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Welcome to the Beyond Trigger Point Seminars Upper Torso & Shoulder Module 2 on the Pectoralis Major and Minor, the Deltoids and Serratus Anterior Muscles. Lucy told Charlie Brown, Chuck, if you want to look depressed, round your shoulders forward. There is some truth couched in Lucy’s advice. For not only will a rounded shoulder posture make you look disheveled and depressed but it will aggravate and perpetuate the muscles covered in this module. We’ll also study a variety of chest and shoulder pain patterns & become familiar with the symptoms of neurovascular entrapment when the pectoralis minor is shortened.

The pectoralis major is a broad, powerful muscle located on the chest. And except for the part beneath the breast tissue, its superficial fibers are easily accessible. Male therapists in particular and female practitioners in general need to be careful working around this area. Later, I will be presenting some palpation strategies for this region.

On page 16, the actions of the entire muscle working together are: adduction and medial rotation at the glenohumeral joint. Do you remember which rotator cuff muscle from Module 1 also medially rotates the shoulders? I hope you said the subscapularis. Again the muscle as a whole adducts and medially rotates. The upper fibers of the pectoralis major flex the shoulder and horizontally adduct. The lower fibers extend the shoulder. Interestingly, the upper and lower fibers perform opposing actions at the shoulder joint—flexion and extension, thus making this muscle an antagonists to itself.

The Pectoralis major is divided into sections as seen on page 17 or page 825 of the textbook: the clavicular the sternal and the costal. In our textbook, the abdominal section is also considered a fourth distinctive division though in other anatomical texts, it can be omitted. In some individuals, the abdominal section may not be developed. The muscle’s lateral attachment twists and attaches on the greater tubercle of the humorous like playing cards or a fan when held in your hand. Medially, the fibers attach on the medial half of the clavicle, the sternum, the ribs and the superficial aponeuroses of the abdominal muscles.

Knowing the muscular fiber arrangement will increase your accuracy when palpating for trigger points (TrPs) and when performing cross fiber friction. When we ask the question, why are the trigger points formed in the mid section of individual muscle fibers? What would you say? Trigger points consistently form over the motor endplate zone found in the midregion of each muscle fiber. The motor endplate is where the motor neuron synapses or makes contact with the individual muscle fibers. Remember, central trigger points form directly over the site where the nerve synapses with the individual muscle fibers.

When I was in your seat 20 some years ago and just learning about myofascial pain syndromes, the answer to why trigger points formed in predictable locations within the muscle wasn’t known. The connection between the motor endplates and the individual muscle fibers was unknown. Today, due primarily to electromylographic/EMG studies and histological findings, the etymology of trigger points has been proven to be a neuromuscular disease entity.

According to our text on page 825 each strip of muscle very likely has its own nerve branch and mid-fiber endplate. As you draw the documented trigger points of the pectoralis major keep in mind that each strip of muscle may develop its own trigger point. The trigger points you are drawing are over the most commonly found locations. Also, for your knowing, rib number 6 is in line with the xiphoid process which is the distal end of the sternum.

On page 16 of your study guide, draw what you believe to be the trigger points and the pain patterns of the pectoralis major. The picture is on page 820 of the textbook or on the next page of the study guide. Try to interpret what you are seeing and draw an X over the documented trigger points and color in the pain pattern for each section of this muscle. The solid area is going to represent the primary pain complaint and the dotted area will represent the spill over pattern. The spillover pattern may or may not be present. The solidly colored area represents the most commonly reported pain patterns from pectoral TrPs.

With the clavicular trigger points, shown in picture A, your client will show you where it hurts by taking their hand and covering the front part of the deltoid area.

Can you see why people think they are having heart problems with a left sternal division TrP? The pain pattern picture is in the upper right corner of that page and on page 822 of the text. Attachment trigger points near the midline create a sharp pain alongside the sternum. True story now, my family dragged me to the local emergency room one Sunday afternoon because of this nagging pain I had along my sternum. It had been bothering me for two or so weeks. After having a chest X-ray and an exam and finding nothing wrong, the ER doc referred me to a cardiologist. On his way out the door he thought to ask me if I had injured my chest muscle. That’s when I remembered the three hours of swimming in a rough ocean two weekends earlier. Then he scribbled in my chart his diagnose of a sprain/ strain of the pectoral muscle. We often miss the obvious don’t we with ourselves or our family. So the soft tissue along the sternum can be strained or torn or develop TrPs because of injury or overuse.

