As I wrote several months ago, the Serratus Posterior Superior can be implicated in a great deal of shoulder and arm pain cases.    But this isn’t about that – this is about the value of blogging about case studies.

That article was found by a woman in Europe, who had been diagnosed with trigger points in the SPS muscle, and she had been unable to find any relief from the constant pain.  She found my article and wrote to me about an appointment.  She coincidentally was going to be visiting San Francisco and wanted an appointment.  We booked a two-hour session and she showed up.

I did a careful assessment and found out some interesting things – sleeps almost exclusively on her right side, sat at her desk with one leg folded under the other while at work, reached fairly far away from her body for keyboard and mouse.   I found the primary trigger point in her serratus posterior superior muscle and deactivated it.  We finished the session with a half-hour of relaxation work, and she left very happy.

Anyway, I had the opportunity to work with this client because I blogged about another client case study.  That’s the real lesson here – write about your work, what it does and why it works.  Be specific in what you do – talk about benefits of the work, not the techniques and jargon.  Clients don’t know the difference between myofascial release and myofascial therapy, they think deep tissue massage means painful.  Stay away from those terms.  Instead, say things like “relieve your back pain,” “eliminate headaches,” “you don’t have to hurt,” and other things.

Write about what you do – people in pain will find you, and you’ll get clientele.

A client with a diagnosis of capsulitis in his left second metatarsal-phalangeal joint presented with constant nagging pain when walking or standing. I worked on his foot, relaxing and stretching the interosseous muscles – the muscles between the metatarsal bones of the foot. My thought process on this was that if I could get those muscles to relax and to open up the space between the bones, some of the tension in the foot would be resolved and the ligaments would have a chance to have a bit more breathing room and heal.

Client reported eliminated pain more than one week later following treatment. Recommended to client a protocol of self-massage and stretching of the affected region of the foot for continued maintenance, and periodic massage sessions to continue to improve and reduce foot pain.

With all of the new iPhones and smartphones and other handheld internet devices that so many people seem to be constantly attached to, it’s no wonder when some come to see me with pain in their elbow.  In some extreme examples, the pain can radiate out from the elbow during flexing the elbow or rotating the wrist under load.  Carrying one’s internet device in the hand and keeping the elbow at a constant 90 degree bend can over time cause Lateral Epicondylitis to develop.  This condition has also been called “tennis elbow” but since most people no longer play tennis, but carry a device instead, let’s call it “iPhone Elbow.”

Massage can be very useful in relieving the pain and tenderness associated with iPhone elbow.  Longitudinal release and Cross-fiber friction will help to relax the forearm extensor muscles, and local compression will help to deactivate any trigger points.  Ice massage will greatly reduce inflammation, and client education in conducting self-care for between massage sessions.

The best way to avoid iPhone Elbow is to carry your device in your pocket, purse, or in a belt pouch when you are not actively using it.  Answer your phone, look up information, send a text, and then put it away.  If you must use it for a prolonged time, say in an extended text message conversation, then find a place to sit down and rest it on a tabletop or on your knees.  You’ll spare your hands and elbows pain, and you won’t be one of those distracted iPhone users who bumps into lampposts and other people.

Let your arms hang freely at your sides when you are not using the device, and do some wrist stretches throughout the day.  Here’s a useful stretch for you:

1. Take one hand in the other and gently flex the held hand’s wrist.  That is, bend the wrist in the direction of the palm of the hand.
2. Straighten that same arm’s elbow.
3. Slowly rotate the forearm so the elbow crease is pointing away from your body.
4. Hold for 30 – 60 seconds.

If you are doing this correctly, you should feel a stretch from wrists all the way up to the outside of the elbow – the lateral side of the arm.  Gradually, you will be able to increase the amount of wrist flexion, and even add flexing the fingers at the closest knuckle to the palm.  Do this stretch three or more times a day, and you will notice a big improvement in the reduction of tightness and pain in the elbow.  Self-care is a great way to help relieve your pain.

Stretching will help, but the services of a professional massage therapist can usually completely relieve the pain associated with lateral epicondylitis, usually in one to four one-hour sessions.  This, of course, depends on the severity of the case, but in mild to moderate cases, a single session usually brings tremendous relief.

