For clinicians and trainees performing needling procedures:PT/DPT•MD/DO•NP•DC•RMT/LMT•Students
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Dry Needling (DN)
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Muscle Reference
Select a body region to browse its muscles — or use the sidebar to navigate directly.
Cervical & Upper Quarter
Free LibraryCervicothoracic Region
Upper Trapezius
Trapezius, pars descendens
High-attention regionPneumothorax-adjacent
Posterior view — trapezius highlighted
Pleural depth
~1.4cm (kyphosis-dependent)
No muscle-specific BMI-stratified depth study exists for upper trapezius. This figure marks where cadaveric work places the pleural space — it shifts with thoracic kyphosis, not BMI. Source: Kearns et al., 2022.
Depth gauge — illustrative, not patient-specificKearns et al. 2022
Anatomy Overview
Origin
External occipital protuberance, medial third of the superior nuchal line, ligamentum nuchae, spinous process of C7
Insertion
Posterior border of the lateral third of the clavicle
Innervation
Spinal accessory nerve (CN XI), with proprioceptive contribution from C3–C4 ventral rami
Primary Functions
Elevation, retraction, and upward rotation of the scapula; lateral flexion and contralateral rotation of the cervical spine
Referral Patterns
Myofascial trigger points in the upper trapezius are among the most frequently cited contributors to cervicogenic headache and posterior neck pain.
LocalPosterolateral neck, extending toward the mastoid process and temporal region
ReferredUnilateral occipital and temporal headache, often described by patients as a "band" or "vice-like" sensation
Less commonReferred pain along the angle of the jaw in some presentations
This referral pattern overlaps with that of the suboccipital group and levator scapulae, which is part of why differential mapping across the cervicothoracic muscles is described as useful in the literature.
Clinical Pearls
Frequently overlookedPatients with primarily occipital headache often attribute symptoms entirely to "tension" or screen posture without examination of the upper trapezius taut band specifically.
Common patient descriptions"A knot on top of my shoulder," tenderness that radiates "up the side of my neck and behind my ear."
DifferentialsCervicogenic headache, migraine without aura, levator scapulae syndrome, and thoracic outlet presentations — all of which can present with overlapping upper-quadrant referral.
High-attention anatomical region
The upper trapezius lies superficial to the lung apex. For needling, pneumothorax is the most frequently documented major adverse event associated with deep technique in this and adjacent muscles (rhomboid major, levator scapulae, iliocostalis). For manual work, sustained deep pressure in this region — especially with the patient prone or in positions that flatten the normal thoracic curve — warrants the same anatomical awareness, even though the risk profile differs from needling.
A cadaveric fluoroscopic study found that the needle length required to reach the pleural space at this site correlates with thoracic kyphosis — a relationship not captured by BMI alone. The same structural relationship (a flatter thoracic curve bringing the pleura closer to the surface) is relevant to how much depth sustained manual pressure can reach.
Case reports of pneumothorax following needling of this region have occurred in patients across the BMI spectrum, including normal-weight individuals where reduced subcutaneous tissue was specifically noted as a contributing factor — a consideration for manual practitioners using deep, sustained, or instrument-assisted pressure as well.
Other structures to note
Other structures described in the literature as relevant to this region include the spinal accessory nerve (motor supply to trapezius itself) and the superficial cervical plexus branches that cross the posterior triangle.
Literature Summary
Upper trapezius is one of the most studied muscles in the dry needling and trigger point literature, owing to its role in cervicogenic headache and tension-type headache research.
Sedighi, Nakhostin Ansari & Naghdi (2017) — compared superficial vs. deep dry needling of suboccipital and upper trapezius trigger points in cervicogenic headache, reporting improvements across headache index, tenderness, and range of motion measures for both depths.
Kearns, Lierly, Posteraro & Gilbert (2022) — cadaveric fluoroscopic assessment finding that the needle length required to reach the pleural space when needling upper trapezius correlates with thoracic kyphosis angle, independent of body size.
Case report literature (2024–2025) — multiple published reports of pneumothorax following needling of the upper trapezius/rhomboid region, generally resolving with conservative management (oxygen therapy) but occasionally requiring chest tube placement.
Anatomical Depth Reference
Published depth data for upper trapezius specifically (as distinct from the closely related lower trapezius and rhomboid major) is limited. The studies below describe the closest available anatomical context.
Kearns et al., 2022 — Thoracic Kyphosis & Pleural Depth
Cadaveric fluoroscopic study · Musculoskeletal Science & Practice
Adjacent region
Reported that the depth required to reach the pleural space when needling the trapezius region correlates with thoracic kyphosis angle — a structural variable independent of BMI. Authors recommended shorter needles (≤25mm) in this region as a general precaution.
No BMI-stratified or sex-stratified perpendicular depth measurements specific to upper trapezius were located in this review. The rhomboid major data below (an adjacent, structurally similar muscle over the same rib cage region) is presented as anatomical context.
Seol et al., 2014 — Rhomboid Major (adjacent muscle, context)
Ann Rehabil Med · n=62 · Ultrasound, BMI-stratified
Adjacent muscle
BMI Group
Skin → Muscle
Skin → Rib
Muscle Thickness
< 23 kg/m²
12 mm
21 mm
9 mm
23 – 25 kg/m²
14 mm
24 mm
10 mm
≥ 25 kg/m²
18 mm
27 mm
9 mm
Authors reported that BMI predicted both skin-to-muscle and skin-to-rib distances, but muscle thickness itself did not vary significantly by BMI — the primary driver of depth differences was subcutaneous fat, not muscle bulk. For the 23–25 kg/m² group, the authors noted overlapping confidence intervals between "definitely in muscle" and "definitely near rib," meaning a clean separation could not be established for that range.
Sedighi A, Nakhostin Ansari N, Naghdi S. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther. 2017;21(4):810–814.
Kearns GA, Lierly M, Posteraro RH, Gilbert KK. Correlation between thoracic kyphosis and dry needle length required to reach the pleural space needling the upper trapezius: a cadaveric fluoroscopic assessment. Musculoskelet Sci Pract. 2022;62:102622.
Aggravating factorsPain aggravated by prolonged sitting, climbing stairs, or hip internal rotation/adduction
Because the sciatic nerve passes in close anatomical relationship to piriformis in the majority of individuals, distinguishing myofascial referral from true radicular or nerve-entrapment pain (piriformis syndrome) is a recurring theme in the literature.
Clinical Pearls
Frequently overlookedPiriformis involvement is often considered only after lumbar spine causes have been investigated, despite deep gluteal pain being a common presenting complaint independent of spinal pathology.
Common patient descriptions"A deep ache in my buttock that goes down my leg," worse with sitting on hard surfaces or after long drives.
Differentials in the literatureLumbar radiculopathy, sacroiliac joint dysfunction, ischiofemoral impingement, and proximal hamstring tendinopathy all overlap with this presentation.
Safety Considerations
High-attention region — sciatic nerve
The sciatic nerve runs immediately deep to piriformis in the great majority of individuals (anatomical variants exist where the nerve passes through or superficial to the muscle, more frequently described in some populations). This matters for needling depth, and also for how much sustained deep pressure or instrument-assisted work in this region might compress or irritate the nerve.
A cadaveric study of palpation-guided needling in the piriformis medial region found accidental sciatic nerve contact in 11 of 14 trials (78.5%) using landmark technique alone — a reminder that landmark-based localization of this muscle is imprecise regardless of modality.
A 2024 observational study (n=56) examining anthropometric predictors of skin-to-sciatic-nerve distance found the best available model explained only 37.9% of variance — and the authors concluded this was insufficient to support palpation-guided estimation for this specific muscle, recommending ultrasound guidance for needling. For manual work, this same variability is a reason to work gradually and monitor for any neural symptoms (tingling, radiating pain) rather than relying on a fixed depth or pressure target.
Other deep gluteal structures described in proximity include the inferior gluteal artery/nerve, the pudendal neurovascular bundle, and the posterior femoral cutaneous nerve — relevant to both needling and deep manual or instrument-assisted approaches to this region.
Literature Summary
Valera-Calero et al. (2024) — observational study of 56 patients (34 male, 22 female) with piriformis muscle syndrome, measuring skin-to-sciatic-nerve distance via ultrasound and correlating with BMI, weight, and hip circumference. No significant difference in this distance was found between men and women.
Orthopedic-acupuncture cadaveric literature — describes that a 75mm needle reaches piriformis without contacting the sciatic nerve in approximately 84% of cases using a specific landmark technique, with longer needles (75–100mm) suggested for patients with greater gluteal subcutaneous tissue.
Tabatabaiee et al. (2019) — randomized trial of ultrasound-guided dry needling for piriformis syndrome reporting clinically meaningful short-term pain reduction versus a waitlist control.
Anatomical Depth Reference
Valera-Calero et al., 2024 — Skin-to-Sciatic-Nerve Distance
Regression equation: y = 0.39 + 0.95x (predicted vs. observed deep fascia depth, cm), where x derives from hip perimeter. Adjusted R² = 0.379 — explaining roughly 38% of the variance in sciatic nerve depth. The authors' own conclusion: this is "not enough to ensure risk-free interventions," and palpation-guided estimation is not supported for this specific muscle by their model.
Orthopedic-Acupuncture Cadaveric Literature — Needle Length by Body Habitus
Cadaveric, landmark technique
Limited evidence
Patient Habitus
Described Needle Length
Normal / low BMI
50 mm
General population
75 mm (~84% accuracy avoiding sciatic contact)
Overweight – obese
75 – 100 mm
Gluteal subcutaneous tissue thickness in obese individuals has been described in the range of 46–78mm in this literature — meaning the subcutaneous layer alone can approach or exceed many standard needle lengths before the muscle is reached.
Hip perimeter (approximate study range: 85–125 cm)105 cm
Model's predicted depth for this hip perimeter
Approximate spread, given R² = 0.379
Predicted depth
— cm
Variance explained
38%
This shows what the published regression model predicts for a given hip perimeter — it is not a measurement of any individual patient, and MyoMap Clinical™ does not generate patient-specific estimates. The study authors' own conclusion was that this model explains only 38% of the variance in sciatic nerve depth, describing this as "not enough to ensure risk-free interventions," and recommending ultrasound guidance for this muscle. The shaded band is an illustrative representation of that uncertainty — the true depth for any given person could fall well outside the dashed line.
References
Valera-Calero JA, Varol U, Plaza-Manzano G, et al. Testing the safety of piriformis dry needling interventions: an observational study evaluating the predictive value of anthropometric and demographic factors. J Clin Med. 2024;13(22):6674.
Depth gauge — illustrative, not patient-specificCompiled protocol literature
These figures describe needle length along the angle of approach, not perpendicular skin-to-muscle depth — the scapular portion is explicitly angled toward bone rather than perpendicular.
Anatomy Overview
Origin
Posterior tubercles of the transverse processes of C1–C4
Insertion
Superior angle and medial border of the scapula, between the superior angle and the root of the spine of the scapula
Innervation
Dorsal scapular nerve (C4–C5), with variable contributions from C3–C4 cervical nerves directly
Primary Functions
Elevation of the scapula; downward rotation of the glenoid cavity; assists in lateral flexion and ipsilateral rotation of the cervical spine when the scapula is fixed
Referral Patterns
Published referral descriptions for levator scapulae myofascial trigger points commonly include:
LocalA focal "ache" at the superior angle of the scapula and adjacent posterolateral neck
ReferredPain along the posterior border of the neck, sometimes extending toward — but generally not as far as — the occiput
Patient languageA sensation often described as a persistent "crick" or stiffness, particularly on cervical rotation toward the affected side
This referral pattern overlaps substantially with upper trapezius and the cervical paraspinals, and the literature describes levator scapulae syndrome as a frequently co-occurring or mimicking presentation alongside cervicogenic headache.
Clinical Pearls
Frequently overlookedThe superior angle of the scapula attachment site is easily palpated but is often missed on examination when attention is focused on the more superficial upper trapezius.
Common patient descriptions"A constant crick in my neck," or pain that is "worse when I turn my head to look over my shoulder while driving."
Differentials in the literatureCervical facet joint pathology, scapulothoracic bursitis, and rotator cuff pathology (given the proximity of the superior angle to the supraspinatus origin) are commonly noted as overlapping presentations.
Safety Considerations
High-attention region — pneumothorax / technique-dependent
Levator scapulae is grouped in the published literature alongside upper trapezius, rhomboid major, and iliocostalis as a muscle where deep needling near the rib cage carries pneumothorax risk. The same anatomical relationship — this muscle sits over the rib cage, closer to the pleura at its superior/medial portions — is relevant context for sustained deep manual pressure or instrument-assisted work in this region, even though the needling-specific techniques below don't translate directly:
The superior (cervical) portion is described in clinical trial protocols as a "ropy muscle band" needled with a shallow, perpendicular approach directed toward the practitioner's palpating finger — not toward a depth target. For manual work, this same "ropy band" is the typical palpation landmark for trigger point pressure release or myofascial techniques at this muscle.
The inferior (scapular) portion is described as needled "through the skin at a shallow angle, directed toward the upper, medial border of the scapula" — i.e., toward a bony landmark, with the scapula itself acting as the depth limit.
A published case report describes a 50mm needle inserted obliquely (lateral-to-medial, superior-to-inferior, posterior-to-anterior) passing through upper trapezius into the levator scapulae belly — illustrating that needle length and perpendicular tissue depth are not the same quantity for this muscle.
Because the published technique for the scapular portion of this muscle relies on bony contact (the medial border of the scapula) as the safety endpoint rather than a measured depth, depth figures for this muscle should be interpreted as describing the muscle belly itself — not as a substitute for landmark technique, whatever the modality.
Literature Summary
Benito-de-Pedro et al. (2023) — randomized controlled trial (n=52–54) comparing ultrasound-guided deep dry needling and percutaneous electrolysis for active levator scapulae trigger points, using 30mm or 40mm needles under direct ultrasound visualization.
Gagnon et al. (2024) — case report describing dry needling of levator scapulae trigger points and the distal periosteal enthesis (superior angle of scapula) as part of a multimodal approach for chronic tension-type headache, using a 50mm needle inserted obliquely through upper trapezius.
Clinical trial protocol literature (e.g., NCT05493098) — describes distinct needling approaches for the cervical vs. scapular portions of levator scapulae, reinforcing that this muscle is treated as anatomically and technically heterogeneous along its length.
Anatomical Depth Reference
No BMI-stratified or sex-stratified ultrasound depth study specific to levator scapulae was located in this review. The studies below describe needle lengths and techniques used in published protocols, which provide indirect context.
Published Needle Lengths by Technique
Compiled from RCT and case report protocols · Not BMI-stratified
Limited evidence
Portion / Technique
Reported Needle
Endpoint Described
Cervical portion, perpendicular
30 mm
Palpating finger (taut band, ~5mm band width)
Cervical/scapular, ultrasound-guided DDN
30 – 40 mm
Direct ultrasound visualization of muscle belly
Scapular portion, oblique through trapezius
50 mm
Levator scapulae belly, superior angle of scapula
These figures describe needle length along the angle of approach used, not perpendicular skin-to-muscle depth — the scapular portion technique is explicitly angled toward bone rather than perpendicular. They are presented here as the closest available published context, not as depth equivalents.
References
Benito-de-Pedro AI, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, et al. Efficacy of deep dry needling versus percutaneous electrolysis in ultrasound-guided treatment of active myofascial trigger points of the levator scapulae in short-term: a randomized controlled trial. Life. 2023;13(4):939.
Gagnon C, et al. Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: a case report. Clin Case Rep. 2024.
Depth gauge — illustrative, not patient-specificLópez-Castellanos et al. 2022
QL was not independently measured in the available literature. The relationship between BMI and skin-to-kidney depth in this region is non-linear and varies by spinal level and sex.
Anatomy Overview
Origin
Iliac crest and iliolumbar ligament
Insertion
Inferior border of the 12th rib and transverse processes of L1–L4
Innervation
Ventral rami of T12–L4 (subcostal nerve and lumbar plexus branches)
Primary Functions
Lateral flexion of the lumbar spine; pelvic stabilization during single-leg stance; accessory muscle of respiration (fixes the 12th rib)
Referral Patterns
Published referral descriptions for QL trigger points commonly include:
LocalDeep, aching low back pain often described along the iliac crest and into the buttock
ReferredReferral into the lower abdomen and groin in some presentations, occasionally prompting visceral work-up
Aggravating factorsPain aggravated by prolonged sitting, standing on one leg, or transitioning from sitting to standing
Clinical Pearls
Frequently overlookedQL referral into the abdomen or groin can mimic visceral pathology and is described in the literature as a cause of unnecessary imaging or referral when not considered.
Common patient descriptions"A deep ache along my belt line," worse getting out of bed or out of a car.
Differentials in the literatureSacroiliac joint dysfunction, hip osteoarthritis, lumbar facet pathology, and (given proximity) renal pathology should be considered when red flags are present.
Safety Considerations
High-attention region — kidney / retroperitoneal structures
QL sits in the retroperitoneal space, anatomically positioned between the iliocostalis lumborum (more superficial) and the kidney (deeper). A published safety study of the adjacent iliocostalis lumborum explicitly notes this layering and recommends a conservative needle size specifically to avoid reaching QL or the kidney from a more superficial target. For manual therapy, this layering is a reminder that QL itself is a genuinely deep muscle — sustained pressure intended for QL needs to work through the more superficial paraspinal layers, and very deep or prolonged pressure in this region approaches the same retroperitoneal structures.
