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Pectoralis Major and Subclavius Static Manual Release (Soft Tissue Mobilization)

Learn how to perform static manual release techniques on the pectoralis major and subclavius muscles for soft tissue mobilization. Decrease pain, increase range of motion and optimize movement performance with this easy to follow technique.

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00:04 - 00:07This is Brent of the Brookbush Institute, and in this video we're bringing
00:07 - 00:09you another manual technique. Now if you're watching this video I'm assuming
00:09 - 00:13you're watching it for educational purposes, and that you are a licensed
00:13 - 00:17manual therapist following the laws regarding scope of practice in your
00:17 - 00:20state or region. That means athletic trainers, chiropractors, physical
00:20 - 00:25therapists, osteopaths, licensed massage therapists you are likely in the clear
00:25 - 00:30to do these techniques. Personal trainers this probably does not fall within your
00:30 - 00:33scope of practice, although you might be able to use the palpation portion of
00:33 - 00:38this video to aid in learning your functional anatomy in an educational
00:38 - 00:43setting, supervised by a licensed manual therapist. Now before we place our hands
00:43 - 00:48on a patient or client it is important that we assess, and have a good rationale
00:48 - 00:53for doing so, and of course if we're going to assess then we should be
00:53 - 00:57reassessing to ensure that the manual technique we're using is effective, and
00:57 - 01:01we have a good rationale for continuing to use that technique. We're going to go
01:01 - 01:05over static manual release of the pectoralis major and subclavius muscles.
01:05 - 01:08My friend Melissa is going to help me demonstrate this technique. We're going
01:08 - 01:11to use that same palpate and compress release technique we've used in all of
01:11 - 01:15our static manual release videos. We are going to break it down a little bit
01:15 - 01:20though, and use our four-step process of differentiate, know where our common
01:20 - 01:23trigger points are, know what tissues we probably shouldn't be compressing are,
01:23 - 01:27and of course patient client and professional positions so that we have
01:27 - 01:30good technique and our patient and client is comfortable. Now let's start
01:30 - 01:36off with how large the pectoralis major is because that's going to be the first
01:36 - 01:42step in our palpation. I think individuals kind of underestimate how
01:42 - 01:49big this muscle is. It essentially attaches its origin to all of the
01:49 - 01:52clavicle that isn't covered by the deltoid, so the medial two-thirds of the
01:52 - 01:57clavicle, and then this is the the really large part, it also goes from
01:57 - 02:04sternoclavicular joint all the way down to the xiphoid process. So this is a very
02:04 - 02:11broad muscle and all of these fibers converge into the lateral lip of the
02:11 - 02:14occipital groove, which you guys can see kind of how all this tissue right here
02:14 - 02:17converges into the shoulder, kind of passing
02:17 - 02:21underneath the anterior deltoid here. We do need to think about a couple muscles
02:21 - 02:27that run underneath the pectoralis major, we have the pectoralis minor underneath
02:27 - 02:32the lateral side of the pectoralis major. The nice thing from a palpation
02:32 - 02:37standpoint is the pectoralis minor runs nice and vertical, while most of the
02:37 - 02:41pectoralis major fibers run horizontal. So if you happen to be releasing this
02:41 - 02:45pectoralis major trigger point then all of a sudden start hitting fibers that go
02:45 - 02:50this way, you know you're not on pec major. Now if you want to release the
02:50 - 02:55pec minor that's fine, but be cognizant of what you're releasing and ensure that
02:55 - 02:59it's going to contribute to your goal. The other muscle that is underneath your
02:59 - 03:03pectoralis major, I've marked a trigger point off with an X here, I'm going to
03:03 - 03:07show you guys how to get to it, but it's your subclavius. Your subclavius is
03:07 - 03:16a funny little muscle which can restrict posterior rotation and upward rotation,
03:16 - 03:21or what's actually called elevation of the clavicle. So it can affect elevation
03:21 - 03:25of the arm. We're going to show where that trigger point is, but it's it's way
03:25 - 03:30up here in the corner right next to your your sternoclavicular joint. You kind of
03:30 - 03:37have to wrap your finger underneath some of the pec major fibers. Now the trigger
03:37 - 03:42points for the most part, the majority of the trigger points are right in the
03:42 - 03:47middle of the length of these fibers. So I don't know if you guys can see these
03:47 - 03:51X's, of course we'll do a close-up so you guys can see these X's, but these X's run
03:51 - 03:57right down the middle, right right down the middle of the pec here, that's where
03:57 - 04:02the majority of our trigger points are. There's an additional trigger point out
04:02 - 04:09on this little wing of the pec major here and then we have one other trigger
04:09 - 04:14point which I just mentioned, which is way up in here and this is generally
04:14 - 04:20speaking a subclavius trigger point. Now getting into step 3, are there tissues
04:20 - 04:25that we probably don't want to compress. Well when we're here we probably want to
04:25 - 04:30be aware that we're kind of close to the brachial plexus, and if we put
04:30 - 04:34tension on the pec major and the pec minor we could compress the brachial
04:34 - 04:38plexus, and that's going to give us some some weird nerve sensations, either
04:38 - 04:42numbing or tingling in the fingers, or that sharp burning pain. Of course if you
04:42 - 04:48press down and any of that happens just move a little bit, nerves are fairly thin
04:48 - 04:53structures so you should be able to move a half centimeter in any direction and
04:53 - 04:59not be on that nerve tissue anymore. The bigger issue with pec major is if
04:59 - 05:05you happen to be a male therapist treating a female about half of the
05:05 - 05:07pectoralis major is covered by breast tissue.