The costal trigger points shown in picture B are palpated with a pincer palpation. Trigger point release technique is applied by using your thumb and index finger to slowly compress the lateral border of the pectoralis muscle from above and below it. And finally what you can’t draw but what I’d like you to note on the picture of the costal and abdominal trigger points is this. Clients may have hypersensitivity over their nipple. Or they may have edema or tenderness in their breast tissue that will resolve by treating the trigger point. They may not think it’s related to their muscles until you either reproduce their pain pattern or after eliminating the trigger point and restoring the pectoralis to a normal resting position, your client will realize their breast tissue is no longer sensitive. So I encourage you to draw those patterns and begin memorizing them. To help you remember the pain patterns, Dr Travell nicknamed this muscle the Poor Posture and Heart Attack Muscle.

Let’s regress for a moment so we can better understand the layout of our textbook. If you don’t have a textbook, that’s okay, this information will be useful for you too. On page 823 of the textbook, there’s a little know muscle called the subclavius. It lays just inferior to the clavicle and over the first rib. It has one documented trigger point with a pain pattern traveling down the arm. We’re not studying the pain pattern and I’ll tell you why in just a moment. For those of you with the book, if you look on the edge of the book’s pages, you see red tabs. Do you see where the red tab of section 5 begins? Turn to that page, 802 now. Move your eyes down to the section titled Front- of -Chest Pain. Are you with me? The subclavius is listed as a muscle referring pain into the chest region. But do you see how far down the list it is? Even though the subclavius has a primary pain spillover to the chest, it is listed third from the bottom. Because the muscles are listed in the order of most frequent involvement, from the top of the list down, this is not the muscle you should think to treat first. All the other muscles in bold type: the pectoralis major, the pectoralis minor, the scaleni, refer pain into the chest. The non-bolded type indicates muscles, like the diaphragm, with only spillover patterns to the front of the chest. Pain patterns from ten muscles in all have an overlapping chest pain pattern.

Memorizing the pain patterns for each muscle is a good beginning. In addition, by following along in this program and applying your knowledge with your clients, you will be able to distinguish the characteristics of each muscle and their different nuances. By paying attention to the life styles stories, the quality of discomfort, postural presentation, and type of injuries, you will more accurately be able to distinguish between the varying pain presentations. Each muscle is unique. So, yes, the subclavius can be involved in chest pain, but the pectoralis major, minor and scaleni develop trigger points referring into the chest more frequently.

Let’s go now to page 18 of our study guide to list pectoralis major’s activating and perpetuating factors. I’ll list six. Remember the same factor initially creating the trigger point can also be the same factor perpetuating it.

1. Rounded shoulder position. A rounded shoulders posture can be caused from many things. According to cartoon famed Lucy, our attitudes are expressed through our postural carriage. Medially rotated shoulders can also be caused from repetitive motion like hunkering over a massage table, or a desk. Recently I treated a woman who knew her poor posture was due from a lifetime of doing needlework. Our shoulders and neck follow our eyes through life.

2. Immobilization of an arm like when it’s in a sling.

3. Gross trauma. I had a gal once who had been in four car accidents. Once was in route to see me. God bless her. During the fourth accident, she was bruised badly from the seat belt. She had had an X-ray to rule out a broken rib. The rib was fine. However when I compressed into the pectoralis major trigger point it exactly reproduced her pain complaint. She was so relieved to find out it was just a muscle she sobbed on my table. Her baby had been in a car seat during that incident and was unharmed but I felt the emotional imprint of what could have happened to her baby was also being released with those tears. I used to quietly slip Kleenex into my client’s hand during these occasions. Now I lay a nice clean hand towel over their eyes, breathe with them and set my inward intention on providing a safe environment for them to emote.

