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12 Articles in Volume 16, Issue #1
A New Look at Sphenopalatine Ganglion Blocks for Chronic Migraine
Can Weight Loss Help Reduce Psoriatic Arthritis Symptoms?
Chronic Back and Neck Pain in America 2015 Survey Results
Efficacy of Acupressure Plus Manipulation for Lumbar Disc Herniation: A Clinical Report
Is Tapentadol a Glorified Tramadol?
Letters to the Editor: Naloxone, Opioid Tolerance, Polyarthropathy
New Research Into Psoriatic Arthritis
New Technique Shows Promise as Adjunct In Chronic Pain Management
Pharmacogenetic Testing in Pain Management: Where Do We Stand?
Reinventing IM and Procedural Injections: The Sota Omoigui Short Needle Technique
Timely- versus Delayed-Use of TNFi’s: Which Approach Is Better?
Undiagnosed Atlas Subluxation in Patient with Pain and Poor Myofascial Function

Undiagnosed Atlas Subluxation in Patient with Pain and Poor Myofascial Function

A patient is treated with a combination of Sarapin and bupivacaine injections prior to myofascial trigger point therapy, but pain and lack of range of motion in neck persists. The case report below describes how a team of clinicians unravels the underlying pathology in this patient.

This article explores the case of a patient with myofascial dysfunction who underwent years of myofascial trigger point injection to improve pain and range of motion (ROM). The patient would improve immediately after treatment, but then pain would return.

The authors suspected a diagnosis of atlas subluxation (misalignment of the top cervical vertebrae), and pursued the diagnosis and treatment aggressively. Part of the delay in diagnosis came down to a “turf battle” between chiropractors, physical therapist, and myofascial trigger point therapists. The specific training of each of these specialties can sometimes prevent the diagnosis of unusual cases. But working together, the four clinicians unraveled the underlying cause of dysfunction in this difficult case.

Case Description

A 33-year-old man presented in 2010 complaining of pain and reduced ROM in his neck, shoulders, and low back that was worse on his left side. His occupation as a stock-
broker involved 12- to 14-hour days of sitting at a computer terminal. He noted that his activities of daily life (ADLs) were severely limited, despite the fact that he had previously been active in sports, including coaching baseball and playing golf.

His past medical history included a fall on his right hip and buttocks, with resulting sharp sacroiliac pain, and a head-trauma injury, both occurring 3 years previously. Physical therapy and work with a personal trainer had not produced any improvement in his pain or dysfunction.

Physical examination revealed a well-developed man whose neck was tilted to the right and shoulders hunched forward. There was loss of thoracolumbar lordosis, his left shoulder was higher than the right, and his left hip was lower than the right. His feet were flat. He had taut bands and muscle spasm in his neck and entire back.

Laboratory findings included a low vitamin D level. No imaging examinations were performed.

Initial Treatment Plan

The patient was started on vitamin D therapy and embarked on a weekly program of myofascial trigger point therapy (MFTPT) to release taut bands and to provide pain relief and increase ROM.

Although the term “myofascial dysfunction” in not addressed in current medical school curricula and does not appear in International Classification of Diseases coding manuals, it is present in virtually all patients with neck, torso, back, and extremity pain. Fascia is connective tissue (woven like a web) that surrounds and connects every muscle and organ. “Traditionally, fascia has been thought of as a passive structure. However, it is now evident that fascia is a dynamic tissue with complex vasculature and innervation.”1 In fact, fascia is finally recognized as a body system and is one of “ most important sensory organs in body perception.”2

Myofascial trigger points are inflamed,tender areas caused by excessive acetylcholine released at numerous motor end points, resulting in calcium accumulation, hypoxia, and acidosis. This results in the release of inflammatory mediators, causing swelling and edema that eventually leads to fibrosis between muscle and fascia, and between fascia and skin.3

Untreated myofascial trigger points result in traction on tendons and ligaments, both of which are confluent fascial bands. Muscle shortening, traction of tendons (ie, tendonitis), and eventually periosteal elevation, bone spurs, and tendon ruptures occur. The solution to avoiding these complications is to lengthen the fascia and disrupt the adhesions between fascia and other tissues.

