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Massage treatment for the anterior shoulder

This is an excerpt from Anatomy and Physiology of Sports Massage, The by Portia B. Resnick.

Treatment for the anterior shoulder starts with the patient positioned supine, but it also uses the side-lying position for the clinician to access the muscles. For patients with breast tissue, the techniques described can be used with the patient wearing a tank top or sports bra (depending on their comfort level). This clothing will allow for enough access to the clavicle and superior part of the sternum without being invasive. During the treatment, breast tissue will fall away, either to the sides when the patient is supine or toward the table when they are in a side-lying position, assuming it is natural tissue; augmented breast tissue will remain in place. As the clinician, it is important for you to respect the clothing as a boundary by not working underneath articles of clothing or moving clothing out of the way without the patient's permission.This respect is true for all patients, regardless of sex or gender identity, should they decide to wear a shirt. It is possible to achieve effective treatment while keeping the patient comfortable and respected. Techniques shown include those with a patient in a sports bra for ideas on how to work around the clothing.

With the patient supine, treatment begins with warming the pectoralis major. Loose fist compressions can be used here. If you choose to use the palm of your hand, ensure your fingers are not engaging with or otherwise touching breast tissue or the nipple region. You can position yourself at the top of the table (near the patient's head) or along the side of the table for warming. Remember to use a staggered stance or lunge position. Moving to different positions around the table can help maintain good mechanics as you use the warm-up to examine the tissue for any areas of concern.

Because of the properties of tensegrity, effective treatment of the pectoralis major does not have to involve the entire muscle belly. Treatment can focus on the attachments at the clavicle, upper sternum, and axillary region, allowing the treatment to remain noninvasive. Following the warm-up, fingertip glides can be done just off the clavicle. Position yourself at the top of the table, maintaining a lunge stance. Use your fingertips to traction the pectoralis major from its attachment at the clavicle, starting medially at the sternum, and work a small area until it softens before you move laterally to the next section. Keeping the work to the area just distal to the clavicle will release the clavipectoral fascia without being invasive. The same treatment can be applied to the sternum: Position yourself either at the top of or on the opposite side of the table to traction the tissue off the sternum using your fingertips, working along the areas available on the patient (who is wearing a tank top or sports bra). Depending on the amount of area available, there may only be the opportunity for two or three sets of glides off the sternum.

After the origin of the muscle has been treated, treatment can move to the insertion and the muscle belly along the anterior axilla (figure 6.14a). Position yourself on the side of the table, and use a pincer grip of one or two hands to grasp the muscle in the anterior axillary region, between the humerus and the ribs. Make sure to grasp the entire muscle between your fingers and thumb. From here, use gentle traction to move the muscle linearly from the ribs and from the humerus (avoid lifting the muscle; keep it in the same plane moving toward the humerus or toward the ribs). To add movement to the treatment, shorten the muscle by passively putting the arm into horizontal adduction. From this starting point, the arm can be brought into a variety of positions—flexion, horizontal abduction, abduction, or external rotation—either passively or actively (figure 6.14b).

What makes the pectoralis major difficult to learn as an anatomy student is the number of actions to which it contributes. Yet for this treatment, you, the clinician, cannot go wrong with lengthening the muscle using so many different positions. However, use caution in this position to grasp only muscle, which can be identified through muscle testing. To test a muscle, you want to resist the action of the muscle. With manual therapy treatment, you can use the contraction to confirm that you are grabbing the correct muscle, because you will feel it contract in your hands.

Once the pectoralis major has been treated, the deeper muscles of the pectoralis minor and the serratus anterior can be addressed. For the easiest access to these muscles and the best use of body mechanics, place the patient in a side-lying position (figure 6.15). The patient's legs can be positioned comfortably as long as they can keep their shoulders pointed toward the ceiling, maintaining the position directly on their side. The patient's head can be supported with a pillow. Both arms should be at 90 degrees of shoulder flexion and 90 degrees of elbow flexion, with the bottom hand supporting the top arm. This position opens more space in the axilla to work the scapular protractors, pectoralis minor, and serratus anterior. For the pectoralis minor treatment, stand behind the patient to access the anterior aspect of the ribs with your fingertips. Treatment for the pectoralis minor starts with moving your fingers along the ribs in the direction of the coracoid process until you run into the edge of the pectoralis minor (I refer to it as "hitting a speed bump"). Once you reach the muscle, gently move your fingertips along the muscle with deviation of the wrist. The movement of the fingertips is subtle but effective. Make sure to keep checking in with the patient about how they are feeling with this treatment. Keep in mind that the subtle movement with the fingers will affect the myofascial system overall, especially when combined with stretching and strengthening.

The same side-lying position is used to treat the serratus anterior (figure 6.16). Switch your position on the side of the table so you now are facing the patient. From this position, the fingertips of one hand will rest on the ribs, with glides performed on the ribs headed toward the medial border of the scapula. To enhance the treatment, have the patient put the hand of the arm you are working (the top hand) on your shoulder. As they reach forward, it will open more space between the ribs and scapula, exposing more muscle for you to address. To gain even more space, you can reach the free hand to the medial border of the scapula, mobilizing the scapula to create more space to address. Make sure to slowly disengage from the scapula prior to moving your hands off the ribs.

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