05:07 - 05:13This creates not only a issue where we need to be sensitive and respectful, and
05:13 - 05:18also it kind of hurts to just smash breast tissue like that, that doesn't feel good
05:18 - 05:23for anybody. So when we talk about how we're going to lay our hands down that's
05:23 - 05:27going to be the biggest challenge, how do we lay our hands down get to these
05:27 - 05:34trigger points and not just compress and put our hands where they probably
05:34 - 05:40shouldn't be. Now with that being said you probably want to do a little bit
05:40 - 05:46extra work assessing, explaining to your client where you're going to place your
05:46 - 05:52hands, what you expect your outcome to be and get a verbal confirmation that it is
05:52 - 05:58okay for you to do this technique. Obviously we don't want to allow
05:58 - 06:06embarrassment or any sort of fear of sexual misconduct, which I know is a
06:06 - 06:10terrible thing. If you have to bring another female physical therapist in the
06:10 - 06:12room, or another female professional in the room because you feel uncomfortable
06:12 - 06:17great. We really don't want that stuff though to prevent us from being good
06:17 - 06:22practitioners. So I hope with the techniques I show you in this video you
06:22 - 06:26guys feel totally comfortable placing your hands where you need to place your
06:26 - 06:32hands. So patient and client positioning, you guys will notice I'm standing at
06:32 - 06:37about her shoulder height, and for most of the trigger points in the pec I'm
06:37 - 06:43actually not going to do the side closest to me, I'm going to do the side
06:43 - 06:48further from me, and the reason being is I can get my hands out straight this way.
06:48 - 06:54And then if you guys kind of see how I even put my hands just from
06:54 - 06:59practice, I kind of have that fingers tilted up position so I can put my hand
06:59 - 07:03down, starting at sternum and move laterally,
07:03 - 07:10keep my fingers up and I'm nowhere close to sensitive areas. Melissa doesn't feel
07:10 - 07:14uncomfortable, I don't feel uncomfortable, we're all in the clear once we're there.
