ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.
This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of Pectoralis Minor Muscle Syndrome. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 226-232 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Pectoralis Minor Muscle Syndrome.
In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.
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EVALUATION OF A PATIENT WITH PECTORALIS MINOR MUSCLE (PMM)
PMM is one of key areas on the upper extremity. The lower part of the brachialis plexus is protected by the pectoralis minor muscle on the anterior shoulder.
Under the pectoralis muscle, all five nerves which innervate the upper extremity are still bundle together. Distally to the pectoralis minor muscle, each peripheral nerve acquires its own unique pathway.
Thus, tension in the PMM may irritate the brachial plexus the same way as anterior scalene muscle does. In such case, the Pectoralis Minor Muscle Syndrome may trigger clinical picture of any abnormality on the upper extremity from the Deltoid Muscle Syndrome to the Carpal Tunnel Syndrome. This is why the practitioner must examine PMM in every patient who exhibits any abnormality in the upper extremity.
There are five commonly used tests the practitioner may apply to evaluate PMM.
1. Questioning
The clinical symptoms of tension in PMM itself include pain and tension on the anterior surface of the shoulder joint and the upper quadrant of the thoracic cage. The pain may radiate to the axilla and to anterior chest on the same side.
However, the clinical picture of Pectoralis Minor Muscle Syndrome (PMMS) can be much more complicated. These are symptoms which can be part of the clinical picture of PMMS: radiation of the pain along the upper extremity, tingling or numbness on the arm, forearm or different parts of the hand, vasculatory abnormalities (cold sweaty hand, edema on the dorsal surface of the hand). All these symptoms are possible signs of the brachial plexus irritation by PMM but the same symptoms can be associated with Anterior Scalene Muscle Syndrome.
Thus before examination of the PMM the practitioner must always examine the anterior scalene muscle to rule out the irritation of the brachial plexus by this muscle located on the higher on the anterior neck. The Anterior Scalene Muscle Syndrome itself may cause the tension in the PMM. In such case, the treatment must target anterior scalene muscle first.
PMM may develop tension if the patient has a habit to sleep with his or her arm above the head. In this position, the PMM elicits pressure on the brachial plexus.
Those clients who train excessively with weight lifting to increase size of the pectoral group may also exhibit clinical picture of the Pectoralis Minor Muscle Syndrome.
2. Sensory Test (ST)
The tension in the different parts of the PMM will irritate a different part of the brachial plexus with the resulting development of a clinical picture down on the arm, forearm and hand.
When the PMM slightly irritates any part of the brachial plexus the patient may not complain about any sensory abnormalities yet, but they can be detected during the ST.
The evaluation of each finger will detect even the earliest stages of sensory deficit. Ask the patient to close eyes and to compare the sensations from both sides while the practitioner simultaneously strokes the similar parts on the affected and unaffected side using the fingernails.
The ST gives you exact information which peripheral nerve is affected in what degree. Thus without even examining the PMM itself you may predict what part of the brachial plexus irritated by it.
3. Motor Test (MT)
MT allows the practitioner to detect the earliest stages of muscle weakness. Of course this test is very general, but it is simple and really helps examine muscle strength.
First, ask the patient if he or she is right or left handed. Stand in front of the patient, cross your forearms and grasp the patients’ right hand with your right hand and his or her left hand with your left hand. Now ask the patient to slowly squeeze your hands with the same force until you tell him or her to stop and maintain the same pressure.
Concentrate on your sensations. You are examining three parameters:
General strength:
First, compare the general muscle strength or how the squeeze feels on the unaffected side as compared to the normal side. Remember that the patients primary hand is always stronger.
Correct grip:
Normally when an individual squeezes one’s hand, he or she applies more pressure using the thumb-index fingers, while the rest of the fingers support the hands compression. Let us consider that the patient has initial stages of the weakness of the thumb and thenar eminence of the hand. In such cases the practitioner will feel more pressure elicited by the 3rd-5th fingers instead of the thumb-index fingers. In another scenario, the weakness of the hypothenar muscles (5th finger eminence) the practitioner will feel as a soft, weak attempt of compression by the 3rd-5th fingers as compared to the unaffected hand. The white arrows indicate areas of muscle weakness during the hand squeeze.
