This is Brent of the Brookbush
Institute, and in this video we're bringing
you another manual technique. Now if
you're watching this video I'm assuming
you're watching it for educational
purposes, and that you are a licensed
manual therapist following the laws
regarding scope of practice in your
state or region. That means athletic
trainers, chiropractors, physical
therapists, osteopaths, licensed massage
therapists, you are likely in the clear
to do these techniques, personal trainers
this probably does not fall within your
scope of practice; although you might be
able to use the palpation portion of
this video to aid in learning your
functional anatomy, in an educational
setting supervised by a licensed manual
therapist. Now before we place our hands
on a patient or client it is important
that we assess and have a good rationale
for doing so, and of course if we're
going to assess then we should be
reassessing to ensure that the manual
technique we're using is effective, and
we have a good rationale for continuing
to use that technique. In this video
we're going to go over static manual
release of the rhomboids. I'm going to
have my friend Melissa step out and help
me demonstrate. Now this technique uses
the same protocol we've used for all of
our static manual release techniques,
that basically comes down to palpate and
compress, although we are going to get a
little bit more detailed, talk about how
to differentiate the rhomboids from the
other tissues in the area. We're going to
talk about where our common trigger
points are, we're going to talk about
what other tissues in the area maybe
are contraindicated to press on, and then
of course the last thing we're going to
talk about is patient and client
position and your position, so that you
have great technique.
Now the rhomboids are deceptively
difficult to get a good release on. iIt's
a fairly thin muscle, we don't have those
big thick fibrous bands to find, that gives
us really good indication of like a
fiber direction; and there are a couple
of other muscles in the area, not to
mention the rib cage right underneath it.
So let's talk about how to differentiate
this tissue. The thing to start with
would be your origins and insertions to
set up some borders for the area that
you should be in. The origin of your
rhomboids major and minor goes from C7
to T5, and then the insertion is the
vertebral border of your scapula which
is fairly easy to palpate there. So if
you find these things
roughly C7 to T5 to the vertebral border,
and you draw a little box around that
you get this little twisted square, also
known as a rhomboid, which is where the
rhomboid muscle gets its name from.
We know that this is the area we
should be palpating in, so what other
tissues are there that maybe we need to
differentiate? Well, I happen to know that
our traps lie on top of our rhomboids, so
our lower trap and middle traps
specifically, we need to kind of figure
out how are we going to differentiate
between lower trap and rhomboid. Well
being that my rhomboid goes in this
direction we would expect more of a
horizontal fiber direction. My lower trap
goes from the spine of the scapula, the
medial portion of the spine of my
scapula, all the way down to T12. So we
get this somewhat oblique but mostly
vertical fiber direction, and what the
lower traps actually feel like is a
somewhat triangular shaped vertical
column of muscle, being that those fibers
are vertical it makes it very easy to
differentiate that from what would be
horizontal fibers of the rhomboids. Now
the middle traps do have that horizontal
fiber direction, but if we follow them
they don't go into the vertebral border
of the scapula they continue on to the
spine of the scapula, not to mention the
middle traps are much much thicker than
the rhomboids. So after you've done this
a few times you've learned how to
identify the rhomboids, you know how to
identify the mid traps, you're going to
know when you're on the trapezius muscle
in general just because it's a much much
thicker muscle. Now the only other muscle
that's in that area is the serratus
posterior superior which is deep to the
rhomboids, very thin, not generally
something we think about palpating,
something we think about having trigger
points. I would imagine if we were trying
to go after it, it would have something
to do with CT junction dysfunction, maybe
breathing dysfunction, maybe some
sort of assessed dysfunction of the upper
ribs. If we're trying to palpate the
rhomboids, my guess is we had more of the
thoracic or scapular dyskinesis
that we're worried about. I think it's
actually fairly uncommon for us to go
after the rhomboids, when the serratus
posterior superior was involved, or vice
versa.
I think that muscle for the most part is
not something that we're going to have
to worry about, and when we talk about
step 2 - where are the common trigger points,
we're going to find out that our hands
are actually going to be even further
from the serratus posterior superior. So
the trigger points here, that's getting
into step 2, are all along the vertebral
border of the rhomboids. This is a really
important fact because this is what's
going to save us when we try to locate
these hypertonic fascicles within the
rhomboids, because if you try to
feel here, like let's say you just start
trying to feel in that rhomboid area for
horizontal fibers, I don't think you're
going to find much. There's like there's
not these differentiated fascicles in
here and unfortunately we have the
ribcage which has these little bumps in
it, which make it a little hard to figure
out whether you're just feeling bumps on
the ribcage, or you're actually feeling
some fascicles on the rhomboid. You can
even end up just feeling this flat mush
over the ribcage until you get down into
the vertebral border here, and at the
vertebral border you can feel a little
bit of thickness as the rhomboid turns
into these tendinous fibers
that invest into that vertebral border.