07:14 - 07:19We can then use those same palpatory techniques we've been going through in
07:19 - 07:23all of our videos. I know these fibers are horizontal, all
07:23 - 07:28right so I'm going to use a perpendicular stroke to find the most
07:28 - 07:35dense or overactive fibers. Now a little trick here guys so that you don't play
07:35 - 07:40the finger on top of a wet marble game, where the marble keeps trying to shoot
07:40 - 07:44out, you want to pin these tissues down a little bit so you can really get your
07:44 - 07:48fingers on top of one of these hyperactive nodules. I'm going to go
07:48 - 07:53ahead and have Melissa place her hands behind your head. Now that she has her
07:53 - 07:59hands behind her head I'm going to go ahead and start my perpendicular strokes,
07:59 - 08:06and I can feel some nice nice overactive fascicles right there, and once I find
08:06 - 08:10those overactive fascicles I will then search the length of the fiber, I told
08:10 - 08:15you it's usually closer to the middle. Once I get close to the middle of
08:15 - 08:21these fibers I do in fact feel like a little nodule of hyperactivity, what I'm
08:21 - 08:24going to do is I'm going to actually keep my hand with my fingers flared out
08:24 - 08:31like this, and then rather than try to like grip or press down with this hand,
08:31 - 08:35I'm going to leave this is my dummy thumb. So if I keep my hand off of breast
08:35 - 08:39tissue, I'm going to use this hand to apply pressure with kind of that
08:39 - 08:45pisiform hamate grip we'd use for mobilizations, just like so. And you
08:45 - 08:50can see Melissas face turn, I think I got that trigger point. It is a little tough
08:50 - 08:54to play with the tension on these because the the muscle becomes pretty
08:54 - 08:59thin here, but do try to be careful to not press too hard. You're
08:59 - 09:05just pressing enough to get a little tissue tension back. Once you feel a
09:05 - 09:10little increase in tissue tension then you just want to hold real still. So in
09:10 - 09:14this position with my arms long using my right arm to apply most of the pressure,
09:14 - 09:21I can just kind of lean in a little bit and then wait for a release. Now if this
09:21 - 09:26technique you're not comfortable with, you could use thumb over thumb. I have
09:26 - 09:32seen that, I have seen this before right, that tends to work too. I think a lot of it is
09:32 - 09:36going to depend for you guys on the size of your hands. I happen to have some
09:36 - 09:40pretty large hands and some very long fingers so this works better for me. I
09:40 - 09:44have seen people do it this way who don't have as large hands, and this
09:44 - 09:49is comfortable for them, so they put down this way and they end up keeping their
09:49 - 09:53hands out of any sensitive areas. You're going to want to practice on a partner
09:53 - 09:56and figure out what techniques work best for you.
09:56 - 10:02Alright so as I mentioned, perpendicular strokes, perpendicular strokes then go
10:02 - 10:05the length of the tissue to find the tightest nodules, and you can see I have
10:05 - 10:11common trigger points I found earlier already marked off here, but just to show
10:11 - 10:17you guys can you use this, perfect, up, there, yup, yep, okay right. And
10:17 - 10:21then once again I'm just going to put this part of my hand right
10:21 - 10:25over this thumb, this becomes my dummy thumb. I can even lay this down on top of her
10:25 - 10:32sternum, like my thenar eminence over my sternum
10:32 - 10:37here, and then just apply a little pressure just like this, and go ahead and
10:37 - 10:43release all those trigger points. Now there's two trigger points that require
10:43 - 10:47slightly different technique. The nice thing is they're not nearly, they're not
10:47 - 10:53in the same sensitive areas. We have the lateral, very lateral trigger point of
10:53 - 10:57the pectoralis major, which is really close to the shoulder. You guys can see I
10:57 - 11:02have it marked off here. This one I actually do on the same side. I think I
11:02 - 11:06showed you guys a technique when we did pectoralis minor, the hand position I
11:06 - 11:09like to use for this stuff is I actually just take this hand
11:09 - 11:13the hand that's farthest from my patient I guess now, and I just cup their
11:13 - 11:17shoulder. So I'm just going to go up and grab their shoulder just like so. If I
11:17 - 11:22grab their shoulder that puts my thumb right over these lateral fibers, and then
11:22 - 11:26I can do my perpendicular strokes because these fibers are now running
11:26 - 11:30this way. I can do my perpendicular strokes like this and then use this hand
11:30 - 11:38to apply pressure. How's that feel? Yeah that's tender right. So I just cup her
11:38 - 11:43shoulder, use this thumb to palpate, use this thumb for pressure. The trickiest
11:43 - 11:49one is subclavius, because if you just put your hand down right here on the
11:49 - 11:55let's say just lateral and just inferior to the sternoclavicular joint,
11:55 - 12:01you end up on some really thick pectoralis major fibers. This is not your
12:01 - 12:06subclavius, your subclavius is a thin little muscle. So what you have to do is
12:06 - 12:12you have to find a way to fall, either fall off the clavicle inferiorly
12:12 - 12:17underneath these thick fibers that are the pec major, or you need to find a way
12:17 - 12:23to fall superiorly off the thick fibers of the pectoralis major into the
12:23 - 12:29depression that's created right between the clavicle and the bulk of the pec
12:29 - 12:34major. And of course if you're very careful with your palpation, meaning you
12:34 - 12:41don't over press too fast you really work to find the depth that allows you
12:41 - 12:47to kind of scan that layer of tissues, you'll find a trigger point which I just
12:47 - 12:53did, and then you can kind of press on in. All right, so this one up here guys
12:53 - 13:00is the subclavius trigger point, and just keep in mind that it's not just
13:00 - 13:06lateral and inferior to your sternoclavicular joint, it's off the
13:06 - 13:11pectoralis major fibers, in fact you might have to kind of push the
13:11 - 13:14pectoralis major fibers out of the way with like a scooping motion so that they
13:14 - 13:20lay on the inferior aspect of your thumb there. So just a quick review because I
13:20 - 13:23know I just went over a whole bunch of stuff.
