Response to "Knot in a muscle' post

Replies to This Discussion

Permalink Reply by Boris Prilutsky on July 19, 2011 at 10:58am

Hi Stephen.

Gary posted perfect definitions and descriptions in regards of  what he have discovered. by all means it didn't described clinical picture of thoracic outlet syndrome. in such a case no need to consider dissociation phenomena.

because in cases of thoracic outlet syndrome the clinical picture always including pain and not only local pain,but also presenting obvious  neurological picture( shooting pain to upper extremitie) additionally to described pains ,patients experiencing,both numbness and tingling,arm edemas as well  collar change and more .Gary presented none of this in his post.

This is not the matter of terminology.

Best wishes.

Boris

PS.I love our discussions because a lot of useful information. I mean every participant can learn some.

Stephen Jeffrey said:

Hi Dr Ross Turchaninov

I am saying whatever the terminology, whatever the syndrome, whatever the test, however likely pain is to be the "normall experience", we need to keep in mind the dissociation phenomena in human pain experience.

 

 

 

 
Dr. Ross Turchaninov said:

Hi Stephen

 

I think this matter of terminology. The Thoracic Outlet Syndrome(TOS) is always painful because it involves compression of brachial plexus and subclavian artery. The same condition in the same area but on the level of irritation of the same structures called Anterior Scalene Muscle Syndrome and isn't always painful. If let say Adson's test positive which is one of the signs of TOS the pain on the upper extremity is already there for sure.

To Gary

 

if you think that this mass in the trapezius itself it can me large myogelosis we discussed before. If there is no peripheral hypertonuses core of myogelosis will fill as a painless and movable mass.

 

Dr. Ross Turchaninov

 

Stephen Jeffrey said:

 

Hi Dr Ross,

thankyou for your reply, however, I must strongly disagree with your supposition that =

it will be always painful to touch

the reason I stated normally but not always painfull is because of the power of dissociation of pain =

http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...                                                          

 

Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)

 

Hi Gary

Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.

Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.

 

Dr. Ross

Stephen Jeffrey said:

Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.

Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.

 

I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).

Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.   

Hope this helps

 

• ▶ Reply

Permalink Reply by Therese Schwartz on July 19, 2011 at 1:01pm

I haven't read the entire thread in a few days, but Stephen, I like the idea that working the arms first is helpful to the neck.  I've been doing them after the neck because I know it helps the neck/shoulders.  I will try doing them before and see what happens.  Thanks!!

 

I know what you are talking about with dissociation.  It is a genuine phenomenon and one which we talk a lot about in SomatoEmotional Release.  I think it's something that should always be considered; people can be really adept at it and working with them to stay in their bodies can be a real challenge.

• ▶ Reply

Permalink Reply by Stephen Jeffrey on July 20, 2011 at 1:48am

You may also want to include head and even face massage (alot depends on how well you know the client).

The longer the chronic condition of the neck pain, the more often we need to treat the muscles and fascia of local structures. Especially as these are likely to be overlooked by other professions, eg chiro. imo. 

 

Re dissociation, yes you are right, people can be very adept......way too adept,(as is possible with Gary's client) that is why we sometimes have to feel what the client does not (palpation experience). 

 

Dissociation I very much regret, was not covered at all in my original training, its a huge difficult (more psychological)subject,  but much too important not to be discussed, prehaps on a separate thread:)

 

What do you think Therese ?

 

 

 

 

 

Therese Schwartz said:

I haven't read the entire thread in a few days, but Stephen, I like the idea that working the arms first is helpful to the neck.  I've been doing them after the neck because I know it helps the neck/shoulders.  I will try doing them before and see what happens.  Thanks!!

 

I know what you are talking about with dissociation.  It is a genuine phenomenon and one which we talk a lot about in SomatoEmotional Release.  I think it's something that should always be considered; people can be really adept at it and working with them to stay in their bodies can be a real challenge.

• ▶ Reply

Permalink Reply by Gary W Addis, LMT on July 20, 2011 at 7:58am

This isn't exactly on topic.

