Upper Torso Muscles: Trigger Points and Massage Considerations

1. Chapter 6 Upper Torso

2. Chapter Objectives • Overview of Upper Torso Region • Posterior shoulder and upper back muscles • Anterior shoulder and chest muscles

3. Overview • Muscle overview • Trigger points (TP) and referral zones • Trigger point activation • Stressors and perpetuating factors • Precautions and massage therapy (MT) considerations

4. Trapezius: The Coat Hanger Muscle • Diamond-shaped posterior back muscle Attachment sites for the trapezius

5. Trapezius Trigger Points Trapezius TPs: • Commonly found in 7 areas Referral Zones: • TP1- posterolateral neck pain with headache • TP2- neck pain with no headache • TP3-4- sensation in suprascapular, acromial areas

6. Trapezius Trigger Points cont’d • TP5-burning interscapualar sensation • TP6-sensation across the acromion • TP7-associated with goose bumps on upper arm

7. Trapezius Trigger Point Map Trigger points and referral zones for the trapezius

8. Trapezius Trigger Point Map cont’d Trigger points and referral zones for the trapezius

9. Stressors and Perpetuating Factors Trapezius TP Activation: • Sudden trauma, body asymmetry, postural overload Stressors and Perpetuating Factors: • Habitual elevation of shoulders • Protracted head postures • Kyphotic and scoliotic conditions

10. Precautions and MT Considerations Trapezius Precautions • Avoid the brachial plexus • Lower trapezius usually has adhesions MT Considerations • Rotate head toward the working side • Use a pincer compression

11. Splenii Muscles: Ache inside the Skull • Splenii muscles: Splenius capitis and splenius cervicis • Bilaterally muscles form a ‘V’ Attachment sites for the splenius capitis Attachment sites for the splenius cervicis

12. Splenii Trigger Points Splenii TPs and Referral Zones: • Capitis: refers to top of head (creates headaches) • Cervicis: refer head, eye and occiput

13. Splenii Trigger Point Map Attachment sites and trigger points with referral zones for the splenius cervicis and splenius capitis

14. Stressors and Perpetuating Factors Splenii TP Activation: • Postural stress Stressors and Perpetuating Factors: • Excessive neck hyperextension • Cold air blowing on neck • Use of dominant eye only while reading

15. Precautions and MT Considerations Splenii Precautions: • Be careful with passive stretching MT Considerations: • Friction origin sites on each spinous process • Use pincer grip when client is prone

16. Anatomical Region of the Shoulder

17. Supraspinatus: Subdeltoid Bursitis • Rotator cuff muscle • Major player in rotator cuff conditions Attachment sites for the supraspinatus

18. Supraspinatus Trigger Points Supraspinatus TPs: • Found in muscle belly and tendinous insertion Referral Zones: • Refer to mid deltoid • Pain when combing hair, brushing teeth, shaving

19. Supraspinatus Trigger Point Map Trigger points and referral zones for the supraspinatus

20. Stressors and Perpetuating Factors Supraspinatus TP Activation • Prolonged elevation of arms Stressors and Perpetuating Factors • Lifting or carrying heavy objects i.e. briefcase • Walking a dog that pulls hard on the leash

21. Precautions and MT Considerations Supraspinatus Precautions • Avoid using too much pressure • Mimics sub-deltoid bursitis • Common area for tendinitis MT Considerations • Use pressure bar in back and forth motion only

22. Infraspinatus: Shoulder Joint Pain Muscle • Rotator cuff muscle • Produces pain deep within shoulder joint Attachment sites for the infraspinatus

23. Infraspinatus Trigger Point Infraspinatus TPs: • Found in the belly of the muscle • Causes intense anterior shoulder pain Referral Zones • Refer pain lateral forearm, radial aspect of hand, fingers • Refer pain to posterior neck

24. Infraspinatus Trigger Point Map Trigger points and referral zones for the infraspinatus

25. Stressors and Perpetuating Factors Infraspinatus TP Activation • Acute overload • Lifting back to reach heavy objects Stressors and Perpetuating Factors • Sleeping on affected and unaffected side • Mis-hitting a ball during racquet sports

26. Precautions and MT Considerations Infraspinatus Precautions • Muscle is prone to TP formation • Work gently; muscle is extremely tender MT Considerations • Examine infraspinatus insertion in all rotator cuff injuries • Examine in all shoulder, arm and hand syndromes

27. Teres Minor: The Silver Dollar Pain • Rotator cuff muscle • Teres Minor a.k.a the little brother to infraspinatus Attachment sites for the teres minor

