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Back Pain from Gluteus Medius Trigger Points

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By: David Kent, LMT, NCTMB

Each week, I treat several clients who complain of “low back pain.” For many patients, however, the primary cause of pain is not the lower back but the gluteus medius muscle. No matter what kind of massage practice you have, a great deal of your success will depend on how quickly you are able to determine the origin of a patient’s complaint and your ability to produce measurable results. This article will review some ways to identify when the gluteus medius muscle is responsible for causing pain.

Anatomy:

The gluteus medius muscle lies superficial to the gluteus minimus muscle and deep to the gluteus maximus muscle. Proximally, it attaches along the external surface of the ilium between the anterior and posterior gluteal lines. Distally, it attaches to the lateral surface of the greater trochanter of the femur (See Photo 1).

The gluteus medius muscle “abducts the hip joint; the anterior fibers medially rotate and may assist in flexion of the hip joint; [and] the posterior fibers laterally rotate and may assist in extension.”1 It also helps to keep the pelvis level when the opposite leg is raised during activities such as walking, running, or standing on one leg.

Intake and History:

The first step to designing and implementing an effective treatment plan is to understand the client’s medical history and current circumstances. Utilizing health history intake forms will help you gather the appropriate information; they will also reveal important factors that could be relevant to a patient’s condition.

Using pain scales to document a client’s pain patterns are beneficial, as well. Ask the client to color the diagram form illustrating where on the body he/she experiences pain. Then ask the client to add modifiers that adequately describe the pain, followed by a number from 1-10 to rate its intensity (See Photo 2 ). This diagram provides a helpful visual tool that you can reference during the session. You will also see how pain patterns often match common trigger point patterns, which are discussed in more detail below.

Ask the client if any of his/her daily activities are affected by the pain. If the answer is yes, ask the client which muscles hurt, what movements aggravate the pain, and what he/she believes caused the pain. Ask if the client has recently started or modified an exercise program. Answers like walking, running, tennis, aerobics and other types of activities may indicate gluteus medius involvement. Has the client had any falls or sustained any hip injuries? What is the client’s occupation? Does the client place a wallet or tools in a back pocket? All of these questions will help you narrow down the origin of pain. (Read “Questions with Direction,”)

Gait & Postural Analysis:

Observe the client as he/she walks. A painful or “weak gluteus medius muscle forces the client to lurch toward the involved side to place the center of gravity over the hip; such movement is called an abduction, or gluteus medius lurch.”2

Show your client the relationship between posture and pain, and describe how you can help. Just like chiropractors advertise free “spinal exams” to attract new patients, you could provide free postural analysis to attract new clients. Market the postural analysis as a value that you include during the initial visit; then include a second postural analysis taken upon completing a series of treatments. This is a great way to sell packages, and it also demonstrates postural progress. (Read “Getting Comfortable with Postural Analysis,”) When conducting a postural analysis, look for signs of gluteus medius muscle involvement. Shortness of the gluteus medius muscle “may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity.”3

Trigger Points

“Myofascial trigger points (TrPs) in the gluteus medius are a commonly overlooked source of low back pain.”4 There are three trigger points frequently identified in the gluteus medius muscle. TrP1 (See Photo 1) is located lateral and superior to the posterior superior iliac spine (PSIS) just below the iliac crest. TrP1 refers pain and tenderness over the sacrum, above the iliac crest into the lumbar region, and throughout the gluteal region on the same side of the body as the trigger point.

TrP2 (See Photo 1) is positioned midway between the anterior superior iliac spine (ASIS) and the PSIS just below the iliac crest. “Pain referred from TrP2 is projected more laterally and to the midgluteal region; [and] may extend into the upper thigh posteriorly and laterally.”5

TrP3 (See Photo 1) is rarely present and can be located just posterior to the ASIS and just below the iliac crest. Referred pain is primarily produced over the sacrum bilaterally.

Educate your clients about trigger points. Use wall charts or flip charts to demonstrate their location on the body. Using charts and other aids will not only help the client, but it will also build your credibility with the client. This is also an excellent time to explain how the muscle affects posture.

Pain is a symptom. As massage therapists, our job is to address the cause of the pain and work to prevent its return. Educate your clients. Discuss proper ergonomics, stretching and strengthening. Identifying the gluteus medius as a source of back pain is easy once you have the knowledge.

