0:04 This is Brent of the Brookbush Institute, and in 0:06 this video we're going over static 0:07 manual release of the subscapularis. Now, 0:10 if you're watching this video, I'm 0:11 assuming you're watching it for 0:12 educational purposes and that you are a 0:14 license to manual therapist. That is, in 0:16 your state or region, it is legal for you 0:19 to do manual techniques. That is 0:21 chiropractors, athletic trainers, physical 0:23 therapists, massage therapists, osteopaths. 0:25 I'm sure I'm missing a couple, but if you 0:27 are unsure, please look up the laws in 0:30 your state. Personal trainers, this 0:31 probably does not fall within your scope 0:33 of practice, although you could use the 0:35 patient portion of this video in an 0:38 educational setting to help you learn 0:39 your anatomy. I'm going to have my friend, 0:41 Crystal, come out. She's going to help me 0:42 demonstrate this technique. If I'm going to 0:45 put my hands on Crystal, if I'm going to do 0:46 some sort of manual intervention, I'm 0:49 going to be pretty sure that that manual 0:51 technique is going to have an effect on 0:53 either the symptoms she was complaining 0:55 of or her performance. The only way 0:57 to get there is through assessment. So, 0:59 we're going to assume in Crystal's case 1:01 that she came in with a little anterior 1:03 shoulder pain from working out, and it's most 1:07 prevalent when she works out. We did 1:09 her overhead squat assessment and her 1:11 arms fall forward. We did some goniometry, 1:14 and she had some restrictions in 1:15 external rotation and flexion. Subscapularis 1:18 will restrict flexion a little bit. And 1:21 even when I did my manual muscle 1:22 test, she tested a little weakness and 1:24 external rotation. I know that 1:26 overactivity of my subscapularis can 1:29 reciprocally inhibit my infraspinatus 1:32 and teres minor. So, I got my good working 1:35 hypothesis going, and now I just have to 1:37 think about my protocol for manual 1:39 techniques. They basically all come 1:41 down to palpate and compress. Now, we do 1:46 want to get a little bit more detail 1:49 than that. 1:50 So if I first start off with, "How do I 1:53 palpate the subscapularis?" Well, my 1:55 subscapularis is on the anterior face, 1:58 the entire anterior face of my scapula. 2:00 So, with the portion of my scapula that 2:03 is under my rib cage, I need to get my 2:06 scapula out from under my rib cage. The 2:08 way to do that, guys, is you're going to pull 2:10 them into 2:11 protraction, and then if you take the 2:14 shoulder into flexion, the scapula 2:15 will generally upwardly rotate. You can 2:17 mess around with a little abduction and see 2:19 if that gets you a little better upward 2:22 rotation. And now this, her axilla, is showing. 2:26 Her armpit is showing. If I take my 2:29 thumb and I press straight down into her 2:32 axilla with my thumb against her 2:34 rib cage, I'll actually press through some 2:37 soft tissue, press through some soft 2:38 tissue, press through some soft tissue, 2:40 but eventually I hit bone. I can feel 2:43 it. 2:44 That is the anterior face of her scapula. I know if I'm on the anterior face 2:48 I know that if I'm on the anterior face of her scapula, I have to be on her 2:49 subscapularis. Now, this whole portion 2:53 here, this tissue that you can see my 2:56 thumb disappear behind, is not her 2:59 subscapularis. This tube of muscle is her 3:02 latissimus dorsi, her teres major, and her 3:05 teres minor. I want to make sure I'm 3:07 medial to that musculature, so make 3:12 sure you're in between that border of 3:16 muscle and the rib cage. Now, the next 3:19 things I need to think about now that I 3:20 know how to palpate my subscapularis is 3:24 where are my trigger points? The trigger 3:26 points for my subscapularis are 3:28 generally in the middle of the length of 3:32 my scapula. So, this is her inferior angle 3:34 and this is the glenoid fossa here, so if 3:38 I press down right in the middle of that, 3:40 usually there's some dense fascicles 3:42 there, and then the other trigger point 3:45 is usually right up near the glenoid 3:48 fossa there and the superior fibers of 3:52 the subscapularis. This kind of brings 3:54 us to our next point. I do need to also 3:56 be aware of 3:58 are there any tissues around her 4:00 subscapularis that I could offend or 4:02 insult or injure with compression? I 4:04 have to think that her 4:06 long, thoracic nerve runs along the 4:08 anterior face of her scapula, so if I get 4:10 that burning, searing, tingling, 4:12 I want to get off that. Usually I can 4:15 move my thumb just medial or lateral and 4:18 be off that tissue. As I get up into here, 4:20 I definitely need to consider that my 4:23 lymph nodes, my axillary artery, and some of 4:25 those other nerves coming off the 4:27 brachial plexus as it passes out from 4:29 underneath the pectoralis minor are up in 4:32 there. So, again, if there are any symptoms 4:34 that are not that tenderness associated 4:37 with trigger point compression, get off it. 4:40 Move around a little bit. 4:42 Chances are, all of these structures are 4:44 like a millimeter or two millimeters wide, so 4:46 you should be able to move a little bit and 4:48 get that same trigger point without 4:50 doing any compression or making the 4:54 patient or client uncomfortable by 4:55 compressing those tissues. So, now we 4:59 know how to palpate the subscapularis. 