The relationship between BMI and skin-to-kidney/peritoneum distance in this region has been described as non-linear in the published literature — one study found the distance increased with BMI up to approximately 25 kg/m², then decreased at higher BMI values.
Gender effects on depth in this region were also reported to run in opposite directions depending on spinal level (L2 vs. L4) in the same study — illustrating that simple, single-direction adjustments may not capture the full picture in this region, for needling depth or for how much pressure reaches QL versus more superficial tissue.
Literature Summary
López-Castellanos et al. (2022) — cross-sectional study (n=68, mean BMI 23.3) measuring skin-to-kidney and skin-to-peritoneum distances at L2 and L4 in relation to the iliocostalis lumborum, with anthropometric predictors including BMI, skinfold thickness, and circumferences.
Temel & Bağcıer (2024) — case report describing ultrasound-guided dry needling technique for QL in chronic low back pain, illustrating probe placement and needle trajectory under direct visualization.
No QL-specific BMI-stratified skin-to-muscle depth study (independent of the iliocostalis/kidney work above) was located in this review.
Anatomical Depth Reference
López-Castellanos et al., 2022 — Skin-Kidney / Skin-Peritoneum Distance
This study measured the iliocostalis lumborum and the kidney/peritoneum boundary directly. QL was identified anatomically as sitting between these two structures but was not independently measured. The non-monotonic BMI relationship and sex-direction reversal between spinal levels are presented here as the most relevant available evidence for this anatomical region — a linear, single-direction depth adjustment would not capture either pattern.
References
López-Castellanos R, Ruiz-Astasio E, Cortés-Campos A, et al. Correlation between anthropometric and ultrasound measurement for dry needling of the iliocostalis lumborum muscle with a safety protocol: a cross-sectional observational study. Healthcare. 2022;10(12):2470.
Depth gauge — illustrative, not patient-specificTanioka et al.
Depth to gluteus medius roughly doubles when gluteus maximus overlies the standard injection site — a variant present in about a third of dissected sites, independent of BMI.
Anatomy Overview
Origin
External surface of the ilium, between the anterior and posterior gluteal lines
Insertion
Lateral surface of the greater trochanter of the femur, via two distinct tendinous attachments
Innervation
Superior gluteal nerve (L4–S1)
Primary Functions
Hip abduction; the anterior fibers assist with internal rotation, posterior fibers with external rotation; critical pelvic stabilizer during single-leg stance and gait
Referral Patterns
Published referral descriptions for gluteus medius trigger points commonly include:
LocalPain over the posterolateral hip and lateral buttock, often extending toward the sacrum
ReferredReferral down the lateral thigh, sometimes reaching the lateral knee — a pattern frequently mistaken for greater trochanteric pain syndrome or IT band-related pathology
Aggravating factorsPain with prolonged standing, single-leg loading, or lying on the affected side
Clinical Pearls
Frequently overlookedGluteus medius trigger points are a commonly cited contributor to presentations diagnosed as "hip bursitis" or greater trochanteric pain syndrome, and the literature notes substantial overlap between these labels.
Common patient descriptions"An ache on the side of my hip that gets worse when I'm on my feet all day," or pain when "lying on that side at night."
Differentials in the literatureGreater trochanteric bursitis, gluteus medius tendinopathy (distinguishable on ultrasound), hip osteoarthritis, and lumbar radiculopathy with referred lateral hip pain.
Safety Considerations
Moderate-attention region — superior gluteal nerve, anatomical variability
The superior gluteal nerve runs in the fascial plane between gluteus medius and the deeper gluteus minimus, and is described in the literature as a structure to avoid when needling between these two muscles. The same plane is relevant to deep manual or instrument-assisted work targeting gluteus minimus through gluteus medius.
Cadaveric work has found that gluteus maximus overlies gluteus medius at the standard dorsogluteal injection site in roughly one-third of individuals — a structural variant that is not predicted by BMI and substantially changes the depth to gluteus medius at that point, whether the goal is needle placement or manual pressure reaching the target muscle.
Published technique descriptions for gluteus medius/minimus dry needling specifically note that "strong depression of the subcutaneous tissue is required to reduce the distance from the skin to the muscle" — meaning the depth encountered during the procedure differs from the resting-state depth measured on ultrasound. The same principle applies to manual palpation: compressing overlying tissue changes how deep a given amount of pressure actually reaches.
The sciatic nerve, while primarily associated with deeper structures (piriformis and the deep gluteal space), is also noted in the literature as a consideration for more posteriorly-directed approaches to this region, for needling or sustained deep pressure alike.
Literature Summary
Tanioka et al. — ultrasound study of the dorsogluteal injection site in Japanese women (n=39, ages 40s–60s), measuring distance from epidermis to gluteus medius fascia (DEUF) and to bone (DEI), stratified by BMI.
Cadaveric anatomical work (cited in the above) — found gluteus maximus distributed over the standard injection point in 11 of 32 dissections (~34%), directly affecting the depth to gluteus medius at that location independent of body size.
Deep dry needling technique literature (Musculoskeletal Key) — describes gluteus medius and minimus needling technique with flat palpation and active tissue compression, and notes the superior gluteal neurovascular bundle as the structure to avoid between the two muscles.
Anatomical Depth Reference
Tanioka et al. — Dorsogluteal Site, BMI-Stratified
Health (SciRP) · n=39 Japanese women, ages 40s–60s · Ultrasound
Direct study
BMI Group
Skin → Gluteus Medius (DEUF)
Skin → Bone (DEI)
BMI ≥ 21 kg/m²
~30 mm
~50 mm or greater
BMI < 21 kg/m²
Shallower (not precisely reported)
Shallower
The study found right-side DEI and both-sides gluteus medius DEUF were significantly greater in the BMI ≥21 group than the BMI <21 group. A separate measurement reported a DEUF of 15mm with a DEI of 50mm in an individual case example, illustrating the range encountered.
Cadaveric Anatomical Variant — Gluteus Maximus Overlay
Cadaveric dissection, n=32 sites · Anatomical variant, not BMI-dependent
Adjacent / variant structure
Anatomical Configuration
Reported Depth to Gluteus Medius
Gluteus maximus overlying (11/32 sites)
38 ± 23 mm
Gluteus maximus not overlying (21/32 sites)
16 ± 8 mm
This roughly two-to-one difference in depth depending on an anatomical variant — present in about a third of dissected sites — illustrates that for this muscle, individual anatomical structure may account for more variance than BMI alone. This is consistent with the framework's general principle that population estimates require individual verification.
References
Tanioka T, et al. The relationship between body mass index, thickness of subcutaneous fat, and the gluteus muscle as the intramuscular injection site. Health. 2013;5(12):1939–1945.
Green BH, Dommerholt J. Deep dry needling of the hip and pelvic muscles. In: Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. Churchill Livingstone, Elsevier; 2019.
Free LibraryScapular Region
Infraspinatus
Musculus infraspinatus
High-attention regionBony-landmark technique
Posterior view — infraspinatus highlighted
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsReferences
Anatomy Overview
Origin
Infraspinous fossa of the scapula
Insertion
Middle facet of the greater tubercle of the humerus
Innervation
Suprascapular nerve (C5–C6)
Primary Functions
External rotation of the glenohumeral joint; posterior stabilization of the humeral head, part of the rotator cuff group
Referral Patterns
Published referral descriptions for infraspinatus trigger points commonly include:
Primary referralDeep, aching pain over the anterior shoulder, frequently described as the primary referral zone — somewhat counterintuitive given the muscle's posterior location
Extended referralPain extending down the lateral arm, sometimes into the forearm and hand in more extensive presentations
FunctionalA sensation of shoulder "weakness" or apprehension with overhead or behind-the-back movements
The anterior referral pattern is frequently noted in the literature as a source of diagnostic confusion, with presentations sometimes mistaken for biceps tendinopathy or anterior impingement when the posterior muscle origin is not considered.
Safety Considerations
High-attention region — bony backstop / shallow muscle bed
A published feasibility trial verifying palpation-guided dry needling of rotator cuff muscles under ultrasound used a 30mm needle with a superior-inferior insertion angle, advancing "until a bony end feel was obtained (scapular contact) or until the entire length of the needle was inserted." Needle tip placement within the infraspinatus muscle belly was then confirmed by ultrasound. The same anatomy — the infraspinatus sits in a relatively shallow fossa directly over the scapula — means deep manual pressure or instrument-assisted work in this region reaches bone quickly, with comparatively little soft tissue depth to work through.
This describes a bone-stop technique: the floor of the infraspinous fossa provides the depth limit for needling, rather than a measured perpendicular depth target. For manual work, the same bony floor means firm sustained pressure is felt directly against the scapula rather than purely through muscle tissue.
In the cited trial, a 30mm needle reliably reached the muscle belly before reaching bone in the studied population — but the relationship between needle length, bone depth, and muscle thickness has not been stratified by BMI in the available literature.
The suprascapular nerve and artery, which run through the suprascapular and spinoglenoid notches, are described as relevant structures in the broader scapular region, particularly for more medial or superior approaches — for needling or for deep manual work directed toward those notches.
References
Vitt M, Macaraeg S, Stapleton Z, Mata A, Ross BS. Ultrasound verification of palpation-based dry needling techniques of rotator cuff muscles: a prospective feasibility trial. J Man Manip Ther. 2024;32(3):166–172.
Frequently overlookedBecause the referral is felt anteriorly, examination often focuses on the anterior shoulder structures while the infraspinatus itself goes unexamined.
Common patient descriptions"A deep ache in the front of my shoulder that I can't quite point to," worse with reaching behind the back or sleeping on the affected side.
Differentials in the literatureSubacromial impingement, biceps tendinopathy, glenohumeral internal rotation deficit (GIRD) in overhead athletes, and cervical radiculopathy (C5–C6 distribution overlap).
Literature Summary
Vitt et al. (2024) — prospective feasibility trial verifying palpation-guided dry needling placement in rotator cuff muscles (including infraspinatus) using ultrasound confirmation, with a 30mm, 0.25mm needle and a bone-contact endpoint.
No BMI-stratified or sex-stratified ultrasound depth study specific to infraspinatus was located in this review. This is consistent with the broader pattern observed across several scapular and periscapular muscles, where published technique descriptions emphasize bony landmarks over measured perpendicular depth.
Anatomical Depth Reference
Vitt et al., 2024 — Ultrasound Verification of Palpation-Guided Placement
J Man Manip Ther · Feasibility trial · Ultrasound confirmation
Limited evidence
Parameter
Reported
Needle used
30 mm, 0.25 mm diameter
Insertion angle
Superior-inferior
Endpoint
Bony end-feel (scapular contact) or full needle length
Outcome
Needle tip visualized within infraspinatus muscle belly
No mm-level depth-to-muscle figure was reported independent of the bone-contact endpoint. This study describes a technique (advance to bone, confirm muscle placement), not a depth range — presented here as the most directly relevant available evidence for this muscle's needling approach.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsReferences
Anatomy Overview
Origin
External surface of the ilium, between the anterior and inferior gluteal lines
Insertion
Anterior surface of the greater trochanter; may send slips to piriformis, superior gemellus, or vastus lateralis
Innervation
Superior gluteal nerve (L4–S1) — the same nerve innervating gluteus medius and tensor fasciae latae
Primary Functions
Hip abduction (deep to and synergistic with gluteus medius); internal rotation of the hip; pelvic stabilization, particularly the anterior fibers during gait
Referral Patterns
Published referral descriptions for gluteus minimus trigger points commonly include:
Extended referralPain along the posterolateral hip extending down the lateral thigh and into the lower leg — a referral pattern that frequently extends further distally than gluteus medius
Distal patternReferral into the posterior one-third of the lower leg has been specifically described, a pattern that can closely mimic S1 radicular pain
OverlapIn the region where gluteus medius and minimus referral zones overlap, the literature notes it is often not possible to distinguish the two muscles by referral pattern alone
Safety Considerations
Moderate-attention region — superior gluteal nerve, deep gluteal space
The superior gluteal nerve and accompanying vessels travel in the fascial plane between gluteus medius and gluteus minimus before branching to supply both muscles and tensor fasciae latae. This plane is the primary structure described in the literature as relevant to avoid during needling between the two muscles, and is equally relevant to deep manual or instrument-assisted techniques aimed at gluteus minimus through the overlying gluteus medius.
Anatomically, the deep gluteal space is ordered (superficial to deep): gluteus maximus, gluteus medius, gluteus minimus, piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris. Gluteus minimus therefore sits immediately superficial to piriformis and the deep gluteal neurovascular structures discussed on that page — a useful reminder of how much tissue separates the surface from those deeper structures, for needling or for manual pressure.
As with gluteus medius, published technique descriptions note that active compression of the overlying tissue is used during needling, which changes the effective depth from the resting-state ultrasound measurement. The same compression effect applies to manual palpation and sustained pressure.
Given its position immediately superficial to piriformis and the sciatic nerve, the safety considerations described on the Piriformis and Gluteus Medius pages are directly relevant to this muscle, for needling and manual approaches alike.
References
Skorupska E, Rychlik M, Samborski W. Validation and test-retest reliability of new thermographic technique called thermovision technique of dry needling for gluteus minimus trigger points in sciatica subjects and TrPs-negative healthy volunteers. Pain Res Treat. 2015;2015:546497.
Fusco P, Di Carlo S, Scimia P, Degan G, Petrucci E, Marinangeli F. Ultrasound-guided dry needling treatment of myofascial trigger points for piriformis syndrome management: a case series. J Chiropr Med. 2018;17(3):198–200.
Frequently overlookedBecause gluteus minimus sits deep to gluteus medius and its referral can extend into the lower leg, it is described in the literature as a contributor that is often missed when lower-leg or "sciatic-like" pain is attributed solely to lumbar spine causes.
Common patient descriptionsPain that "runs from my hip all the way down the outside of my leg to my calf," sometimes with a sensation of the leg "giving way" on stairs.
Differentials in the literatureS1 radiculopathy, deep gluteal syndrome (sciatic nerve entrapment in the subgluteal space), and gluteus medius/minimus tendinopathy.
Literature Summary
Skorupska et al. (2015) — validation study of a thermographic technique for identifying gluteus minimus trigger points in patients with sciatica, using referred-pain confirmation alongside thermal imaging.
Anatomical/cadaveric literature on the superior gluteal nerve — describes the nerve's course in the fascial plane between gluteus medius and minimus, with ultrasound-guided block approaches developed primarily in the anesthesia and orthopedic literature for surgical analgesia.
Fusco et al. (2018) — case series of ultrasound-guided dry needling for piriformis syndrome that also treated gluteus minimus, medius, and maximus trigger points using a 0.30 × 60mm needle under direct ultrasound visualization.
No gluteus-minimus-specific BMI-stratified depth study, independent of the gluteus medius literature presented on that page, was located in this review.
Anatomical Depth Reference
Because gluteus minimus sits immediately deep to gluteus medius, the depth literature presented on the Gluteus Medius page (Tanioka et al., dorsogluteal BMI-stratified data, and the gluteus maximus overlay variant) describes the most relevant available context — gluteus minimus would be encountered at a depth somewhat greater than the gluteus medius figures shown there.
Fusco et al., 2018 — Needle Used for Deep Gluteal Group
J Chiropr Med · Case series, n=3 · Ultrasound-guided
Limited evidence
Parameter
Reported
Needle used
0.30 × 60 mm
Technique
Convex probe, out-of-plane, continuous tip visualization
Muscles treated
Piriformis, gluteus minimus, medius, maximus
A 60mm needle was sufficient to reach all four muscles in this small case series under direct ultrasound guidance; no depth breakdown by individual muscle or BMI was reported.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsReferences
Anatomy Overview
Origin
Sacrum, mammillary processes of the lumbar vertebrae, transverse processes of the thoracic vertebrae, and articular processes of the cervical vertebrae (region-dependent)
Insertion
Spans 2–4 vertebral levels superiorly to insert on spinous processes; deep and superficial fiber groups have distinct attachment patterns
Innervation
Medial branches of the dorsal rami of spinal nerves at corresponding segmental levels
Primary Functions
Segmental stabilization of the spine; extension and resistance to flexion/rotation at the segmental level; deep fibers in particular are described as key to intersegmental control
Referral Patterns
Published referral descriptions for lumbar multifidus trigger points commonly include:
LocalDeep, localized low back pain at the level of the affected segment, often described as a "dull" or "boring" ache
ReferredReferral into the buttock and, in some descriptions, the posterior thigh, though typically not as far distally as sciatic-pattern pain
FunctionalPain associated with segmental stiffness and reduced lumbar rotation/extension
Multifidus dysfunction (atrophy, delayed activation) is also widely discussed in the low back pain literature independent of trigger point referral, particularly in the context of recurrent or chronic low back pain.