4. Cold air on the chest. The swimmers and surfers on the Eastern Shore, Maryland, myself included, would come in from the ocean, strip our wet suits down to our waists and sit on the beach for hours chilling our chest and shoulders. When any muscle is chilled, a pilomotor response or goose bumps, shivering and muscle tension occurs to produce heat. Dr Travell was in her mid eighties and had a head full of long white hair when I knew her. I once commented on the length of her hair. She said she keep it long to keep her posterior cervicals warm.

5. Heart disease is another factor to note in your study guide. Pain from the heart can cause a viscerosomatic effect; meaning pain from the organ refers into the muscle. In one study 61% of 72 patients with cardiac disease, so over half of this sample population with cardiac disease, had trigger points in their chest muscles. Dr. Travell was a cardiologist by training. The connection between referred pain down the arm and during a heart attack is a well known fact. This viscerosomatic effect spurred her thinking about skeletal muscles having the same potential to refer pain elsewhere.

6. Finally, overuse from repetitive horizontal arm AB and Adduction. Let me give you two examples. One man I treated had trimmed his bougainvillea bushes all weekend. It was the repetitive motion of pulling those big clippers together that set his pectoralis off. Another gal I worked with was an assembly worker in a Perdue chicken factory. Her job was to pull dead chickens along the assembly line with one hand and then with the other hand she’d pluck, pluck, pluck the feathers off. This was one of my first cases where the pectoralis major was the primary complaint. On intake I noticed she didn’t wear a bra. So I said gee Ms so and so I notice you don’t wear a bra. She was a big heavy breasted woman. Her bosoms were actually resting on my desk during the intake. And she said well, yea and as soon as I can I’m gonna take this t-shirt off ‘cause you know, even the material on my bosom is bothering me. That’s when I understood about the sensitivity created from trigger points in the pec major. I’m really not making this up! One breast can be lumpier and swollen possibly due to entrapment of a lymph duct within a taut band of muscle.

So the six factors are rounded shoulder position, immobilization, gross trauma, chilling, heart disease and repetitive horizontal AB and AD duction.

I also want to share with you some of my early timidness around working with large breasted women when I was first beginning my practice. I’m sharing this because you may have been in a similar situation or will be soon. With the heavy breast woman I just mentioned, I gave up too soon. I had gotten so far with her and then felt like I needed to refer her back to the referring neurologist whose office I conveniently worked in.

The doctor did trigger point injections into the pectoralis major muscle by comfortably placing her on the table and asking her to pull her breast tissue up and around while he palpated for the taut band and injected the spots. That worked out just fine. Within two sessions of injections, she had complete resolution. So, trigger point injection by a skilled practitioner is always an option. Many of the pain clinics either privately owned or in hospitals are operated by physicians, often anesthesiologists, who are highly skilled and trained in trigger point injection. Or you can become more comfortable, as I did after that experience, by asking your client to help you.

Let’s answer the question now, what are some findings and tests? I’ll list two.

1. Rounder shoulder presentation. Looking at your client from behind, you will notice protracted shoulder blades. Medially rotated shoulders round the thoracic spine. Ida Rolf, a pioneer in the field of structural integration, said human structure typically will be locked short anteriorly and locked long posteriorly.

Think about this observation and how it relates to trigger points. Do you see more trigger points in the back body or do you see more in the front body? In the back body, like in the trapezius or the thoracis erector spinae muscles, you typically find more trigger points. How often though have you worked yourself silly in the back body only to discover the locked short muscles in the front needed your attention?

2. Angina Pectoris is a diagnosis a doctor may have given to the pectoralis major pain pattern. Myofascial pain due to trigger points show a wider response to activity, meaning there may be pain at rest or during exercise, while angina pectoris pain is only exercise induced. Remember, relieving the referred pain of a pectoral trigger point does not in any way or means, rule out cardiac disease. Also according to the ER doctor I saw, tears will typically heal in six or so weeks.