 

Last night in NMT class I learned.  I have been relieving TPs for some time whenever I encountered one while doing Swedish, but that found only the ones that stood up and growled at me as I glided over it.  Textbooks sometimes politely disagree about this or that.  For instance, one of my NMT textbooks describes trigger points as "knots," another says that, no, the knot isn't a trigger point although a trigger point will usually be nearby.  Maybe both are right? 

 

Last night in NMT clinic, we were short of outside clients, so in spare time, we worked on one another.  Working on Matt, a more advanced student, I found a biggie--like a baby mouse beneath the skin, when I applied pressure, it scooted away.  My friend directed me to the actual TP, which bordered the knot a mm or so away.  When I compressed it, the nearby mouse dissolved within seconds.  When it was my turn on the table, my friend found numerous TPs.  I actually dosed off while he was working, his pressure felt "just right."

 

My one client for the night canceled at the last minute, so rather than sit around, I invited Mike, my instructor, onto my table.

 

Mike is a muscular guy; he's into karate and, like me, he was once a competitive bodybuilder.  But he has put on a few pounds.  The skin is taut.  The muscles are deep, however.  When I applied my usual amount of pressure while exploring for TPS, I couldn't feel a thing.  Lying face down in the cradle, he took my hand and placed it on a posterior scalene, and instructed me to really dig in.  He had to correct my pressure three times before I got deep enough.  Honestly, I never did feel the TP in his scalene--but I felt it when it released!  I worked on Mike's upper back for a full hour, and released numerous trigger points, mostly with my thumb, all an inch or more beneath the surface.  In one rear deltoid alone, I released four in a space smaller than a silver dollar.  He had injured that shoulder in a kickboxing match several years ago, and the tissue still has not forgiven him; in a week or so he'll need the work again.  My work earned both his praise and the mild rebuke that I need to apply more pressure.  

 

Well, Mike's "7" is the next client's screaming "10"-- that was every ounce of pressure my quivering arm could stand.  But... But I now understand Boris's point.  The first release isn't necessarily all there is.  Before, when I felt the superficial release and heard the client's sigh of relief, I immediately let up and moved on.  Mike forced me to keep the pressure on, and one by one the layers melted; it was akin to pushing through several "sticking points" during a single repetition in the bench press.  Tissue would melt, I would sink in but keep the pressure up, then encounter another wall.  Later, lying in bed at home, I explored my pecs and shoulders using the same pressure--Wow! Four TPs in the pec majors alone!

 

It had been some time since I had received any bodywork, so Matt released trigger points all over my upper back, and he did it without applying much pressure.  But when trying to teach me the correct pressure, Mike put me face down and sorta skimmed my upper back (the same area worked by my fellow student), and darned if Mike   didn't discover two more very tender TPS with his deeper pressure. 

 

Yes, I know that I can't go "caving" in the tissue of every client--most will want and need nothing more intensive than a relaxing Sweish.  But when a returning client is complaining of chronic pain that other student therapists have failed to cure, I'll know to ask for permission to work deeper (somewhat painfully deeper) and take out previously undiscovered trigger points.

 

I'm loving it!  What a journey! 

• ▶ Reply

Permalink Reply by Therese Schwartz on July 20, 2011 at 10:48am

Hi Stephen, I think I will get a thread started about dissociation!  We did talk about it in MT school as well as what I've learned since then in my SomatoEmotional Release classes.  But I still have only scratched the surface, so maybe our colleagues out there can add much to the discussion!

Stephen Jeffrey said:

You may also want to include head and even face massage (alot depends on how well you know the client).

The longer the chronic condition of the neck pain, the more often we need to treat the muscles and fascia of local structures. Especially as these are likely to be overlooked by other professions, eg chiro. imo. 

 

Re dissociation, yes you are right, people can be very adept......way too adept,(as is possible with Gary's client) that is why we sometimes have to feel what the client does not (palpation experience). 

 

Dissociation I very much regret, was not covered at all in my original training, its a huge difficult (more psychological)subject,  but much too important not to be discussed, prehaps on a separate thread:)

 

What do you think Therese ?

 

 

 

 

 

Therese Schwartz said:

I haven't read the entire thread in a few days, but Stephen, I like the idea that working the arms first is helpful to the neck.  I've been doing them after the neck because I know it helps the neck/shoulders.  I will try doing them before and see what happens.  Thanks!!

