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Welcome to Beyond Trigger Point Seminars Upper Torso and Shoulder Unit, Module 3 on the latissimus dorsi, teres major, rhomboids and serratus posterior superior. This is Cathy Cohen. In this module we will discover a little known muscle involved in 90% of patients with a painful shoulders. We’ll also be reviewing the efficacy of various treatment techniques on trigger points (TrP).

Let’s begin by sticking one arm up like you’re raising your hand. Are you ready? Now bring it down in front of you and tuck in your back shirttail. The movement of extending the arm and bringing it behind demonstrates the four actions of the latissimus dorsi. On page 28 of your student study guide, let’s list four major actions now.

1. Extends the arm like when swimming the crawl stroke or chopping wood

2. Adducts and assists medial rotation of the arm

3. Depresses the humerus

4. Draws the shoulder girdle downward as when tucking in the back of your shirt

Again, while you are thinking about bringing your arm down from overhead to tuck in your shirttail, memorize the actions of extending the arm, adduction and medial rotation, depressing the humerus and finally, number four is drawing the shoulder girdle downward.

You will find a picture of the pain pattern on page 29 and on page 573 in the book Myofascial Pain and Dysfunction The Trigger Point Manual, Volume 1. To help remember the trigger point’s referred pain pattern it’s been nicknamed, Midthoracic Backache. Picture A and B are the same TrP within the axillary portion shown from the front and the back. It refers pain into a concentrated area of the inferior angle of the scapula causing a midthoracic backache. Your client may have difficulty reaching behind their back to show you where it hurts. But likely, they’ll tell about a solid area of discomfort off their lower shoulder blade. Spillover, which may or may not be present, refers into the medial arm down to the 4th and 5th digits. Finding the superior TrP requires a pincer palpation into the fleshy, posterior axillary fold with the arm at 90 degrees and laterally rotated like an Indian how sign. In class you will become expert at distinguishing the latissimus dorsi from the teres major which also forms the posterior axillary border.

The second more inferior trigger point shown on picture C and D refers pain to the anterior shoulder and sometimes to the lower lateral aspect of the trunk above the iliac crest. The superior TrP is more commonly found than the inferior location. I hope you are drawing the pain patterns. If you Xerox your pictures and then cut and paste them onto index cards, you can create your own flashcards. It will help you recognize the problems you are probably already encountering. We don’t think about the things we never think about. So now that you are adding TrPs to your toolbox, you may see these patterns more frequently. Or, if you are like me, for whatever reason, still to this day, whenever I’m preparing for a workshop on a specific body region, two or three clients will present to my practice with the problem we are studying that week!

With a new client, the first question I ask on intake is, can you point at where it hurts? Can you point at where it hurts? Have them touch the areas on their own body. Don’t have them show you on your body or rely on what they drew on an intake form; you’ll be better informed if they touch the area on themselves. Then you draw the pain pattern onto a pain scan sheet or into a computer program. Show them what you drew and have them change it if it’s not correct or complete. I actually hand them my clipboard and a pen and ask them to change it if it’s not correct. To help a person with a muscular pain complaint, the essential first step is drawing their pain pattern. Then you’ll begin seeing these referral patterns. By working backwards from their problem to the muscle involved, you’ll be able to make educated guesses about which muscle to touch first. So start with the question, where does it hurt?

Still on page 28, let’s answer the question, how is the latissimus dorsi activated and perpetuated?

1. Repetitive action. For example repetitively reaching overhead, throwing a baseball or performing pull downs at the gym. A hairdresser I once treated presented with a constant nagging pain over the inferior angle of her right scapula. She couldn’t identify when the pain started nor could she exactly reach the area in her back where it hurt. She said the discomfort in her mid back was bothering her progressively more at rest as well as when working at her beauty station. Her specialty was creating big puffy hairdos. Can you guess what the repetitive action was? It was constantly pulling down with her comb to tease hair. Eventually that action of extending and adducting her arm created a trigger point. Because the latissimus dorsi is a long and slack muscle, it rarely causes pain during movements that only partially stretch it. Your clients are not likely to remember the exact cause of the insult like they would with the infraspinatus. So it is important for you to identify the source of the insidious, repetitive action.