Still on page 18, four corrective actions for this muscle are:

1. The In-doorway Stretch. A seated spinal twist also opens the chest. Patient handouts of some of these correctives can be found on the resource tab at . Feel free to download them. Those of you participating in the entire program will have a file full of corrective homework for your clients when you complete these online lessons. Dr Travell was adamant about client education. I remember her saying if you can give your patient one thing to do after each treatment, they will feel in control. And for a client who has been controlled by their perception of pain, self help exercises puts them back in charge. This is very important in recovery.

2. Sleep position. Placing a pillow along the chest prevents the chest from collapsing when sidelying.

3. Seated ergonomics. Many car seats for example seem to be shaped like an ice cream scooper. This places the low back into a posteriorly curved position which rolls the chest forward. Dr. Travell liked to have people sit with a rolled towel placed in the small of the back. On page 27 of your study guide there is a more complete explanation and picture of seated ergonomics for you and your clients. This handout was modified from the book, Save Your Hands! The Complete Guide to Injury Prevention and Ergonomics for Manual Therapists by Lauriann Greene. I highly recommend it for any manual practitioner though it was written specifically for massage therapists. The book is loaded with information on how to take care of our bodies over our professional lifetime. After reading her book and taking one of her workshops, I modified a few techniques I had been teaching. I can only imagine how many therapists have been helped.

I want you to know how serious I am about protecting your body while working around the table. In my workshops, I will be your mirror reflecting your habitual postures and work habits around the table. Most of us could use a little tweaking when it comes to our own work posture.

4. A Five-Point Stance. This is a wonderful postural awareness exercise to begin practicing yourself. There is a handout of it on page 26. Almost every one of my clients is trained in this after the first treatment. So the four corrective actions are stretching, sleep positions, seated ergonomics and postural awareness. Let’s take a break and do the Five-Point Stance exercise now. I’ll talk you through it.

A five- point stance begins by standing with your legs hip width apart and all ten toes pointing forward. Look down and observe. Often the right leg will be externally rotated. So turn the leg in a little so all ten toes are pointing forward even if it feels awkward. Now move your awareness to your hips. Most of us have bellies which tip forward. So we need to pelvic tilt by pressing our belly button towards our spine. Now lift your chest up and pull your shoulder blades down in the back. I didn’t say to squeeze the shoulder blades together. Simply lift the chest up on an inhale and allow the shoulder blades to drip down towards the buttocks. Now bring your arms along the side seams of your pants and pull your fingertips down. Think of this movement as an isometric exercise. Really depress the shoulders down while the chest is lifting the abdominal muscles are engaging and your sacrum is dropping down towards the earth. Pose and repose until you get this aligned. The fifth piece is to elongate the back of your neck. Feel like you are a Halloween skeleton and the top back part of your head is being pulled up to the sky. Now breathe two or three breath cycles; an inhale and exhale being one count. All right- fall out and repeat these three times every two hours for seven days until it becomes a habitual position for your body to hold. Every time you look at yourself in the mirror, do a Five-Point Stance.

Lets move on now to the pectoralis minor. The pectoralis minor lies next to the rib cage, deep to the pectoralis major. The fibers of the pectoralis minor run longitudinally from the coracoid process of the scapula to the third, fourth and fifth rib. So our fingers will be under the meat of the pec major and strumming along the ribs.

Its two actions are:

1. Pulling the scapula and shoulder region down and forward and

2. Assisting in forced inhalation. Saying that slightly differently; pectoralis minor’s actions are to pull the scapula down and forward which helps stabilize the shoulder when the ribs are fixed like when doing a push-up and two, assists in respiration by pulling up on the ribs.

Another important anatomical consideration is its relationship to the brachial plexus. The lower portion of the brachial plexus which contains a part of the axillary artery and the nerves innervating the arm, pass directly underneath this muscle. Abnormally taut pectoralis minor fibers especially when the arm is abducted can cause entrapment symptoms. Its nickname, to help you remember its characteristics, is Neurovascular Entrapper.

