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