 

I know what you are talking about with dissociation.  It is a genuine phenomenon and one which we talk a lot about in SomatoEmotional Release.  I think it's something that should always be considered; people can be really adept at it and working with them to stay in their bodies can be a real challenge.

• ▶ Reply

Permalink Reply by Stephen Jeffrey on July 21, 2011 at 6:34am

And we are loving hearing about it Gary ....but always be cautious because =

http://www.amazon.com/forum/massage/Tx1ON6V5Y80UZGE?_encoding=UTF8&...

This isn't exactly on topic.

 

Last night in NMT class I learned.  I have been relieving TPs for some time whenever I encountered one while doing Swedish, but that found only the ones that stood up and growled at me as I glided over it.  Textbooks sometimes politely disagree about this or that.  For instance, one of my NMT textbooks describes trigger points as "knots," another says that, no, the knot isn't a trigger point although a trigger point will usually be nearby.  Maybe both are right? 

 

Last night in NMT clinic, we were short of outside clients, so in spare time, we worked on one another.  Working on Matt, a more advanced student, I found a biggie--like a baby mouse beneath the skin, when I applied pressure, it scooted away.  My friend directed me to the actual TP, which bordered the knot a mm or so away.  When I compressed it, the nearby mouse dissolved within seconds.  When it was my turn on the table, my friend found numerous TPs.  I actually dosed off while he was working, his pressure felt "just right."

 

My one client for the night canceled at the last minute, so rather than sit around, I invited Mike, my instructor, onto my table.

 

Mike is a muscular guy; he's into karate and, like me, he was once a competitive bodybuilder.  But he has put on a few pounds.  The skin is taut.  The muscles are deep, however.  When I applied my usual amount of pressure while exploring for TPS, I couldn't feel a thing.  Lying face down in the cradle, he took my hand and placed it on a posterior scalene, and instructed me to really dig in.  He had to correct my pressure three times before I got deep enough.  Honestly, I never did feel the TP in his scalene--but I felt it when it released!  I worked on Mike's upper back for a full hour, and released numerous trigger points, mostly with my thumb, all an inch or more beneath the surface.  In one rear deltoid alone, I released four in a space smaller than a silver dollar.  He had injured that shoulder in a kickboxing match several years ago, and the tissue still has not forgiven him; in a week or so he'll need the work again.  My work earned both his praise and the mild rebuke that I need to apply more pressure.  

 

Well, Mike's "7" is the next client's screaming "10"-- that was every ounce of pressure my quivering arm could stand.  But... But I now understand Boris's point.  The first release isn't necessarily all there is.  Before, when I felt the superficial release and heard the client's sigh of relief, I immediately let up and moved on.  Mike forced me to keep the pressure on, and one by one the layers melted; it was akin to pushing through several "sticking points" during a single repetition in the bench press.  Tissue would melt, I would sink in but keep the pressure up, then encounter another wall.  Later, lying in bed at home, I explored my pecs and shoulders using the same pressure--Wow! Four TPs in the pec majors alone!

 

It had been some time since I had received any bodywork, so Matt released trigger points all over my upper back, and he did it without applying much pressure.  But when trying to teach me the correct pressure, Mike put me face down and sorta skimmed my upper back (the same area worked by my fellow student), and darned if Mike   didn't discover two more very tender TPS with his deeper pressure. 

 

Yes, I know that I can't go "caving" in the tissue of every client--most will want and need nothing more intensive than a relaxing Sweish.  But when a returning client is complaining of chronic pain that other student therapists have failed to cure, I'll know to ask for permission to work deeper (somewhat painfully deeper) and take out previously undiscovered trigger points.

 

I'm loving it!  What a journey! 

• ▶ Reply

Permalink Reply by Boris Prilutsky on July 21, 2011 at 10:37am

Hi Stephen.

I appreciate your post including warning and link. It is important to do so, because we can afford in some rare cases not to help one, but in no case we can afford injuring one. Damaging to clients we possibly can if we will not abate contraindications to massage and/or will apply vigorous pressure and/or not trained how perform massage protocol Correct. Using the opportunity would like to offer link to my video where I am demonstrating hands-on in cases of TOS as well approximately 3:30  addressing  approach to safe and effective trigger point therapy. I hope you will appreciate it.

http://www.youtube.com/watch?v=fIrncoar9qk

Best wishes.

