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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
00:20:5500:21:00
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.