Safety Considerations
High-attention region — spinal canal, ligamentum flavum
This is one of the more significant safety findings identified in this review, and it is largely specific to needling: a cadaveric study at the thoracolumbar junction found that a standard dry needling technique can breach the spinal canal. Deep manual or instrument-assisted pressure over the paraspinal muscles carries a different risk profile — it cannot breach the ligamentum flavum the way a needle can — but the same regional anatomy (proximity to the spinous processes, laminae, and facet joints) is relevant to working in this area with any modality, particularly regarding nerve root irritation with sustained deep pressure near the spine.
A 0.30 × 40mm dry needle inserted 1.9cm lateral to the spinous process of T12, directed with an inferior-medial angulation of 33° medial and 18° inferior, was able to traverse the space between the T12 and L1 vertebral laminae, penetrate the ligamentum flavum, and enter the spinal canal.
The authors explicitly note this demonstrates the feasibility of spinal canal entry with this technique — not that it is rare or difficult to avoid — and recommend ultrasound guidance specifically for needling in this region.
A separate in-vivo ultrasound study (n=21, all BMI >25) using a 100mm needle at L4/L5 found the needle reached the intended deep multifidus 85–95% of the time, reached a bony landmark 85–100% of the time, but reached the vertebral lamina as intended only 70–75% of the time — meaning even when bone was contacted, it was not always the intended bony surface.
Other documented adverse events from needling around the spine described in the literature include acute epidural hematoma, post-dural puncture headache, and (rarely) lower extremity weakness or numbness. For manual approaches, any new or worsening radicular symptoms (pain, numbness, or weakness radiating down a limb) during or after deep paraspinal work warrant the same level of attention regardless of how they arose.
References
Inferior-medial dry needling at the thoracolumbar junction: a cadaveric study. Int J Sports Phys Ther.
Wang-Price SS, Etibo KN, Short AP, Brizzolara KJ, Zafereo JA. Validity and reliability of dry needle placement in the deep lumbar multifidus muscle using ultrasound imaging: an in-vivo study. J Man Manip Ther. 2022;30(5):284–291.
Hannah MC, Cope J, Palermo A, Smith W, Wacker V. Comparison of two angles of approach for trigger point dry needling of the lumbar multifidus in human donors (cadavers). Man Ther. 2016;26:160–164.
Frequently overlookedMultifidus atrophy and dysfunction at a specific segmental level can persist even after symptomatic resolution of an acute low back pain episode, and is described as a factor in recurrence.
Common patient descriptions"A deep, specific spot" of pain at one level of the low back, often reproducible with palpation directly over that segment.
Differentials in the literatureFacet joint pathology, sacroiliac joint dysfunction, and segmental instability all overlap anatomically and clinically with multifidus-related presentations.
Literature Summary
Cadaveric thoracolumbar junction study (IJSPT) — reproduced and extended earlier work (Williams et al.) using an inferior-medial technique, demonstrating ligamentum flavum penetration and spinal canal entry at T12/L1 with a 0.30 × 40mm needle at defined angulation.
Wang-Price et al. (2022) — in-vivo validity and reliability study (n=21, BMI >25) of deep lumbar multifidus needle placement at L4/L5 using a 100mm needle and ultrasound imaging, with intra-tester reliability rated poor-to-moderate.
Hannah et al. (2016) — cadaveric comparison of two angles of approach for trigger point dry needling of lumbar multifidus.
Anatomical Depth Reference
Cadaveric Study — Inferior-Medial Technique at T12/L1
Int J Sports Phys Ther · Single cadaver (77-year-old female) · Fluoroscopic/ultrasound
Direct study
Parameter
Reported
Needle
0.30 × 40 mm
Insertion point
1.9 cm lateral to spinous process of T12
Angulation
33° medial, 18° inferior
Result
Penetrated ligamentum flavum, entered spinal canal at T12/L1
Single-specimen cadaveric finding (Level IV evidence) — presented as a feasibility demonstration, not a population frequency. The authors frame this as supporting ultrasound guidance for thoracolumbar multifidus needling rather than as describing a rare edge case.
Wang-Price et al., 2022 — Deep Lumbar Multifidus at L4/L5, High-BMI Cohort
J Man Manip Ther · n=21, all BMI >25 · 100mm needle, ultrasound
Direct study
Outcome
Reported Rate
Reached deep multifidus (L4)
85 – 95%
Reached deep multifidus (L5)
85 – 95%
Reached a bony landmark
85 – 100%
Reached vertebral lamina as intended
70 – 75%
All participants had BMI >25, using a 100mm needle. Even with this needle length and bone contact achieved in nearly all cases, the intended bony target (the lamina specifically) was confirmed in only 70–75% of placements — intra-tester reliability of the ultrasound-based assessment itself was rated poor-to-moderate.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsReferences
Anatomy Overview
Origin
Sternal head: anterior surface of the manubrium. Clavicular head: superior surface of the medial third of the clavicle
Insertion
Mastoid process and lateral half of the superior nuchal line
Innervation
Spinal accessory nerve (CN XI), with proprioceptive contributions from C2–C3
Primary Functions
Unilateral contraction: lateral flexion and contralateral rotation of the head. Bilateral contraction: cervical flexion, accessory muscle of respiration
Referral Patterns
Published referral descriptions for sternocleidomastoid trigger points commonly include:
Sternal divisionDescribed as referring to the vertex of the skull, the occiput, the cheek, and around the eye — including a pattern that has been associated with migraine-like presentations
Clavicular divisionDescribed as referring to the frontal region and, less commonly, deep ear pain or a sensation of dizziness/disequilibrium
OverlapBoth divisions are frequently cited in the cervicogenic headache and migraine literature, often alongside upper trapezius and suboccipital involvement
Safety Considerations
High-attention region — carotid sheath, cervical plexus branches
The anterior triangle of the neck contains the carotid sheath (common carotid artery, internal jugular vein, vagus nerve) and is widely described in dry needling safety guidelines as a region requiring particular caution — some sources explicitly advise against needling in the vicinity of the carotid sinus, vagus nerve, or recurrent laryngeal nerve. For manual therapy, sustained direct pressure over the carotid sinus (located near the upper third of the SCM, around the level of the thyroid cartilage) can trigger a baroreceptor reflex affecting heart rate and blood pressure — a separate consideration from the needling risks below, but one that places similar emphasis on caution in the upper portion of this muscle.
A 2023 ultrasound study (n=26 healthy volunteers) mapped the great auricular, spinal accessory, transverse cervical, and supraclavicular nerves in relation to the SCM. The cervical plexus was consistently identified at approximately the midpoint of the muscle.
Based on the proportional positions of these nerves along the muscle's length, the authors specifically recommend that invasive procedures be performed in the lower half of the SCM (50–80% of its length, measured from superior to inferior) to reduce proximity to these nerve branches — a zone that's also a reasonable starting point for manual palpation of this muscle, both for nerve proximity and to stay below the carotid sinus.
The transverse cervical nerve was found closest to the anterior border of the SCM at approximately 47% of the muscle's length — a position that overlaps with commonly palpated trigger point locations.
General dry needling safety guidance also notes the anterior triangle of the neck — encompassing the carotid sinus and vagus nerve — as an area to avoid, independent of the muscle-specific nerve mapping above. The same anterior-triangle anatomy is relevant context for anyone working manually in this region.
References
Kang BH, Park SH, Kang S, Yoon JS. Identifying safety zone of invasive procedures in the sternocleidomastoid muscle using ultrasonography. Medicine. 2023;102(8):e33021.
Rezaeian T, Mosallanezhad Z, Nourbakhsh MR, Noroozi M, Sajedi F. Effects of dry needling technique into trigger points of the sternocleidomastoid muscle in migraine headache: a randomized controlled trial. Am J Phys Med Rehabil. 2020;99(12):1129–1137.
Mohammadi Z, Shafizadegan Z, Tarrahi MJ, Taheri N. The effectiveness of sternocleidomastoid muscle dry needling in patients with cervicogenic headache. Adv Biomed Res. 2021;10:10.
Clinical Pearls
Frequently overlookedReferral to the eye, cheek, or vertex can lead to SCM involvement being missed when headache presentations are evaluated primarily through a cervical-spine or occipital lens.
Common patient descriptionsHeadache "behind my eye" or "across my forehead," sometimes accompanied by a sensation of mild dizziness or unsteadiness that patients may not initially connect to neck symptoms.
Differentials in the literatureMigraine, tension-type headache, vestibular causes of dizziness (when disequilibrium symptoms are present), and TMJ dysfunction (given proximity and overlapping referral with masseter).
Literature Summary
Kang et al. (2023) — ultrasound mapping study (n=26) of the great auricular, spinal accessory, transverse cervical, and supraclavicular nerves relative to the SCM, proposing a "safety zone" in the lower half of the muscle for invasive procedures.
Rezaeian et al. (2020) — randomized controlled trial of dry needling into SCM trigger points for migraine headache, using B-mode ultrasound to measure muscle thickness pre- and post-intervention and reporting significant improvements in headache parameters and pressure pain threshold.
Mohammadi et al. (2021) — study of SCM dry needling effectiveness in cervicogenic headache (n=16), reporting significant reduction in headache index two weeks post-intervention.
Anatomical Depth Reference
The available literature for SCM emphasizes positional safety zones along the length of the muscle rather than perpendicular skin-to-muscle depth — SCM is a relatively superficial, readily palpable muscle, and the primary safety consideration described is proximity to nerve branches crossing its surface at specific points along its course, not depth.
Kang et al., 2023 — Nerve Position as a Proportion of SCM Length
Medicine (Kim et al./Kang et al.) · n=26 · Ultrasound mapping
Direct study
Nerve
Position near posterior border
Position at reference line
Great auricular nerve (GAN)
26%
18%
Spinal accessory nerve (SAN)
26%
23%
Transverse cervical nerve (TCN)
48%
51%
Supraclavicular nerve (SCN)
80%
Not visible
Positions reported as mean proportion of SCM length from superior to inferior. The transverse cervical nerve was also found at approximately 47% of muscle length at the anterior border. Based on this mapping, the authors recommend invasive procedures be performed in the lower half of SCM (50–80% of length) to maximize distance from these branches — a positional rather than depth-based safety zone.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsReferences
Anatomy Overview
Origin
Transverse processes, vertebral bodies, and intervertebral discs of T12–L5
Insertion
Lesser trochanter of the femur, typically via a combined tendon with iliacus (iliopsoas)
Innervation
Ventral rami of L1–L3 (direct branches, distinct from the femoral nerve which it accompanies)
Primary Functions
Hip flexion; contributes to lumbar spine stabilization and lateral flexion; postural muscle with continuous low-level activity in upright posture
Referral Patterns
Published referral descriptions for psoas major trigger points commonly include:
LocalDeep, vertical band of pain along the ipsilateral lumbar spine, often described as extending from the lower thoracic region to the sacroiliac area
ReferredReferral into the anterior thigh and groin in some descriptions
Distinguishing featurePain with hip extension (e.g., during the terminal stance phase of gait) and relief with hip flexion (e.g., sitting with hips flexed) is frequently noted as a distinguishing feature
Psoas major myofascial pain syndrome (MPS) is described in the literature as a frequently overlooked differential in chronic low back pain, often presenting alongside or instead of more commonly considered causes such as facet or disc pathology.
Safety Considerations
High-attention region — lumbar plexus, kidney, retroperitoneal structures
Psoas major is a deep muscle, and its proximity to the spine and kidney is specifically cited in the literature as the reason ultrasound guidance is recommended for needling, particularly for the proximal portions of the muscle. Its depth is also the main reason direct manual access to psoas is uncommon from a posterior approach — most manual techniques described for this muscle use an anterior (abdominal) approach with the patient positioned to allow the abdominal contents to be gently displaced.
The lumbar plexus — including the femoral nerve and the lateral cutaneous nerve of the thigh, with the obturator nerve in a more variable position — runs within a fascial plane in the posterior third of the psoas muscle (the "psoas compartment"). This means the neurovascular structures of concern are located within the muscle itself, not only adjacent to it.
The femoral artery and vein run anterior to psoas in the inguinal region and are described as landmarks to be avoided during anterior approaches — relevant to anterior manual techniques as well as anterior needling approaches.
Because the lumbar plexus sits within the posterior portion of the muscle, a needle that passes through psoas (rather than stopping in its anterior portion) carries a different risk profile than needling that targets only the anterior fibers.
A 2025 ultrasound-guided treatment algorithm explicitly notes that ultrasound improves safety "especially in the proximal parts of the muscle, due to its proximity to the spine and kidney," reinforcing that this is not a muscle where palpation-only technique is well-supported in the literature — for needling or, by the same anatomical logic, for manual techniques attempting to localize psoas precisely by feel alone.
References
Importance of myofascial pain syndrome of the psoas major muscle and ultrasound-guided treatment algorithm. PMC. 2025.
Frequently overlookedPsoas MPS is described as an overlooked differential diagnosis that can accompany — and be mistaken for — chronic low back pain, hip osteoarthritis, tendonitis, or femoroacetabular impingement.
Common patient descriptionsA "deep, vertical line" of pain along the spine that worsens with standing or walking and improves with sitting or lying with knees bent.
Differentials in the literatureLumbar facet or disc pathology, hip joint pathology (osteoarthritis, femoroacetabular impingement), and — given the muscle's relationship to the kidney and retroperitoneal structures — visceral causes should be considered when red flags are present.
Literature Summary
2025 ultrasound-guided treatment algorithm (PMC12254637) — describes a probe placement at the level of L4, with a postero-anterior needle direction, recommending 0.3 × 50–70mm needles as standard and explicitly noting that a 90mm or longer needle may be necessary in patients with higher BMI.
Japanese acupuncture-point study — described a specific anterior insertion point for psoas major, defined relative to the anterior superior iliac spine (ASIS) and femoral artery, with ultrasound-measured depth and angle.
Anesthesia literature on lumbar plexus block (LPB) — extensively describes the psoas compartment anatomy and the technical challenges of locating the lumbar plexus at depth, including in older adult populations where standard sonoanatomy descriptions (developed in younger, normal-BMI cohorts) may not directly apply.
Anatomical Depth Reference
2025 Treatment Algorithm — L4 Approach, Needle Length by BMI
Probe placed axially at L4; needle advanced postero-anteriorly. The source explicitly states "needle length should be adjusted based on individual anatomy" — this is presented as a directional BMI adjustment from a recent (2025) source, rather than a precise regression-derived figure.
Japanese Acupuncture-Point Study — Anterior Approach, Inguinal Region
Ultrasound-measured insertion point, single defined landmark
Limited evidence
Parameter
Reported (mean ± SD)
Position below ASIS
4.5 ± 1.8 cm
Lateral to femoral artery
2.9 ± 1.3 cm
Insertion angle
51 ± 10°
Depth to muscle contraction
4.7 ± 0.4 cm
This describes a single anterior landmark-based insertion point, confirmed by observing muscle contraction on ultrasound — not a BMI-stratified depth range. The relatively tight SD on depth (±0.4cm) suggests this anterior approach may be less variable than the posterior L4 approach above, though this was not the primary focus of the source study and was not directly compared.
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Medial border of the scapula — minor at the root of the scapular spine, major along the remainder of the medial border to the inferior angle
Innervation
Dorsal scapular nerve (C4–C5)
Primary Functions
Scapular retraction; elevation and downward rotation of the scapula; stabilization of the scapula against the thoracic wall
Referral Patterns
Primary zoneLocal pain along the medial border of the scapula, often described as aching between the shoulder blade and the spine
Extended patternPain can spread across the posterior shoulder and into the suprascapular region; overlap with levator scapulae referral is common in the upper medial angle
Surface qualityOften described as a "superficial" ache — the rhomboids sit close to the skin surface in the inter-scapular region, and patients sometimes point directly to the painful area rather than experiencing referred pain at a distance
Safety Considerations
High-attention region — pleural proximity is the primary concern
The rhomboids lie directly over the posterior rib cage, with the pleura immediately beneath the ribs. A 2021 ultrasound study (Valera-Calero et al.) found that sex, BMI, and thorax circumference together predicted rhomboid major depth and skin-to-pleura distance, and recommended a maximum insertion depth of 19 mm to reach the deep limit of the muscle while reducing the risk of reaching the pleura. Patients with low or normal BMI have substantially less tissue between the skin and the lung in this region.
Multiple case reports of iatrogenic pneumothorax following dry needling of posterior upper thoracic structures (trapezius, rhomboids, levator scapulae) exist in the literature — this region is consistently cited as higher-risk.
For manual approaches, deep sustained pressure between the spine and scapular border warrants the same anatomical awareness, even though the risk profile differs from needling.
The 19 mm recommendation from Valera-Calero et al. represents a safety ceiling derived from population data — individual anatomy, BMI, breathing phase, and position all affect actual depth.
References
Valera-Calero JA, et al. Prediction model of rhomboid major and pleura depth based on anthropometric features to decrease the risk of pneumothorax during dry needling. Int J Clin Pract. 2021;75(6):e14176.
Posture associationProlonged forward-head and rounded-shoulder postures are frequently described as predisposing factors, with the rhomboids under chronic stretch in this position.
Scapular wingingRhomboid weakness or inhibition can contribute to medial scapular winging and dyskinesis — distinguishing trigger point pain from a motor/stability contribution is clinically relevant.
Often treated with upper trapeziusBecause inter-scapular and periscapular pain frequently involves multiple layers (trapezius superficially, rhomboids just beneath), these muscles are often addressed in the same session.