13:23 - 13:28Most of the pectoralis major trigger points fall right down the middle of the
13:28 - 13:34pec major, which means you need to do some experimenting with hands position
13:34 - 13:42on a partner that maybe is not a patient, to figure out what the best position for
13:42 - 13:46your size hands are, and I mentioned a few different ways. For me it works best
13:46 - 13:54to use this hand as a dummy thumb, all right so the the inferior hand here
13:54 - 13:58compared to my patient, and then use this hand to apply pressure, and I kind of
13:58 - 14:03keep this like up and flared out position for my hand. I think it would
14:03 - 14:09probably be fine to go thumb over thumb too, especially if maybe you had slightly
14:09 - 14:14smaller hands than I do. Somebody who has smaller hands than I do
14:14 - 14:22might also find it's fine to curl under and go on the same side. All these
14:22 - 14:26techniques are very acceptable providing you can get into a position that is
14:26 - 14:32straight-armed, using your bodyweight not your hand strength, and you're trying to
14:32 - 14:36keep your fingertips which of course makes this a little bit more
14:36 - 14:43affectionate, off breast tissue right. Again we don't want to let embarrassment
14:43 - 14:49or any sort of fear of sexual misconduct, keep us from doing techniques
14:49 - 14:51that are going to be effective. So make sure you're communicating with your
14:51 - 14:55client, make sure they understand what's going on, and if you have to if you
14:55 - 15:00happen to be a male therapist with a female patient, bring another female
15:00 - 15:03colleague into the room so everybody feels nice and comfortable. With the most
15:03 - 15:08lateral trigger point remember my cupping the anterior deltoid trick. I think
15:08 - 15:12it works great, you got your thumb here it gives you a lot of leverage and then
15:12 - 15:18subclavius is going to be inferior to the clavicle, lateral to the
15:18 - 15:25sternoclavicular joint, but off these thick superior pectoralis major fibers.
15:25 - 15:30You kind of got to push them out of the way. Stay tuned for a close-up recap. In
15:30 - 15:33this view you guys can see that the trigger points which I've marked off
15:33 - 15:37with X's here, fall right in the middle of the length
15:37 - 15:41of the pectoralis major fibers, and that's the middle of the pectoralis
15:41 - 15:46major fibers running all the way from sternoclavicular joint to the xiphoid
15:46 - 15:50process. So you can see here even these lower X's getting cut off would go all
15:50 - 15:56the way down, having a trigger point at each of the bands of the pectoralis
15:56 - 16:00major fibers. We talked about several hand positions. We're going to need to
16:00 - 16:05not only address these trigger points, but our subclavius trigger point as well
16:05 - 16:10as these trigger points on the lateral aspect of the pectoralis major fibers.
16:10 - 16:15Let's talk about the majority of the trigger points first and the hand
16:15 - 16:21position we used for that. We used a cross-body hand position in this one. I
16:21 - 16:26find that it is most comfortable for me to reach across with my fingers turned
16:26 - 16:33up, and this helps to keep my hands off of sensitive areas and to get my arms
16:33 - 16:37straight so that I can use bodyweight and leaning, rather than hand strength to
16:37 - 16:42try to release these trigger points. We talked about perpendicular strokes to
16:42 - 16:48find the most dense fascicles, that would be fascicles we're going to presume that
16:48 - 16:55are overactive. And then once we find a dense fascicle, we can then go along the
16:55 - 17:03length of that fascicle to find any acute point of overactivity, a nodule, a
17:03 - 17:10trigger point. Once we find that trigger point we can lay our thenar eminence
17:10 - 17:17here, over the sternum so that our hands anchored and relaxed. This turns into our
17:17 - 17:22dummy thumb and we can use our other hand, and I just use my pisiform hamate
17:22 - 17:30here over my thumb to apply pressure, pushing just hard enough to get a little
17:30 - 17:34give back from the tissue. So I feel like this give, give, give and then the tension
17:34 - 17:36increases in a tissue and that's right where I'm going to hold it,
17:36 - 17:44just at tension, 30 seconds to two minutes until I get a release. Of course
17:44 - 17:48guys these are the hardest trigger points to release because
17:48 - 17:51you end up having to do this turned up position with your fingers, to try to
17:51 - 17:57keep your hands from laying down over sensitive tissues. The easier trigger
17:57 - 18:02points to release are the lateral trigger points. The lateral trigger
18:02 - 18:08points can be easily addressed by cupping the anterior deltoid, just put your
18:08 - 18:12thumb in perfect position to do perpendicular strokes of these lateral
18:12 - 18:20fibers. So you guys can see where I marked off the two common trigger points
18:20 - 18:26here, find the densest fascicles. Once I find the densest fascicles I'm going to go
18:26 - 18:32on the length of that fascicle for an acute point. Sometimes you're going to
18:32 - 18:36want to pick up your finger there just so you don't take too much skin with you
18:36 - 18:40and just get a skin short stretch, that wouldn't feel good, and once I find it,
18:40 - 18:47again I can use this part of my hand right here over this palpating thumb now
18:47 - 18:52becoming my dummy thumb, and just apply a little pressure until I get a release.
