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

Pectoralis Major and Subclavius Static Manual Release (Soft Tissue Mobilization) is a therapeutic technique that can improve movement within the upper body, reduce pain and pressure on your nerves, and relieve tension and tightness in the muscles and connective tissues. This technique uses slow, precise movements to lengthen, stretch and mobilize the pectoralis major and subclavius muscles, as well as the surrounding fascia and connective tissues. It helps restore optimal

Transcript

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