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1, 3 Kendell FP, McCreary, et al. Muscle Testing and Function with Posture and Pain, 5th ed.  Lippincott, Williams and Wilkins: 2005.

2 Hoppenfeld S. Physical Examination of the Spine & Extremities. Appleton & Lange: 1976

4 Simons DG, Travell JG. “Myofascial Origins of Low Back Pain, 3: Pelvic and Lower Extremity Muscles,” Postgrad Med 73:99-108, 1983.

5 Simons DG, Travell JG. Myofascial Pain and Dysfunction, The Trigger Point Manual: The Lower Extremities, 2. Lippincott, Williams and Wilkins: 1992

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David Kent live interview on MassageTherapy Radio.com

Click here to download the handout, which includes posture and trigger point references.

Join David Kent for this live entertaining interview Thursday, April 23rd at 9PM EST on www.MassageTherapyRadio.com, where he will discuss tips and techniques for working with clients who suffer from shoulder pain. Debilitating pain and limited range-of-movement of the shoulder are often connected with neck pain, headaches and conditions like rotator cuff injures, thoracic outlet syndrome, tennis or golfers elbow and carpel tunnel syndrome. Knowing how to assess and develop an effective treatment plan is key. The shoulder plays a major roll during most activities so understanding the form and function of the shoulder is critical to providing quality treatment.

David is avalable for your questions during this live interview via streaming audio online or over the phone Thursday, April 23, 30, May 28 at 9PM ET. Go to www.MassageTherapyRadio.com and sign up today for notification on the broadcasts and to view the scheduled training call information.

This broadcast is entitled “Shouldering the Pain: Tips and Techniques”. David will be teaching this class at the 2009 FSMTA Convention.

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Practice Building For Massage Therapists: Consistency Breeds Success

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By: David Kent, LMT, NCTMB

The current economic slowdown is stressful to everyone. Business is slow, treatments are down, and both are affecting the bottom line. During these challenging times, however, there are things you can do to consistently to breed your success. Instead of getting frustrated and discouraged, use this extra downtime to your advantage. Following the tips in this article will help you achieve ongoing success in your practice, whether you are in a clinical, spa or outcall setting.

Getting Out There

Marketing professionals know how important repetition is to “imprint” a product in the mind of the consumer. This same concept applies to massage therapy and your ability to imprint your services on potential referral sources. Each week, I visit specific locations that have become my best referral sources. If you aren’t getting the number of referrals you would like, it’s time to get out there and introduce yourself. Here are just a few places to start:
o      Medical and chiropractic clinics

o      Acupuncturists and homeopaths

o      Hotels and salons

o      Personal training centers and gyms

o      Tennis and golf courses

o      Yoga studios

o      Health food stores

o      Gymnastic and dance studios

o      Business centers

Talk it Up

You took the time to get out there; now you need to make it count! Your goal is to attract business by educating your referral sources about the importance of massage therapy.  Advertisers use test markets and focus groups to refine their messages. But before you begin pitching your services, you will need to practice and refine your “commercial” with your “test market,” which is located in the next community over.

That’s right. You need to practice your selling skills before you officially launch your marketing campaign with your “real” audience in your own community. Practicing gives you the opportunity to build your confidence while simultaneously getting comfortable with introducing yourself to strangers, telling them what you do, and answering commonly asked questions. But don’t let yourself off the hook with your practice sessions. Make sure that you are as professional and courteous with your test audience as you plan to be with your “real” audience. The following tips will help you get comfortable in this newfound role as salesperson.
o      Introduce yourself. Let people know who you are, what you do, and where you practice.

o      Talk to everyone you come into contact with—everyone! From waiters and waitresses to the FedEx delivery person to your mechanic, dentist, or insurance agent.

o      Never assume that people know what massage is or how it can help them.

o      Following each encounter, reevaluate your performance and ask yourself the following questions: What did I learn?  What will I do different next time? What other strategies could I try in the future? Answering these questions will help you do a better job each time.

o      Finally, ask your clients and referral sources what they think is important for you to tell others when marketing your services. You’ll be surprised at how helpful their feedback will be.

