The Role of Leopard Spot Technique Acupuncture for Shoulder Impingement with Myofascial Pain Syndrome

Summary

Shoulder impingement syndrome can be defined as a collection of symptoms and signs in the shoulder caused by pathology within the intrinsic or extrinsic that cause pinching in the narrowed space between the acromion and the head of the humerus. Myofascial pain yndrome can occur because of shoulder impingement syndrome. We report a 66-year-old male patient who presented with complaints of limited motion in the right shoulder area accompanied by pain to a medical acupuncture clinic in Jakarta, Indonesia, in 2024. Leopard spot technique manual acupuncture was performed at the palpable myofascial trigger point area in each therapy session. After multiple sessions, the patient experienced a reduction in the NRS scale, improvement in range of motion in shoulder, increased pressure using an algometer and improvement in Shoulder Pain and Disability Index scores without side effects. Therefore, manual acupuncture using Leopard spot technique may effectively improve shoulder motion limitations in shoulder impingement syndrome accompanied by myofascial pain syndrome.

1. Introduction

Shoulder impingement syndrome can be defined as a collection of symptoms and signs in the shoulder caused by pathology within the rotator cuff tendons themselves (intrinsic) or external structures (extrinsic) that cause pinching in the narrowed space between the acromion and the head of the humerus.¹ Myofascial pain syndrome (MPS) can occur due to various factors, one of which is shoulder impingement syndrome.² MPS is described as sensory, motor and autonomic symptoms caused by trigger points (TrPs).^3,4 The Leopard spot technique involves rapid needle insertion that delivers high-pressure stimulation to hypersensitive points, effectively eliciting local twitch responses (LTRs) and providing immediate pain relief following swift and repeated needle stimulation.^5,6 This report describes a MPS patient on whom manual acupuncture using Leopard spot technique was used to improve clinical presentation in shoulder impingement.

2. Case report

A 66-year-old male patient visited a medical acupuncture clinic in Jakarta, Indonesia, in 2024 with complaints of limited motion in the right shoulder area accompanied by pain. The patient had been experiencing pain in the right shoulder and difficulty moving it for the past 3 months. The pain began after the patient fell due to slipping, during which he extended his right arm to prevent falling, causing pressure on the hand against the floor. The pain had been constant and had interfered with arm mobility for the past 2 months. He reported that the pain improved with rest. Movements of the right arm, such as reaching backward, upward and sideways, were limited. The pain radiated from the shoulder to the lower arm.

The patient underwent an X-ray 1.5 months prior to presentation and an othopaedic specialist confirmed that there were no bone displacements but noted calcification in the shoulder joint. He experienced only mild pain with no movement restrictions in his left shoulder.

The patient had been using pain relievers (paracetamol 1,000 mg and gabapentin) as needed and applied heat therapy using an unspecified device. However, there was no significant improvement in pain or mobility with this treatment. When experiencing pain, the patient rated it as 5 on a scale of 10, which decreased to 4 after taking medication. The pain mildly disrupted sleep.

On physical examination, the patient communicated well, appeared to be comfortable and was not in any emotional distress. His height was 163 cm, he weighed 64 kg and his body mass index was 24.1 kg/m². General physical examination was normal. A specific local examination of his shoulder region was performed and there were no deformities or hyperaemia; the movement of right shoulder area was limited. His maximum movement of shoulder abduction was 87°, extension was 37° and external rotation was 152° [Fig. 1A–C]. Pain was noted between 89° and 120°, but movements beyond 120° become pain-free (positive painful arc of motion). No restrictions were observed in adduction and internal rotation movements.

Fig. 1.

Photographs of the examination of the shoulder area of a 66-year-old male showing limitation range of motions in right shoulder, specifically (A abduction, (B extension and (C external rotation showing signs of shoulder impingement which were all positive based on the (D Neer's test, (E Jobe's test and (F Hawkin-Kennedy's test.

Specific examinations for shoulder impingement were performed such as Hawkin-Kennedy test, Jobe test and Neer test. All tests were positive [Fig. 1D–F].

On laboratory examinations, complete blood count showed that the leukocyte count was higher than normal (13.300 mg/dL) but all other tests were normal. A random blood glucose was also higher than normal (340 mg/dL). A triglyceride blood test was also higher than (222 mg/dL). HbA1c was performed on the patient and presented higher than normal (7.6%). The patient regularly takes medication for diabetes mellitus and hyperlipidaemia prescribed by an internal medicine specialist.