Boris

PS. This video clip also covering little bit  carpal tunnel  syndrome. We can discuss it too.

 

Stephen Jeffrey said:

And we are loving hearing about it Gary ....but always be cautious because =

http://www.amazon.com/forum/massage/Tx1ON6V5Y80UZGE?_encoding=UTF8&...

This isn't exactly on topic.

 

Last night in NMT class I learned.  I have been relieving TPs for some time whenever I encountered one while doing Swedish, but that found only the ones that stood up and growled at me as I glided over it.  Textbooks sometimes politely disagree about this or that.  For instance, one of my NMT textbooks describes trigger points as "knots," another says that, no, the knot isn't a trigger point although a trigger point will usually be nearby.  Maybe both are right? 

 

Last night in NMT clinic, we were short of outside clients, so in spare time, we worked on one another.  Working on Matt, a more advanced student, I found a biggie--like a baby mouse beneath the skin, when I applied pressure, it scooted away.  My friend directed me to the actual TP, which bordered the knot a mm or so away.  When I compressed it, the nearby mouse dissolved within seconds.  When it was my turn on the table, my friend found numerous TPs.  I actually dosed off while he was working, his pressure felt "just right."

 

My one client for the night canceled at the last minute, so rather than sit around, I invited Mike, my instructor, onto my table.

 

Mike is a muscular guy; he's into karate and, like me, he was once a competitive bodybuilder.  But he has put on a few pounds.  The skin is taut.  The muscles are deep, however.  When I applied my usual amount of pressure while exploring for TPS, I couldn't feel a thing.  Lying face down in the cradle, he took my hand and placed it on a posterior scalene, and instructed me to really dig in.  He had to correct my pressure three times before I got deep enough.  Honestly, I never did feel the TP in his scalene--but I felt it when it released!  I worked on Mike's upper back for a full hour, and released numerous trigger points, mostly with my thumb, all an inch or more beneath the surface.  In one rear deltoid alone, I released four in a space smaller than a silver dollar.  He had injured that shoulder in a kickboxing match several years ago, and the tissue still has not forgiven him; in a week or so he'll need the work again.  My work earned both his praise and the mild rebuke that I need to apply more pressure.  

 

Well, Mike's "7" is the next client's screaming "10"-- that was every ounce of pressure my quivering arm could stand.  But... But I now understand Boris's point.  The first release isn't necessarily all there is.  Before, when I felt the superficial release and heard the client's sigh of relief, I immediately let up and moved on.  Mike forced me to keep the pressure on, and one by one the layers melted; it was akin to pushing through several "sticking points" during a single repetition in the bench press.  Tissue would melt, I would sink in but keep the pressure up, then encounter another wall.  Later, lying in bed at home, I explored my pecs and shoulders using the same pressure--Wow! Four TPs in the pec majors alone!

 

It had been some time since I had received any bodywork, so Matt released trigger points all over my upper back, and he did it without applying much pressure.  But when trying to teach me the correct pressure, Mike put me face down and sorta skimmed my upper back (the same area worked by my fellow student), and darned if Mike   didn't discover two more very tender TPS with his deeper pressure. 

 

Yes, I know that I can't go "caving" in the tissue of every client--most will want and need nothing more intensive than a relaxing Sweish.  But when a returning client is complaining of chronic pain that other student therapists have failed to cure, I'll know to ask for permission to work deeper (somewhat painfully deeper) and take out previously undiscovered trigger points.

 

I'm loving it!  What a journey! 

• ▶ Reply

Permalink Reply by Dr. Ross Turchaninov on July 24, 2011 at 4:07pm

Hi Stephen

On this issue we definitely disagree with each other. Unfortunately I wasn't able to open link you provided but I generally understand what it is about. I may use medical references to support my statement but it will be back and forth.

I just would like to mention that main cause of TOS' clinical picture is compression of different parts of the brachial plexus between anterior and middle scalene muscles.BTW, Gary correct when he mentioned omohyoid because it may contribute but to the clinical picture of Anterior Scalene Muscle Syndrome. However its anatomical position is very rarely triggers enough compression to develop full picture of TOS.