2. Muscular imbalances. The authors of our text identify the latissimus dorsi as one of four muscles responsible for myofascial pseudothoracic outlet syndrome (pseudo-TOS). The other three muscles I mentioned in module 2 are the pectoralis major, the teres major and the subscapularis muscles. When at least three of these muscles have active trigger points, the combined pain patterns suggest a thoracic outlet syndrome. To quote from our textbook, “A thoracic outlet syndrome is a collection of syndromes. Like low back pain, it is not a well-defined diagnosis but often is reported as if it were a specific disease.” A true thoracic outlet syndrome however is caused from an entrapment of structures in the thoracic outlet. Again, the muscles involved in a pseudothoracic outlet syndrome are: latissimus dorsi, teres major, pectoralis major and subscapularis. All four of these muscles have trigger points referring pain down the arm. All four of these muscles are relatively strong medial rotators of the shoulder. All four of these muscles can create a muscular imbalance in the shoulder.

Because TrPs in these muscles can severely restrict shoulder range of motion, our clients experience a tremendous benefit by having the trigger points eliminated and muscular balance restored through exercise. I hope you will seriously consider making it your goal to reduce medial rotation at the glenohumeral joint hopefully before they develop a frozen shoulder or thoracic outlet syndrome. This goal is especially critical for clients who have suffered a stroke as they tend to have spasticity of the medial rotators and adductors.

On the next page of our study guide, let’s answer the question, what are some findings and tests? Looking at the picture on the right you’ll see the Mouth Wrap-around test. This test requires full abduction and lateral rotation of the shoulder joint as well as normal scapular mobility. I’ll talk you through this useful shoulder-girdle muscle test as you perform the action on yourself. Are you ready? Bring your hand and forearm behind your head and slide your hand as far forward as you can as you try to cover your mouth. Don’t allow your head to tilt or turn more that 45 degrees. Normally the fingertips can cover the mouth halfway. An individual with hypermobile joints will be able to cover the entire mouth with the hand. A person with short upper arms, as we discuss in other units or at the workshop, will not make it to the half way point on the lips. But even if you don’t know if your arms are long or short, by comparing the left to the right, you can gauge range of motion restrictions. The picture demonstrates a positive test, there is restriction. The dotted arm shows movement towards the midline of the lips but range is diminished.

Those of you working with chiropractors might use the following finding. Because of the attachments on the crest of the ilium, the latissimus can cause an upslip to one of the hips. Also, if the chiropractor is manipulating from T7 or T8 to L3or L4, this might be suggestive of articular dysfunctions associated with trigger points in the latissimus dorsi.

What are the corrective actions?

1. Avoid reaching repetitively overhead

2. Use a stool when reaching high for a heavy object

3. Sleep in an anatomically neutral position

On page 31, the actions of teres major are exactly the same as the four actions of latissimus dorsi: extension, adduction, medial rotation and scapular depression. You can just write same as lats. In fact we can nickname this muscle, The Twin to the Latissimus Dorsi.

Their innervations are different and the teres major has a distinct pain pattern caused from its three documented trigger points found on the preceding page or page 588 of the text.

When a person presents to your office with this pain, they will cover the shoulder with their hand to show you where it hurts. There is a reason one of the body scans on the study guide is turned sideways. I want you to remember to use a pincer palpation. Your thumb and index finger will be compressing the belly of the muscle from both the front and back side. Finding the teres major involved by itself is rare. You may however see this pain pattern after releasing the trigger points from the other shoulder muscles. So on the third or forth treatment you may decide to spend more time cleaning up any taut bands and checking for trigger points in the teres major. Because the teres major and latissimus dorsi work synergistically, the activation, findings and corrective actions are also similar.