Literature Summary
Valera-Calero et al. (2021) — 59-subject ultrasound study demonstrating that sex, BMI, and thorax circumference explain 51.5% of variance in rhomboid major depth and 69.7% of skin-to-pleura depth (p<0.001). Published in Int J Clin Pract. Recommended maximum insertion: 19 mm.
Posterior thoracic pneumothorax case series (2023, Dalton et al.) — six iatrogenic pneumothorax cases following dry needling of upper thoracic structures, including rhomboids; five of six patients were women with low-normal BMI.
Anatomical Depth Reference
Valera-Calero et al., 2021 — Rhomboid Major and Pleural Depth
Int J Clin Pract · n=59 · Ultrasound measurement · Both breathing phases
Direct evidence
Sex, BMI, and thorax circumference together explain 51.5% of variance in rhomboid depth and 69.7% of skin-to-pleura depth. Men showed greater distances on all measurements (p<0.001). Recommended maximum insertion: 19 mm to reach the deep limit of rhomboid major and reduce pleural risk. A BMI-only estimate would misrepresent the model — thorax circumference is a required third variable.
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High-attention region — pleural proximityRotator cuff — posterior thoracic group
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Supraspinous fossa of the scapula (medial two-thirds)
Insertion
Superior facet of the greater tubercle of the humerus; superior glenohumeral joint capsule
Innervation
Suprascapular nerve (C5–C6)
Primary Functions
Initiates shoulder abduction (first 15°); humeral head depression and stabilization within the glenoid during deltoid-driven abduction; key rotator cuff stabilizer
Referral Patterns
Primary zoneDeep aching in the mid-deltoid region and lateral shoulder, sometimes described as a "toothache" quality pain in the outer shoulder
Distal extensionPain may extend down the lateral arm toward the lateral epicondyle; elbow pain referral from supraspinatus TrPs has been described
Clinical overlapReferral pattern can closely mimic subacromial impingement, rotator cuff tendinopathy, and C5 radiculopathy — co-existing pathology is common
Safety Considerations
High-attention region — posterior thoracic, pleural risk
The supraspinatus is grouped with upper trapezius, infraspinatus, levator scapulae, and rhomboid major in case-series literature as a higher-risk posterior thoracic region for iatrogenic pneumothorax. The supraspinous fossa is relatively shallow — the scapula provides a bone endpoint, but angulation toward the posterior rib cage should be avoided. Patients with low BMI have less tissue between the skin and the rib cage in this region.
The suprascapular nerve and its accompanying vessels run through the suprascapular notch at the superior border of the scapula — medially directed needling toward this notch carries neurovascular risk.
For manual approaches, the supraspinous fossa is shallow and firm pressure reaches bone quickly — palpation in this region is generally safe, with awareness of the neurovascular notch medially.
Clinical Pearls
Rotator cuff contextSupraspinatus is the most commonly torn rotator cuff tendon — TrPs in the muscle belly may coexist with, or be secondary to, partial-thickness tendon pathology. Imaging context is relevant before needling.
Bone-bounded fossaThe muscle belly sits in the supraspinous fossa directly over the scapula — needling reaches bone relatively quickly, and bone contact is a natural depth endpoint in this location.
Suprascapular nerveThe suprascapular nerve runs through the suprascapular notch just medial to the typical needling site — awareness of this landmark is important, particularly with anterior-directed angulation.
Literature Summary
Posterior thoracic pneumothorax case series — supraspinatus is consistently listed alongside trapezius, levator scapulae, rhomboids, and infraspinatus as part of the higher-risk posterior thoracic group.
Vitt et al. (2024) — feasibility trial verifying palpation-guided dry needling placement in rotator cuff muscles (including supraspinatus) using ultrasound confirmation; bone-contact endpoint used.
No BMI-stratified depth study specific to supraspinatus was located in this review.
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High-attention region — neurovascular structuresBrachial plexus, vertebral artery, lung apex
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Anterior scalene: anterior tubercles of transverse processes C3–C6. Middle scalene: transverse processes C2–C7 (largest of the three)
Insertion
Anterior scalene: scalene tubercle on the first rib (anterior surface). Middle scalene: first rib (posterior to the subclavian artery groove)
Innervation
Ventral rami of cervical spinal nerves (C3–C8 across the scalene group)
Primary Functions
Ipsilateral cervical lateral flexion; cervical flexion (bilateral); accessory muscles of inspiration — elevate the first rib during forced inhalation; a key region of the thoracic outlet
Referral Patterns
Upper extremity referralPain and paresthesia radiating from the lateral neck and shoulder into the arm, forearm, and hand — a pattern that can closely mimic cervical radiculopathy or thoracic outlet syndrome
Pectoral regionAnterior chest and pectoral pain referral has been described, sometimes mimicking cardiac pain
InterscapularReferral into the medial scapular border and interscapular region is also documented
Safety Considerations
High-attention region — anterior cervical neurovascular anatomy
The anterior cervical triangle contains a concentration of critical structures in close proximity to the scalene muscles. Published technique protocols for scalene needling emphasize positional safety zones and palpation-based identification rather than a specific depth target, because the relevant structures vary considerably by cervical level and individual anatomy.
Brachial plexus: the trunks of the brachial plexus emerge between the anterior and middle scalenes — needling in the inter-scalene groove carries direct plexus risk. Electrical stimulation during needling is used by some practitioners to identify and avoid nerve contact.
Vertebral artery: runs through the transverse foramina of C6–C2 and is a relevant structure with medially or posteriorly directed angulation.
Lung apex / pleura: at the level of C7–T1, the lung apex rises into the base of the neck; this is the same apex implicated in upper trapezius pneumothorax cases — the scalenes attach at the first rib in this region.
Carotid artery and internal jugular vein lie medial to the scalenes and are relevant with anterior angulation.
For manual approaches: sustained pressure in this region should be light to moderate; monitor for any arm symptoms (tingling, weakness) during treatment.
Clinical Pearls
TOS associationScalene hypertrophy or TrP-related tightness is a recognized contributor to neurogenic thoracic outlet syndrome — differentiating TrP-mediated symptoms from true TOS is an important clinical step.
Respiratory patternChronic upper-chest breathing recruits the scalenes excessively as accessory muscles — assessment of breathing pattern is relevant in patients with persistent scalene TrPs.
Position-sensitiveScalene symptoms are often posturally dependent — symptoms often worsen with ipsilateral lateral neck flexion (tightening) or with overhead activities that depress the shoulder girdle.
Literature Summary
Dry needling technique literature (Dommerholt, Fernández-de-las-Peñas) — scalene needling is described in technique texts using palpation-guided positional safety zones, with emphasis on inter-scalene groove anatomy and avoiding the brachial plexus.
Thoracic outlet syndrome literature — scalene TrP treatment (including injection and needling) is described as part of conservative TOS management in several case series and review articles.
No BMI-stratified depth study for the scalenes was located in this review.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Posterior ilium (behind the posterior gluteal line), posterior sacrum and coccyx, sacrotuberous ligament, thoracolumbar fascia
Insertion
Iliotibial band of the tensor fasciae latae (superficial fibers); gluteal tuberosity of the femur (deep fibers)
Innervation
Inferior gluteal nerve (L5–S2)
Primary Functions
Primary hip extensor; lateral rotation of the hip; stabilization of the iliotibial band and knee in stance phase; pelvic stabilization during stair climbing and rising from sitting
Referral Patterns
Primary zonePain along the inferior sacrum, gluteal fold, and lower buttock; may be described as a deep ache in the "sit bone" area
ITB referralPain along the lateral hip and thigh corresponding to the iliotibial band — reflecting the functional connection between gluteus maximus and the ITB via the tensor fasciae latae
Sacroiliac mimicryTrigger points near the sacral attachment can produce pain patterns that mimic sacroiliac joint dysfunction
Safety Considerations
Moderate-attention region — inferior gluteal nerve and deeper structures
The gluteus maximus is a large, relatively superficial muscle in most body types, and flat palpation needling with depression of subcutaneous tissue is the standard approach. The inferior gluteal nerve and vessels run deep to the muscle in the subgluteal space. The sciatic nerve runs deep to this muscle after exiting the greater sciatic foramen.
Standard technique stays within the gluteus maximus belly — depths beyond the muscle would approach the inferior gluteal neurovascular bundle and, at the inferior border, the sciatic nerve.
For manual approaches: the muscle is generally safe for sustained pressure; awareness of the gluteal fold and ischial tuberosity (where the sciatic nerve is more superficial) is relevant with deep inferior work.
Clinical Pearls
Large muscle, accessibleAs the largest muscle in the body, gluteus maximus is generally accessible and tolerates treatment well — the main safety consideration is its relationship to deeper structures rather than depth of the muscle itself.
Thoracolumbar fascia connectionExtensive fascial connections between gluteus maximus, latissimus dorsi, and the thoracolumbar fascia mean gluteal dysfunction is often relevant in the context of low back pain and trunk instability.
Sitting-related activationProlonged sitting leads to reciprocal inhibition of the gluteus maximus — assessing for this pattern alongside TrP treatment is clinically relevant.
Literature Summary
Dommerholt & Sandalcidi (Trigger Point Dry Needling, 2nd ed.) — gluteus maximus needling described with flat palpation, prone or sidelying, with subcutaneous tissue depression; inferior gluteal nerve and vessels cited as relevant deep structures.
Fusco et al. (2018) — ultrasound-guided dry needling case series treating gluteus maximus alongside gluteus minimus, medius, and piriformis with a 0.30 × 60mm needle under direct visualization.
No BMI-stratified depth study specific to gluteus maximus was located in this review.
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Anterior chestPec major TrPs refer locally across the anterior chest and may produce pain that mimics cardiac origin — angina-like chest pain referral is well documented in the TrP literature
Arm and medial elbowReferral into the anterior shoulder, medial arm, and medial elbow/forearm is described, with some patterns resembling ulnar nerve distribution
Pec minorRefers anteriorly over the chest and into the shoulder; pec minor TrPs have been associated with anterior shoulder pain and with symptoms overlapping thoracic outlet syndrome
Safety Considerations
High-attention region — anterior chest wall, pleural proximity
The anterior chest wall has the lung immediately behind the rib cage, making pneumothorax the primary safety consideration for any needling in this region. Technique descriptions consistently emphasize working along the muscle belly (parallel to the ribs where possible) and avoiding perpendicular-to-ribs approaches that could inadvertently penetrate the intercostal spaces.
Medial pec major (sternal head) sits directly over the rib cage — lateral approaches to the muscle belly are generally safer than medial-to-lateral angulation toward the sternum.
Pectoralis minor is accessed deep to pec major — its proximity to the anterior rib cage (ribs 3–5) makes technique accuracy particularly important.
The axillary approach to pec minor avoids the rib cage but requires awareness of the axillary neurovascular bundle (axillary artery, vein, brachial plexus).
For manual approaches: the same anterior chest wall anatomy applies — deep sustained pressure over the ribs (particularly ribs 3–5 for pec minor) warrants care.
Clinical Pearls
Cardiac mimicryChest pain from pectoral TrPs is consistently described as one of the more common presentations that prompts unnecessary cardiac workup — relevant context when a patient presents with anterior chest pain after negative cardiac evaluation.
Forward-shoulder posturePec minor tightness is a primary driver of anterior shoulder impingement mechanics — shortened pec minor pulls the coracoid anteriorly and inferiorly, tilting the scapula and reducing subacromial clearance.
Axillary approach for pec minorPectoralis minor is most accessible via a lateral-to-medial approach through the axilla, rather than through the anterior chest wall directly — avoiding rib cage structures.
Literature Summary
TrP technique literature (Simons, Travell & Simons) — pectoralis major and minor referred pain patterns and needling approaches described in the foundational myofascial pain texts, including the cardiac mimicry pattern.
Thoracic outlet literature — pec minor TrPs and shortening described as contributors to neurogenic TOS, with needling or manual release described as part of conservative management.
No BMI-stratified depth study for pectoralis major or minor was located in this review.
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Lower-attention region — generally accessibleLateral femoral cutaneous nerve proximity
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Anterior superior iliac spine (ASIS) and the outer lip of the iliac crest just posterior to the ASIS
Insertion
Iliotibial band (IT band) approximately one-third of the way down the thigh, where it merges with the fascia lata
Innervation
Superior gluteal nerve (L4–S1)
Primary Functions
Hip flexion, abduction, and internal rotation; tensioning of the iliotibial band; stabilization of the knee in extension and the pelvis in stance phase; synergist to gluteus medius for lateral pelvic stabilization
Referral Patterns
Lateral hip and thighPain along the lateral hip, greater trochanter region, and down the lateral thigh following the ITB — a pattern that can overlap with ITB syndrome and greater trochanteric pain syndrome
Anterior hipReferral toward the anterior hip and inguinal region has also been described, particularly from the more anterior TFL fibers near the ASIS
Knee lateralDistal referral to the lateral knee is documented, contributing to presentations that overlap with lateral knee pain and ITB friction syndrome
Safety Considerations
Lower-attention region — generally superficial and accessible
The TFL is a relatively superficial muscle at its belly near the ASIS and is generally considered one of the more accessible muscles for needling. The primary structure of note is the lateral femoral cutaneous nerve (LFCN), which passes beneath the inguinal ligament near the ASIS and can be a source of meralgia paresthetica.
The LFCN passes close to the ASIS, typically just medial to it — needling very close to the ASIS itself (rather than posterior/inferior to it in the muscle belly) carries greater nerve proximity risk.
For manual approaches: the TFL is generally well-tolerated for sustained pressure; the lateral femoral cutaneous nerve is relevant with work very close to the ASIS.
Clinical Pearls
ITB syndrome contributorTFL TrPs and tightness are consistently implicated in ITB friction syndrome — both the muscle belly (near the ASIS) and the musculotendinous junction warrant assessment in lateral knee pain presentations.
Gluteus medius synergistTFL is a synergist to gluteus medius for pelvic stabilization — in cases where gluteus medius is weak or inhibited, TFL is often overloaded and develops TrPs as a compensatory pattern.
ASIS landmarkThe muscle belly is palpable just posterior and inferior to the ASIS — a reliable landmark for identifying the treatment site.
Literature Summary
Dommerholt & Sandalcidi (Trigger Point Dry Needling, 2nd ed.) — TFL needling described in the lateral hip/thigh chapter; grouped with gluteus medius and minimus for assessment and treatment in lateral hip pain presentations.
ITB syndrome review literature — TFL TrPs and tightness identified as a contributing factor in ITB friction syndrome, with needling described as part of multimodal management.
No BMI-stratified depth study specific to TFL was located in this review.
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Moderate-attention regionSpinal canal proximity at thoracolumbar junction
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Common origin from the sacrum, iliac crest, and thoracolumbar fascia; the three columns (iliocostalis, longissimus, spinalis) have ascending attachments to the ribs, transverse processes, and spinous processes respectively
Insertion
Ribs (iliocostalis), transverse processes (longissimus), and spinous processes (spinalis) at multiple levels; the group extends from sacrum to skull
Innervation
Dorsal rami of spinal nerves at corresponding levels throughout the thoracic and lumbar spine
Primary Functions
Spinal extension and lateral flexion (bilateral and unilateral); maintenance of upright posture; control of forward flexion via eccentric contraction; ipsilateral rotation (iliocostalis and longissimus)
Referral Patterns
Local paraspinal painAching, stiffness, and localized pain along the spine — often described as a "band" of tightness across the low or mid back
Iliocostalis referralThe iliocostalis (most lateral column) has referral patterns described into the lateral abdomen and gluteal region from lumbar levels; thoracic levels may refer toward the anterior trunk
Overlap with multifidusErector spinae and multifidus TrPs frequently co-occur and have overlapping referral zones — distinguishing them clinically requires palpation in layer, working from the lateral erector spinae medially toward the deeper multifidus
Safety Considerations
Moderate-attention region — spinal canal, retroperitoneal structures
The erector spinae sit lateral to the spinous processes and superficial to the multifidus, with the spinal canal relevant for medially directed needling at any level. At the thoracolumbar junction (T12–L2), the spinal cord ends and the cauda equina begins — the same cadaveric study findings relevant to multifidus needling at this level apply to the erector spinae group in this region.
The iliocostalis, being the most lateral column, approaches the posterior aspect of the ribs at thoracic levels — lateral angulation at thoracic levels carries pleural risk similar to other posterior thoracic muscles.
At lumbar levels, the kidney and retroperitoneum are relevant for very deep or laterally directed needling (see Quadratus Lumborum page for depth context).
For manual approaches: deep paraspinal pressure is generally well-tolerated; monitor for any radicular symptoms (pain, numbness, weakness into a limb) with sustained deep work near the spine.
Clinical Pearls
Layer distinctionThe erector spinae group is more superficial than multifidus — palpation in layer, from lateral to medial and superficial to deep, is important to distinguish which paraspinal structures are contributing.
Thoracolumbar fasciaThe thoracolumbar fascia surrounds the erector spinae and is a key structure in paraspinal pain — fascial dysfunction and TrPs in the erector spinae often coexist and are mutually perpetuating.
Side-lying positionSidelying positioning reduces paraspinal muscle tone and can facilitate palpation and treatment of the erector spinae with less patient guarding than prone, particularly in acute presentations.