Show and Tell

Explaining the basics helps others understand how massage therapy can help with headaches, sciatica, neck and back pain, and more. Additionally, using “props” can help educate your clients.
o      Carry a trigger point flip chart with you. Explain how trigger point patterns are often the cause of severe pain.
o      Take a moment to examine the posture of the person you are speaking with. Educate your contact about how each individual’s unique postural pattern can be treated with massage therapy. Then describe your ability to custom tailor your treatments accordingly.

Mutual Benefits

Discuss how you can be of mutual benefit to each other.
o      Can you send them business?

o      Take some of their business cards to pass out, and ask them to do the same.

Leave Treasures

Do something unique so that your referral sources remember you.

o      Give a helpful tip. If you are talking with a secretary who complains of neck pain, suggest that he/she try a telephone headset, or adjust the height and angle of the computer monitor or chair.

o      Teach simple stretching techniques.

o      Leave healthy snacks. I know people who are always on the run and rarely stop to eat. Sometimes, I’ll drop off an apple, nuts, and a bottle of water, along with my business card.

o      Leave samples of topical pain relievers.  

Contact Information
You’ve invested your time and energy marketing your practice. Now make sure that your referral sources can find your name and number when it counts. Be sure to leave
o      Business cards

o      Magnets

o      Flyers

o      Pens

o      Notepads

o      Any other tool you think will leave an impression.

Education
Clients often want to understand and learn more about their condition, so put your education to good use.
o      Continually educate and re-educate your clients.

o      Show them how to stretch and maintain themselves between sessions.

o      Explain the importance and benefits of regular exercise.

o      Use visuals, such as anatomical models, textbooks, trigger point charts or other charts to show the musculoskeletal origins of their condition.

o      Review the effects of poor posture and explain how it contributes to pain. Since a picture is worth a thousand words and many cell phones have cameras, taking postural analysis photos on the road is easier than ever. Read “Getting Comfortable with Postural Analysis” (Massage Today, July 2008) for more tips on using postural analysis photos.

o      Discuss the uses of ice, heat, and topical analgesics for pain.

Say “Thank You”

o      Place follow-up calls to new clients.

o      Send thank you notes to clients and referral sources.

We typically avoid the things that we are uncomfortable doing; however, with practice, you will quickly realize that certain thoughts and actions consistently focused in positive directions will ensure your success. And if you practice your selling skills consistently, you will improve each time you sell your services to somebody new. Remember: practice makes perfect! Hang in there and don’t get frustrated. Results don’t always happen overnight. Just invest the time and keep a positive attitude. You’ll be amazed with the results!

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

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Tax Tips Save Massage Therapists Money

David Kent interviews Jennifer Grant, CPA, LMT; take a few minutes to listen as they discuss the three ways a massage therapist can save money at tax time. Learn how you can take or increase your work related milage deductions. They discuss how to Keep it, Document it and Store it. David and Jennifer use everyday examples therapist encounter.

Click play ↓ to listen.
[audio:http://www.kenthealth.com/wp-content/uploads/KentHealthCast-012-JenniferGrant.mp3]

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David Kent talks about Headaches on World Massage Conference .com

Join David Kent for this live entertaining interview Wednesday, October 28th at 8PM EST on www.worldmassageconference.com, David discusses the topic of headaches with passion after suffering for over 20 years with debilitating headachs and neck pain. David’s interviews are are filled with tips and techniques that you can use immediately.

Surveys indicate that 55% of headache sufferers are frustrated with their ineffective medical treatment. A solid understanding of the muscular components of headaches and neck pain and how to quickly address them will give you the ability to promote your skills to this lucrative market. David discusses the system he has developed to assess, educate patients about your findings and how you can help by providing treatments that are customized for each individual’s challenges.

David is avalable for your questions during this live interview via streaming audio online or over the phone Wednesday, October 28th at 8PM EST. Go to www.worldmassageconference.com and sign up today for notification on the broadcasts and to view the scheduled training call information.

This broadcast is entitled “Headaches: Types, Triggers and Treatment”.