Muscle Resistance to the Isometric Contraction:
The isometric contraction in much more energy demanding compared to the isometric contraction. This is why you will feel that the grip on the affected side may get weaker despite that initial 5 – 10 seconds of hand squeezes that felt the same on both sides.
MT allows the practitioner to evaluate the intensity of the clinical picture because motor abnormalities, muscle weakness, atrophy, trigger points, etc. appear later, after the sensory abnormalities have already formed and exhibited themselves.
4. Trigger Point Test (TPT)
The PMM is located under the pectoralis minor muscle and it requires the special mobilization of the pectoralis major muscle to get to the PMM. The TPT gives information if the tension accumulated in the PMM. The video shows the application of TPT on the pectoralis minor muscle.
The TPT considered positive if the patient reports acute pain under the practitioner’s thumb or pain or any other uncomfortable sensations travel or appear on the arm, forearm or/and hand.
5. Compression Test (CT)
CT gives 100% information if the PMM irritates the brachial plexus. At the beginning the video shows the patient’s position during the application of the CT. Notice that the patient’s palms are turned skyward (supination). The second part of the video shows the application of the CT to examine PMM.
The CT considered positive if the patient reports acute pain under the practitioner’s thumb or pain or any other uncomfortable sensations travel or appear on the arm, forearm or/and hand. Notice the way the practitioner’s thumb applied the pressure during the CT.
MEDICAL MASSAGE PROTOCOL IN CASES OF PECTORALIS MINOR MUSCLE SYNDROME
Duration of the protocol – 30 minutes
Step 1. Work on the upper middle back, the neck and the shoulder on the affected side
a. Effleurage in the direction of drainage
Duration: 1 min
Pressure: below the pain threshold
Start with superficial effleurage and later switch to the deep effleurage. Pay attention to the direction of the strokes.
b. Kneading of the upper portion of the trapezius muscle
Duration: 2 min
Pressure: below the pain threshold
In the video different types of the kneading are shown.
c. Friction along the muscles’ insertions
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Start with the application of cross-fiber friction along the insertion of the lower portion of the trapezius muscle and rhomboideus major muscle into the medial edge of the scapula.
Next, apply friction along the insertion of the tendinous part of the infraspinatus and deltoid muscles into the lower edge of the spine of the scapula.
Finish with the application of friction along the insertion of the upper portion of the trapezius muscle into the upper edge of the spine of the scapula.
The friction should be conducted next to the bone. Don’t slide along the skin. Always apply friction while the finger compresses the skin against the bone.
Step 2. Work along the upper thoracic and cervical spine
a. Relaxation of the paravertebral muscles in the upper back and neck
Duration: 2 min
Pressure: below the pain threshold
Apply the technique of the relaxation of the paravertebral muscles in the middle and upper back. To review the step-by-step application of this technique, click here.
b. Friction on the lateral surface of the spinous processes of the C7-T1 vertebrae
Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Work on the spinous processes of the C7-T1 vertebrae. To review the step-by-step application of this technique, click here
c. Stimulation of the cutaneous branches of the spinal nerves
Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Work on the cutaneous branches of the C7-T1 spinal nerves (origin of the innervation of the pectoralis minor muscle). In the video, the application of superficial friction on the cutaneous branch of the T1 spinal nerve is shown.
Step 3. Work on the pectoral area and on the pectoralis minor muscle through the fibers of the pectoralis major muscle
a. Effleurage in the direction of drainage
Duration: 2 min
Pressure: below the pain threshold
Start with strong effleurage in the direction of drainage from the pectoral area.
Apply superficial and later strong effleurage along the arm. Pay attention to the direction of the strokes.
b. Kneading of the pectoralis major muscle
Duration: 2 min
Pressure: below the pain threshold
Apply bi-manual kneading along the pectoralis major muscle. Be sure to grasp as much muscle tissue as possible in each hand.
If the patient is female, be sure that the breast is covered. If the breast is large, ask the patient to move it to the side to expose the maximum of the pectoralis major muscle.
c. Work along the belly of pectoralis minor muscle
Duration: 2 min
Pressure: below the pain threshold
The practitioner should work on the belly of pectoralis minor muscle through the fibers of the pectoralis major muscle. Thus, apply effleurage and strong friction on the pectoralis major muscle first.