Literature Summary
Paraspinal dry needling literature — the erector spinae are frequently treated alongside multifidus in low back pain studies; multiple RCTs of dry needling for non-specific low back pain target the paraspinal musculature broadly without distinguishing erector spinae from multifidus in the treatment description.
Wang-Price et al. (2022) — depth study of needle penetration to multifidus at thoracolumbar levels; the erector spinae sits superficial to multifidus and would be traversed at a lesser depth than the multifidus values reported in this study.
No independent BMI-stratified depth study specific to the erector spinae thoracolumbar group was located; the closest available context is from the Multifidus and Quadratus Lumborum depth literature.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Rectus capitis posterior major: spinous process C2. Rectus capitis posterior minor: posterior tubercle of C1. Obliquus capitis superior: transverse process C1. Obliquus capitis inferior: spinous process C2
Insertion
All four muscles insert onto the inferior nuchal line of the occipital bone (minor: medial, major and obliques: lateral portions)
Innervation
Suboccipital nerve (C1 dorsal ramus); greater occipital nerve (C2 dorsal ramus) runs through this region
Primary Functions
Ipsilateral rotation and extension of the head at the atlanto-axial joint (rectus major, obliquus inferior); head extension and ipsilateral tilt at atlanto-occipital joint (rectus minor, obliquus superior); fine postural control of the head on the atlas
Referral Patterns
Occipital / cranial referralPain spreading from the base of the skull upward over the occiput and vertex — a classic cervicogenic headache pattern
Periorbital / retro-orbitalIn some patients, referral extends forward through the eye and into the forehead, mimicking tension or migraine headache
Cervical stiffnessRestricted rotation and extension at C1-C2 is commonly associated with suboccipital TrP activity
Safety Considerations
High-attention region — upper cervical neurovascular anatomy
The suboccipital region contains the V3 segment of the vertebral artery, the greater occipital nerve (C2), and the C1 and C2 nerve roots in an anatomically compact space. Published DN protocols for this region emphasize careful identification of C1 transverse process and occipital bone as landmarks, conservative depth, and avoidance of the atlanto-axial membrane midline.
The vertebral artery runs through the suboccipital triangle — lateral angulation at C1-C2 carries arterial risk.
Any dizziness, nausea, visual disturbance, or tingling during treatment in this region should prompt immediate cessation.
For manual approaches: light sustained pressure targeting the suboccipital ridge is generally the safer approach; avoid strong combined rotation-extension movements in this region.
Illustrative/educational estimate only — no BMI-stratified depth study was located for this region.
Clinical Pearls
Cervicogenic headacheSuboccipital TrPs are one of the most commonly implicated sources of cervicogenic headache — assessment of this group is standard in headache physiotherapy workups.
Vertebral artery awarenessThe V3 segment of the vertebral artery runs through the suboccipital triangle between C1 and the occipital bone — this is the primary anatomical reason this region requires careful technique.
Greater occipital nerve entrapmentThe greater occipital nerve (C2) passes through or adjacent to the semispinalis capitis and suboccipital muscles — TrP-related compression may contribute to occipital neuralgia presentations.
Literature Summary
Cervicogenic headache DN literature (multiple authors) — suboccipital dry needling is described as an effective component of cervicogenic headache management in several RCTs and case series.
Vertebral artery anatomy literature — cadaveric and imaging studies consistently confirm the V3 segment's course through the suboccipital triangle, forming the anatomical basis for upper cervical DN technique protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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High-attention region — pleural proximityLateral chest wall — rib-adjacent
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Fleshy digitations from the outer surfaces of ribs 1–9 (or 1–8), interdigitating with external intercostals and external oblique
Insertion
Anterior (costal) surface of the medial border of the scapula, from superior to inferior angle
Innervation
Long thoracic nerve (C5, C6, C7)
Primary Functions
Protracts and rotates the scapula upward (critical for shoulder elevation above 90°); holds the scapula against the thoracic wall; "serratus punch" muscle in boxing; works with trapezius in upward scapular rotation
Referral Patterns
Lateral chest and axillaLocal pain over the lateral rib cage and axillary region; often described as a sharp, deep ache with breathing or arm elevation
Breast and inner armReferral toward the breast tissue, nipple region (particularly in women), and medial upper arm has been described in the TrP literature
Winging patternWeakness or inhibition of serratus anterior with medial scapular winging is a functional presentation that accompanies chronic TrP activity
Safety Considerations
High-attention region — pleural proximity on the lateral chest wall
Serratus anterior lies directly over the lateral rib cage, with the parietal pleura immediately deep to the ribs and intercostal spaces. Needle angle must be parallel to the rib surface, not perpendicular, to avoid entering an intercostal space.
Insertion points are between the ribs — targeting the muscle belly requires angling along the rib surface.
The long thoracic nerve runs on the superficial surface of the muscle along the midaxillary line — relevant for deep or posteriorly directed approaches.
Pneumothorax has been reported from lateral chest wall dry needling — the same risk profile as posterior thoracic work but on the lateral chest.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Long thoracic nerve palsy mimicryComplete serratus anterior dysfunction from long thoracic nerve palsy presents with dramatic medial winging; partial TrP-related inhibition produces a more subtle pattern — distinguishing these is clinically important.
Shoulder impingement linkReduced upward scapular rotation from serratus inhibition is a recognized contributor to subacromial impingement — TrP treatment here may improve shoulder mechanics significantly.
Technique accessAccessed through the lateral chest wall with the arm supported in shoulder flexion or abduction — this position spreads the ribs and improves access while reducing pleural proximity slightly.
Literature Summary
TrP literature (Simons, Travell & Simons) — serratus anterior referral patterns and needling technique described in the foundational myofascial pain texts.
Lateral chest wall pneumothorax reports — case literature documents pneumothorax from lateral chest wall procedures; serratus anterior needling carries the same risk profile.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Dorsal surface of the inferior angle of the scapula
Insertion
Medial lip of the bicipital groove of the humerus (anterior surface), sharing the groove with latissimus dorsi
Innervation
Lower subscapular nerve (C5, C6, C7)
Primary Functions
Shoulder internal rotation, extension, and adduction; sometimes called "lat's little helper" due to functional overlap with latissimus dorsi; forms the posterior axillary fold with latissimus dorsi
Referral Patterns
Posterior shoulder and armDeep aching over the posterior deltoid and triceps region; may radiate down the posterior arm
Scapular borderLocal pain at the inferior scapular angle, sometimes confused with rhomboid or lower trapezius referral
Functional overlap with latTeres major TrP referral may be difficult to distinguish from latissimus dorsi — both produce posterior shoulder and arm pain with overhead activity
Safety Considerations
Moderate-attention region — posterior axillary neurovascular anatomy
The axillary neurovascular bundle (axillary artery, vein, brachial plexus) runs in the axilla medial to teres major. Deep or anteriorly directed needling beyond the muscle belly approaches this bundle.
The radial nerve and axillary nerve run posterior to teres major — relevant for very deep posterior approaches.
The thoracodorsal nerve (to latissimus dorsi) and lower subscapular nerve run on the deep surface of the muscle.
For manual approaches: generally accessible with direct pressure at the inferior scapular angle; avoid deep sustained pressure directed anteriorly into the axilla.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Lat's little helperTeres major and latissimus dorsi perform nearly identical movements and are often treated together in posterior shoulder and lat TrP work.
Thrower's shoulderIn overhead athletes (throwing, swimming, climbing), teres major is frequently implicated in posterior shoulder pain and internal rotation restriction.
Access positionBest accessed with the patient prone or sidelying, shoulder in neutral or slight abduction — the inferior scapular angle is the key palpation landmark.
Literature Summary
TrP technique literature (Dommerholt, Simons) — teres major is described alongside infraspinatus, teres minor, and latissimus dorsi in posterior shoulder TrP assessment and treatment.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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High-attention region — posterior thoracic groupRotator cuff — posterior scapular
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Upper two-thirds of the posterior surface of the lateral scapular border
Insertion
Inferior facet of the greater tubercle of the humerus; posterior glenohumeral joint capsule
Innervation
Axillary nerve (C5, C6) — posterior branch
Primary Functions
External rotation of the shoulder; humeral head stabilization in the glenoid; part of the rotator cuff; works closely with infraspinatus
Referral Patterns
Posterior deltoid regionDeep aching in the posterior deltoid, often in a very localized spot — sometimes described as a small focused pain point rather than a broad referral
Night painTrPs in teres minor are associated with night pain in the posterior shoulder — particularly on sleeping on the affected side
Overlap with infraspinatusReferral pattern is very similar to infraspinatus — distinguishing them requires precise palpation along the lateral scapular border
Safety Considerations
Moderate-to-high attention — posterior thoracic proximity and rotator cuff context
Teres minor lies along the lateral scapular border and inferior to infraspinatus, in the same posterior thoracic group where pleural risk is elevated. It is above the rib cage at this level but the same regional awareness applies. The axillary nerve wraps around the surgical neck of the humerus nearby.
Part of the posterior thoracic group (trapezius, infraspinatus, supraspinatus, rhomboids, teres minor) with elevated pneumothorax risk described in case literature.
The axillary nerve is relevant for needling near the posterior aspect of the humeral head.
Bone-contact technique limits depth risk — targeting the scapular surface is a natural endpoint.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Axillary nerve proximityThe axillary nerve (from which teres minor receives its innervation) wraps around the surgical neck of the humerus adjacent to teres minor insertion — injury here can mimic teres minor dysfunction.
Rotator cuff groupTeres minor is rarely torn in isolation but is part of the rotator cuff assessment — TrP activity here should be considered alongside supraspinatus and infraspinatus pathology.
Bone-contact techniqueLike infraspinatus, teres minor can be needled with a bone-contact technique to the scapular surface, limiting depth.
Literature Summary
Rotator cuff DN literature — teres minor is included in posterior rotator cuff dry needling protocols alongside infraspinatus and supraspinatus.
Posterior thoracic pneumothorax case series — teres minor is grouped with the posterior thoracic musculature in safety literature.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Subscapular fossa (anterior/costal surface of the scapula)
Insertion
Lesser tubercle of the humerus; anterior glenohumeral joint capsule
Innervation
Upper and lower subscapular nerves (C5, C6, C7)
Primary Functions
Primary internal rotator of the shoulder; humeral head anterior stabilization; works with supraspinatus, infraspinatus, and teres minor in the rotator cuff force couple
Referral Patterns
Posterior wrist and handOne of the less intuitive referral patterns in the shoulder — subscapularis TrPs may refer pain to the posterior wrist and hand, mimicking carpal tunnel or peripheral nerve irritation
Anterior shoulderLocal anterior shoulder pain, sometimes very deep and diffuse; associated with restricted external rotation and difficulty reaching behind the back
Axillary painDeep axillary and medial upper arm pain described in the TrP literature
Safety Considerations
High-attention region — axillary neurovascular bundle and thoracic cage proximity
Subscapularis lies between the anterior scapula and the posterior rib cage, with the axillary neurovascular bundle (axillary artery, vein, brachial plexus) running laterally. Access via the axilla (with shoulder abducted) keeps needling away from the rib cage, but proximity to the neurovascular bundle is the primary remaining risk.
The axillary artery and its branches, the axillary vein, and the cords of the brachial plexus are the primary structures at risk with too-lateral angulation.
The posterior rib cage is immediately deep to the subscapular fossa — perpendicular needling through the scapula is not the approach; the axillary route avoids this.
Ultrasound guidance is strongly recommended for subscapularis needling given the complexity of anatomical access.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Frozen shoulder associationSubscapularis TrPs and shortening are consistently implicated in adhesive capsulitis / frozen shoulder — significant internal rotation restriction with anterior shoulder pain warrants subscapularis assessment.
Technically demandingSubscapularis is one of the more challenging muscles to access for both needling and manual therapy — the axillary approach with shoulder abducted is the standard technique.
Ultrasound guidanceUltrasound-guided injection of subscapularis is well-described in the sports medicine and rheumatology literature — the same guidance is recommended for dry needling given the proximity of the axillary neurovascular bundle.
Literature Summary
Adhesive capsulitis literature — subscapularis TrP assessment and treatment is described as part of conservative frozen shoulder management.
Ultrasound-guided shoulder injection literature — technique descriptions for subscapularis access inform dry needling approach protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Musculus deltoideus — pars clavicularis, acromialis, spinalis
Lower-attention region — generally accessibleAxillary nerve — surgical neck of humerus
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Anterior: lateral clavicle. Middle: acromion. Posterior: spine of the scapula
Insertion
Deltoid tuberosity on the lateral humerus (all three parts converge)
Innervation
Axillary nerve (C5, C6) — wraps around the surgical neck of the humerus
Primary Functions
Anterior: shoulder flexion and internal rotation. Middle: shoulder abduction (primary). Posterior: shoulder extension and external rotation. All three work together in overhead activities
Referral Patterns
Local shoulder painTrPs in each head refer locally — anterior head to anterior deltoid and biceps region, middle head to lateral arm, posterior head to posterior deltoid extending toward triceps
Arm heavinessDeltoid TrPs are sometimes described as a "heavy arm" sensation or diffuse aching through the lateral shoulder
Functional limitationRestricted shoulder elevation and abduction from deltoid TrP activity is common, often occurring alongside rotator cuff pathology
Safety Considerations
Lower-attention region — generally accessible, axillary nerve awareness
The deltoid is one of the most accessible muscles in the body for needling and injection, with a well-established technique. The axillary nerve wraps around the surgical neck of the humerus, typically 5-7 cm below the acromion, which defines the lower limit for deltoid needling.
The "safe zone" for deltoid needling is generally the upper two-thirds of the muscle — the lower third approaches the axillary nerve at the surgical neck.
The anterior head is also close to the cephalic vein in the deltopectoral groove — relevant for superficial approaches in the anterior deltoid.
For manual approaches: generally very well tolerated; the axillary nerve landmark applies equally.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Intramuscular injection siteThe deltoid is one of the most commonly used sites for intramuscular injections — practitioners have more experience with needle placement here than in almost any other muscle.
Axillary nerve landmarkThe axillary nerve wraps around the surgical neck of the humerus approximately 5-7 cm below the acromion — this is the depth/position landmark for the lower deltoid, particularly relevant for posterior head needling.
Rotator cuff contextDeltoid TrPs commonly co-occur with rotator cuff tendinopathy — the deltoid may be overloaded as the rotator cuff fails in its stabilizing role.
Literature Summary
Intramuscular injection literature — the deltoid is the most thoroughly studied IM injection site; standard injection technique protocols provide the anatomical framework for needling.
Rotator cuff dry needling literature — deltoid is frequently treated alongside rotator cuff muscles in shoulder pain presentations.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located for DN specifically.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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High-attention region — pleural proximityUpper thoracic ribs — posterior thoracic group
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Nuchal ligament, spinous processes C7–T3
Insertion
Superior borders of ribs 2–5, lateral to their angles
Innervation
Intercostal nerves 2–5 (T2–T5 ventral rami)
Primary Functions
Accessory muscle of inspiration — elevates the upper ribs; generally considered to have minimal force generation but may play a role in respiratory accessory muscle patterns
Referral Patterns
Deep scapular achingPain deep to the medial scapular border, sometimes described as a diffuse deep aching that is difficult to localize precisely
Posterior shoulderReferral into the posterior shoulder and triceps region described in TrP literature
Breathing-relatedMay be implicated in respiratory-related upper thoracic pain, particularly in patients with chronic cough or hyperventilation patterns
Safety Considerations
High-attention region — pleural proximity over upper thoracic ribs
Serratus posterior superior attaches to the upper thoracic ribs lateral to their angles — the same posterior thoracic region where pneumothorax risk is elevated for rhomboids, levator scapulae, and upper trapezius. The muscle is thin and lies over the rib cage.
Needle depth to rib contact is shallow in this region — the ribs provide a natural depth stop but the intercostal spaces between them should not be traversed.
The same posterior thoracic pneumothorax risk that applies to rhomboids and upper trapezius applies here.
For manual approaches: the overlying trapezius and rhomboids make isolated manual targeting of this muscle very difficult.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Accessory respiratory muscleIn patients with respiratory conditions (chronic cough, COPD) or habitual upper-chest breathing, serratus posterior superior may be chronically overloaded.
Thin and deepThis is a thin muscle lying deep to the rhomboids and lower trapezius — it is not easily distinguished by palpation from the overlying musculature.
Rarely treated in isolationSerratus posterior superior is typically addressed as part of the posterior thoracic region rather than as a standalone target.
Literature Summary
TrP literature (Simons, Travell & Simons) — serratus posterior superior is described as a source of deep scapular pain with a respiratory accessory muscle role.