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Self-Care for Massage Therapists: Preparing for the Game of Treatment

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By: David Kent, LMT, NCTMB

While massage therapists are not professional athletics like Michael Phelps, Tiger Woods or the William sisters there are a few similarities we should examine and learn from. Professional athletes consistently perform certain actions that helped ensure their success. Massage Therapists can apply many of the same philosophies and actions to help their success. Unlike professional athletes that have contracts that pay them even when they are injured or sick, the income of a massage therapist is often directly related to the number of treatments they are performing. This article will review some of the similarities between these two groups and ways massage therapists can protect themselves while treating their clients.

Physical Demands:

Professional athletics prepare their physical bodies to avoid injuries while executing their skill in a particular sport. They train regularly since they make their living competing on the field, the court or in the pool and cannot afford to be sidelined since future competitions and rankings depend their current performance. Similarly, massage therapists require their physical bodies at high levels in the treatment room, doing outcalls or performing chair massage. Therapists are also being “ranked” by their clients on whether to reschedule, the amount of the tip, or to refer family, friends and co-workers.

Many sporting events place physical demands on the players for 30 to 90 minutes a game. Likewise, the length of a typical massage therapy session is 30-90 minutes. The physical demands on the therapist can be enormous depending on the client’s size, techniques being integrated, room temperature, flooring type, table height, and other factors.

Self-Care:

Michael Phelps competed in 17 races during the 2008 Olympics winning 8 gold medals, injury free. Do you think he integrated self-care techniques like: stretching, resting, eating nutritious foods, working-out and massage therapy? Many massage therapists perform seventeen plus treatments every few days with little to no self-care. Massage therapists must train and maintain their bodies to avoid injuries and be prepared for the physical demands needed in the treatment room. Care for your body by:

o      Sleeping enough so your mind and body are well rested.

o      Stretch daily to maintain flexibility, good posture and avoid injuries.

o      Workout regularly to have the strength and endurance to perform therapy. Yoga is a great workout that includes flexibility.

o      Drink plenty of water.

o      Eat nutritious foods.

o      Receive massage regularly

Protect your Body:

Athletes wear special equipment to protect their bodies like: helmets, padding, eye goggles, gloves or support braces on their knees, ankle and elbows. The equipment gives them an edge and allows them to work smarter not harder while avoiding injury. Here are a few tips for protecting your body:

o      Wear the proper shoes to avoid pain in the feet, knees, back and neck. Would you expect a pro sports athlete to wear dress shoes for competition?

o      Adjust your table height for the size of the client and techniques being integrated. You are setting yourself up for injury if your table is not set ergonomically correct for the job being performed. It will be impossible to use proper body mechanics, if your table height is too high or too low.

o      Use proper body mechanic. This is the easiest way to avoid injury and conserve your energy.

o      Sit in a chair or ball when working on a client’s neck or feet, to give your body a break.

o      Use pressure bars, rollers and other devices once you are trained and proficient in there safe use.

Collecting the Data and Facts:

Competitive athletes collect any data possible by reading articles or reviewing video clips of prior competitions to identify patterns and design counterstrategies. Here are a few ways to learn more about your clients, their conditions and how to design customized treatment plans:

o      Gather information by having the client complete intake forms. This process also helps the client get clear on the chronological order that this condition has progressed and recall the types of treatments and their effectiveness to date. Then you can ask for clarification of what they have written

o      Identify patterns by taking postural analysis photos. Many cell photos have cameras built in to them, making it easy to take postural analysis photos. Review Trigger Point or other charts that determine the possible origins of their condition.

o      Design a customized treatment plan to address their condition with in information gathered from the intake forms, postural analysis photos, range-of-motion, discussion with the client, trigger point findings, etc.

o    Educate your client during and after the session. Again, postural analysis photos show how their poor posture is causing stress on various muscles, joints and ligaments of their body. You can also use the photos to show postural improvements over time. I also use a wet erase marker to circle all of their Trigger Point patterns on the charts so they better understand what I am doing and the goals we are trying to achieve.

The Fundamentals:

The top athletes in any field will tell you they consistently practice and apply the basic fundamentals of their craft. They also have a coach on staff to ensure they are applying the fundamentals. You can easily have a coach with you everyday by integrating the following:

o      Watching DVD programs over and over will help reinforce the information and is similar to being in a seminar.

o      Review manuals and handouts adding special notes. Some programs have manuals that correspond to the DVD programs and cross-reference other products like charts of that same system. This helps you “connect the dots” and integrate the information.

o      Receive massage regularly from different therapists. This helps you reevaluate your approach and “tableside” manner.

o      Read articles in trade journals and online.

o      Take seminars to improve your skills.

o      Stay connected and interact with your peers.