5:01 You know where the trigger points are. We 5:04 know where some of those other tissues 5:07 are. I mentioned in some of the other 5:09 videos the way we find the appropriate 5:12 tissues is with these broad strokes. 5:17 The subscapularis is no different, other 5:19 than we're just not going to take our 5:20 thumb and run it from inferior angle all 5:23 the way up into her armpit, because 5:24 that's obviously going to be 5:26 uncomfortable. 5:27 We're going to take a lot of skin, a lot 5:29 of soft tissue with us if we go from 5:30 here to here. This is pretty delicate 5:32 tissue already, and we really don't want to 5:35 do anything to make this any more 5:36 uncomfortable. So, we're still going to go 5:39 cranial- oh, I'm sorry- 5:41 kajal to cranial with our strokes, but 5:44 we're going to do little short strokes. 5:46 You guys can see here that I can start 5:49 at inferior angle and do this little short 5:51 stroke to see if I feel anything. 5:54 No dense fascicles there. I pick up my 5:56 finger and go a little higher. No dense 5:58 fascicles there. I pick up my finger and 6:00 move a little- ah, there we go. We've got 6:02 some dense fascicles right there. Once 6:04 I find dense fascicles, I 6:05 can then compress and hold for 30 to 120 6:09 seconds until I get a release. Then, I 6:12 can keep going looking for those other 6:14 trigger points that are closer to the 6:17 glenoid fossa. Now, there is one other subscapular 6:21 trigger point, but we need to get 6:24 Crystal into a little different position 6:26 here. I'm going to have you roll over and 6:27 face me. 6:30 It's actually closer to the vertebral 6:32 border of her scapula but on the 6:35 superior portion. Now, what I wouldn't do 6:38 is try to get underneath the scapula 6:40 starting up here. Here's a little trick: 6:44 start at the triangle of auscultation. 6:47 It's this little point medial to the 6:50 inferior angle of the scapula, where my 6:53 rhomboids, lower traps, and my left 6:58 lortissimus dorsi don't actually cover. I 7:02 can actually take my fingers like this 7:03 and almost just push her scapula right 7:08 over the top of my fingers. Now I'm 7:10 underneath, and I can do my searching 7:14 without having to go straight through 7:17 all of this tissue, which is 7:19 her middle traps and rhomboids. If 7:21 you're on a muscular person, that's going 7:22 to be really tough. Once I'm 7:26 already underneath, then I can look for 7:28 that trigger point and I can hold it for 7:31 30 to 120 seconds. Now, the last thing that you 7:35 need to think about, and this is very 7:36 important, is what is your appropriate 7:39 body position so that you are 7:42 comfortable. What I just showed you 7:44 wasn't it. 7:46 I was leaning over. I don't want to be 7:48 leaning over my patient and be using 7:50 my hand strength. I want to be standing 7:52 straight up and using my body weight to 7:54 apply pressure. So, I'm going to go ahead 7:56 and have Crystal lay on her back. The way 7:59 i would do this is, of course, I would be 8:02 on the side that I was going to release. 8:04 I would take her arm, pull her into 8:07 protraction and flexion, and now I can 8:10 use this hand, or I can even do this and 8:12 have her just kind of hold my side there, 8:14 and then I can control 8:15 her shoulder, and I can even use my body. 8:19 I can do that same stroking motion 8:21 with this hand, and then when I need to 8:23 apply pressure, this arm's straight and I 8:26 just lean forward. 8:29 Same thing happens with the other technique. 8:30 Rather than leaning across and pulling 8:33 up like this, 8:34 what I'm going to do is I'm going to 8:35 have Crystal go ahead and turn and face 8:38 the camera. I'm going to control her 8:44 shoulder this way and use this hand to 8:47 get underneath the scapula. Then I 8:50 can basically just continue to 8:54 use this shoulder to push her scapula 8:57 over my fingers, rather than using my 8:59 fingers dig. Next up, we'll do the close-up 9:01 recap. Now, for our close-up recap: I 9:05 need to be able to get to the 9:07 subscapularis, so the first thing I have 9:09 to do is get the scapula out from 9:11 underneath the rib cage. The way I'm going to 9:13 do that is I'm going to go ahead and protract 9:16 Crystal's scapula by pulling her arm up 9:18 this