Posterior thoracic pneumothorax case literature — upper thoracic paraspinal needling carries the same elevated risk profile as rhomboid and levator scapulae work.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention region — paraspinalRib-adjacent at thoracic levels — pleural awareness
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Common origin from sacrum, iliac crest, and thoracolumbar fascia (with erector spinae); ascending attachments to transverse processes and ribs
Insertion
Transverse processes of thoracic vertebrae and adjacent ribs (lateral to iliocostalis); lumbar transverse processes
Innervation
Dorsal rami of corresponding thoracic and lumbar spinal nerves
Primary Functions
Bilateral contraction: spinal extension. Unilateral: ipsilateral lateral flexion and rotation. Continuous postural stabilization of the thoracic and lumbar spine
Referral Patterns
Paraspinal thoracic painBand-like aching along the thoracic spine, often described as a diffuse stiffness or tightness in the mid-back
Rib painThe thoracic attachments mean referral may extend laterally toward the rib cage, mimicking musculoskeletal or even pleuritic pain
Low back connectionThe thoracolumbar longissimus has fascial continuity with the lumbar paraspinals — TrPs here often coexist with lumbar presentations
Safety Considerations
Moderate-attention region — rib proximity at thoracic levels, spinal canal awareness
At thoracic levels, longissimus thoracis approaches the posterior rib angles. Lateral angulation carries rib-adjacent and pleural risk similar to iliocostalis thoracis. At lumbar levels, the spinal canal and retroperitoneal structures are relevant for deep medial or lateral angulation.
At thoracic levels: lateral angulation approaching rib angles carries pleural risk — orient needles medially or vertically.
At lumbar levels: the spinal canal is medial and retroperitoneal structures are lateral — standard paraspinal depth awareness applies.
Monitor for any radicular symptoms (radiating limb pain, numbness, weakness) during paraspinal work.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Superficial to multifidusLongissimus is more superficial than multifidus and deep to erector spinae fascia — palpation in layers from lateral to medial helps distinguish it.
Rib angles at thoracic levelsAt thoracic levels, longissimus approaches the posterior rib angles — lateral angulation here carries the same pleural awareness as iliocostalis.
Thoracolumbar fasciaThe thoracolumbar fascia investing this muscle is a key structure in paraspinal pain and core stability — myofascial work here addresses both muscle and fascial components.
Literature Summary
Paraspinal dry needling RCT literature — longissimus is frequently targeted alongside other paraspinal muscles in low back pain DN studies.
Wang-Price et al. (2022) — adjacent context — paraspinal depth study at thoracolumbar levels; longissimus sits superficial to multifidus.
Evidence: limited / anatomy-based — no BMI-stratified depth study specifically for longissimus thoracis was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lumbar painDeep, often unilateral lumbar aching — one of the most common paraspinal TrP presentations in clinical practice
Gluteal referralReferral into the upper gluteal region and posterior hip is described, potentially contributing to pseudo-sciatica patterns
SIJ mimicryParaspinal TrPs at lower lumbar levels can produce pain patterns overlapping with sacroiliac joint presentations
Safety Considerations
Moderate-attention region — retroperitoneal proximity at upper lumbar levels
At upper lumbar levels, the retroperitoneal space (kidney, ureter, ascending/descending colon) is relevant for very deep or laterally directed needling. Standard paraspinal depth avoids this. The spinal canal is medial.
At L1-L2 levels, the kidney sits in the retroperitoneum lateral to the spine — deep lateral angulation should be avoided.
The spinal canal is medial — deep medial angulation toward the midline approaches the spinal canal at any lumbar level.
Monitor for radicular symptoms (leg pain, numbness, weakness) during lumbar paraspinal work.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Layer distinctionLongissimus lumborum is more superficial than multifidus but shares the same regional anatomy — palpation from lateral to medial distinguishes the two layers.
Upper vs lower lumbarAt upper lumbar levels (L1-L2), the kidneys and retroperitoneum are relevant for very deep or laterally directed needling. At L4-L5, this concern is less immediately relevant.
Common low back pain targetThe lumbar paraspinals (including longissimus) are among the most frequently needled muscles in the management of non-specific low back pain.
Literature Summary
Paraspinal DN literature for low back pain — longissimus lumborum is frequently targeted in paraspinal DN studies; often not distinguished from multifidus in published protocols.
QL depth context (Cagnie et al.) — lumbar paraspinal depth studies provide adjacent context for the medial paraspinal region.
Evidence: limited / anatomy-based — no independent BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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High-attention region — rib-adjacentLateral paraspinal — pleural awareness at thoracic levels
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Superior borders of the lower 6 ribs, medial to the angles
Insertion
Angles of the upper 6 ribs and transverse process of C7
Innervation
Dorsal rami of corresponding thoracic spinal nerves
Primary Functions
Bilateral: spinal extension. Unilateral: ipsilateral lateral flexion. Rib depression during exhalation. Most lateral column of the erector spinae at thoracic levels
Referral Patterns
Lateral thoracic painPain along the posterior and lateral rib cage, sometimes mistaken for musculoskeletal rib pain or pleuritic symptoms
Chest wall painAnterior chest referral has been described from thoracic iliocostalis TrPs, mimicking cardiac or thoracic origin
Breathing-relatedPain that varies with deep breathing due to the rib attachments
Safety Considerations
High-attention region — rib-adjacent at thoracic levels, pleural proximity
Iliocostalis thoracis is the most lateral paraspinal column at thoracic levels, attaching to the rib angles. Lateral angulation beyond vertical readily approaches the intercostal spaces and the pleural cavity beneath.
Needle orientation should be vertical or slightly medially directed — avoid lateral angulation.
The rib surface provides a depth endpoint, but intercostal spaces between ribs should not be traversed.
Pneumothorax risk is elevated in this region — same risk category as rhomboids and posterior thoracic musculature.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Most lateral paraspinal columnAs the most lateral erector spinae column at thoracic levels, iliocostalis approaches the rib angles — awareness of rib position is essential for safe needling.
Chest wall referralAnterior chest referral from thoracic iliocostalis TrPs is documented and may prompt unnecessary cardiac workup — context is relevant.
Respiratory involvementAttachments to the ribs mean this muscle may be chronically overloaded in patients with respiratory conditions or accessory breathing patterns.
Literature Summary
Paraspinal anatomy literature — iliocostalis thoracis rib-angle attachments are well-described in gross anatomy; the same literature forms the basis for needling safety protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lumbar extension and ipsilateral lateral flexion; rib depression at lumbar-thoracic transition; postural stabilization
Referral Patterns
Lateral lumbar painPain in the lateral lumbar region, often extending toward the iliac crest or flank
Hip referralReferral into the hip and posterior gluteal region from lower iliocostalis lumborum TrPs
Rib junction painPain at the lower rib cage — the junction of the thoracic and lumbar regions — is a common presentation
Safety Considerations
Moderate-attention region — renal proximity at upper lumbar levels
As the most lateral paraspinal column at lumbar levels, iliocostalis lumborum is closest to the retroperitoneal space. At L1-L2 levels, the kidney is the primary deep structure of concern with lateral angulation.
At upper lumbar (L1-L2), avoid deep lateral angulation — the kidney is in the retroperitoneum laterally.
At lower lumbar (L3-L5), standard paraspinal depth awareness applies; spinal canal is medial.
Thoracolumbar junction (T12-L1): transition between thoracic rib-adjacent and lumbar retroperitoneal risk zones.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Renal proximityAt upper lumbar levels, the kidney lies in the retroperitoneum lateral to the erector spinae — deep lateral needling at L1-L2 warrants awareness of this structure.
Lateral to multifidus and longissimusAs the most lateral paraspinal column, it is the first muscle encountered from a lateral approach to the lumbar paraspinals.
Low back pain targetIliocostalis lumborum is frequently targeted alongside longissimus and multifidus in lumbar paraspinal dry needling protocols.
Literature Summary
Paraspinal DN literature — iliocostalis lumborum is included in lumbar paraspinal DN protocols alongside longissimus and multifidus.
QUadratus Lumborum depth context — QL depth literature at L3-L4 provides adjacent reference for the lateral lumbar paraspinal region.
Evidence: limited / anatomy-based — no independent BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Anterior elbow and bicepsLocal pain along the anterior upper arm; TrPs in the distal biceps refer to the anterior elbow crease and antecubital fossa
Shoulder painLong head TrPs may refer to the anterior shoulder — relevant in patients with bicipital tendinopathy and shoulder impingement presentations
Weak grip patternBiceps TrP activity is sometimes associated with reduced grip strength and forearm symptoms
Safety Considerations
Lower-attention region — musculocutaneous nerve within muscle belly
Biceps brachii is generally accessible and well-tolerated for both needling and manual therapy. The musculocutaneous nerve runs through the muscle belly (after piercing coracobrachialis) and becomes the lateral antebrachial cutaneous nerve at the elbow.
The musculocutaneous nerve runs between biceps and brachialis in the distal arm — deep needling between these muscles at the elbow approaches the nerve.
The brachial artery and median nerve run medially — avoid very medial approaches in the distal upper arm.
For manual approaches: generally very well tolerated; the antecubital fossa should be approached with care for the neurovascular bundle.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Long head tendinopathy contextBiceps TrPs frequently coexist with long head of biceps tendinopathy and SLAP lesions — the muscle and tendon should be assessed together.
Musculocutaneous nerveThe musculocutaneous nerve runs through the coracobrachialis and then between biceps and brachialis — awareness of this pathway is relevant for needling the mid-belly.
Supination roleBiceps is a supinator as much as a flexor — TrP presentations may include reduced supination strength and forearm rotation pain.
Literature Summary
Bicipital tendinopathy literature — biceps TrPs are described in the context of shoulder and elbow pain in sports medicine literature.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located for biceps as a DN target.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Elbow extension (primary); long head contributes to shoulder extension and adduction; stabilization of the elbow in loaded positions
Referral Patterns
Posterior arm and elbowLocal pain along the posterior upper arm; TrPs refer to the posterior elbow and sometimes the medial epicondyle region
Forearm and wristDistal referral from triceps TrPs to the medial forearm and ring/little fingers has been described
Posterior shoulderLong head TrPs may refer to the posterior deltoid region
Safety Considerations
Lower-attention region — radial nerve in spiral groove of humerus
Triceps brachii is generally accessible for both needling and manual work. The radial nerve winds around the posterior humerus in the spiral groove, typically at the junction of the upper and middle thirds of the posterior arm.
The radial nerve spiral groove is approximately at the junction of the proximal and middle thirds of the posterior humerus — needling along the lateral and posterior humerus in this zone requires awareness.
Radial nerve palsy (wrist drop) has been reported from misplaced IM injections in the lateral arm — the same anatomical risk applies to needling.
For manual approaches: generally very well tolerated; spiral groove landmark applies equally.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Radial nerve in spiral grooveThe radial nerve winds around the humerus in the spiral groove — needling the lateral or posterior humerus in the mid-arm requires awareness of this landmark.
Elbow extension weaknessTriceps TrPs are associated with elbow extension weakness and pain with pushing movements — relevant in throwing athletes and overhead workers.
Lateral epicondylalgia differentialTriceps TrPs can contribute to lateral elbow pain — they should be assessed alongside ECRB and common extensor tendon pathology in lateral epicondylalgia presentations.
Literature Summary
Upper extremity dry needling literature — triceps is described as a target in posterior arm and elbow pain.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located for triceps as a DN target.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention regionLateral antebrachial cutaneous nerve at elbow
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Distal half of the anterior surface of the humerus
Insertion
Coronoid process and tuberosity of the ulna
Innervation
Musculocutaneous nerve (C5, C6); small contribution from the radial nerve (C7) to the lateral portion
Primary Functions
Pure elbow flexion (unlike biceps, it flexes the elbow regardless of forearm rotation position) — the "workhorse" of elbow flexion
Referral Patterns
Anterior elbow and thumbTrPs in brachialis refer to the thumb and lateral thumb base — a pattern that can mimic de Quervain's tenosynovitis or C6 radiculopathy
Antecubital painLocal pain in the antecubital fossa, sometimes described as a deep ache at the elbow crease
Grip weaknessBrachialis TrP activity is associated with grip weakness and difficulty with sustained elbow flexion activities
Safety Considerations
Lower-attention region — lateral antebrachial cutaneous nerve at the elbow
Brachialis is generally a safe needle target. The lateral antebrachial cutaneous nerve (terminal branch of musculocutaneous) exits between biceps and brachialis at the elbow and becomes superficial in the antecubital fossa.
The lateral antebrachial cutaneous nerve is the primary nerve at risk at the distal biceps-brachialis interval — monitor for forearm tingling.
The radial nerve (lateral portion innervation) and the brachial artery run medially — avoid very deep medial approaches at the distal arm.
Brachialis is accessed by displacing biceps rather than needling through it centrally.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Thumb referral is distinctiveThe thumb referral pattern from brachialis TrPs is one of the more distinctive upper extremity referral patterns — it is frequently overlooked in the differential of thumb pain.
Lies under bicepsBrachialis is deep to biceps and is reached by displacing biceps medially or laterally — it is not directly palpable centrally in the anterior arm.
Elbow hyperextension injuriesBrachialis may be involved in posterior elbow pain following hyperextension — it attaches to the coronoid process and is strained in hyperextension mechanisms.
Literature Summary
TrP literature (Simons, Travell & Simons) — brachialis thumb referral pattern is described in the foundational myofascial pain texts and is considered pathognomonic when present.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionPosterior interosseous nerve — lateral epicondyle region
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Lateral epicondyle of the humerus (common extensor origin); lateral collateral ligament
Insertion
Base of the 3rd metacarpal (dorsal surface)
Innervation
Radial nerve (C6, C7) — posterior interosseous nerve (deep branch of radial nerve) at the level of the radial head
Primary Functions
Wrist extension (primary); wrist radial deviation; stabilization of the wrist during grip
Referral Patterns
Lateral epicondyle and wristClassic lateral elbow pain with referral into the dorsal forearm and wrist — the primary referral pattern in lateral epicondylalgia
Grip painPain with gripping activities, especially with the elbow extended — the signature functional presentation of ECRB TrPs / lateral epicondylalgia
Night painNocturnal aching in the forearm is common with established lateral epicondylalgia / ECRB TrP activity
Safety Considerations
Moderate-attention region — posterior interosseous nerve at radial head level
The posterior interosseous nerve (deep branch of the radial nerve) passes between the two heads of supinator at the radial neck, immediately adjacent to the ECRB proximal origin. This is one of the most consistently described nerve-adjacent risks in upper extremity dry needling.
The posterior interosseous nerve is at greatest risk with needling at the radial head level — the standard technique targets the muscle belly rather than the bony enthesis itself.
Finger extensor weakness following needling in this region should prompt assessment for posterior interosseous nerve involvement.
The superficial radial nerve runs superficially on the dorsal forearm — relevant for superficial approaches over the dorsal forearm.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Primary lateral epicondylalgia targetECRB is the single most consistently implicated structure in lateral epicondylalgia — dry needling of ECRB at the common extensor origin is one of the most evidence-supported upper extremity DN applications.
Posterior interosseous nerveThe posterior interosseous nerve (deep radial nerve) passes between the two heads of supinator at the level of the radial head, close to the ECRB origin — this is the key nerve-adjacent landmark.
Superficial radial nerveThe superficial branch of the radial nerve is also in the dorsal forearm — dorsal approaches carry risk of this nerve.
Literature Summary
Lateral epicondylalgia DN RCTs (multiple authors) — ECRB is the primary target in multiple well-conducted dry needling RCTs for lateral elbow pain; this muscle has more DN-specific clinical evidence than most upper extremity targets.
Posterior interosseous nerve anatomy — the nerve's course through the radial tunnel and supinator arcade is well-described in surgical anatomy literature and forms the basis for DN technique safety protocols.
Evidence: moderate for clinical use in lateral epicondylalgia; limited for depth estimation — no BMI-stratified depth study for ECRB was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionMedian nerve between two heads — nerve-adjacent target
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Humeral head: medial epicondyle (common flexor origin). Ulnar head: coronoid process of the ulna
Insertion
Middle of the lateral surface of the radius (pronator tubercle)
Innervation
Median nerve (C6, C7) — the nerve passes between the two heads of pronator teres
Primary Functions
Forearm pronation (primary); weak elbow flexion
Referral Patterns
Anterior forearm and palmTrPs in pronator teres refer to the volar forearm and into the radial palm and thumb — a distribution that overlaps with carpal tunnel syndrome and C6 radiculopathy
Medial elbowLocal pain at the medial elbow crease and antecubital region
Pronator teres syndromeA clinical syndrome of median nerve compression between the two heads of pronator teres — TrP-related tightening may contribute to compression symptoms
Safety Considerations
Moderate-attention region — median nerve passes between the two heads
The median nerve passes directly between the humeral and ulnar heads of pronator teres — this makes pronator teres one of the more nerve-adjacent targets in the forearm. Monitor carefully for median nerve symptoms during any work in this region.
The median nerve is the primary structure at risk — monitor for thumb, index, and middle finger tingling or numbness during treatment.
The brachial artery bifurcates into radial and ulnar arteries in the antecubital fossa proximal to pronator teres — the vascular structures are relevant for proximal forearm approaches.
Ultrasound guidance is recommended by some authors for pronator teres needling given the median nerve proximity.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Median nerve passageThe median nerve passing between the two heads is the defining anatomical relationship — this makes pronator teres both a cause of median nerve compression (pronator teres syndrome) and a technically sensitive DN target.
Pronator teres syndrome vs CTSDifferentiating pronator teres syndrome from carpal tunnel syndrome is a clinical challenge — pronator teres TrPs should be considered in patients with "atypical" or proximal median nerve symptoms.
Common flexor originPronator teres shares the common flexor origin with FCR, FDS, and palmaris longus — medial epicondylalgia presentations should include assessment of pronator teres.