An ultrasound examination of shoulder examinations revealed calcific tendinosis of the right supraspinatus with subacromial impingement and right infraspinatus tendinopathy. Left infraspinatus tendinopathy, suspected to be accompanied by low-grade partial tears on the anterior bursal side was noted. There was no evidence of bilateral adhesive capsulitis.

Acupuncture therapy was performed using the manual acupuncture Leopard spot technique at the palpable myofascial trigger point (MTrP) area in each therapy session [Fig. 2]. The diagnostic criteria for MTrP are hypersensitive spots located on a taut band or palpable hypersensitive nodules, or the presence of referred pain or a local twitch response in the palpated area. The selected MTrP is the primary MTrP, which is the trigger point that causes local pain and referred pain when the point is stimulated. The Leopard spot technique was performed using 0.25 mm × 5mm (31G × 3/16′′) BD Micro-fine Needle and involves a needle being inserted into the MTrP area 5 times in each area; this can be repeated up to a maximum of 2 times in each area until it reaches the dermis. The therapy was administered twice in a week. After 6 therapy sessions, the patient experienced symptom improvement, evidenced by a significant reduction in MTrP areas, which continued through the 12th session. After 12 sessions, the Shoulder Pain and Disability Index (SPADI) questionnaire scores decreased from 54.61% (severe shoulder pain and disability) to 20% (mild shoulder pain and disability), reflecting reduced pain and disability levels. Outcomes assessed included pain levels using the NRS scale, pressure pain threshold using an algometer, range of motion in the right shoulder area and SPADI questionnaire scores [Fig. 3,Table 1]. Clinical changes were improved in the patient without side effects.

Fig. 2.

Photograph of the Leopard spot technique manual acupuncture performed at palpable myofascial trigger point.

Fig. 3.

Improvement in the patient's (A range of motion in abduction, extension and external rotation and (B scoring in the shoulder pain and disability index questionnaire for during the progression of Leopard spot acupuncture technique sessions.

SPADI = Shoulder Pain and Disability Index.

Table 1.

Improvement of pressure pain of threshold using an algometer in the muscles before and after Leopard's spot technique in kg.

Session number	Deltoid muscle		Upper trapezius muscle		Supraspinatus muscle		Infraspinatus muscle		Extensor carpi radialis dextra muscle	Triceps dextra muscle
	Dextra	Sinistra	Dextra	Sinistra	Dextra	Sinistra	Dextra	Sinistra
1st therapy	1.8 to 2	2.3 to 3	2.8 to 3.2	3.2 to 3.5	2.2 to 3	2.1 to 2.5	2.4 to 3	3.2 to 3.8	2.8 to 3.2	1.5 to 2
4th therapy	2.8 to 3	2.8 to 3.3	2.5 to 3.5	3.5 to 3.7	2.8 to 3.2	2.8 to 3.2	2.6 to 3	3.8 to 4	2.8 to 4	1.9 to 2.5
6th therapy	3.2 to 4	2.8 to 3.8	2.5 to 2.8	2.8 to 3.5	3 to 3.5	3.2 to 3.5	3.5 to 4	4 to 4.3	3 to 4.2	2.3 to 2.8
9th therapy	3.8 to 4.5	4 to 4.3	3 to 3.5	3.5 to 4	-	-	-	-	4.3 to 4.5	3.8 to 4.3
12th therapy	3.2 to 3.7	4 to 4.5	3.8 to 4	4 to 4.2	-	-	-	-	4 to 4.7	-

3. Discussion

MPS can occur due to various factors, one of which is shoulder impingement syndrome; however, most patients who present with shoulder pain are not aware that they also have MPS that worsens the outcomes.^2,7 The current case describes the effect of Leopard spot technique in a 66-year-old male patient with shoulder impingement syndrome accompanied with MPS.

MPS is a common musculoskeletal condition characterised by the presence of MTrPs, which can lead to localised and referred pain, muscle stiffness and functional limitations. While pharmacological interventions such as analgesics and muscle relaxants are often used, they may not be sufficient or suitable for long-term management due to potential side effects. Therefore, non-pharmacological therapies have gained increasing attention as effective and safer alternatives. Among these, rehabilitation and acupuncture are widely utilised approaches. Rehabilitative interventions include myofascial release therapy, ultrasound therapy, extracorporeal shock wave therapy and ischaemic compression techniques, all of which aim to restore muscle function, reduce pain and improve quality of life. In parallel, acupuncture—particularly when targeting MTrPs—has shown promising results in modulating pain pathways and promoting muscle relaxation through both mechanical and neurophysiological mechanisms. Both rehabilitative therapies and acupuncture have their own advantages; however, the Leopard spot acupuncture technique demonstrates a more rapid effect in relieving pain compared to other therapeutic approaches.^11,12,13