I would like to specifically mention that when the patient has TOS he or she in the emergency room or at least in office of neurologist. The massage therapy is last on their mind as treatment options (unfortunately). Because compression of brachial plexus frequently accompanied by the various circulatory abnormalities their life is miserable. There is no pain dissociation mechanism for the patient with TOS while for the patient with Anterios Scalene Muscle Syndrome it is a factor and you correct about that.

If you saw and examined the patient with TOS you will never forget that. It is horrible combination of shooting and burning pain through entire arm or along ulnar nerve distribution, severe numbness and parasthesia, they have very shallow breathing (to avoid anterior scalene muscle engagement), they didn't sleep at night, they are psychologically devastated by the pain and lack of sleep. Thus the dissociation from the pain as important protective mechanism you mentioned is possible on the Anterior Scalene Muscle Stage but when it gets to TOS it is already to late.

Dr. Ross Turchaninov 

Stephen Jeffrey said:

 

Hi Dr Ross,

thankyou for your reply, however, I must strongly disagree with your supposition that =

it will be always painful to touch

the reason I stated normally but not always painfull is because of the power of dissociation of pain =

http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...                                                          

 

Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)

 

Hi Gary

Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.

Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.

 

Dr. Ross

Stephen Jeffrey said:

Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.

Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.

 

I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).

Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.   

Hope this helps

 

• ▶ Reply

Permalink Reply by Dr. Ross Turchaninov on July 24, 2011 at 4:10pm

Hi Gary

 

If it is myogelosis you will make big favor for your client if you work along its borders. This allows to control core expansion and engulfing healthy fibers in it.

Dr. Ross Turchaninov

Gary W Addis said:

Dr, the definition of myogelosis fits this as well as anything else I've heard.  A large one, though.  I'll leave it alone.   

Dr. Ross Turchaninov said:

Hi Stephen

 

I think this matter of terminology. The Thoracic Outlet Syndrome(TOS) is always painful because it involves compression of brachial plexus and subclavian artery. The same condition in the same area but on the level of irritation of the same structures called Anterior Scalene Muscle Syndrome and isn't always painful. If let say Adson's test positive which is one of the signs of TOS the pain on the upper extremity is already there for sure.

To Gary

 

if you think that this mass in the trapezius itself it can me large myogelosis we discussed before. If there is no peripheral hypertonuses core of myogelosis will fill as a painless and movable mass.

 

Dr. Ross Turchaninov

 

Stephen Jeffrey said:

 

Hi Dr Ross,

thankyou for your reply, however, I must strongly disagree with your supposition that =

it will be always painful to touch

the reason I stated normally but not always painfull is because of the power of dissociation of pain =

http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...                                                          

 

Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)

 

Hi Gary

Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.

Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.

 

Dr. Ross

Stephen Jeffrey said:

Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.

Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.

 

I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).

Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.   

Hope this helps

 

• ▶ Reply

Permalink Reply by Gary W Addis, LMT on July 24, 2011 at 4:25pm

Dr Ross, is that axonal TOS you're referring to? The TOS that can cause muscle degeneration in the thumb of affected hand/arm?  An instructor mentioned this, and that the condition is often not painful, not even in the affected thumb.  Is this correct?

Dr. Ross Turchaninov said:

Hi Stephen

On this issue we definitely disagree with each other. Unfortunately I wasn't able to open link you provided but I generally understand what it is about. I may use medical references to support my statement but it will be back and forth.

I just would like to mention that main cause of TOS' clinical picture is compression of different parts of the brachial plexus between anterior and middle scalene muscles.BTW, Gary correct when he mentioned omohyoid because it may contribute but to the clinical picture of Anterior Scalene Muscle Syndrome. However its anatomical position is very rarely triggers enough compression to develop full picture of TOS.

I would like to specifically mention that when the patient has TOS he or she in the emergency room or at least in office of neurologist. The massage therapy is last on their mind as treatment options (unfortunately). Because compression of brachial plexus frequently accompanied by the various circulatory abnormalities their life is miserable. There is no pain dissociation mechanism for the patient with TOS while for the patient with Anterios Scalene Muscle Syndrome it is a factor and you correct about that.

If you saw and examined the patient with TOS you will never forget that. It is horrible combination of shooting and burning pain through entire arm or along ulnar nerve distribution, severe numbness and parasthesia, they have very shallow breathing (to avoid anterior scalene muscle engagement), they didn't sleep at night, they are psychologically devastated by the pain and lack of sleep. Thus the dissociation from the pain as important protective mechanism you mentioned is possible on the Anterior Scalene Muscle Stage but when it gets to TOS it is already to late.

Dr. Ross Turchaninov 

Stephen Jeffrey said:

 

Hi Dr Ross,

thankyou for your reply, however, I must strongly disagree with your supposition that =

it will be always painful to touch

the reason I stated normally but not always painfull is because of the power of dissociation of pain =

http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...                                                          

 

Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)

 

Hi Gary

Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.

Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.

 

Dr. Ross

Stephen Jeffrey said:

Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.

Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.

 

I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).

Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.   

Hope this helps

 

• ▶ Reply

Permalink Reply by Gary W Addis, LMT on July 24, 2011 at 4:27pm

Thank you.  I will follow your advice.

Dr. Ross Turchaninov said:

Hi Gary

 

If it is myogelosis you will make big favor for your client if you work along its borders. This allows to control core expansion and engulfing healthy fibers in it.

Dr. Ross Turchaninov

• ▶ Reply

Permalink Reply by Dr. Ross Turchaninov on July 24, 2011 at 4:59pm

Hi Gary

This is matter of terminology confusion as I mentioned above. What your instructor described is Anterior Scalene Muscle Syndrome stage of the same abnormality. Yes, indeed it may trigger muscle wasting without significant pain. BTW it mostly affects ulnar nerve distribution and much less frequently radial or median nerve.  Thoracic Outlet Syndrome is much more severe compression of the brachial plexus and this is very painful condition. As a matter of fact in 1940-1950es the surgery to cut anterior scalene muscle was used on emergency basis to decompress brachial plexus asap. Nobody does it now but it gives you sense of emergency situation.

Dr Ross Turchaninov

Gary W Addis said:

Dr Ross, is that axonal TOS you're referring to? The TOS that can cause muscle degeneration in the thumb of affected hand/arm?  An instructor mentioned this, and that the condition is often not painful, not even in the affected thumb.  Is this correct?

Dr. Ross Turchaninov said:

Hi Stephen

On this issue we definitely disagree with each other. Unfortunately I wasn't able to open link you provided but I generally understand what it is about. I may use medical references to support my statement but it will be back and forth.

I just would like to mention that main cause of TOS' clinical picture is compression of different parts of the brachial plexus between anterior and middle scalene muscles.BTW, Gary correct when he mentioned omohyoid because it may contribute but to the clinical picture of Anterior Scalene Muscle Syndrome. However its anatomical position is very rarely triggers enough compression to develop full picture of TOS.

I would like to specifically mention that when the patient has TOS he or she in the emergency room or at least in office of neurologist. The massage therapy is last on their mind as treatment options (unfortunately). Because compression of brachial plexus frequently accompanied by the various circulatory abnormalities their life is miserable. There is no pain dissociation mechanism for the patient with TOS while for the patient with Anterios Scalene Muscle Syndrome it is a factor and you correct about that.

If you saw and examined the patient with TOS you will never forget that. It is horrible combination of shooting and burning pain through entire arm or along ulnar nerve distribution, severe numbness and parasthesia, they have very shallow breathing (to avoid anterior scalene muscle engagement), they didn't sleep at night, they are psychologically devastated by the pain and lack of sleep. Thus the dissociation from the pain as important protective mechanism you mentioned is possible on the Anterior Scalene Muscle Stage but when it gets to TOS it is already to late.

Dr. Ross Turchaninov 

Stephen Jeffrey said:

 

Hi Dr Ross,

thankyou for your reply, however, I must strongly disagree with your supposition that =

it will be always painful to touch

the reason I stated normally but not always painfull is because of the power of dissociation of pain =

http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...                                                          

 

Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)

 

Hi Gary

Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.

Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.

 

Dr. Ross

Stephen Jeffrey said:

Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.

Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.

 

I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).

Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.   

Hope this helps

 

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