On page 20 of the study guide and page 845 of the text, you see the two documented trigger points. Draw its primary pain pattern over the anterior deltoid. With very active TrPs, the pain can extend over the entire pectoral region. Spillover referred pain extends down the ulnar side of the arm into palmer hand including the third, fourth and fifth digit. Do you remember drawing a very similar pain pattern for the pectoralis major? So again, pain patterns may overlap but the presentation factors, like their story of activation and perpetuation will help you differentiate.

On page 19, five A & P factors are:

1. Over use of this muscle for shoulder depression- for example pushing down on crutches.

2. Shallow breathing or episodes of severe coughing.

3. A tight strap across the chest; particularly baby carriers compressing just in front of the arm pits.

4. Like the pectoralis major, a rounded shoulder posture can either activate or perpetuate tightness.

5. Direct trauma to the chest.

Some years back, another excellent teacher, cloaked as a client, presented to my office. She was referred to me by a chiropractor with chest and arm pain which wasn’t responding to cervical adjustment. Cookie was also a large breasted woman who resisted any initial attempts I made to touch into the axillary area and under the breast tissue where the pectoralis minor lays. After a few treatments of preparing the superficial area and using some stretching techniques, I finally thought to ask her why she wouldn’t let me touch this area. She immediately looked me in the eye and told me stories of how her step father used to hit her with a tire rod across her chest. Now we were both sharing the Kleenex box and when she was all spent with her story, she invited me to touch in that area while she lifted her bosom and I went underneath to strum along the ribs. She had a trigger point in her pectoralis minor exactly reproducing her symptoms. The issue in her tissue resolved. Every year I pull out the dish trivets Cookie knitted my family for Christmas and think of her. She taught me so much.

Let’s answer the question, what findings and tests confirm involvement? I’ll list three. Aren’t you glad I wrote them out for you?

1. Rounded shoulder posture. When the client is lying supine on your table, one shoulder may be lifted up and off the table more than the other due to shortening of this muscle. This finding, as review, may also be indicative of subscapularis shortening.

2. Horizontal extension of the arm is painful. So when you ask your client to reach backwards, similar to the movement of reaching backwards to place something on a night stand when lying in bed, it hurts.

3. A shortened pectoralis minor will restrict scapula movement. The diminished movement of the shoulder blade is palpable and sometimes visible. So again, the pectoralis minor restricts movement of the scapula while the subscapularis, do you remember, restricts glenohumeral movement. However, both the subscapularis and the pectoralis minor can significantly restrict lateral rotation of the arm when the shoulder reaches 90 degrees of abduction. If that’s not clear yet, then plan on joining us in a hands-on workshop where we will do lots of assessment techniques. The significance of treating a tight pectoralis minor muscle aside from improving a rounded shoulder posture is this; quoting from our textbook, “When the arm is abducted and laterally rotated at the shoulder, the artery, vein, and nerves are bent and stretched around the pectoralis minor muscle close to its attachment, and are likely to be compressed if the muscle is firm and tightened by myofascial TrPs.”

Answering the question, what findings and test confirm pectoralis minor involvement; I’ll mention two.

1. Neurovascular entrapment. This is the nickname for this muscle. Neurovascular entrapment symptoms cause pain on the ulnar side of the forearm, tingling, numbness and dysesthesia. Dysesthesia is an altered sensitivity to touch primarily.

2. Wright Abduction test. This is shown on page 850 of the textbook. I’ll talk you through it. The shoulder is fully abducted with the arm by the ear and the clinician tests for a radial pulse by the wrist. The neurovascular structures are sandwiched between a tight pec minor on top and the boney clavicle and first two ribs underneath. So if there is a loss of radial pulse while the arm is over head, this could be indicative of compression on the neurovascular bundle. In our module on the scalene muscles, Module 4, we will be returning to this subject of neurovascular entrapment as it relates to thoracic outlet syndromes.

The correctives are fairly similar to the pectoralis major. One example is to place padding under the bra straps of a heavily bosomed woman to distribute the weight more evenly. Dr. Travell said if you can see any indentation made from clothing, then the circulation of the underlying muscle is being impaired. A second corrective is limiting the duration of activity stress such as working over a desk or in a garden. The In-Doorway stretch can be done either through a doorjamb or in the corner of a room. And finally, avoid rolling the shoulder forward while side sleeping by encouraging your clients to uncurl their body. Teach them to sleep in a neutral anatomical position. The last corrective action is treating the related muscles.