Leopard spot technique acupuncture was chosen because this technique has been shown to enhance the excitability of alpha motor neurons, increasing the motor unit fibres' activity and the amplitude of muscle movement. Additionally, acupuncture improves oxygen supply and microcirculation, balancing the dynamic movement of muscles.^5,6,8

Research has demonstrated that the Leopard spot technique stimulates cell proliferation and migration, particularly fibroblasts, modulates cytokines, growth factors and inflammatory mediators, enhances tissue oxygenation, reduces oxidative stress and oedema and alleviates pain. It also stimulates medullary haematopoiesis via neuro-humoral regulation and promotes tissue regeneration. The Leopard spot technique at acupuncture points may activate sensory receptors along pathways affected by trigger points, helping restore homeostasis related to oedema. This mechanism is supported by the absence of changes in serum ESR and CRP, indicating that acupuncture effects are more related to microcirculation than inflammation.^5,9

The rapid needle movements create high-pressure stimulation at sensitive points to trigger more LTRs. The most plausible mechanism for immediate and complete pain relief after rapid, repeated needle stimulation is hyperstimulation analgesia via descending pain inhibition systems. Strong pressure stimulation from rapid needle movements at MTrP points (sensitive nociceptors) sends strong nerve impulses to the dorsal horn cells in the spinal cord, interrupting the ‘MTrP circuit’ via descending pain inhibition pathways.^5,6

Direct needling at trigger points affects sarcomere length and fascia in muscle myofibrils with trigger points, reducing pain in the trapezius muscle and promoting relaxation and improved circulation. Acupuncture enhances blood circulation through calcitonin gene-related peptide- and nitric oxide-mediated vasodilation, stimulates mast cell activation to produce histamine (a vasodilator) and increases capillary and vein permeability, improving fluid diffusion. Enhanced blood circulation boosts oxygen flow to tissues, accelerates metabolism and clears excess substances and nociceptive agents.^5,6 In previous research, Leopard spot technique had a specific effect on increasing the range of motion of the patellar reflex (30.71%) and showed improvement the recruitment of motor units promoting the increase of the muscular power of the quadriceps muscle.¹⁰ In the present case, the patient had immediate pain relief after each session of therapy and improved his limited range of motion after completing 1 session of acupuncture therapy.

Hypercholesterolemia, defined as a total cholesterol level greater than 5 mmol/L, is associated with a 1.5-fold increased risk of upper extremity tendon injury. The presence of metabolic syndrome further elevates this risk, with a 2.5-fold increase observed.¹⁴ The current patient had diabetes mellitus type 2 and hyperlipidaemia; acupuncture has a positive therapeutic effect on diabetes via regulating blood sugar and delaying central nervous system damage. Acupuncture treatment helps in decreasing blood lipids and plays a significant role in improving the immunity system.^12,13 Acupuncture is safe to perform on patients with well-controlled diabetes mellitus. An increase in leukocyte levels may indicate the presence of inflammation and muscle injury. Recovery in the current patient needs 3–4 days after 1 session of acupuncture.^12,13

4. Conclusion

Manual acupuncture using the Leopard spot technique performed on patients with shoulder impingement syndrome accompanied by MPS may improve shoulder movement limitations, reduce pain scale and decrease disability. This is achieved through mechanisms such as enhancing local blood circulation in the shoulder area, suppressing proinflammatory cytokine levels, inhibiting descending pain pathways and strengthening muscles in the shoulder region. In the current case, it was also observed that the therapy did not cause any side effects, making it safe to administer. However, further research with longer observation periods is needed to evaluate the durability of the effects of acupuncture using the Leopard spot technique.

Authors' Contribution

Dewi Ratnasari: Conceptualization, Methodology, Investigation, Writing – Original Draft, Visualization. Sri Wahdini: Methodology, Resources, Writing – Review & Editing, Supervision.

Acknowledgement

The authors would like to express their sincere gratitude to dr. Yoshua Viventius, Sp.Ak, as the supervising physician at the Medical Acupuncture Clinic of Cipto Mangunkusumo Hospital (RSCM) Jakarta, for his guidance and support throughout the patient therapy process.

Ethics Statement

The patient provided informed consent for the publication of this case.

Data Availability

Data is available upon reasonable request from the corresponding author.