Introduction to the CTB™ Approach and Scapular Positioning

Focus: Scapular positioning is a term that we use to talk about the normal or at rest position of the scapula. The scapular stabilizer muscles exist in a carefully orchestrated relationship. Ideally, these muscles will each be at a relatively normal resting length, however it is very common for some fibers to become chronically shortened, and their antagonists to defacilitate and exist in some degree of stretch at all times.

This relationship determines our shoulder posture. Many factors can influence this group of muscles and cause distorted posture. Excessive protraction is very common, also called rounded shoulder posture.

At the Coaching the Body Institute, we've developed a scapular positioning treatment approach using the Muscle Liberator™ tool that can be completed typically in 45 minutes or less - sometimes much less. This is an extremely valuable treatment, because improper positioning of the scapula can in turn trigger dysfunction and pain in many other muscles.

Our treatment is easy to understand, because it analyzes fiber directions and classifies the stabilizers into easily remembered groups of agonist and antagonist. We get fantastic results with this treatment, and it represents a core part of any therapist's arsenal in treating shoulder pain.

• Using the Muscle Liberator™
• Intro to Coaching The Body™
• Intro to the Scapular Positioning Treatment
  
• Serratus Anterior Fiber Directions

Trigger Point Physiology

Focus: In this lesson we go in-depth on the micro and macro physiology of trigger points; how and why they are formed and how they cause neuromuscular dysfunction and pain.  Trigger points are a major source of pain in the body, yet they are completely unknown to most conventional medical practitioners.  Even when therapists are aware of trigger points, the origins and physiology remain a mystery.  In this course we draw back the curtains and delve into the "trigger point mystery".  Understanding the physiology of trigger points will enhance your clinical work and help you explain the nature of referral pain to your clients.

Dr. Janet Travell was a cardiologist and avid tennis player.  In the 1940's she experienced anterior shoulder pain that disrupted her tennis playing.  She discovered that if she put compression on tender points in the infraspinatus muscle (posterior shoulder), she would feel her anterior shoulder pain.  She had her father (also a cardiologist) inject the tender points with procaine using a hypodermic syringe.  Her anterior shoulder pain disappeared.  Thus began her and Dr. David Simons' comprehensive investigation of trigger points and referral pain.  Together they authored Myofascial Pain and Dysfunction, The Trigger Point Manual, the two volume "trigger point bible".

A trigger point occurs when the normal sliding filament mechanism of a muscle fiber becomes disrupted due to metabolic stagnation at the motor endplate zone.  The individual muscle fiber goes into contracture; the middle part of the fiber is hyper-contracted, irritable to touch and causes pain and many other symptoms, often far removed from the site of the trigger point.  In this course, we explore how trigger points form at a micro level and how they cause pain and movement dysfunction.

• Trigger Point Overview
• Trigger Point Animation 1
• Nervous System Anatomy
• Trigger Point Micro-Physiology
• Trigger Point Animation 2
• Trigger Point Macro Effects 1
• Trigger Point Macro Effects 2

Low Trapezius

Focus: The trapezius muscle is a large, superficial muscle on the posterior thorax with fibers fanning out more than 90 degrees.  It is a scapular stabilizer and is divided into 3 parts; upper, middle, and lower.  Each part has its own function.  This week the focus is on the low trapezius.

The low trapezius fibers attach from the spinal segments T5-T12 to the spine of the scapula.  It's action is to retract the scapula and it is a key scapular stabilizer during all motions of the arm.  If the low trap is not functioning properly there are vast repercussions.  Scapular positioning and shoulder posture is disturbed.  The ability of the scapula to rotate is inhibited.  The function and balance of the rotator cuff muscles is disturbed.  The proper functioning of the low trap is central to all scapular and glenohumeral movement.

Not only does it have "mechanical" influence throughout the shoulder and arm, trigger points in the low trap have a wide distribution of referral pain and can be the key to many satellite referral situations.  Low trap trigger points commonly refer strongly into the high trapezius, posterior neck and base of the cranium.  From there the referral chains upward into the head and jaw.  The low trap also refers over the middle trapezius and supraspinatus near the acromion process.  Additionally, the low trap is the satellite of other key trigger points in the serratus anterior and lat.  So, long chains of referral are possible all around the shoulder and to the head/neck with the low trap functioning as the central hub.