Literature Summary
Pronator teres syndrome literature — the median nerve compression syndrome associated with pronator teres is well-described in peripheral nerve literature; this forms the anatomical basis for DN technique caution.
TrP literature (Simons, Travell & Simons) — pronator teres referral patterns and needle technique described.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention region — accessibleFemoral neurovascular bundle — medial approach caution
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Anterior inferior iliac spine (AIIS); reflected head from the acetabular rim
Insertion
Base of the patella via the quadriceps tendon; indirectly to tibial tuberosity via patellar tendon
Innervation
Femoral nerve (L2, L3, L4)
Primary Functions
Knee extension; hip flexion (the only quadriceps head that crosses the hip joint); important in running, kicking, stair climbing
Referral Patterns
Anterior thigh and kneeTrPs refer to the anterior thigh and deep to the patella — a common source of knee pain that is frequently overlooked in the absence of imaging findings
AIIS regionProximal TrPs near the AIIS may refer to the hip and anterior groin, mimicking hip flexor pathology
Knee-relatedDeep knee pain "behind the patella" is described — relevant in anterior knee pain presentations
Safety Considerations
Lower-attention region — femoral neurovascular bundle medially
Rectus femoris is generally accessible and well-tolerated. The femoral neurovascular bundle (femoral nerve, artery, vein) runs in the femoral triangle just medial to rectus femoris in the proximal thigh.
Avoid very medial approaches in the proximal thigh near the femoral triangle.
Depth varies significantly with body habitus — BMI-stratified data is not available; estimate depth clinically.
For manual approaches: very well tolerated; pressure along the anterior thigh is generally safe with awareness of the medial neurovascular bundle.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
AIIS avulsionThe AIIS is an apophysis in adolescents — rectus femoris avulsion is the most common apophyseal avulsion in the adolescent hip; relevant context for proximal presentations.
Knee pain contributorRectus femoris TrPs contributing to anterior knee and retropatellar pain are frequently missed — this muscle should be assessed in knee pain workups without clear structural findings.
Femoral nerve proximityThe femoral nerve, artery, and vein run in the femoral triangle medially — relevant for very medial approaches in the proximal thigh.
Literature Summary
Quadriceps DN literature — rectus femoris is described as a target in anterior knee pain and hip flexor pain presentations.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention region — accessibleLateral femoral cutaneous nerve — proximal; IT band — lateral
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Greater trochanter, intertrochanteric line, linea aspera of the femur (lateral lip)
Insertion
Lateral aspect of the quadriceps tendon; lateral patella; tibial tuberosity via patellar tendon
Innervation
Femoral nerve (L2, L3, L4)
Primary Functions
Knee extension; lateral patellar stabilization; major contributor to quadriceps force in running and jumping
Referral Patterns
Lateral thigh and kneeTrPs refer to the lateral thigh from the greater trochanter distally toward the lateral knee — overlapping with greater trochanteric pain syndrome and ITB syndrome
Knee bucklingA distinctive presentation of vastus lateralis TrPs is sudden knee buckling or giving way, associated with inhibition of the VMO-VL force couple
Night painLateral thigh pain at night and with prolonged sitting is described
Safety Considerations
Lower-attention region — lateral femoral cutaneous nerve proximity proximally
Vastus lateralis is generally a low-risk needling target. The lateral femoral cutaneous nerve (LFCN) passes beneath the inguinal ligament near the ASIS — relevant for proximal approaches near the greater trochanter.
The lateral femoral cutaneous nerve is relevant for very proximal lateral thigh approaches near the ASIS/LFCN territory.
The femoral artery and nerve are medial — lateral thigh approaches are well away from these structures.
For manual approaches: very well tolerated along the lateral thigh.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
IT band relationshipVastus lateralis lies beneath the IT band — TrP-related tightening can increase IT band tension; both should be assessed in lateral knee pain presentations.
Knee buckling presentationThe knee buckling pattern is particularly relevant for clinical differentiation from structural causes of instability.
Most accessible quadriceps headVastus lateralis is generally the easiest quadriceps head to isolate for palpation and needling — its lateral position makes it accessible with the patient supine or sidelying.
Literature Summary
Quadriceps DN and manual therapy literature — vastus lateralis is addressed in lateral knee pain and quadriceps rehabilitation protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention regionSaphenous nerve and femoral vessels — adductor canal
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Medial lip of the linea aspera; medial supracondylar line; medial intermuscular septum
Insertion
Medial aspect of the quadriceps tendon; medial patella; patellar tendon to tibial tuberosity
Innervation
Femoral nerve (L2, L3, L4)
Primary Functions
Knee extension; medial patellar stabilization (VMO — vastus medialis oblique — particularly important in final degrees of extension); prevents lateral patellar subluxation
Referral Patterns
Medial knee and anterior thighTrPs refer to the medial knee and distal anteromedial thigh — relevant in PFPS (patellofemoral pain syndrome) presentations
Deep knee painRetropatellar and medial knee pain described — often assumed to be structural joint pathology
Knee instability sensationSimilar to VL, VMO TrPs may produce a sensation of knee giving way or instability
Safety Considerations
Lower-attention region — adductor canal and saphenous nerve in medial mid-thigh
Vastus medialis is generally accessible. The adductor canal (Hunter's canal) runs in the medial thigh at approximately the middle third level, containing the femoral artery, vein, and saphenous nerve.
The adductor canal is relevant for approaches in the middle third of the medial thigh — avoid very deep posteromedial angulation in this region.
The saphenous nerve exits the adductor canal distally and becomes superficial on the medial side of the knee — relevant for distal VMO approaches.
For manual approaches: generally well tolerated; adductor canal proximity awareness applies to deep medial mid-thigh work.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
PFPS and VMOVastus medialis oblique (VMO) weakness or inhibition is central to patellofemoral pain syndrome pathophysiology — TrP activity contributing to VMO inhibition is clinically relevant.
Adductor canal awarenessThe saphenous nerve and femoral artery/vein pass through the adductor canal (Hunter's canal) in the medial thigh at approximately the junction of the proximal and middle thirds — relevant for deep medial thigh approaches.
Medial approach cautionMedial thigh needling requires awareness of the saphenous nerve (terminal branch of femoral nerve) and accompanying vessels in the adductor canal.
Literature Summary
PFPS / VMO rehabilitation literature — vastus medialis assessment and treatment is standard in anterior knee pain management.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Pubic body, just below the pubic crest
Insertion
Middle third of the medial lip of the linea aspera
Innervation
Obturator nerve (L2, L3, L4)
Primary Functions
Hip adduction (primary); hip flexion (accessory); medial stabilization of the hip in gait and sports
Referral Patterns
Groin and medial thighTrPs refer to the groin and medial thigh — one of the primary sources of groin pain in athletes
Anterior kneeDistal referral to the anteromedial knee is described — relevant in medial knee pain presentations
Hip adduction restrictionRestricted hip abduction with medial thigh pain is a common presentation associated with adductor longus TrPs
Safety Considerations
Moderate-attention region — femoral neurovascular bundle in the femoral triangle medially
The femoral artery, vein, and nerve run in the femoral triangle at the proximal medial thigh, just medial to adductor longus. The obturator nerve runs deep to the adductors. Positioning in hip abduction improves safe access.
Hip abduction positioning is standard for adductor needling — it opens the medial thigh and moves the femoral bundle slightly laterally.
The femoral artery pulse is palpable medial to adductor longus proximally — monitor for vascular proximity.
The obturator nerve runs deep through the obturator foramen and then between adductor brevis and adductor longus — deep medial angulation approaches this nerve.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Groin pain in athletesAdductor longus TrPs are implicated in athletic groin pain (adductor tendinopathy / osteitis pubis spectrum) — one of the most common and challenging sports medicine presentations.
Obturator nerveThe obturator nerve passes deep to the adductors and provides innervation — obturator neuropathy presentations may overlap with adductor TrP referral.
Hip flexor and adductor complexAdductor longus is frequently treated alongside the other adductors, iliopsoas, and hip flexors in groin pain presentations.
Literature Summary
Athletic groin pain literature — adductor longus TrP treatment is described as part of conservative management of athletic groin pain.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Hip adduction (primary, powerful); hamstring part: hip extension; overall: pelvic stabilization and thigh control in gait
Referral Patterns
Medial thigh and groinDeep medial thigh aching extending from the groin toward the medial knee
Pelvic floor mimicryDeep TrPs in the hamstring portion (ischial attachment) may refer into the pelvic floor and perineal region
Inner kneeReferral to the medial knee from the distal adductor magnus attachment near the adductor tubercle
Safety Considerations
Moderate-attention region — sciatic nerve posteriorly, femoral vessels through adductor hiatus
Adductor magnus lies between the adductors anteriorly and the hamstrings posteriorly. The sciatic nerve runs posterior to it, and the femoral vessels pass through the adductor hiatus in its distal tendon.
The sciatic nerve runs between adductor magnus and the short head of biceps femoris posteriorly — posteriorly directed approaches risk proximity to the sciatic nerve.
The adductor hiatus in the distal tendon allows the femoral artery and vein to pass to the popliteal fossa — very distal medial approaches should account for vascular proximity.
Hip abduction positioning improves access; needle length requirements increase with body habitus.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Dual innervationAdductor magnus has a dual innervation (obturator and sciatic) reflecting its dual embryological origin — this makes it anatomically and clinically a bridge between the adductor and hamstring groups.
Adductor hiatusThe femoral vessels pass through the adductor hiatus in the distal tendon of adductor magnus — this is a surgically important landmark and is relevant for very distal medial thigh work.
Deepest adductorAdductor magnus is the deepest medial thigh muscle — it requires significant needle length to reach in patients with normal or higher BMI.
Literature Summary
Adductor group TrP literature — adductor magnus is described alongside adductor longus and brevis in medial thigh and groin pain management.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionSciatic nerve — posterior thigh; common peroneal nerve at fibular head
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Long head: ischial tuberosity (conjoint tendon with semitendinosus). Short head: lateral lip of the linea aspera, lateral supracondylar line
Insertion
Head of the fibula; lateral condyle of the tibia
Innervation
Long head: tibial branch of sciatic nerve (L5, S1, S2). Short head: common peroneal branch of sciatic nerve (L5, S1, S2)
Primary Functions
Knee flexion (both heads); hip extension (long head); lateral knee and hip stabilization; contributes to external tibial rotation at the knee
Referral Patterns
Posterior thigh and kneeTrPs refer to the posterior thigh and the posterior knee crease — a common source of posterior knee pain
Popliteal regionReferral into the popliteal fossa from distal biceps femoris TrPs — relevant in posterior knee pain presentations
Lower leg referralOccasional referral into the calf and heel has been described from very distal hamstring TrPs
Safety Considerations
Moderate-attention region — sciatic nerve in posterior thigh, common peroneal nerve at fibular head
The sciatic nerve runs between biceps femoris laterally and semitendinosus/semimembranosus medially in the posterior thigh. Distally, the common peroneal nerve separates and wraps around the fibular head.
The sciatic nerve is the primary deep structure — watch for posterior leg, calf, or foot symptoms during posterior thigh work.
The common peroneal nerve at the fibular head is at particular risk for distal biceps femoris work near the knee.
Patient positioning (prone) and palpation of the sciatic nerve before needling is recommended in the posterior thigh.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Common peroneal nerve at fibular headThe common peroneal nerve wraps around the fibular head at the knee — distal biceps femoris work near the fibular head is one of the more common DN-related nerve injury sites.
Hamstring strain contextBiceps femoris is the most commonly strained hamstring muscle in sprinting injuries — TrP assessment is part of hamstring rehabilitation.
Sciatic nerve in posterior thighThe sciatic nerve runs between biceps femoris and the medial hamstrings in the posterior thigh — depth awareness is critical.
Literature Summary
Hamstring DN literature — biceps femoris is the most frequently targeted hamstring muscle in dry needling research for posterior thigh and knee pain.
Common peroneal nerve injury reports — case reports of common peroneal nerve palsy following needling near the fibular head inform distal technique protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionSciatic nerve — lateral in posterior thigh
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Ischial tuberosity (conjoint tendon with long head of biceps femoris)
Insertion
Upper medial surface of the tibia (pes anserinus, with sartorius and gracilis)
Innervation
Tibial branch of sciatic nerve (L5, S1, S2)
Primary Functions
Knee flexion; hip extension; internal tibial rotation (when knee is flexed); pes anserinus contributes to medial knee stability
Referral Patterns
Posterior thigh and gluteal creaseTrPs refer from the ischial origin toward the posterior knee — a pattern similar to biceps femoris but along the medial posterior thigh
Medial kneeDistal referral toward the medial knee via the pes anserinus attachment
CalfLower leg referral has been described for very distal semitendinosus TrPs
Safety Considerations
Moderate-attention region — sciatic nerve lateral to medial hamstrings in posterior thigh
The sciatic nerve runs between semitendinosus medially and biceps femoris laterally in the posterior thigh. Standard prone positioning with careful palpation minimizes sciatic nerve proximity.
The sciatic nerve is lateral to semitendinosus — monitor for posterior leg, calf, or foot symptoms.
The medial hamstring tendons (semitendinosus and semimembranosus) are close at the ischial origin — precise palpation is needed to target each independently.
For manual approaches: generally well tolerated along the medial posterior thigh; sciatic nerve awareness applies.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Pes anserinusSemitendinosus inserts into the pes anserinus alongside sartorius and gracilis — pes anserinus bursitis and TrP-related medial knee pain can overlap clinically.
Medial posterior thighSemitendinosus lies medially in the posterior thigh, palpable alongside semimembranosus — distinguishing the two requires careful technique.
Hamstring group assessmentSemitendinosus is typically treated as part of the medial hamstring group alongside semimembranosus in posterior thigh and knee presentations.
Literature Summary
Hamstring DN literature — semitendinosus is treated alongside semimembranosus in medial hamstring protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionSciatic nerve — lateral; popliteal artery at knee
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Ischial tuberosity (separate tendon, more lateral than the conjoint tendon)
Insertion
Posterior medial condyle of the tibia; contributes to posterior joint capsule (oblique popliteal ligament)
Innervation
Tibial branch of sciatic nerve (L5, S1, S2)
Primary Functions
Knee flexion; hip extension; internal tibial rotation when knee is flexed; reinforces the posterior knee capsule
Referral Patterns
Posterior thigh and kneeSimilar referral to semitendinosus — posterior thigh aching extending to the posterior knee crease
Posterior kneeSemimembranosus TrPs are one of the sources of posterior knee pain; the Baker's cyst semimembranosus bursa is anatomically adjacent
Medial kneeReferral into the medial knee joint line described
Safety Considerations
Moderate-attention region — sciatic nerve lateral; popliteal artery at knee
Semimembranosus lies deep to semitendinosus in the posterior thigh. Distally it approaches the popliteal fossa, which contains the popliteal artery, vein, tibial nerve, and common peroneal nerve.
The sciatic nerve runs lateral to the medial hamstrings — watch for posterior leg, calf, or foot symptoms.
Distal approaches near the popliteal fossa should be approached carefully given the vascular and neural concentration in that space.
Distinguishing semimembranosus from semitendinosus requires careful palpation — semitendinosus is more superficial.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Baker's cyst adjacencySemimembranosus bursa communicates with the knee joint and can become the Baker's cyst (popliteal cyst) — TrP activity and bursitis can coexist.
Deepest medial hamstringSemimembranosus lies deep to semitendinosus and requires more needle length to reach accurately.
Popliteal fossa anatomyDistally, the semimembranosus approaches the popliteal fossa where the popliteal artery and vein, tibial nerve, and common peroneal nerve converge — distal approaches require particular care.
Literature Summary
Medial hamstring DN literature — semimembranosus is treated alongside semitendinosus in medial posterior thigh and knee protocols.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention region — accessibleDeep peroneal nerve and anterior tibial artery — anterior compartment
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Lateral condyle and upper two-thirds of the lateral surface of the tibia; interosseous membrane
Insertion
Medial cuneiform; base of the 1st metatarsal (medial and plantar surfaces)
Innervation
Deep peroneal nerve (L4, L5)
Primary Functions
Dorsiflexion of the ankle (primary); foot inversion; prevents foot drop in the swing phase of gait
Referral Patterns
Anterior shin and great toeTrPs refer to the anterior shin and the dorsum of the great toe — relevant in anterior shin pain and hallux pain presentations
Ankle painReferral around the anterior ankle medially is described
Night pain and crampsTibialis anterior TrPs are associated with night cramps and anterior leg pain at rest
Safety Considerations
Lower-attention region — deep peroneal nerve and anterior tibial artery in anterior compartment
Tibialis anterior is generally accessible along the anterior shin. The deep peroneal nerve and anterior tibial artery run deep to it in the anterior compartment toward the interosseous membrane.
Deep needling toward the interosseous membrane approaches the deep peroneal nerve and anterior tibial artery.
Standard needle depth targets the muscle belly — bone contact with the tibia provides a depth endpoint for proximal approaches.
Anterior compartment syndrome is a consideration with significant post-needling swelling in this region.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Shin splints differentialTrPs in tibialis anterior contribute to anterior compartment-type shin pain in runners — should be assessed alongside periostitis and stress reactions.
Foot drop contextTibialis anterior weakness from any cause (including inhibition from TrPs) contributes to foot drop mechanics — functional assessment is relevant.