Moving on to the rhomboid muscle, we have two actions to list:

1. Adduct the scapula- pulls the scapula toward midline and

2. Stabilize the scapula

There are 3 documented trigger points shown on page 614. All 3 are attachment trigger points. Draw your Xs right up against the scapular border. The pain patterns project over the trigger point locations. Trigger points in the rhomboids can cause the snapping & crunching sounds you hear when moving the scapula. The fill in the blank to the question, during trigger point examination, the tenderness adjacent to the scapula often represents the development of, and the fill is, enthesitis. Enthesitis is inflammation, calcification and fibrous formation over the attachment site of the muscle onto the bone. Why would enthesitis occur along the medial border of the scapula? A clue is found in its nickname, Superficial Backache from Rounded Shoulders.

So often I hear therapists saying a pain complaint in the thoracic back is due to the rhomboids. I hope my trigger point gang will think differently. Dr. Travell had a theory about the rhomboids and why enthesitis occurs along the medial border of the scapula. While I share her theory with you, keep in mind the chief synergist-the muscle working together with the rhomboids-is the trapezius. The main antagonist-the opposing muscle-is the pectoralis major. Here is the struggle. When structure is rounding forward you will unconsciously pull your shoulders back and down to right yourself. Didn’t you just do that now since I mentioned it? But who wins in this repetitive cycle of slouching and straightening; the relatively small rhomboid or the bigger lower trapezius and pectoralis major? In fact, the rhomboid often becomes inhibited and loses it strength all together. Attachment trigger points and facial thickening create a convenient holding pattern for a muscle losing the battle to more powerful muscles. Your job as a therapist then, if you decide to accept it, is to release the tension in the pectoralis major, loosen up both the lower and upper fibers of the trapezius, and to teach your client to stand tall. So answering the question, what activates and perpetuates the rhomboid muscles?

1. Rounded-shoulder position- from prolonged leaning forward without back support.

2. Upper thoracic scoliosis- either from congenital factors or functional compensation.

What are some findings and tests?

1. A flattened thoracic spine. When a vertebral body becomes rotated the spine will appear flattened. A flattened thoracic curve is a sign the rhomboids may be pulling the vertebral bodies out of alignment. Vertebral bodies may also be chronically subluxed if the rhomboid attachments have become calcified. Then you may hear crunching noises during scapular movement.

2. The cobra test. It’s performed while lying on their belly. Ask the client to place their hands and forearms flat on the table alongside their breast and to squeeze their shoulder blades together while straightening their elbows. They test positive for weak/inhibited rhomboids when the ability to adduct the scapula is restricted. I’ve observed this often after whiplash accidents.

The correctives for the rhomboids are:

1. Sit back in the chair and bring the elbows into the side

2. Correct body mechanics to align the body

3. Stretch the chest

4. See a chiropractor, physical therapist or an osteopath for adjustments

5. Self-massage the sore areas along the medial border of the scapula by lying on tennis balls

6. Finally these muscles need to be strengthened more then stretched. When they have been injured they tend to be weak and overstretched.

The last muscle in this module is the serratus posterior superior. Many of you may not be in the habit of treating this deep muscle. In a study with 58 patients who had painful shoulders, 90 percent had this muscle involved and 10% had this as the single source of their pain. We can nickname this muscle Cryptic, Deep Upper-Back Pain. The action of the serratus posterior superior muscle is: raises ribs 2-5 during inhalation. It’s a respiratory muscle. Turning to page 36 of the study guide or page 901 of the book, you see one documented trigger point. When the scapula is in a normal rest position as shown on figure D, this attachment trigger point is inaccessible. To palpate it, the scapula must be abducted to expose the attachment site of the muscle on the rib. When a client is lying prone on the table, I like to hang the involved arm off the side of the table to expose the TrP. Then the spot to palpate is off the medial superior border of the scapula directly superior the attachment of the levator scapulae. If you’re not sure you are on it, press firmly and ask them to inhale deeply. Then you will feel the muscle and the rib moving. The levator scapulae won’t move.