In terms of agonist/antagonist relationships, low trap is antagonist to the pec minor and high serratus anterior fibers.  These muscles protract the scapula while the low trap retracts the scapula.  In rounded shoulder and upper crossed syndrome, low trap is pulled into a chronically lengthened position and defacilitates.  It becomes unable to retract the scapula.

• Low Trapezius - Anatomy & Theory 1
• Low Trapezius - Anatomy & Theory 2
• Low Trapezius - Palpation
• Low Trapezius - Treatment 1
• Low Trapezius - Treatment 2

Pectoralis Minor

Focus: In week 4, we focus on the pec minor muscle.  It is an important scapular stabilizer and is the antagonist to the low trapezius, which we covered in week 3.  When normalizing scapular positioning, this is the first pair of muscles treated.

Pec minor is a strong protractor of the scapula.  It attaches above to the coracoid process of the scapula, below to ribs 3-5.  It is an accessory breathing muscle, and normally assists the upper chest muscles in lifting the rib cage during forced inhalation.  It can become troubled if it is chronically overloaded by dysfunctional breathing.  It is also capable of entrapping the thoracic outlet if it becomes adaptively shortened and tight.  This can happen when a client has chronically protracted shoulders.

Some muscles in the body tend to lengthen and defacilitate (e.g. low trapezius), others tend to shorten and tighten (e.g. pec minor).  In anterior shoulder posture (rounded shoulders, upper crossed syndrome), pec minor shortens and protracts the scapula while its antagonist, low trapezius, lengthens and defaciliates.  To be energy efficient in stabilizing this posture, the body purposefully converts normal muscle fibers into contracture fibers.  These contracture fibers act as straps that do not require energy input to maintain.  However, this distorted posture causes dysfunction of the shoulder and glenohumeral muscles, and produces pain.  The anterior shoulder posture is rampant in our culture of constant shoulder, thoracic and head flexion during computer and mobile device use.

In a scapular positioning treatment, low trapezius is treated first.  Most therapists will relentlessly hammer away at the low trap and are not able to soften the hard fibers very much.  It is important to monitor tissue change.  When the limit of hard fiber softening is reached with low trap, switch to treating the pec minor.  After pec minor is softened the low trapezius will be able to soften more.  It is very productive to flip back and forth between agonist/antagonist pairs to normalize their length/tension relationships.

• Pectoralis Minor - Anatomy & Theory
• Pectoralis Minor - Palpation
• Pectoralis Minor - Treatment 1
• Pectoralis Minor - Treatment 2

Clavicular, Sternal & Costal Pectoralis Major

The pectoralis major group of muscles is both a direct and indirect cause of shoulder pain. While this muscle group is implicated as a key component of Upper Crossed Syndrome, we find that the serratus anterior muscle is a more significant contributor to shoulder protraction.

The clavicular branch of the pec major is the most significant contributor to disturbed shoulder posture, and is a direct cause of anterior shoulder pain. We find this branch to be the most commonly involved in shoulder issues. The sternal and costal branches are far less common, and you would only expect involvement of these muscles when there is a lifestyle perpetuator of some kind.

Our scapular positioning treatment visits the clavicular branch because it tends to elevate and protract the scapula via the humerus. These fibers are effectively opposed to the low mid trap fibers.

• Pectoralis Major - Anatomy & Theory
• Pectoralis Major & Minor - Palpation
• Pectoralis Major - CTB™ Lecture
• Pectoralis Major - Treatment
  
• Pectoralis & Trapezius Treatment for Scapular Positioning

Complete Shoulder Coverage, Moving Into Other Body Areas

We will continue to delve deeply into shoulder pain for several more weeks, culminating in coverage of the full CTB™ Shoulder Protocol and Scapular Positioning Protocol. After that, we turn our attention to other important and common areas of pain complaints: knee pain, sciatica, low back, mid back, hip pain and much more. Given that this is a two-year program - when pursued in full - we have time to explore deeply each pain complaint. Students have opportunities to interact with instructors via a private Facebook group, course comments and live events.