18:52 - 18:58Now the trickiest palpation is the subclavius trigger point because if I
18:58 - 19:02just push down right here, I'm actually not going to hit it. If I push down right
19:02 - 19:07here I just get these thick, I don't know if you guys can see a little bit of
19:07 - 19:14Melissa's hypertrophied pecs as she's obese, she works out hard, but this
19:14 - 19:18is all really thick pectoralis major fibers. I need to find a way to get
19:18 - 19:22around these. So you kind of have two options, you can either find these fibers
19:22 - 19:28and then fall off them superiorly, pushing them down inferiorly as you do,
19:28 - 19:35so you fall into the canyon between these fibers and your clavicle. Or what's
19:35 - 19:40probably easier is put your thumb on the clavicle, and then fall
19:40 - 19:45off the clavicle by pushing these pectoralis major fibers out of the way.
19:45 - 19:51Once you're there, you're going to search that level of tissue for anything that
19:51 - 19:56feels like a increase in tissue density, feels a little bit more tender to your
19:56 - 20:01patient. You can watch their face in this position. Sometimes you find that first once
20:01 - 20:05you're there, maybe thumb over thumb technique works here because we just
20:05 - 20:10don't have as much room. I don't want to put my hand down over somebody's neck
20:10 - 20:14that's going to be real uncomfortable. So I might just do a little thumb over
20:14 - 20:18thumb here, maybe use a little bit more hand strength than I would on the other
20:18 - 20:22techniques. So there you have it knowing your functional anatomy will definitely
20:22 - 20:26help your manual technique. It'll help you differentiate structure so you can
20:26 - 20:29place your hands where they need to be, as well as make you aware of these
20:29 - 20:33sensitive structures around the tissue that you're trying to target. Things like
20:33 - 20:38nerves and lymph nodes, and arteries. Make sure that if you're going to place your
20:38 - 20:41hands on a patient that you have done an assessment and have a good rationale for
20:41 - 20:45placing your hands on that patient, and if you're going to assess make sure you
20:45 - 20:49reassess to ensure that your technique was effective, and you have a good
20:49 - 20:55rationale for using that technique again. Now with manual therapy, one on one live
20:55 - 21:00education is incredibly important. Please be looking for opportunities like
21:00 - 21:06workshops and mentorships, and maybe even classes at your local university that
21:06 - 21:11can get you some one-on-one individual instruction, or at least some live
21:11 - 21:18classroom instruction, so you've had a chance to be critiqued and mentored by
21:18 - 21:22somebody senior to you with some experience in manual therapy techniques.
21:22 - 21:29And before you bring this stuff back to your rehab fitness or performance
21:29 - 21:35setting, please practice on colleagues, there is no substitute for practice, and
21:35 - 21:40it is going to take a while to get accustomed to some of the techniques
21:40 - 21:45that we show in these manual technique videos, don't expect to learn them in two
21:45 - 21:50or three, or even five minutes. You want to have hours of experience under your
21:50 - 21:56belt working on various different body sizes and shapes, so that when you do get
21:56 - 21:59that first paying client first paying customer and you're really trying to
21:59 - 22:06make a good positive impact, really trying to promote better outcomes, you
22:06 - 22:09feel comfortable with that technique. I look forward to hearing about your
22:09 - 22:13outcomes and hearing your questions in the comment section of this
22:13 - 22:17video. I'll talk with you soon.
22:23 - 22:25

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