The bottom line is massage therapists can protect their bodies and income by applying the same fundamentals as professional athletes. The key is making certain actions priorities in your life and consistently following through. I encourage you to read all the articles in my “Keeping It Simple” series and hang this article in a place that allows you to review it often as a “coach” to help keep you on target.

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs.

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Blind Massage Therapist Takes Dissection Seminar

Full Body Dissection Seminar June 19-23, 2013

  • For more information call 888-574-5600 M-F 9-4 EST.
  • Blind Therapist Takes Full Body Dissection Seminar

    Feeling Is Believing – Improve Your Massage Therapy Skills

    By David Kent, LMT, NCTMB

    I recently took an online survey and was interested to discover that of the five senses, 76 percent of men and 72 percent of women feel that vision is the most important. But while “seeing is believing” to many, Edgar Moon, a blind certified massage therapist from Philadelphia, believes that “touching is seeing and understanding.” Edgar, who primarily is a kinesthetic learner, “sees” with his hands.

    Edgar became a massage therapist after he lost his sight serving our country in Vietnam. A couple of years ago, he joined me in the dissection lab for a week of training. Following the experience, Edgar expressed both appreciation and excitement for his newfound knowledge, “Now I understand exactly what I am treating on my clients. This experience has been so enlightening and a dream come true.”

    The level of enthusiasm in the dissection lab truly is amazing. I’ve seen faces light up with excitement in anticipation of embarking on this incredible exploration of the human body. Yet, at the same time, each person is extremely respectful of the process. All of the participants honor these “silent teachers,” since it is through their foresight and planning that we have been given this ultimate gift and learning experience. Additionally, we in the anatomy lab recognize that performing an outstanding dissection and then using that knowledge to benefit our clients is the most respectful way we can honor these exquisite souls.

    While Edgar did not use a scalpel to perform the dissection, he did use his hands to palpate every layer, separate the fascial planes, and feel the fascia, muscles, nerves and organs. Additionally, Edgar and his dissection team continually palpated the same structures on 11 different cadavers to compare the shapes and sizes of each. Edgar maneuvered around the dissection lab with confidence. As he approached each cadaver, a team member would place his hands on a bony landmark so that he could identify his starting point. Working with Edgar in the lab reminded each of us how fortunate we are to have the gift of sight. We were all proud that we had the opportunity to “loan our eyes” to a fellow massage therapist so he could follow his passion.

    In my last column, I discussed how most of us learn and experience life through the five senses: visual (sight), auditory (speech), kinesthetic (touch), olfactory (smell) and gustatory (taste). While most of us are fortunate enough to have the full use of our senses, each person typically is more reliant on one or two of the senses; these are referred to as the dominant senses. Since the senses affect how we interpret and interact with the world on a daily basis, it is easy to understand how the dominant senses could guide us into a specific profession.

    Edgar Moon, a blind certified massage therapist from Philadelphia, says “touching is seeing and understanding.” he is a kinesthetic learner, and “sees” with his hands.

    For example, someone whose dominant sense is taste probably would enjoy being a chef, a food taster or a wine connoisseur; a speech-dominant person might gravitate toward a profession in acting, music or politics; and a sightdominant person might prefer a career as a graphic designer, architect or painter. So, it makes perfect sense that a touch-dominant person would lean toward a career in massage therapy. In fact, when massage therapists are in the process of learning a new technique or structure of the body, it often is necessary for them to see (visual) it, hear (auditory) about it, and, of course, use touch (kinesthetic) to feel or perform it.

    It was beautiful to witness Edgar as he began making all of these connections in the lab. Occasionally, while palpating, he would say, “I see.” I remember thinking how much more sensitive Edgar’s hands are since they play such a dominant role in his life.