Please notice that the strokes on the pectoralis major muscle are arranged in the direction of the underlying pectoralis minor muscle. The pressure should be strong enough to compress the pectoralis minor muscle against the ribs without activating the pain-analyzing system.
d. Work on the tendinous part of the pectoralis minor muscle
Duration: 2 min
Pressure: below the pain threshold
Start with the application of circular friction in the area of the insertion of the pectoralis minor muscle into the coracoid process of the scapula. Pay attention to the position of the thumb in the video.
Next, apply repetitive compression on the tendon of the pectoralis minor muscle to inhibit the H-reflex and to decrease muscle tension (refer to pp.105-106 of MM, Vol. I).
Remember that the brachialis plexus is just underneath the tendon, so the intensity of the compression should be correlated with the patient’s sensation. Decrease the pressure immediately as soon as the patient complains of any pain under the thumb or along the upper extremity. Also, the compression must be applied during the patient’s prolonged exhalation.
Step 4. Work directly on the pectoralis minor muscle
a. Friction and kneading on the pectoralis minor muscle
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
At the beginning, the video shows the practitioner’s and the patient’s positions for best access to the pectoralis minor muscle. The patient’s arm should be comfortably relaxed on the practitioner’s leg, and the practitioner’s armpit controls the patient’s hand.
Both thumbs are major therapeutic tools because they are working directly on the free edge of the pectoralis minor muscle which is underneath the free edge of the pectoralis major muscle. The skin in the armpit is gentle, so the practitioner should be sure to trim his or her nails short and to use mostly the padded parts of the distal phalanges rather than the actual fingertips. Don’t scratch the skin in the armpit. The rest of the fingers are on the anterior surface of the pectoralis major muscle and they provide counterresistance to the work conducted by the thumbs.
Start with friction across the free edge of the pectoralis minor muscle and later switch to kneading. To render kneading more effective, the practitioner should place his or her thumbs as deep as possible (without activating the pain-analyzing system) to act upon the pectoralis minor muscle which is located underneath the pectoralis major muscle.
b. Passive stretching of the pectoralis minor muscle
Duration: 4-5 stretches (1 min)
Pressure: at the level of the pain threshold (first sensation of discomfort)
Place the patient on the edge of the table, grasp his or her arm above the elbow joint and place the other hand on the pectoral area. Ask the patient to inhale deeply and then to slowly exhale. Pull both hands apart, stretching the shoulder joint and pectoralis minor muscle during the patient’s long exhalation. The white arrow shows the direction of the passive stretch.
Cutaneous Reflex Zones and Connective Tissue Zones
Cutaneous Reflex Zones and Connective Tissue Zones are relevant if they are located on the upper extremity as a secondary reaction to the irritation of the brachial plexus by the pectoralis minor muscle. Their location depends upon which part of the brachial plexus is irritated by the muscle. Use Glezer/Dalicho zones as a guide (see Fig. 53, MM, Volume I).
Reflex Zones in the Skeletal Muscles
Add this treatment at the end of Step 4 of the presented protocol
a. Trigger Point Therapy
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Considering the complex anatomy of the pectoralis minor muscle, the practitioner should adopt a special approach to its trigger point. In the video, pay attention to the position of, and the direction of pressure applied by, the thumb. Concentrate on the sensation under the thumb which is placed directly under the free edge of the pectoralis major muscle. With slow application of pressure, the practitioner will be able to feel the smaller and thinner lateral edge of the pectoralis minor muscle, which is directly on the ribs and under the lateral edge of the pectoralis major muscle. All tissue above the thumb in the video corresponds to the free edge of the pectoralis major muscle. To review the applicable scientifically based trigger point therapy protocol, click here.
b. Postisometric Muscular Relaxation
Duration: 4 min
Pressure: below the pain threshold
To isolate the pectoralis minor muscle for PIR, the patient should push his or her arm down and forward simultaneously. The isometric contraction against resistance is conducted on two levels, and it is alternated by 3 to 4 passive stretches during the patient’s prolonged exhalation. The white arrows show the direction of contraction against the resistance provided by the practitioner.
Full Protocol: