1. Chapter 6
Upper Torso

2. Chapter Objectives Overview of Upper Torso Region
Posterior shoulder and upper back muscles
Anterior shoulder and chest muscles

3. Overview Muscle overview Trigger points (TP) and referral zones
Trigger point activation
Stressors and perpetuating factors
Precautions and massage therapy (MT) considerations

4. Trapezius: The Coat Hanger Muscle
Diamond-shaped posterior back muscle
Attachment sites for the trapezius

5. Trapezius Trigger Points
Trapezius TPs:
Commonly found in 7 areas
Referral Zones:
TP1- posterolateral neck pain with headache
TP2- neck pain with no headache
TP3-4- sensation in suprascapular, acromial areas

6. Trapezius Trigger Points cont’d
TP5-burning interscapualar sensation
TP6-sensation across the acromion
TP7-associated with goose bumps on upper arm

7. Trapezius Trigger Point Map
Trigger points and referral zones for the trapezius

8. Trapezius Trigger Point Map cont’d
Trigger points and referral zones for the trapezius

9. Stressors and Perpetuating Factors
Trapezius TP Activation:
Sudden trauma, body asymmetry, postural overload
Stressors and Perpetuating Factors:
Habitual elevation of shoulders
Protracted head postures
Kyphotic and scoliotic conditions

10. Precautions and MT Considerations
Trapezius Precautions
Avoid the brachial plexus
Lower trapezius usually has adhesions
MT Considerations
Rotate head toward the working side
Use a pincer compression

11. Splenii Muscles: Ache inside the Skull
Splenii muscles: Splenius capitis and splenius cervicis
Bilaterally muscles form a ‘V’
Attachment sites for the splenius capitis
Attachment sites for the splenius cervicis

12. Splenii Trigger Points
Splenii TPs and Referral Zones:
Capitis: refers to top of head (creates headaches)
Cervicis: refer head, eye and occiput

13. Splenii Trigger Point Map
Attachment sites and trigger points with referral zones for the splenius cervicis and splenius capitis

14. Stressors and Perpetuating Factors
Splenii TP Activation:
Postural stress
Stressors and Perpetuating Factors:
Excessive neck hyperextension
Cold air blowing on neck
Use of dominant eye only while reading

15. Precautions and MT Considerations
Splenii Precautions:
Be careful with passive stretching
MT Considerations:
Friction origin sites on each spinous process
Use pincer grip when client is prone

16. Anatomical Region of the Shoulder

17. Supraspinatus: Subdeltoid Bursitis
Rotator cuff muscle
Major player in rotator cuff conditions
Attachment sites for the supraspinatus

18. Supraspinatus Trigger Points
Supraspinatus TPs:
Found in muscle belly and tendinous insertion
Referral Zones:
Refer to mid deltoid
Pain when combing hair, brushing teeth, shaving

19. Supraspinatus Trigger Point Map
Trigger points and referral zones for the supraspinatus

20. Stressors and Perpetuating Factors
Supraspinatus TP Activation
Prolonged elevation of arms
Stressors and Perpetuating Factors
Lifting or carrying heavy objects i.e. briefcase
Walking a dog that pulls hard on the leash

21. Precautions and MT Considerations
Supraspinatus Precautions
Avoid using too much pressure
Mimics sub-deltoid bursitis
Common area for tendinitis
MT Considerations
Use pressure bar in back and forth motion only

22. Infraspinatus: Shoulder Joint Pain Muscle
Rotator cuff muscle
Produces pain deep within shoulder joint
Attachment sites for the infraspinatus

23. Infraspinatus Trigger Point
Infraspinatus TPs:
Found in the belly of the muscle
Causes intense anterior shoulder pain
Referral Zones
Refer pain lateral forearm, radial aspect of hand, fingers
Refer pain to posterior neck

24. Infraspinatus Trigger Point Map
Trigger points and referral zones for the infraspinatus

25. Stressors and Perpetuating Factors
Infraspinatus TP Activation
Acute overload
Lifting back to reach heavy objects
Stressors and Perpetuating Factors
Sleeping on affected and unaffected side
Mis-hitting a ball during racquet sports

26. Precautions and MT Considerations
Infraspinatus Precautions
Muscle is prone to TP formation
Work gently; muscle is extremely tender
MT Considerations
Examine infraspinatus insertion in all rotator cuff injuries
Examine in all shoulder, arm and hand syndromes

27. Teres Minor: The Silver Dollar Pain
Rotator cuff muscle
Teres Minor a.k.a the little brother to infraspinatus
Attachment sites for the teres minor

28. Teres Minor Trigger Points
Teres Minor TPs:
TP in the muscle’s belly near musculotendinous junction
Pain the size of silver dollar
Referral Zones
Refer pain to posterior deltoid area
May result in numbing and tingling in 4th and 5th finger

29. Teres Minor Trigger Point Map
Trigger points and referral zones for the teres minor

30. Stressors and Perpetuating Factors
Teres minor TP Activation
Teres minor is not a single muscle syndrome
TPs activated with infraspinatus TPs
Stressors and Perpetuating Factors
Holding steering wheel too tight during accident
Playing volleyball

31. Precautions and MT Considerations
Teres Minor Precautions
Work gently; muscle is extremely tender
MT Considerations
Work teres minor and infraspinatus together
Infraspinatus TP referrals present as pain in front of shoulder
Teres minor TP referrals present as pain in back of shoulder

32. Latissimus Dorsi: Midthoracic Backache
Attachment sites for the latissimus dorsi

33. Latissimus Dorsi Trigger Points
Latissimus Dorsi TPs:
Often confused with intrathoracic disease pain
Usually found in upper and lower muscle bellies
Referral Zones:
Refer as mid-thoracic back pain
Constant aching at the inferior angle of scapula

34. Latissimus Dorsi Trigger Point Map
Trigger points and referral zones for the latissimus dorsi

35. Stressors and Perpetuating Factors
Latissimus Dorsi TP Activation
When muscle is stretched by reaching forward and up
Wearing a tight bra
Stressors and Perpetuating Factors
Hanging from a rope
Throwing a baseball

36. Precautions and MT Considerations
Latissimus Dorsi Precautions
Firmly grasp the entire bundle lateral to armpit
Creates discomfort if just the bundle’s edge is pressed
MT Considerations
Pincer compression is very effective
Can also use a side-lying position

37. Teres Major: Latissimus Dorsi’s Twin
Teres major, latissimus dorsi, long head of triceps brachii work together as a myotatic unit
Attachment sites for the teres major

38. Teres major Trigger Points
Teres major TPs
Found mid-muscle belly to area of origin
Also found in musculotendinous junction
Usually produces no tenderness
Referral Zones
Refer to posterior deltoid, long head of triceps brachii

39. Teres major Trigger Point Map
Trigger Point and referral zones for the teres major

40. Stressors and Perpetuating Factors
Teres major TP Activation
Driving a vehicle with no power steering
Serving in a tennis match
Stressors and Perpetuating Factors
Using a butterfly stroke to swim

41. Precautions and MT Considerations
Teres Major Precautions
When compressing the latissimus dorsi and teres major
together they can be extremely tender
MT Considerations
Pincer compression is very effective
Isolate muscle from the latissimus dorsi

42. Serratus Anterior: Stitch in Side Muscle
Serratus Anterior TPs
Mild TPs; create a stitch in side sensation
Cause shortness of breath or inability to take deep breaths
Referral Zones
Refer to chest
May contribute to heart attack pain

43. Serratus Anterior Trigger Point Map
Attachment sites and trigger points with referral zones for the serratus anterior

44. Stressors and Perpetuating Factors
Serratus Anterior TP Activation
Excessive exercise
Severe cough
Stressors and Perpetuating Factors
Lifting heavy weights
Irritation from asthma, smoking, pollution

45. Precautions and MT Considerations
Serratus Anterior Precautions
Burning sensation occurs when muscle is worked on
MT Considerations
Weak muscle indicated in winged scapula
Most of muscle is obstructed by pectoralis major

46. Rhomboids: Round Shoulder Muscles
Rhomboids are antagonistic to the pectoralis muscles
Pectoralis muscles are much stronger
This imbalance overstretches the rhomboids
Result in a chronic round shoulder posture
Attachment sites for the rhomboids major and minor

47. Rhomboids Trigger Points
Rhomboids TPs:
TPs are rare in rhomboids
TPs have similar pattern to levator scapula (without neck involvement)
Referral Zones:
Refer to medial scapula and between shoulders

48. Rhomboids Trigger Point Map
Trigger points and referral zones for the rhomboids major and minor

49. Stressors and Perpetuating Factors
Rhomboids TP Activation
Leaning forward and working with rounded shoulders
Side sleeping
Stressors and Perpetuating Factors
Scoliosis in upper thoracic area
Sewing or writing in long hand

50. Precautions and MT Considerations
Rhomboids Precautions
Muscles are thin; do not use too much pressure
MT Considerations
Examine rhomboids when fibromyaglia is diagnosed
TPs sensation often misdiagnosed as scapulocostal syndrome