex forward properly.
• Scapulocostal Syndrome:
Pain in the back and or shoulder that may involve other parts of the arms or chest. The
cause is unknown but may be a result of postural problems.

Discussion:

Location: The rhomboid muscle group is found between the spine and the scapula in the mid-
back region. It lies deep to the Trapezius muscle and is composed of the rhomboid major and
rhomboid minor muscles.

Function: In everyday life, the rhomboid muscles

function to position the scapula (a.k.a. the shoulder
blade) during various movements of the shoulder and
arm.

Muscle Structure: The rhomboid minor is smaller than

and lies above (superior to) the rhomboid major. Both
muscles originate along the thoracic spine with their
fibers running diagonally downward and outward to
attach along the inside border of the scapula.
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• The rhomboid minor originates on the spinous processes of C7 and T1 and attaches to the
medial border of the scapula near the root of scapular spine.
• The rhomboid major originates from the spinous processes of T2 to T5 and attaches along
the lower half of the scapular border.
Muscle Actions: Contracting as a whole, the rhomboid muscles pull the shoulder blade
towards the spine (scapular adduction). They can also act to elevate the shoulder blade and
rotate the shoulder blade so that it lowers the shoulder joint (glenoid fossa).

Symptoms & Findings: Clients with active rhomboid pain will present with any or all of the
following symptoms or clinical findings:

• Pain Between the Shoulder Blades: an aching (but not deep) pain that is felt along the inside
of the shoulder blade.
• Pain is usually felt at rest and not typically affected my movement.
• The client may repeatedly reach to rub this area for relief.
• The pain feels superficial
• Clients may hear snapping or grinding noises from the region around the shoulder blade
during movements of the arm.

Acupuncture Treatment: for pain I use GB20, UB10, GB21, LI16, SI15, SJ14, LI15 and then Tonify
Sp Qi ST36, Sp3, 6, 9, UB20, 21

Special Acupuncture Technique: DNA (Distal Needling Acupuncture) by Bod Doane

Rhomboid Muscle - Target Hand Yang Ming, Needle Bilaterally: LI5 to 12, ST41 to 35, LV4 to 8,
Lu 9 to 5
Mostly in my technique I use distal needle points first and Patient need to move the effect area
for at least 10 mins then I use local points after.

References:

- The treatment of pain with Chinese Herbs and Acupuncture Edited by Sun Peilin
- Rhomboid Trigger Points: A Pain Between the Shoulder Blades October 16, 2015 by Dr. Laura
Perry TriggerPointTherapist.com
- Rhomboid Muscle Strain: Rehab Exercises
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zp4503