In fact we're going to make this even
easier for ourselves, we're going to go
ahead and ask Melissa to put her hands
up over her head. If she didn't have a
face cut out in this table we could
actually have her put her hands
underneath her forehead which sometimes
it's just more comfortable, now I've
lengthened out these rhomboid fibers
even further. That's going to add a
little tension, maybe make it easier for
me to feel the horizontally oriented
fibers. It's also going to help me with
that finger on a marble game right, we
don't want to play that, we don't want to
play that game where we keep trying to
hit trigger points but they keep sliding
out from underneath our fingers. We can
use
this increase in length, increase in
tension on the rhomboids to help
stabilize that trigger point. I think
once you get somebody in this position
and you start strumming perpendicular to
those fibers right up against the
vertebral border, now you start feeling
some fascicles. But it's really not until
we get into this position and feel very
specific to about where these trigger
points are along the vertebral border
that we can feel anything, and I want you
guys to experiment with this, experiment
with hand down and then hand up and I
think you'll see what I'm talking about.
Now before we take this to the actual
technique and getting a good release
here, is there anything contraindicated,
is there anything that I shouldn't put
pressure on, is there anything that's
sensitive in this area -the answer is no
not really. You always run the risk of, or
the chance of over stretching like a
sensory nerve or something, like
something that gives us some
sensation in the skin and that would
give us some sort of like sharp twinge
of pain, like it's that burning searing
pain I know we've all felt when somebody
like stretches our skin the wrong way
and you like it that little that little
zap, but even that's fairly uncommon in
this area. I don't think it's something
that you're going to have to worry about.
So this is probably the best position
for the patient, before I go through this
technique also notice that I am working
on the rhomboid that's farthest from me,
and they're the reason for that has to
do with how we're going to pin the
tissues. If I were to try to do the
rhomboid closest to me I end up kind of
like this trying to push down towards my
thigh, which this type of force just
isn't a real easy force to apply. I'd
much rather be pushing across my body be
able to walk out my arms and just lean.
So this is the patient position I know
it was a long explanation to try to get
to where we're going to be, and the
technique isn't that difficult. All I'm
going to do is take a thumb, strum
perpendicular to what would be the
direction of the fibers at this point,
which is going to be parallel to the
vertebral border of my scapula. Once I
find something that feels like an
increase in tissue density, I'm then
going to go a little bit along the
length of the fiber and see if I can
identify a nodule of tightness. Once
again those nodules are going to be
pretty close to the vertebral border. I
don't know if you guys can see the X's
where I actually marked off the trigger
point parts, but when we get into the
close-up recap I know you will.
Once I've not only identified the tight
fascicles but I've done my palpation
along the length of those fascicles to
find the tight nodule, now what I'm going
to try to do to pin it -is actually push
into the vertebral border of the scapula.
I find that that is easiest and what
I'll usually do is since I was just
strumming this way, I'll use my thumb to
kind of block this way and then I'll put
my thumb right in between my thenar eminence
there, just like so walk out my arms, and
press in. How does that feel? Okay a
little tender I'm sure, I'm sure this is
just a little bit of tenderness here, and
of course after I get one release let's
say after 30 seconds to two minutes of
holding, that's not a tremendous amount
of pressure. I just have to press up to
the point of the tissue giving me some
resistance back, I don't have to like try
to push my thumb all the way down
underneath her scapula per se. I just
wait for a release then I can do the
same thing, perpendicular strums try to
feel for an increase in tissue density,
increase in tissue tightness, right about
there I'm feeling some tight fascicles,
and then I can move along the length of
the fascicles
to find a tight nodule, and then again
I'm going to make sure I can get some
pressure on that nodule and I find that
going in kind of this direction rather
than like let's say straight down, if
you did go straight down it just hurts a
little bit, you just end up pushing into
the rib cage. So if I go this way a
little bit -this direction, I can hold,
get a good release,
and on my bottom hand as soon as this
hand puts pressure becomes the dummy
thumb, I'm not using my hand strength I'm
just using my bodyweight to get a good
release. Now the only tricky point is
this rhomboid minor trigger point in
this position doesn't quite work, because
unfortunately when we
upwardly rotated the scapula
the superior angle ends up
retracting a little bit. So we need to
lengthen out these rhomboid minor
trigger points. I think the easiest way
to do that is to actually have Melissa
put her hands underneath her ASIS,
alright so I know you guys have seen
this position before and then I might
even try to protract her a little bit
further, abduct her scapula as far as I
possibly can and then I'm just going to
go ahead and palpate that superior
portion of her rhomboids right up
against the superior third of the
vertebral border of her scapula.
