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.

While Carpal Tunnel Syndrome is a specific diagnosis, the term is sometimes inaccurately used to describe any RSI that affects the hands.

What is Carpal Tunnel Syndrome?

CTS is a condition where the median nerve is compressed in the wrist at the carpal tunnel. The Carpal Tunnel is the space between the flexor retinaculum, a halter of connective tissues that protects and stabilizes the tendons of the forearms flexors and blood vessels and nerves, and the small bones of the wrist, which are collectively called the carpal (scaphoid, lunate, triquetral, pisiform, trapesium, trapezoid, capitate, hamate) bones. The Carpal Tunnel is small, and when the tissues that pass through it become inflamed, that inflammation can impinge the median nerve.

Area of hand innervated by median nerve.

As seen in the photograph, the median nerve powers the lateral half of the hand. Numbness, pain, and muscle weakness can sometimes be ascribed to impingement of the median nerve in the wrist.

When the median nerve is impinged in the carpal tunnel, symptoms  can make it very difficult to have good hand function.

Other RSI Injuries

The hand can have symptoms in the other parts of the hand not innervated by the median nerve.  For instance the medial half of the hand – that is the other half of the fourth finger, the fifth finger, and the palm not powered by the median nerve – are innervated by the ulnar nerve, and the muscles that move those two fingers and help bring the pinky finger against the thumb in opposition can exhibit similar symptoms to carpal tunnel syndrome.  The difference, though, is that the ulnar nerve does not pass through the carpal tunnel, and treatment of carpal tunnel syndrome will not have an effect.  The ulnar nerve can be impinged in the wrist in the ulnar canal, or further up in the elbow at the cubital fossa.

The radial nerve innervates the forearm extensors, as well as the nerve endings in the dorsal (back) of the hand.  The radial nerve also innervates the triceps in the upper arm, so impingement in the shoulder and neck can have an effect on the functioning of the upper arm and elbow as well.

The Brachial Plexus

The brachial plexus is the bundle of nerves that emerges from the sides of the vertebra in the neck upper chest between the vertebra named C4, C5, C6, C7 in the neck, and T1 in the chest.  The nerves pass through the anterior and medial scalene muscles in the neck before passing down between the first rib and the clavicle, and from there down into the arm  The scalene muscles are often tight from holding the head forward and still for long periods of time of sitting at a computer.   This tightness can cause the first rib to pull up against the clavicle, which can impinge the brachial plexus and subclavian artery.  When these nerves and arteries are impinged, they can cause some of the pain symptoms farther down the line of the nerves.  So it’s a good idea to get the entire nerve pathway checked out when there are pain and numbness in the arm.

How can massage help?

Massage can help by creating relaxation in the muscles along the route of the nerves of the arm.  In a study by the Touch Research Institute at the University of Miami School of Medicine, researchers found that massage was able to bring a significant reduction in pain and other symptoms of carpal tunnel syndrome.  Skilled massage can bring about relief from the numbness, pain, and tingling associated with carpal tunnel syndrome and other repetitive stress injuries.

A trained massage therapist can test of various nerve entrapment locations and craft the necessary treatment plan to release the muscle tension, and free the nerve.

I did some psoas release work on this client to help balance out the interplay between erector spinae and iliopsoas. I am going to have to do some work on the muscles that do ankle plantar flexion, as well as glutei minimi and more abdominal work, although I did do a decent amount of abdominal work on this client today before I did the psoas release.

The psoas and abdominal muscles are sometimes antagonists and sometimes synergists, and it’s important to keep them in balance. Having a six-pack can actually be unhealthy for a person. It’s not uncommon for people with really tight abdominal muscles and psoas muscles to be chronically constipated, as tight psoas muscles can impinge upon the lumbar plexus, which controls the intestines. As well, overtight abdominals can restrict breathing, as the ribcage is pulled down and forward, and also can cause the body to waste energy by engaging the erector spinae in having to work harder to keep the body upright to counterbalance the abdominals’ flexion motion of the spine.

As the iliopsoas muscles are rotators of the femur, the glutei minimi can also be very tight, as they are antagonists in rotation as well as synergists in hip flexion. So it’s important to get them to relax as well when doing a release of the psoas muscles.

With good attention to detail, balance can be brought to this important system, and a dramatic reduction in back pain can be introduced. The flexibility of the pelvic region cannot be stressed enough in maintaining a high quality of life as we age, and psoas release techniques, combined with work on the abdominals, glutei minini, and plantar flexors will help keep us pain free.