Allow me to regress away from the study guide for a moment to talk about muscular relationship. In the textbook, each chapter has a section called, Functional Unit, formerly referred to as the Myotatic Unit. Here the synergist and antagonistic groupings are considered. TrPs in one muscle of the unit increases the likelihood of TrPs developing through out. Weakness and shortening of the muscle due to a TrP tends to overload the other functionally related muscles.

For example, active TrPs in the pectoralis minor rarely present alone without involvement of its functional partner, the pectoralis major. Conversely, TrPs in the pectoralis major often present alone without any problem in the pectoralis minor. Commonly associated muscles harboring trigger points when either pectoral muscle is involved are: the anterior deltoid, scalene and the sternocleidomastoid muscle.

Functional considerations and other relationships need to be considered. For example, myofascial TrPs in the scalene, pectoralis minor and subclavius muscles can produce a true entrapment of the brachial plexus. Like a kink in a water hose, taut bands, again, in the scalene, pectoralis minor or subclavius muscles can squeeze on either the nerves or blood vessels passing through. But consider this, a myofascial variant mimicking an entrapment syndrome involves the pectoralis major, latissimus dorsi, teres major and subscapularis. On page 487 of our text, it states when at least three of these four muscles have active TrPs, and again the four muscles are pec major, lats, teres major and subscap, the client is presenting with a pseudo-thoracic outlet syndrome. We will discuss the assessment of these conditions in more detail during the last module. But I want you to begin considering the functional relationships muscles have with each other.

You can help so many people by being able to recognize when the problem has a muscular origin. If you are well trained, after the first treatment you can assure your client if you can help them. It’s so simple; if you press on exactly the correct spot and it reproduces their pain complaint, mystery solved. Then after 3-5 treatments, if the problem is improving both you and your client will know if their pain is primarily of a soft-tissue origin. My intention in designing these lectures and hands-on workshops is to give you a solid basis to not only temporarily alleviate pain but to eliminate the source of the problem through a solid understanding of anatomy, assessment, pain patterns, perpetuating factors and client education.

Lets move on now to the actions of the deltoid muscle on page 21. All three portions, the anterior, medial and posterior fibers abduct the arm. It has its greatest strength between 90-180 degrees. So moving the arm from shoulder height to the ear is when it is strongest. More specifically, the anterior fibers flex the arm, the middle fibers abduct and the posterior fibers extend. The middle fibers are strongest because of their multipennate arrangement. On the bottom of page 22, do you see how the middle fibers are arranged like feathers around a quill? The anterior and posterior fibers with their parallel, longitudinal, fusiform fiber arrangement, sacrifice strength for speed.

The speedier anterior and posterior fibers develop TrPs more frequently then its stronger middle fibers. Since TrPs develop along the neuromuscular endplates close to the central portion of the muscle fibers, in theory then, the multipennate fibers of the medial deltoid could form TrPs anywhere along its multiple short fibers. So if we know muscle fiber arrangement, we can make educated guesses where central trigger points develop.

The nickname for the deltoid is, A Dull Actor. The discomfort coming from these TrPs are felt on the surface. They won’t cause you to miss work or aggravate you like an infraspinatus or pectoralis minor problem. Draw the documented trigger points now. In class we will learn to pepper the area by applying trigger point compression along the taut bands. Note how these TrPs lack any distant projection of pain. The pain is to the back and front of the shoulder over the deltoid region.

On page 23, the deltoid, most commonly the anterior and posterior fibers, is activated and perpetuated.

1. Direct, and the fill-in is, hits. We run into things or fall onto our deltoids. Injections or the recoil of a shotgun can also be an offending injury.

2. Repetitive adduction. I developed a TrP in mine by raking leaves. The movement of pulling a rake repetitively across my body set in an anterior deltoid trigger point. I had a woman who developed the same trigger point from driving an old truck without power steering.