28. Teres Minor Trigger Points Teres Minor TPs: • TP in the muscle’s belly near musculotendinous junction • Pain the size of silver dollar Referral Zones • Refer pain to posterior deltoid area • May result in numbing and tingling in 4th and 5th finger

29. Teres Minor Trigger Point Map Trigger points and referral zones for the teres minor

30. Stressors and Perpetuating Factors Teres minor TP Activation • Teres minor is not a single muscle syndrome • TPs activated with infraspinatus TPs Stressors and Perpetuating Factors • Holding steering wheel too tight during accident • Playing volleyball

31. Precautions and MT Considerations Teres Minor Precautions • Work gently; muscle is extremely tender MT Considerations • Work teres minor and infraspinatus together • Infraspinatus TP referrals present as pain in front of shoulder • Teres minor TP referrals present as pain in back of shoulder

32. Latissimus Dorsi: Midthoracic Backache Attachment sites for the latissimus dorsi

33. Latissimus Dorsi Trigger Points Latissimus Dorsi TPs: • Often confused with intrathoracic disease pain • Usually found in upper and lower muscle bellies Referral Zones: • Refer as mid-thoracic back pain • Constant aching at the inferior angle of scapula

34. Latissimus Dorsi Trigger Point Map Trigger points and referral zones for the latissimus dorsi

35. Stressors and Perpetuating Factors Latissimus Dorsi TP Activation • When muscle is stretched by reaching forward and up • Wearing a tight bra Stressors and Perpetuating Factors • Hanging from a rope • Throwing a baseball

36. Precautions and MT Considerations Latissimus Dorsi Precautions • Firmly grasp the entire bundle lateral to armpit • Creates discomfort if just the bundle’s edge is pressed MT Considerations • Pincer compression is very effective • Can also use a side-lying position

37. Teres Major: Latissimus Dorsi’s Twin • Teres major, latissimus dorsi, long head of triceps brachii work together as a myotatic unit Attachment sites for the teres major

38. Teres major Trigger Points Teres major TPs • Found mid-muscle belly to area of origin • Also found in musculotendinous junction • Usually produces no tenderness Referral Zones • Refer to posterior deltoid, long head of triceps brachii

39. Teres major Trigger Point Map Trigger Point and referral zones for the teres major

40. Stressors and Perpetuating Factors Teres major TP Activation • Driving a vehicle with no power steering • Serving in a tennis match Stressors and Perpetuating Factors • Using a butterfly stroke to swim

41. Precautions and MT Considerations Teres Major Precautions • When compressing the latissimus dorsi and teres major together they can be extremely tender MT Considerations • Pincer compression is very effective • Isolate muscle from the latissimus dorsi

42. Serratus Anterior: Stitch in Side Muscle Serratus Anterior TPs • Mild TPs; create a stitch in side sensation • Cause shortness of breath or inability to take deep breaths Referral Zones • Refer to chest • May contribute to heart attack pain

43. Serratus Anterior Trigger Point Map Attachment sites and trigger points with referral zones for the serratus anterior

44. Stressors and Perpetuating Factors Serratus Anterior TP Activation • Excessive exercise • Severe cough Stressors and Perpetuating Factors • Lifting heavy weights • Irritation from asthma, smoking, pollution

45. Precautions and MT Considerations Serratus Anterior Precautions • Burning sensation occurs when muscle is worked on MT Considerations • Weak muscle indicated in winged scapula • Most of muscle is obstructed by pectoralis major

46. Rhomboids: Round Shoulder Muscles • Rhomboids are antagonistic to the pectoralis muscles • Pectoralis muscles are much stronger • This imbalance overstretches the rhomboids • Result in a chronic round shoulder posture Attachment sites for the rhomboids major and minor

47. Rhomboids Trigger Points Rhomboids TPs: • TPs are rare in rhomboids • TPs have similar pattern to levator scapula (without neck involvement) Referral Zones: • Refer to medial scapula and between shoulders

48. Rhomboids Trigger Point Map Trigger points and referral zones for the rhomboids major and minor

49. Stressors and Perpetuating Factors Rhomboids TP Activation • Leaning forward and working with rounded shoulders • Side sleeping Stressors and Perpetuating Factors • Scoliosis in upper thoracic area • Sewing or writing in long hand

50. Precautions and MT Considerations Rhomboids Precautions • Muscles are thin; do not use too much pressure MT Considerations • Examine rhomboids when fibromyaglia is diagnosed • TPs sensation often misdiagnosed as scapulocostal syndrome