    As you know, the largest organ in the body is the skin. It provides:

    • Protection for the body from injury, fluid loss (e.g., in minor burns), and invading organisms;

    • Heat regulation through sweat glands and blood vessels; and

    • Sensation (e.g., pain) by way of superficial nerves and their sensory endings. 1

    Additionally, it’s common knowledge that one square-inch of skin contains about 65 hairs, 100 sebaceous glands, 650 sweat glands, 78 heat sensors, 13 cold sensors, 1,300 nerve endings that can record pain, 9,500 cells, 19 yards of nerves, 19,500 sensory cells and 165 pressure apparatuses for stimuli (touch).The fingertips are very sensitive, making them powerful tools for any massage therapist, particularly someone with an enhanced sense of touch, like Edgar. But, how does the dissection experience help heighten one’s sense of touch and subsequently make one a better massage therapist? Well, with or without the use of one’s vision, palpating during dissection provides the therapist with a more thorough understanding of each individual structure, as well as how these structures interconnect to form the whole. A therapist who has received the gift of knowledge thanks to these special “silent” teachers can’t help but function in the treatment room with a heightened appreciation and understanding of the human body. And developing these skills takes little more than a heartfelt desire to learn and a willingness to see with your hands what your eyes cannot. Just ask Edgar.

    David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

  • For more information call 386-574-5600 M-F 9-4 EST.
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    A Year in Review: Practice Building Resources and Tips

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    By: David Kent, LMT, NCTMB

    As 2008 winds down, I am reminded of all that I have to be grateful for: good health, my friends and family, and—for the most part—a thriving business and practice. Yet, at the same time, I am concerned about the future. The economy has reached record lows and has negatively impacted massage therapists everywhere. Right now, you may be wondering if it’s possible for your clinic, spa or outcall practice to weather these storms. The answer is yes; however, surviving these challenging times will depend largely on how resourceful and creative you are when it comes to your business.

    During the course of the last two years, I have had the privilege of writing many articles for Massage Today that offer practical solutions about how to create a flourishing massage therapy practice. I’d like to take a moment to refer you to them now. Whether you are a new or experienced therapist, this article will provide you with a cheat sheet to my previous articles. Think of it as a “Solutions Guide” that will help you find new ways to energize and reinvigorate your practice.

    Eliminating Blind Spots

    Our thoughts determine our focus, which influences our actions and effectiveness. If we think negative, unproductive thoughts, we produce outcomes at a lower level. An example of this would include looking for your keys while continually saying, “I can’t find my keys.” Stating that you can’t find your keys over and over simply reinforces the negative situation that you are trying to avoid. Or, at the very least, it creates a blind spot in your thinking. Are you creating blind spots in your career? Then you need to focus on solutions. If business is slow, don’t focus on how slow it is. Instead, focus on what needs to be implemented to turn things around. One rule of thumb is to focus 80 percent of your time and energy on 20 percent of the things that matter most to you. Read: The 80/20 Rule: Maximizing the Return on your Investment

    Attaining your Goals

    We must take a few minutes every day to work on attaining our goals. What are three things you could do right now that could help your practice, but that you have delayed because you are fearful of the unknown or of possible rejection? To put those thoughts and fears behind you, you need to be proactive. Make a list twice as long of all of the good things that will happen by taking action. You will immediately have clarity and a desire to move forward. Read: The Power of a Minute and The Power of the List.

    Balancing the Systems

    Just as the body has many systems that work in harmony with one another, so must the systems in your practice. Is your practice operating as efficiently as possible? What isn’t working that you would you like to change? Read: Massage Your Balancing Act and All Systems Go.

    Keep Your Skills Sharp

    They say, “If you don’t use it you loose it”. I still regularly treat clients at my clinic and love to receive massage. I learn allot from every treatment I receive. When was the last time you received a massage?  Are you following the recommendations you tell your clients?

    What about hands-on seminars, have you studied anything unique lately? Read: The Body is in Charge and Feeling is Believing. What textbook could you read to improve your knowledge and skills? Are you reading articles on treatment? Read: Safety Protocols: Carotid Artery and Subscapularis: Overlooked and Under Treated For many DVD programs with accompanying photo manuals are get aids. This type of tool supports hands-on seminars by allowing you study prior to or after a training.