way. This is the inferior 9:20 angle of the scapula right here. If I 9:23 take her arm into flexion and 9:25 abduction, I can actually feel the 9:27 inferior angle moving out this way. So as 9:30 I do that, I'm actually taking her 9:33 scapula and moving it under the back of her 9:35 axilla here. To actually feel the 9:38 subscapularis, my suggestion is start 9:41 with your thumb against the rib cage and 9:44 push straight down. This thickness of 9:49 muscle, 9:50 this mass right here, this tube 9:52 of muscle on the axillary border, 9:55 this is not your subscapularis. This is 9:57 lat, teres major, and teres minor, so we 10:01 want to get medial to that. The best or 10:05 easiest thing to do is just start at the 10:07 rib cage and press down. 10:10 And if I press, press, press, press, and press, I 10:13 can actually feel bone at the bottom of 10:15 this palpation. Keep in mind, guys, we 10:17 have that long thoracic nerve, 10:19 the axillary artery, some of the other 10:21 nerves off the brachial plexus, and lymph 10:23 nodes to consider here. If Crystal's 10:25 feeling anything weird, tingling, burning, 10:29 searing type pain, something that's just 10:32 really, really uncomfortable and it 10:34 doesn't seem to be related to 10:36 trigger point pressure, get off it. 10:38 Remember, most of these structures are 10:39 only a couple millimeters wide, so it 10:42 should be easy enough to move your 10:44 fingers around a little bit and still 10:46 get at that trigger point without 10:47 compressing that tissue. I'm going to use, 10:51 starting again at the rib cage and pressing 10:55 down, I'm going to use those kajal to 10:58 cranial short strokes to investigate 11:02 which fascicles of the subscapularis are 11:05 the most dense, seem overactive, seem to 11:10 give up a bit more resistance. I can 11:14 feel some right there, which doesn't 11:17 surprise me, because as we explained in the 11:18 earlier video, from inferior angle to 11:22 glenoid fossa about halfway between is a 11:25 common sight for a trigger point in the 11:27 subscapularis. And there's another one in 11:29 the superior fibers of the subscapularis, 11:32 deep in her armpit and close to her glenoid 11:36 fossa there. That's the one we have to be 11:38 really, really careful not to impinge on 11:40 any of these other structures. Once again, 11:43 short strokes, making sure I'm not taking 11:46 too much skin with me. We don't want to 11:49 make our clients and patients 11:50 uncomfortable for no reason. We're 11:53 going to hold for 30 to 120 11:54 seconds or until we get a release. 11:59 There is, of course, the other subscapular 12:01 point. I'm going to have Crystal lay on her side here. I 12:06 talked about that triangle of 12:08 auscultation. Crystal is so lean that you 12:11 can actually almost see this dent right 12:14 here. If you guys can see that shadow, 12:17 that's where there is no muscle 12:20 covering that area. That triangle of 12:22 auscultation is a stethoscope- 12:24 you can put a stethoscope there and 12:27 hear a little bit easier than trying to 12:29 hear through muscle. We're going to 12:31 use it because it means less tissue to 12:33 dig through. If I put my fingers on that 12:36 triangle of auscultation, I can take my 12:37 other hand, pull back into retraction, and 12:41 her scapula actually falls over the top 12:43 of my fingers. I can then search through, 12:46 search through, and search through until I 12:49 get about two-thirds of the way up the 12:50 vertebral border. And I actually do feel 12:52 an increase in the density of those sub 12:54 scapular tissues. I can hold until I 12:59 get a release. There you guys have it, a 13:01 static manual release of the 13:02 subscapularis. Make sure before you put 13:05 your hands on anybody that you have a 13:06 good working hypothesis on why the 13:09 subscapularis might be overactive, 13:11 indicating a need for release technique. 13:13 The only way you're going to get 13:14 there is assessment. If you're not up 13:16 on your assessment game, check out those 13:18 videos, check out our courses and bring 13:21 your assessment game up. Make sure before 13:23 you do this technique on a patient or 13:25 client, that you've had the chance to 13:27 practice. Grab some of your 13:29 colleagues. Grab a mentor with good 13:32 manual techniques, and go back and forth. 13:34 Make sure they're doing the techniques 13:36 on you so you know what it feels like, 13:39 or should feel like, and you're doing the 13:41 technique on them, so that they can give 13:43 you some good feedback. There is no 13:46 replacing live education and mentorship 13:51 when it comes to manual 13:53 techniques. I hope you guys enjoyed this 13:55 video. Please feel free to leave your 13:58 questions below. I'll make sure I answer 14:00 them as quickly as possible. I look 14:02 forward to hearing from you guys.