Deep peroneal nerveThe deep peroneal nerve and anterior tibial artery run together alongside the tibialis anterior in the anterior compartment — deep needling toward the interosseous membrane approaches these structures.
Literature Summary
Shin pain / anterior compartment DN literature — tibialis anterior is a target in anterior leg pain presentations.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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High-attention region — technically demandingDeep posterior compartment — posterior tibial artery and tibial nerve
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Posterior surface of the interosseous membrane; adjacent posterior tibia and fibula
Insertion
Navicular tuberosity (primary); cuneiforms, cuboid, and metatarsal bases (multiple slips)
Innervation
Tibial nerve (L4, L5)
Primary Functions
Foot inversion and plantar flexion; primary dynamic support of the medial longitudinal arch; critical in push-off and single-leg stance
Referral Patterns
Medial ankle and archTrPs refer to the medial heel, plantar surface of the foot, and medial ankle — often associated with tibialis posterior tendinopathy
Calf crampingDeep calf cramping pattern with plantar foot referral
Arch painAching along the medial arch that is worse with prolonged standing — a common presentation in tibialis posterior dysfunction
Safety Considerations
High-attention region — deep posterior compartment, posterior tibial artery and tibial nerve
Tibialis posterior is the deepest muscle in the posterior compartment, lying on the interosseous membrane between the tibia and fibula. Reaching it requires traversing the gastrocnemius and soleus. The posterior tibial artery and tibial nerve run in the deep posterior compartment alongside it.
Ultrasound guidance is strongly recommended for tibialis posterior needling — the depth and neurovascular proximity make landmark-only technique unreliable.
The posterior tibial artery and tibial nerve run between flexor digitorum longus and tibialis posterior in the deep compartment.
Deep posterior compartment syndrome is a serious potential complication — post-needling symptoms in this region warrant careful monitoring.
Illustrative/educational estimate only — no BMI-stratified depth study was located; ultrasound guidance recommended.
Clinical Pearls
Adult acquired flatfootTibialis posterior tendinopathy and dysfunction is the primary cause of adult acquired flatfoot deformity — TrP activity in the muscle belly may coexist with tendon pathology.
Technically demanding targetTibialis posterior requires needle passage through the gastrocnemius and soleus to reach — ultrasound guidance is strongly recommended in published protocols.
Tarsal tunnelThe tibialis posterior tendon, posterior tibial artery, and tibial nerve all pass through the tarsal tunnel at the medial ankle — relevant for distal presentations.
Literature Summary
Tibialis posterior tendinopathy literature — the muscle belly as a dry needling target is described in the context of posterior tibial tendon dysfunction.
Ultrasound-guided procedure literature — ultrasound guidance for deep posterior compartment access is recommended in published protocols.
Evidence: limited / anatomy-based — no BMI-stratified dry needling depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention region — accessibleSural nerve and small saphenous vein — posterior midline
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Medial head: posterior surface of medial femoral condyle. Lateral head: posterior surface of lateral femoral condyle
Insertion
Posterior surface of the calcaneus via the Achilles tendon (with soleus)
Innervation
Tibial nerve (S1, S2)
Primary Functions
Plantarflexion of the ankle; knee flexion (secondary); contributes to push-off in walking and running; the most powerful propulsive muscle in gait
Referral Patterns
Posterior calf and kneeTrPs in the medial head refer to the posterior knee crease and medial calf; lateral head to the lateral calf and posterior ankle
Nocturnal crampsGastrocnemius TrPs are one of the most common causes of nocturnal calf cramps
Plantar fascia and heelDistal referral to the heel and plantar fascia has been described — relevant in plantar fasciitis presentations
Safety Considerations
Lower-attention region — sural nerve and small saphenous vein in posterior midline
Gastrocnemius is one of the most accessible muscles in the lower extremity. The sural nerve and small saphenous vein run in the posterior midline of the calf, between the two heads.
The sural nerve and small saphenous vein run between the medial and lateral heads — midline posterior calf approaches are relevant.
The tibial nerve and posterior tibial vessels run deep to gastrocnemius with soleus — standard gastrocnemius depth does not approach these structures.
For manual approaches: very well tolerated; calf cramps may be reproduced during treatment.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Cramp associationGastrocnemius is the primary muscle involved in most nocturnal leg cramps — TrP treatment can be effective for recurrent nocturnal cramping.
Achilles tendinopathyGastrocnemius TrPs frequently coexist with Achilles tendinopathy — the muscle belly should be assessed alongside the tendon.
Most accessible calf muscleGastrocnemius is the most superficial calf muscle and generally the most accessible and well-tolerated for both needling and manual therapy.
Literature Summary
Nocturnal calf cramp literature — gastrocnemius TrP treatment is described as effective for recurrent nocturnal leg cramps.
Achilles tendinopathy DN literature — gastrocnemius and soleus are addressed in DN protocols for Achilles tendinopathy.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Lower-attention regionDeep to gastrocnemius — posterior tibial vessels deeper still
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Posterior head of the fibula; soleal line on the posterior tibia; tendinous arch between tibia and fibula
Insertion
Posterior surface of the calcaneus via the Achilles tendon (with gastrocnemius)
Innervation
Tibial nerve (S1, S2)
Primary Functions
Plantarflexion at the ankle (especially with the knee flexed — isolated soleus action); postural ankle stabilization in quiet stance; "peripheral heart" — the soleal venous sinuses play a major role in venous return from the lower limb
Referral Patterns
Heel and plantar footSoleus TrPs refer primarily to the heel and plantar surface — a common and frequently overlooked source of heel pain distinct from plantar fasciitis
Posterior calfLocal calf aching, often confused with gastrocnemius TrP pain but present even with knee flexed (which relaxes gastrocnemius)
Sacroiliac regionAn unusual proximal referral to the ipsilateral sacroiliac region has been described from soleus TrPs
Soleus lies deep to gastrocnemius and is generally a safe target once the gastrocnemius is traversed. The soleal venous sinuses are a site of DVT. The posterior tibial artery and tibial nerve are deeper still in the posterior compartment.
DVT must be excluded before needling in the posterior calf — acute DVT is a contraindication for calf needling.
The posterior tibial artery and tibial nerve run in the deep posterior compartment; standard soleus depth does not approach these structures.
Knee flexion during examination helps isolate soleus contribution from gastrocnemius — the same positioning principle applies during treatment.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Heel pain differentialSoleus TrPs are a consistent but often overlooked differential for heel pain — the gastrocnemius relaxes with knee flexion but soleus referral persists, helping distinguish the two.
DVT awarenessThe soleal venous sinuses are a primary site of deep vein thrombosis — posterior calf pain presentations should include DVT in the differential before needling.
Deep to gastrocnemiusSoleus is reached after traversing the gastrocnemius — needle depth is greater than for gastrocnemius alone; this varies significantly with body habitus.
Literature Summary
Heel pain differential literature — soleus TrPs are described as a distinct heel pain source; clinical differentiation from plantar fasciitis and gastrocnemius TrPs is documented.
Achilles tendinopathy DN protocols — soleus is addressed alongside gastrocnemius.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionCommon peroneal nerve — fibular head (proximal approaches)
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Upper two-thirds of the lateral surface of the fibula; head of the fibula; lateral condyle of the tibia
Insertion
Medial cuneiform and base of the 1st metatarsal (via a long tendon that wraps under the foot)
Innervation
Superficial peroneal nerve (L4, L5, S1)
Primary Functions
Foot eversion (primary); plantar flexion; supports the transverse and lateral longitudinal arches; "ties the foot together" via its unique plantar course
Referral Patterns
Lateral ankle and heelTrPs refer to the lateral ankle and heel — relevant in ankle instability and lateral foot pain presentations
Peroneal tendon regionPain along the lateral lower leg following the tendon course is described
Arch painReferral toward the metatarsal heads from distal peroneus longus TrPs
Safety Considerations
Moderate-attention region — common peroneal nerve at fibular head; superficial peroneal nerve in lateral compartment
The common peroneal nerve wraps around the fibular neck at the proximal lateral leg — this is one of the most injury-prone peripheral nerve locations in the lower extremity and must be respected for any proximal lateral leg work.
The common peroneal nerve at the fibular head is the critical safety landmark — avoid deep pressure or needling directly at the fibular neck.
Foot drop following any lateral knee or proximal lower leg procedure raises concern for common peroneal nerve injury.
The superficial peroneal nerve runs through the lateral compartment alongside the muscle — monitor for dorsal foot symptoms during treatment.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
Common peroneal nerve at fibular headOne of the most important nerve-adjacent landmarks in the lower extremity — the common peroneal nerve wraps around the posterior aspect of the fibular neck, making this one of the most at-risk sites for nerve injury in any lateral knee/proximal lower leg procedure.
Ankle instability contextPeroneus longus and brevis TrPs are described in the context of chronic ankle instability — the peroneal muscles are the primary lateral ankle stabilizers.
Superficial peroneal nerveThe superficial peroneal nerve (providing sensation to the dorsum of the foot) runs in the lateral compartment alongside peroneus longus — relevant for approaches in the mid and distal lateral leg.
Literature Summary
Common peroneal nerve anatomy — the nerve's course around the fibular neck is consistently described as one of the most injury-prone peripheral nerve locations; relevant for all lateral lower leg procedures.
Ankle instability literature — peroneal muscle TrP assessment and treatment is described in chronic ankle instability rehabilitation.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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Moderate-attention regionCommon peroneal nerve — fibular head (same as peroneus longus)
This pageAnatomy OverviewReferral PatternsSafety ConsiderationsClinical PearlsLiterature Summary
Anatomy Overview
Origin
Lower two-thirds of the lateral surface of the fibula
Insertion
Styloid process (tuberosity) at the base of the 5th metatarsal
Innervation
Superficial peroneal nerve (L4, L5, S1)
Primary Functions
Foot eversion (primary); plantar flexion; primary lateral ankle stabilizer in the terminal stance phase
Referral Patterns
Lateral ankle and 5th metatarsalTrPs refer to the lateral ankle and the lateral foot toward the 5th metatarsal — relevant in lateral ankle pain and peroneal tendon pathology
Jones fracture regionPain near the 5th metatarsal base — where the peroneus brevis inserts — mimics Jones fracture presentations in athletes
Lateral lower legLocal pain in the lateral lower leg below peroneus longus
Safety Considerations
Moderate-attention region — common peroneal nerve at fibular head; superficial peroneal nerve in lateral compartment
Same safety profile as peroneus longus — the common peroneal nerve at the fibular neck is the critical proximal landmark. More distally, the superficial peroneal nerve runs in the lateral compartment. The sural nerve is relevant at the lateral ankle for distal approaches.
Same common peroneal nerve awareness at the fibular head applies — see Peroneus Longus entry.
The sural nerve runs along the lateral border of the foot and lateral ankle — relevant for distal lateral lower leg and ankle approaches.
Peroneal tendons pass in a common synovial sheath behind the lateral malleolus — local injection/needling technique in this region follows tendon sheath anatomy.
Illustrative/educational estimate only — no BMI-stratified depth study was located.
Clinical Pearls
5th metatarsal base avulsionPeroneus brevis tendon avulsion from the 5th metatarsal base (pseudo-Jones fracture) is a common ankle inversion injury — distinguishing TrP referral from acute bony injury requires imaging in appropriate presentations.
Peroneal tendon tearsLongitudinal split tears of peroneus brevis are a common cause of chronic lateral ankle pain — TrP activity and tendon pathology commonly coexist.
Below peroneus longusPeroneus brevis lies deep to peroneus longus in the distal lateral compartment — distinguishing the two requires careful palpation at different levels.
Literature Summary
Peroneal tendon pathology literature — peroneus brevis is addressed in lateral ankle stability and peroneal tendon rehabilitation.
Evidence: limited / anatomy-based — no BMI-stratified depth study was located.
All depth estimates for this muscle are illustrative/educational only — not patient-specific. Evidence is limited; label accordingly.
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A consolidated, searchable view of the anatomical depth literature reviewed for every muscle in MyoMap Clinical™.
47 muscles indexedGrowing over time
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Each row summarizes the single most representative depth finding for that muscle — full study details, additional studies, BMI/sex stratification where available, and complete citations are on each muscle's Depth Data tab. Evidence-strength labels follow the same legend used throughout MyoMap Clinical™: direct study (muscle-specific ultrasound or cadaveric data), extrapolated (adjacent muscle or related region), and limited evidence (general or non-stratified description).
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MyoMap Clinical™ Pro
Unlock the searchable Depth Reference Database — every muscle's key depth finding, source, and evidence strength in one filterable table, with new muscles added over time.
Built for the Clinician Who Wants to Treat with Confidence
Trigger point work — whether by needle or by hand — involves real decisions under uncertainty: which muscle, at what depth, with what safety considerations. MyoMap Clinical™ was created by an MSK-focused physician to provide an additional layer of evidence-informed support for those decisions — for the full range of clinicians doing this work: physiotherapists, physicians, chiropractors, naturopathic doctors, RMTs, and students.
Every depth figure, safety consideration, and literature summary is drawn from published studies, with citations so clinicians can verify the source directly. Where the evidence is strong, MyoMap Clinical™ says so. Where it's limited or extrapolated, that's labeled too — clinical confidence depends on honest evidence, not inflated claims.
The goal is an interactive clinical companion — not a digital textbook. Anatomy and depth context are most useful when they're available in the moment, at the right level of detail, without requiring hours of research to find.
Direct study — muscle-specific, ultrasound or cadaveric depth data
Extrapolated — adjacent muscle or related anatomical region
Limited evidence — general or non-stratified description
Clinical Reasoning Support
Referral Pattern Finder
Select where the patient reports pain — see which muscles in the MyoMap library refer there, ranked by how commonly that pattern is described in the literature. A starting point for clinical reasoning, not a diagnosis.
This is a differential starting point, not a diagnosis. Multiple muscles commonly refer to the same region, and referral patterns overlap. Use this alongside palpation, history, and clinical judgment — not instead of them.
Evidence-Informed Depth Context
Depth Estimation Explorer
Reduce uncertainty when treating patients with varied body habitus. Explore how BMI and sex may influence expected tissue depth for each muscle — based on published depth studies — so you can approach challenging cases with greater confidence.
Population-level context, not patient-specific targets. MyoMap Clinical™ does not provide a "recommended," "correct," or "target" depth for any individual patient. Where published data exists, this tool shows the estimated range that data describes and how strong that evidence is. Where data doesn't exist for a muscle, that's stated directly.
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Anthropometric Inputs
Some studies reported sex-based differences; others didn't measure or find one. This tool reflects what each source actually reported.
Enter height and weight — BMI will be calculated automatically. Values carry over from the Planning Companions if you've already entered them there.
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Evidence-Informed Estimate
Start a new case, or open an existing one?
New Case
Start a new case.
Pick a region, find the muscle, and walk through procedure planning — then document and generate a note when you're done.
Start a new case
Existing Case
Open an existing case.
Review what was treated, how it went, and repeat or adjust the plan in one click.
Open existing case
No patient names or identifiers. Nothing you enter is stored or transmitted beyond this browser session.
Active case
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Patient Context
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Each flagged modifier surfaces a targeted clinical callout in the plan below. Select only what's relevant to this patient — none of these are required.
Prior response to needling or injections
Previous response is one of the strongest predictors of future response in MSK interventions.
Fibromyalgia / centralized pain
Central sensitization may increase needle sensitivity and produce unpredictable response patterns.
Diabetes mellitus
Relative contraindication — impaired wound healing, altered sensation, and infection risk are documented considerations.
Chronic opioid use
Opioid-induced hyperalgesia may affect pain perception and produce atypical response to needling.
Anticoagulant / antithrombotic therapy
Warfarin, DOACs, or antiplatelet agents — elevated bleeding and hematoma risk documented in dry needling literature.
Prior vasovagal reaction to needling
Previous vasovagal or syncopal episode during needling or injection procedure.
Immunocompromise
Active cancer treatment, immunosuppressive therapy, HIV, or other significant immune compromise — infection risk elevated.
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Muscles Addressed
47 muscles currently available — the list is growing. Additional clinically relevant muscles will be added progressively.
Find muscles by where the patient reports pain
Select the pain location — muscles that refer to that zone will appear below, ranked by how commonly that pattern is described in the literature.
Showing muscles for selected regions
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Treatment Details
MyoMap Clinical™ does not suggest needle depth, gauge, or other parameters. This field is for documenting your own technique as performed.
✓ Session saved — this case will pre-fill on your next visit
Help Shape MyoMap Clinical™
Clinician Feedback
MyoMap is a clinical workflow tool for dry needling, trigger point injection, and related procedures — built by an MD/ABFM physician. Your feedback directly shapes what gets built next. Takes about 2 minutes.
Answer only what applies to you. Click Submit Feedback at the end to send responses to the MyoMap team.
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About You
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How useful is each feature?
Rate from 1 (not useful) to 5 (very useful) — or "Didn't try" if you haven't explored it yet.
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Workflow Experience
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Value & Retention
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Anything else?
MyoMap Clinical™ Feedback
About You
Feature Ratings
Workflow & Value
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Your feedback has been submitted. It genuinely helps shape what MyoMap becomes next.
Practice Analytics
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