    Maintaining a Polished and Professional Demeanor

    Imagine walking into a store to buy a specific item. You locate the item, which is manufactured by two different companies and sitting on the shelf side by side. Each is priced the same. One box is nice, new and brightly colored; the other box looks like it was run over by a truck. Which one would you buy? Now imagine that you are a potential client or employer looking to hire a massage therapist. Do you think that a therapist’s overall appearance and actions might influence your purchase? Are you dressing or “packaging” yourself in the right light? What sets you apart from other therapists in your area? Do you specialize in a particular modality or possess special training? Are you setting high standards of care by asking your clients the right questions? Are you communicating to clients that you are highly skilled and knowledgeable in your field?  Read: Questions with Direction.

    Tools of the Trade

    All healthcare providers use paperwork, instruments and devices to gather information, as well as to evaluate, educate and treat their clients. Pain scales are great tools to show progress over a series of therapy sessions. Many massage therapists take postural analysis photos to document their client’s progress and educate their clients about the benefits of treatment. Trigger point charts help you explain referred pain patterns to your clients, which gives them confidence that you can design a treatment plan to help them. Read: Charting your Progress: Visuals for Success; Simple Answers Create Positive Results; and Getting Comfortable with Postural Analysis.

    Building Your Practice

    Does the community know about you and your business? How do potential clients contact you? Have you distributed your cards and/or brochures in health food stores, gyms, and chiropractic and medical offices? Have you met the tennis and golf professionals in your area? Have you considered writing an article for the local paper about the benefits of massage therapy and/or your particular specialty? Do you have a Web site that is up to date? If you are a new therapist, are you communicating your availability with phrases like, “Now Accepting New Clients”, “Outcalls Available” and “Introductory Specials”? Are you taking a few minutes to follow up with new clients after their initial visit? Are you sending thank you cards to your clients and referral sources? Remember to show your clients and your referral sources your appreciation. A little acknowledgement goes a long, long way. Read: Building Raving Fans: Consistency is Key.

    As we move into 2009, I encourage you to stay focused and positive. Times are tough, but things will get better. In the meantime, continue to educate yourself and improve your craft. Check out MassageToday.com for unlimited resources to help you build a successful practice, and stayed tuned for more great articles in next year’s “Keeping It Simple” series. Happy Holidays!

    David Kent, LMT, NCTMB

    David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

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    Subscapularis: Overlooked and Under Treated

    Click here for a printable version of this article with photos

    By: David Kent, LMT, NCTMB

    The subscapularis is often neglected and/or undertreated as a cause of posterior shoulder pain with restricted range of motion (ROM). According to Travell and Simons, “differential diagnosis of subscapularis TrPs includes C7 radiculopathy, thoracic outlet syndrome, adhesive capsulitis and ‘impingement’ syndrome.”[1]In this article, I will review how to determine when the subscapularis muscle is responsible for causing shoulder pain and restricted ROM, as well as review its anatomy, function, trigger-point patterns and treatment options.

    Intake and health history forms will help you identify some common factors that may contribute to the formation and perpetuation of trigger points, as well as the shortening of the subscapularis muscle. According to Travell and Simons, some of these factors include the following:

    • Repetitive movements that involve medial rotation, such as swimming the overhead stroke, playing tennis or pitching a baseball;
    • Repeatedly lifting boxes or other objects overhead with both arms extended;
    • Reaching backward to break a fall;
    • Soft-tissue stress when the shoulder joint is dislocated;
    • A fracture to the proximal humerus or trauma to the shoulder joint capsule;
    • The immobilization of the shoulder in an adducted and medially rotated position over a long period of time, such as when the arm is in a sling; and
    • Prior surgeries and procedures.[2]

    Taking a photo of your client in front of a postural analysis grid chart is an effective method of evaluating, documenting, educating and ultimately showing a client his or her postural progress over a series of treatments. For example, a constant slumped, forward-head, adducted-scapulae posture will perpetuate trigger points and the shortening of muscles, like the subscapularis, by continually keeping the humerus in a position of medial rotation.3 [Photo 1]

     

     

    Symptoms

     

    Trigger Points: When trigger points are present in the subscapularis muscle, they produce referred pain “in the posterior deltoid area…down the posterior aspect of the arm, and then skip to a band around the wrist.”4 [Photo 2] Remember that referred pain is a symptom; we want to address the cause. So intake forms, postural analysis evaluations, range-of-motion and orthopedic assessments, and being familiar with trigger point patterns are all helpful to designing and implementing a customized therapy plan. But treating a trigger point is only part of the solution. We need to avoid a recurrence in the future. It is therefore necessary to demonstrate to your client which muscles need more lengthening and which ones need more strengthening so that all of the joints are properly aligned and moving through their full range of motion.