Doing my perpendicular strokes, now I'm
doing my along the fiber to find the
nodule, found it -make sure I can apply
some pressure right without losing it,
it's not trying to shoot out from under
my finger. I'm going to use my hand
here putting my thumb right in the
middle of my palm and just leaning, and
that's it. This is a real easy technique
for me, for Melissa it might not
feel that easy up front, we're going to
get a little bit of tenderness at first,
but then it's going to let go and of
course for example if she had something
like downwardly rotated scapula as part
of like some upper-body dysfunction and
shoulder impingement syndrome, hopefully
this would give her better outcomes
after we finished this technique. Stay
tuned for the close-up recap. The
close-up recap, step one we have to be
able to palpate, differentiate this
muscle from the other muscles in the
area. I already have Melissa's arms up so
we pulled the vertebral border of the
scapula away from the other tissues we
would be concerned about confusing
ourselves with, being like the lower trap
column over here, you know we have the
mid traps that they're way up here,
and then our serratus posterior superior
would be somewhere in here. The vertebral
border of the scapula is, I'm trying to
palpate this for you guys and kind of
show you, you see that crease I just
created in our skin, that crease is the
vertebral border of our scapula, and
you'll notice that these are the common
trigger point sites for the rhomboids
which are all along that vertebral
border. So well now all we have to do is
do our strokes perpendicular to the
fiber direction, all right so we're going
to come through here like this, and not
surprisingly as I do these perpendicular
strokes, I'm finding that I have these
dense fascicles, this increase in tissue
density, this tightness occurring right
around these X's, especially this X on
her, maybe a little bit here too. So once
I find that increase in tissue density
then I'm going to search it this way
right, make sure that I'm right on the
tightest nodule and then I'm going to
try to make sure I have that trigger
point anchored, so that it's not moving
out from under my thumb, and then once I
have it nice and anchored I'm going to
go ahead and put my palm over the top of
that thumb, and I can do this with each
of the dense fascicles, or each of the
tight nodules in the rhomboids here, hold
for 30 seconds to two minutes. The only
one that's a little different is the
rhomboid minor, i'm going to have
Melissa move her arm down so she has
her hands underneath her ASIS, and then
I'm going to make sure she's abducted,
her scapula is abducted as far as
possible, she's protracted as far as
possible,
and then I'll look at the upper rhomboid
fibers, and once again doing my
perpendicular strokes once I find the
tight fascicles,
going along the length of the fiber and
then anchoring that dense nodule, and
putting my palm over the top of it;
to apply that static pressure for 30
seconds to two minutes. So there you have
it, knowing your functional anatomy will
definitely help your manual technique.
It'll help you differentiate structure
so that you can place your hands where
they need to be, as well as make you
aware of these sensitive structures
around the tissue that you're trying to
target. Things like nerves and lymph
nodes, and arteries. Make sure that if
you're going to place your hands on a
patient that you have done an assessment
and have a good rationale for placing
your hands on that patient, and if you're
going to assess, make sure you reassess
to ensure that your technique was
effective and you have a good rationale
for using that technique again. Now with
manual therapy, one-on-one live education
is incredibly important. Please be
looking for opportunities like workshops
and mentorships, and maybe even classes
at your local university that can get
you some one-on-one individual
instruction, or at least some live
classroom instruction so you've had a
chance to be critiqued and mentored by
somebody senior to you with some
experience in manual therapy techniques,
and before you bring this stuff back to
your rehab, fitness, or performance
setting, please practice on colleagues.
There is no substitute for practice and
it is going to take a while to get
accustomed to some of the techniques
that we show in these manual technique
videos. Don't expect to learn them in two
or three or even five minutes. You want
to have hours of experience under your
belt working on various different body
sizes and shapes. So that when you do get
that first paying client, first paying
customer, then you're really trying to
make a good positive impact, really
trying to promote better outcomes, you
feel comfortable with that technique. I
look forward to hearing about your
outcomes and hearing your questions in
the comments section of this video. I'll
talk with you soon.
you
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