Sarapin is an FDA-approved sterile solution of the soluble salts obtained from the botanical pitcher plant (Sarracenia purpurea). Widely used for over 70 years in veterinary medicine, mostly in race horses, as an anti-inflammatory agent, Sarapin’s mechanism of action in humans has not been systematically studied in the laboratory or in controlled clinical trials.

Clinical use today is limited largely to chiropractic and podiatric practices. Manchikanti and others, however, have shown that caudal epidural injections with either steroids or Sarapin are effective for persistent low back pain for up to 3 years after treatment.4 Therapeutic cervical medial branch blocks with Sarapin have been found to be as effective as steroids in controlling neck pain up to 1 year after treatment.5

Despite Relapse of Pain, Treatment Continues

For the next 4 years, the patient would receive MFTPT. Virtually every muscle group in his neck, back, anterior chest, anterior abdomen, buttocks, and thighs were treated depending on his pain findings each week. The treatment sessions allowed him to perform most of his daily activities without significant pain, but he had not resumed coaching or playing golf.

In early 2014, a program of trigger point injections with Sarapin combined with a small amount of 0.25% bupivicaine (less than 20% of the injectate volume), followed 20 to 30 minutes later by MFTPT was begun. At each session, he received between 10 and 20 injections of approximately 1 mL each. In spite of the large volume of injections, adding the bupivacaine allowed for much deeper tissue work in each painful area.

Over the following 6 to 12 weeks, the patient’s pain decreased from a 7 to a 2 or 3 out of 10 and ROM improved in all muscles groups except his neck flexors and extensors. Routine x-rays were interpreted as normal, but we observed that his cervical curve was almost absent and flexion views were incomplete.

On examination, his neck remained locked in extension at –15°. In August 2014, he sustained a twisting injury of his low back while golfing. This resulted in low back pain score of 8 out of 10. His acute injury was remedied within 10 days after 3 combined treatments of Sarapin and MFTPT.

Aggressive Therapy Started

Subsequently, an aggressive approach to improve his neck ROM was undertaken. We focused on the following muscles: levators, splenius cervicis, splenius capitis, multifidi, rotatores, scalenes, and rectus capitus muscles. After 3 months, he could flex his neck to +20° with extreme effort. In the spring of 2015, he resumed golfing and coaching high school baseball.

Because his neck flexion remained limited, the patient’s x-rays were sent to a chiropractor known for advanced interpretation of spinal pathology. The chiropractor diagnosed mildly decreased cervical lordotic curve (27°), dextroscoliosis (scoliosis to the right), forward head carriage, and atlas subluxation (locking of C0-C1 causing atlas misalignment: Figure 1).

Based on this diagnosis, the patient was referred to a certified cervical chiropractor for atlas realignment. Examination by the chiropractor was remarkable for palpable taut bands in the cervical and upper thoracic musculature and restricted cervical ROM.

Postural assessment demonstrated a low right ilium with anterior rotation and a fixed point of leftward displacement in his upper back. In the standing position, there was a 17-pound weight differential and imbalance (left side higher and in the supine position right leg contracted). Cervical x-rays demonstrated C-1 subluxation based on abnormal deviations in the relationship to the vertical axis. There was a deviation of the atlas to the left, with the lower neck tilted significantly to the right and anterior rotation of the atlas (Figure 2). The chiropractor treated the patient with specific manual adjustment of the C-1 subluxation using the protocols of the National Upper Cervical Chiropractic Association (NUCCA).