Book a massage now and be free of your iPhone Elbow!

A client recently came to me complaining about the numbness on the posterior forearm and into his shoulder.  My initial thought was that it was infraspinatus related, from the shoulder referred pain pattern, but after relieving the trigger points in his infraspinatus, the numbness persisted in his forearm.  So more investigation was required.

I found a similar pattern described by Travell and Simons in the Serratus Posterior Superior muscle, which lies deep to the Rhomboids – the third layer of muscle tissue down, beneath the Trapezius and the Rhomboids.  The muscle originates on the spinous processes of the vertebrae, out to the cranial surface of ribs 2 through 5.  It assists in breathing by drawing the ribs superiorly and posteriorly.  When it refers pain, it commonly refers into the anterior surface of the deltoid, and down into the forearm extensors.

So, I place my client prone and place the scapula bone abducted, away from the spine.  This exposes the likeliest location of the SPS’ trigger point, the attachment spot at the second rib insertion.  Stretching the trapezius and rhomboid lengthen and thin out their tissues, allowing me to access the deeper layers of muscle with less effort and more accuracy.

That’s one reason I love my robot table so much; it lets me put my clients into comfortable, fully supported positions that allow me to more effeciently and effectively access tissues that are much more difficult to do on an ordinary flat table.

When I palpated the client’s insertion on the second rib, the referred pain pattern in his forearm and front of the deltoid was elicited, and I felt a moment of relief, happy that I had correctly found the source of the pain.  Since the muscle is so deep, feeling its tissues becomes easier when one moves the scapula out of the way, and lengthens the shallower muscles.

Using a vaulted hand, I applied ischemic compression into the trigger point, which slowly shrank away.  I think part of what is happening is that the ribs are being pulled enough to impinge upon the pathway of the brachial plexus, compressing the nodes that ennervate the anterior deltoid, and forearm extensors.

The client reported the absence of numbness at the conclusion of the session.  The client’s physician had thought that it would take a good massage therapist to be able to access this layer of tissue, and that an injection would probably have been necessary to alleviate the pain.  I am hopeful that that the more invasive approach will not be necessary.  My next steps will probably involve the application of ice for 20 minutes to the area before attempting a shiatsu compression with the client’s breath to stretch the muscle.  I can modify my table to provide excellent side-lying support by changing out the head cushion and using the U-shaped chest cushion.  I love my table!

Anyway, the challenges and satisfaction at being able to find touch-related pain relief for people is very gratifying for me.  It’s fun and rewarding to help other people.

Ankylosing Spondylitis (AS) is an inflammatory condition of the spine and other parts of the body, related to various arthritis conditions. It affects men 3:1 over women, and generally starts within second or third decade of life. Its initial symptoms typically include pain and inflammation in the hips and low back caused from inflammation of the sacroiliac joint. Over time, this inflammation can lead to fusion of the SI joints, as well as fusion of vertebrae, resulting in the inability to bend the spine and pain and loss of range of motion, sometimes known as “bamboo spine.” Also, AS can affect other organs of the body, including the liver and kidneys and eyes (iritis). In women, AS can start in non-vertebral joints, or the cervical spine instead of the sacral or lumbar spine. The inflammation often leads to a flattening out of the lumbar spine, which has the tendency to make the curvature in the upper spine become more pronounced, causing the person with AS to look hunched over, or looking down all the time. Extending the spine becomes increasingly difficult. This increased curvature of the thoracic and cervical spine collapses the chest cavity, decreasing lung capacity and making breathing more difficult and shallow.

Medical treatment for AS typically involves the administering of NSAIDS (asprin, ibruprofen, etc), physiotherapy, and prescribed exercise (typically swimming and breathing exercises). Firm mattresses and thin pillows, encouraging patients to sleep on their back to increase spinal extension are also recommended.

A client in his mid-30s diagnosed from childhood with Ankylosing Spondylitis came to me recently seeking relief from his back pain and to try to regain some flexibility. He has lost appoximately 40% of the range of motion in his spine. He works and has a relatively normal life, but doesn’t enjoy swimming, so has little physical activity outside of normal life activities.