The pain pattern from this muscle is felt intensely as a deep ache under the scapula. When the client presents with this pain they try to show you how it hurts under the shoulder blade but are unable to touch the sore area. Also, draw the primary pain complaint down the posterior deltoid, through the triceps and the olecranon process of the elbow and on the ulnar side of the forearm, wrist and little finger.

Don’t forget to draw a spillover pain pattern into the chest. This is one of a few muscles with a referral pattern from the back body to the front.

Now I’ll list two ways the serratus posterior superior can be activate.

1. Respiratory overload. The coughing and shallow breathing caused from asthma, chronic emphysema and pneumonia can activate this trigger point.

2. Static overload activity causing elevation and rotation of the scapula overloads this muscle. For example I’m treating an Iron Man woman. She trains crazy amounts of hours on her bike with her shoulders hunkered over the handlebars. She also has allergies affecting her respiratory capacity. Whenever she begins to feel pain under her shoulder blade and down the medial side of her arm, she quickly finds me. It’s a difficult muscle to self treat or stretch. It responds beautifully however to trigger point compression. I have another adorably funny histologist. She is all of 4’ 11’’. It’s challenging to keep her shoulders down and back while looking into a microscope and reaching to the back of her high table for slides. She tells me this pain from the serratus posterior superior runs rampant in the lab. I am planting a seed here…chair massage in laboratories might be a good niche for a trained therapist.

Some findings are:

1. Scoliosis-curvature in the spine can cause the rib cage to rub up against the scapula. The rib cage and scapula can then squeeze the muscle. The rubbing can create enthesopathy along the attachment site.

2. Clients with this problem are generally not round-shouldered, like those with rhomboid or pectoral muscle involvement.

3. Shoulder range of motion is okay.

The corrective actions for serratus posterior superior are primarily to correct body mechanics and to correct functional scoliosis from a lower limb length inequality or a small hemipelvis.

I want to end with some thoughts on treatment techniques. Researchers at the University of California in 1997 studied the efficacy of various massage techniques. Twenty some people with trigger points in their upper trapezius of three month duration received various soft tissue techniques. It was concluded, though this was a small sample group, that all soft tissue methods made significant changes. However, trigger point pressure release applied directly over the trigger point site worked best. This means by simply finding the taut band, slowly compressing the TrP with a knuckle tip, a digit or an elbow and maintaining tolerable pressure for 8-10 seconds, acute TrPs are inactivated.

Spray and stretch technique, or ice and stretch like we also learn in class, was the second best method of reducing pain and restoring the muscle to its normal rested position. The message of cold reaches your brain before the message of pain. This allows the therapist to passively erase the memory of insult and holding. Ice and stretch is also completely non-invasive, easy to learn and very, I repeat, very easy on the therapist’s body. Once you learn the basic methodology and learn the specific stretch patterns for the muscles you can apply this in any treatment. Even at the end of your relaxation treatments, ice and stretch is effective for improving range of motion with or without a pain complaint.

Regardless of whatever great techniques you are already doing- keep in mind that the efficacy of any treatment modality is measured upon its ability to a) lengthen the contraction knot and b) interrupt the energy crisis. That's why trigger point release technique and stretching are so effective. Most of you intuitively know where to find the trigger point. You are already following the taut band and pressing on the most sensitive site. In the workshops you gain confidence and refine your skills. In the meanwhile, go use this stuff. Become detectives. Have fun! Go see if you can do a new torso routine from what you have learned so far. Our next and final module on the upper torso and shoulder will focus on a very important muscle, the scalene and the other muscles of the respiratory system. Till then- stay in touch.

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