Post-treatment anatometric measurements revealed that the pelvic deviation and upper back displacements had been corrected and leg lengths were now equal. X-rays indicated a measurable reduction in all aspects of the subluxation complex (atlas shift decreased from 3.5° to zero, lower angle of atlas decreased from 7.5° to 1° on the right, and atlas rotation decreased from 1.5° on the left to 0.75°; Figure 3). Palpation revealed softer cervical musculature and an increase in cervical ROM.

The patient had immediate resolution of his pain and felt as if he were “straight.” However, 24 hours later he had exacerbation in all areas of his body, presumably due to re-adjustment of spinal segments beneath the atlanto-occipital junction (the labyrinthine “righting reflex”).6 He required several more MFTPT sessions over 4 to 6 weeks but gradually had almost complete resolution of his pain and was able to reduce his myofascial therapy sessions dramatically.


MFTPT is one of numerous treatment approaches to painful and latent trigger points, but the combined approach described in this report is unique. We initiated injection of Sarapin with bupivacaine in this patient following the positive results observed by Dr. Hartz in other patients. Dr. Hartz had performed approximately 1,500 trigger point injections in other patients in her practice without observing an allergic reaction or other adverse event. In that group of patients, duration of relief was patient- dependent but typically lasted from 3 to 7 days, allowing patients to perform home exercises more easily.

Sarapin also has been used to treat joint pain and neuralgias. Although the exact mechanism of action of Sarapin has not been elucidated experimentally or clinically, we hypothesize that the mechanical disruption of myofascial adhesions by the hydrostatic pressure of the injection,3 combined with an anti-inflammatory effect, produce sustained relaxation of the taut bands and resolution of symptoms.7 Icing and prolonged periods of rest were assiduously avoided.

In this patient, the diagnosis of atlas subluxation was not made for several years. Post-traumatic injuries to the cervical spine can be difficult to diagnosis, especially in children.8 Although the incidence is low, congenital anomaly of the atlas also must be kept in mind during the differential diagnosis of traumatic atlanto-axial subluxation in a patient.9 Treatment is normally conservative; however, surgery is indicated when patients present atlanto-axis instability and spinal cord compromise.10

In this case, the condition resulted in the numerous areas of myofascial pain and dysfunction throughout his body. After atlas realignment, the patient continued to require occasional MFTPT sessions with decreasing frequency while the other bony misalignments, secondary to atlas subluxation, shifted back into place and myofascial symmetry returned.

It is critical that practitioners treating soft-tissue injuries maintain a high index of suspicion for the presence of bony misalignment(s), especially when patients or clients do not respond rapidly to soft-tissue manipulation, and refer such patients to chiropractors or orthopedic physicians.

Although Andreas Vesalius rendered beautiful anatomic drawings of the body’s myofascial layers in 1543,11 the true importance of fascia in body movement, pain, and injury is only recently being delineated (Image below). Tom Meyer, author of Anatomy Trains,12 describes fascia as “an intricate net (or webbing) without which the human body would disintegrate into a puddle of water at the feet.” Furthermore, he convincingly demonstrates that there is no separation between fascia, tendon, ligaments, and aponeuroses: fascia, therefore, is a system. Anatomy textbooks may soon list fascia along with musculoskeletal, cardiovascular, gastrointestinal, and all the other systems traditionally included in their indices.


Working together, the authors were able to unravel the difficult diagnosis and treatment strategy for a patient who suffered from undiagnosed atlas subuxation. Following atlas adjustment, Sarapin, an inexpensive distillate of the pitcher plant, can be injected into trigger points, with or without admixed local anesthetic agents, to release trigger points or taut bands, thus lengthening muscles and reducing strain on tendons.

Unlike steroid-based preparations, injections can be repeated indefinitely and as often as necessary. In our patient, despite his undiagnosed atlas misalignment, the use of MFTPT and Sarapin injections allowed him to work and function. After his acute low back injury, resolution of the acute pain was accomplished within 10 days.

Last updated on: April 9, 2019
Continue Reading:
Reinventing IM and Procedural Injections: The Sota Omoigui Short Needle Technique

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