3. Prolonged abduction like when excessively poling while snow skiing or pulling in a catch while deep sea fishing. You can probably think of other situations that strain the muscle from direct hits, repetitive adduction and prolonged abduction. The good news is, it’s easily treated and responds quickly to TrP release techniques.

I’ll list 2 findings and tests for the deltoid. One is the Back-rub test pictured on the right. Try this on yourself. The normal reach behind your back is wrist to opposite waistline. The picture of the solidly draw line of the arm is showing a positively restricted deltoid. This also tests for tightness in the coracobrachialis muscle which we aren’t studying in this unit.

A second fun way to differentiate between the anterior and posterior fibers is the thumbs up and thumbs down test. If it hurts to abduct the arm with the thumb up, that’s a positive test for the anterior fibers. If hurtful when abducting with the thumb down, the posterior fibers are involved.

Corrective actions include

1. Eliminating mechanical stress factors like padding the shoulder under the rifle.

2. Self stretching. The anterior portion is stretched during the middle and lower-hand position of the In-doorway stretch. The posterior portion is stretched by grabbing the elbow of the affected arm and pulling it across the chest with warm water of a shower directed over the muscle.

3. Eliminating key TrPs referring pain into the deltoid, like the infraspinatus or the scaleni. So the three correctives are eliminating mechanical stress factors, stretching the muscle in two directions and eliminating key TrPs referring into the deltoid.

Our final muscle for this module is the serratus anterior. In poultry, this is the finger licking, chicken finger meat. It’s shown on page 25 and on page 888 of the text. There’s one documented trigger point which usually lays between ribs six and seven on the side body. A good landmark to find this is drawing an imaginary line from slightly below the nipple around to the side of the chest. TrPs can form in the midfiber regions of any digitations but I think you will find this location to be the most common spot.

Its pain pattern is unique and commonly misdiagnosed. It’s the only muscle with a persistently intense pain complaint along the side of the torso. It also doesn’t respond well when the patient attempts to find relief by changing positions. Most other muscles do. The referral can also project medially along the inferior angle of the scapula and down the medial aspect of the arm and into the palmer surface of the 4th and 5th digits. This TrP can often be involved all by its lonesome with no other involvement of muscles in its functional unit.

Its nickname is Stitch in the Side. Breathing hard while running can cause the runner to press or squeeze the area. Pain along the side or a shortness of breath is associated with serratus involvement. I’ll list four of its actions:

1. Abduction and elevation of the shoulder blade

2. Prevents winging of the scapula

3. An accessory respiratory muscle

4. It thrusts the arm forward. I call it the Touché muscle- its action is thrusting the arm forward at shoulder height like when jousting.

Like the rhomboid, the serratus anterior is prone to weakness and inhibition when it develops a TrP.

I’ll list three ways a serratus anterior can be activated.

1. A muscle strain which the patient can recall. For example a fast and furious set of push-ups or a super fast or prolonged run or a severe bout of coughing.

2. Torsional stress like when the arms stay fixed and the torso twists vigorously.

3. High levels of anxiety according to one study sited in our text.

Findings and tests for this muscle include:

1. A reported shortness of breath.

2. One scapula stands out as viewed from the back. Viewed from the front, one shoulder rolls forward.

3. A taut band between the ribs. Exquisitely tender spots reproducing the client’s pain complaint and local twitch responses are findings consistent with any muscle having a TrP. Because the muscle lies near the surface you might be able to observe the local twitch response easier than on a deeper muscle.

Four correctives are:

1. The In-doorway stretch in the lower and middle positions,

2. Avoid sit-ups

3. Avoid punching and

4. Control coughing.

So there you have it. Feel free to email me at info@. If you haven’t already, I encourage you to download the lectures and put them on your hard drive, a CD, or into an MP3 format. Then they are yours for a lifetime. Listening or reading anything twice brings the highest level of retention. Also, if you are taking this program for CE hours, there is an online ten question quiz for each module. It’s at the same online location you found the student material. Click on the link saying Take the Module quiz and complete it as soon as possible while the information is still fresh in your mind. Of course you can use your notes.

Thanks for listening. Stay in touch.

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