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.
Welcome Shannon Stone, CMP, to Paul Brown Massage Therapy Pain Relief Center. He's available on Sundays and Mondays here at the Center, so why not 
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{ 6 comments… read them below or add one }
Firstly, I appreciate what you were trying to do for the patient, but it seems the order by which to rule out and include things is missing. Certainly if you are the 1st person to see this client, you will do what you know, how you’ve been trained. When someone c/o symptoms into the arm, I wouldn’t 1st think of soft tissues; at least initially. The 1st thing that needs to be done is to rule out a relationship to the c/s motion segment, which includes joints and discs, etc.. Movements of the c/s and/or positions may influence the symptom c/o’s which will tell you soft tissues are not the 1st focus. A good McKenzie evaluation, along with Upper Limb Tension Tests (IF seen needed) can distinguish the problem. If at that time, there is no influence and/or nothing can be done to change the symptoms, then you can examine the soft tissues. I’m sure you get some results with people, but I’m also sure you’ve wondered why you couldn’t get results at other times. This is why I have a problem if someone goes to a Massage Therapist as their 1st approach. I would prefer evaluating someone and then as either the main or adjunctive treatment, let the MT take over from there.
Firstly, what I did for the client was relieve his pain and get him back to work. So I’m glad that you appreciate that.
This article is not a comprehensive case study listing everything step I took to evaluate the client and treat him. It’s audience is not allied health professionals, but potential clients. This client had been treated by a PT and a DC before coming to see me, each of whom had left him in worse shape than before. The DC left him with a half-dollar sized third degree burn from the electrical stimulation unit. My treatment of the client got him back to work and pain free in three sessions, and he remains pain free and working more than a year later.
I agree that most massage therapists do not have the skills to properly evaluate clients, but that is changing as more and more MTs are seeking more knowledge. I predict that in the next five to ten years there will be a Masters of Somatics, and a Doctorate will be just around the corner. In the meantime, I’ll keep doing what I do, which is help clients eliminate their pain.
The serratus posterior superior has been the Bain of my existence for nearly five years. After injuring it in a waterskiing accident and doing two rounds of physical therapy (several sessions) and getting a shoulder MRI, I had doctors and PTs baffled. Finally I found a massage therapist who has gotten me to a manageable point. Unfortunately, the damage has been done, and I don’t trust that surgery would correct such a specific problem. Thank god I know the root cause of the pain. It’s miserable.
Hi, Karl,
Yes, it’s a difficult problem. I had to eliminate the more superficial pain referral patterns before getting deep into the SPS. I’m glad you have a therapist that is helping. It’s very important to make sure you don’t ever sleep on the affected side, as that can perpetuate the TrPs in the SPS. Also, Biceps Brachii, and rotator cuff muscle trigger points can reactivate SPS trigger points. Hope all goes well for you.
I just found this and have been struggling for a year with a deep pain in my shoulder and chest. The pain is under my shoulder blade and wraps all the way around into my ribs and chest. Being a 35 year old woman I freaked out and had a mammogram to make sure it was not my breast. I was diagnosed with costocondritus even though I keept telling the Dr. it hurt in my shoulder, chest, and outside of my arm. Do you think it could be this muscle causing pain for an entire year? I am scheduled to have an MRI this week. I sleep like crap have not been able to workout like I have in the past and am very depressed about the constant pain. Do you have any suggestions for me?
jen, I couldn’t say for certain, but it might be one of the muscles involved, among others. If you can find a myofascial release therapist in your area, you might be able to get some more specific information and help.
I hope you are able to get some relief.