My goal for him is going to be to work on lengthening the hip flexors (iliopsoas), and spinal flexor muscles (rectus abdmoninus, sternocleidomastoids, etc), as well as work on relaxing spinal extensor muscles. AS sets up a serious tug of war between the spine and the muscles that move it, and the increased flexing of the spine causes chronic shortening of the flexor muscles, which cause the extensors to have to compensate by increasing contraction to maintain as upright posture as they can.

So, our first session was performed in sidelying and supine positions, and focused on relaxing the erector spinae muscle group, some work in the sacral ligaments, then work in opening up the chest with work in the pectoralis major and minor to assist in increasing chest capacity.

At the end of the session, client was observed to have slighly improved range of motion in spinal extension. Client also reported that he felt some of his kidney stones start to move during the session, and later that evening he passed three stones. Kidney stones are not uncommon with people who have AS.

Recommended to the client a start of regular bodywork sessions to improve range of motion and pain relief.

Current Mood:  amused

Client is an 81-year old man who woke up in the middle of the night with chest pains. After the doctors determined that he was not having a cardiac episode, they prescribed a bunch of pain meds and muscle relaxants. The meds gave him bad constipation and he lost his appetite and 20 pounds, which on him was far too much weight to lose, so he was keen on finding a non-medical solution to his pain.

He experienced pain and/or limited range of motion in shoulder flexion, abduction, lateral rotation, protraction and retraction. Was unable to upwardly rotate shoulder. Extension, adduction, medial rotation, retraction were within normal limits. After assessing his range of motion, we began the session.

Working on the elderly requires a very deft and gentle touch. Their skin is very fragile and easily torn, and it is important to work to create a comfortable group of positions for them to recline, as their joints are often painful and makes difficult prone or supine positions for very long.

This particular man required trigger point work in his subscapularis and serratus anterior muscles, which have insertions on the anterior surface of his scapula, which means going in through his axilla to access the muscles. Also, his infraspinatus, supraspinatus, levator scapula were all very tight and required work as well. Using very slow, gentle pressure, I was able to get the subscapularus trigger points released, as well as relaxing the posterior rotator cuff muscles and levator scapula.

Recommended a weekly appointment for the next four weeks to continue making progress.

Last night, I had a breakthrough with one of my clients. She had been coming to me for around six months with this problem in your shoulder: she presented nerve pain from her brachial plexus distally to her wrist, and she couldn’t medially rotate her arm into “handcuff position” without considerable pain. I’d been trying various ways of opening her shoulder up without much success, and I could tell she was becoming frustrated with the slow pace of progress.

Part of the problem was that I wasn’t digging down deep enough to discover the exact pattern of referred pain, and I had conflated the two pains. The nerve pain and the deep scapular pain were really from two separate groups of trigger points, and that was causing me a bit of vexation. But last night, she described the nerve pain differently than we had discussed in the past, and a light bulb went on. That lead me to her scalene muscles, and some palpation on them triggered the pain sensations she had been experiencing. Digging into them with vaulted fingers and thumbwork deactivated her trigger points there, and there was immediate relief.

With that solved, I went back to basics on her medial rotation problem. The main muscle of medial rotation is the subscapularis, which is where she was feeling her pain, so I decided to check it’s primary antagonist, the infraspinatus. Started out with some softening, friction circles, and then when she was softened – bingo! – I felt it; a tiny trigger point about the size of a glass-headed pin. Soon as I put pressure on it, she said, “That’s it!” and we went in to some deep direct pressure, trying to crush the TrP against the scapula to get it to release. Over the course of about 10 minutes, that darned trigger point slowly, so slowly, released and let go. I wanted to test it out that I had gotten all of it, so I took her arm and slowly put it into medial rotation, with no pain. Gradually, I was able to move her arm painlessly through its full range of motion in that aspect.

You should have heard us whooping and hollering!

This is exactly why I love this work so much. Every day I get to help people, and then we have this particularly exhilirating moments like this. I am humbled and ecstatic to be able to be of such service to others.