    Anatomy: The subscapularis is one of four muscles that make up the rotator cuff, along with the supraspinatus, infraspinatous and the teres minor muscles. In my dissection seminars, I always highlight the subscapularis, which is the most anterior of the rotator cuff muscles. [Photo 2] It is a thick triangular muscle that attaches medially on the anterior or costal surface of the scapula on the subscapular fossa; it forms part of posterior wall of the axialla. Laterally it attaches on the lesser tubercle of the humerus and the lower half of the shoulder joint capsule.

    Actions: The subscapularis is primarily responsible for medially rotating and adducting the arm. It also helps to hold the humeral head in the glenoid cavity. To check for shortening in the subscapularis it is necessary to evaluate both abduction and external rotation.

    Abduction: According to Travell and Simons, when evaluating a shoulder with restricted abduction, it is first necessary to determine if the restriction is being caused by the inability of the scapula to move on the rib cage, the humerus to properly articulate in the shoulder (glenohumeral) joint, or a combination of the two. The difference can be easily determined by placing your hands on the client’s scapula to prevent its movement while asking the client to abduct his/her humerus. [Photo 3] When the subscapularis is involved, it restricts glenohumeral movements like abduction and lateral rotation, but it does not restrict scapular movements on the rib cage. If scapular movements are restricted, it is necessary to evaluate muscles that run from the torso to the scapulae like the pectoralis minor, serratus anterior, trapezius and the rhomboids.5

    Lateral Rotation: When checking lateral rotation at the shoulder, adduct the arm by placing the elbow at the side. Bend the elbow 90 degrees to show the amount of rotation at the shoulder joint. [Photo 4] The arm should be able to laterally rotate 90 degrees. In addition to the subscapularis, other synergistic muscles like the teres major, latismus dossi and pectoralis major also adduct and medially rotate the arm. These muscles must also be evaluated and treated. Keep in mind that the antagonistic muscles are weak and over lengthened, so they need strengthening. Muscle movement charts can aid in quickly identifying the muscles involved and show the normal range of motion for the muscles and joints being evaluated. [Photo 5]

    Treating the subscapularis: While there are many different approaches to treating the belly of the subscapularis muscle, I find one particularly effective; however, with this method some clients may only be able to tolerate static pressure versus movements, such as with-fiber or cross-fiber techniques.

    1. Place the client in a supine position.
    2. Stand facing the client at level of client’s shoulder.
    3. In the palm of your non-treating hand, cradle the scapula while using your fingertips to secure the vertebral border of the scapula; abduct the scapula.[Photo 6]
    4. Position the fingers of the treating hand against the belly of the subscapularis muscle. [Photo 7]

    NOTE: Some clients may be ticklish, but this is easily overcome by using the client’s hand during the treatment. Have the client place his/her hand on the ticklish region while you treat the area between his/her fingers. [Photo 8]

    1. Drape the client’s arm across his/her chest (adduction) to shorten the muscle. [Photo 9]
    2. Press the fingers of your treating hand down toward the table and into the subscapular fossa.

    Before the session ends, advise your client that he/she will receive the most benefit from your therapy session by actively engaging in self-care stretching techniques, such as the doorway stretch, which will further help improve muscle length, and create and maintain balance in the shoulder. [Photo 10]

    You have now identified several factors associated with subscapularis pain and discomfort with the help of assessment aids and tools like intake forms, charts and postural analysis photos. Continue to study and broaden your skills with hands-on seminars and DVD programs. And to share your tips and experiences in the treatment room, please drop me a line at [email protected]

    For more information related to this month’s topic, check out “Charting Your Progress: Visuals for Success” (February 2008) and “Getting Comfortable with Postural Analysis” (July 2008) online at www.massagetoday.com.

    David Kent, LMT, NCTMB

     

    David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.


    1-5 Simons DG, Travell JG, et al. Myofascial Pain and Dysfunction: The Trigger Point Manual, volume 1, 2nd ed. Williams and Wilkins: 1999.

    Click here for a printable version of this article with photos