DISTRIBUCIÓN POR PRINCIPALES REGIONES DE PUBLICACIÓN SOBRE RSU

The teres (TEH-reez) major and latissimus dorsi (luh-TISS-uh-mus DOR-sye) come together at the back of the armpit and then go around to attach to the front of the upper arm

bone near its top (Figures 5.31 and 5.32). Their action is to bring the arm down and in toward the chest. With the help of the posterior deltoid, they also extend the arm

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backward.

Teres major means "big round muscle." Latissimus dorsi means "wide back muscle."

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the latissimus dorsi is a muscle of the lower back, it's included in this chapter because it moves the upper arm and causes pain in the mid and upper back.

Trigger points in the teres major produce sharp pain in the posterior deltoid when you reach up and forward to

get something from a shelf (see Figure 5.31). When a nearby latissimus trigger point is active, this same motion

causes pain in the mid back centered on the inferior angle

of the shoulder blade (see Figure 5.32). A trigger point lower in the latissimus causes pain low on the side of the abdomen. When latissimus trigger points are unusually active, pain may extend to the inner side of the arm all the

way down to the ulnar or pinky side of the hand and the fourth and fifth fingers (not shown). Trigger points in either the teres major or latissimus dorsi can also inhibit the full stretch that is necessary to reach up and forward. They keep you from fully lifting your arm. (1999: 572- 578)

When you consider the importance of the teres major and latissimus dorsi for strongly pulling the arm down- ward, it's easy to imagine the kinds of strains and overuse

that can affect them. For the causes of trouble, look at activi-

ties such as gymnastics, tennis, swimming, rowing, chop- ping wood, pitching, or throwing a ball. Go easy with any exercise that involves pulling yourself up or pushing down

with your arms. Be cautious with work that makes you overstretch or repeatedly strain these muscles by reaching

forward or overhead.

Pinching the wad of muscle behind the armpit with the fingers and thumb is very effective for locating teres

major and latissimus dorsi trigger points, but massaging

them with the hand tires it very quickly (Figure 5.33). Luckily, these trigger points can be massaged almost without effort with the Thera Cane

or a

tennis ball against the wall. You may encounter an extremely tender area on the ribs just in front of the edge of the latissimus dorsi. This is a serratus anterior trigger point, which can make horrible pain in the side (see Chap- ter 7).

Coracobrachialis

The coracobrachialis (COR-ah-co-bray-kee-AH-liss) lies between the biceps and the triceps on the inner side of the upper arm. The muscle is a little larger than an index fin- ger and about twice as long. At its lower end, it attaches about halfway down the upper arm bone. At its upper end, it attaches to the Coracoid process, the little piece of the shoulder blade that sticks through to the front of the

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shoulder (see Figure 5.8). The action of the coracobrachialis pulls the arm tight against the side.

Pain from coracobrachialis trigger points is felt in the ante- rior deltoid, triceps, back of the forearm, and back of the hand (Figures 5.34 and 5.35). The more active the trigger points are, the more extensive the pain pattern becomes. Under extreme conditions, pain may reach as far as the end of the middle fin- ger. You may not become aware of the involvement of the

coracobrachialis in this pattern

until more obvious trigger

points in the shoulder and

upper arm have been deactivated. Trigger points in this muscle can make it difficult to put

the arm behind your back or raise it up overhead. A coracobrachialis shortened by trigger points can also squeeze the nerves that supply the arm, causing numbness in the biceps, forearm, and hand. (1999: 638-644)

Examples of activities that can strain this muscle are push-ups, rock climbing, rope climbing, swimming, throwing a ball, and playing golf and tennis. Any job that requires repeatedly pulling something downward can stress the coracobrachialis. Be careful about lifting heavy weight with the arms stretched out in front and the palms up.

To locate the coracobrachialis, press your thumb against the inner side of the humerus as high up as you can (Figure 5.36). You can feel the muscle contract at this location when you clamp your elbow tight against your side. This is also the place where you will find coracobrachialis trigger points. Massage them with gen- tle upward and downward strokes of the thumb, taking care to stay on the muscle. Major nerves to the arm run alongside the coracobrachialis in this area, so be conser- vative with your pressure.

Figure 5.35 Coracobrachialis posterior referred pain

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Biceps

The biceps has two heads, one head attaching to

the Coracoid process alongside the coracobrachialis, the other head attaching to the shoulder blade just above the socket (Figure 5.37). This attachment to the

shoulder blade lets the biceps help raise the arm. The

lower end of the biceps attaches to the bones of the forearm, which allows it to bend the elbow and help turn the hand over palm-side up.

Another extremely important function of the biceps is to participate in keeping the arm firmly in its

socket. Many muscles work to maintain the shoulder joint, but without the biceps it would be impossible to carry any weight at all without pulling the joint apart.

Trigger points in the biceps cause pain or aching

primarily in the front of the shoulder itself and in the crease of the elbow (see Figure 5.37). They cause little

pain in the biceps itself. You may also experience

weakness in the arm and difficulty in completely straightening the arm with the palm facing

up. A vague ache may sometimes be felt in the supraspinatus area behind the shoulder (not

shown). Pain referred to the shoulder from the biceps may be mistaken for tendonitis or bur-

sitis. (1999: 654)

Trigger points can be started in the biceps by pain referred to it from the infraspinatus or subclavius muscles. (1999: 652) Other common causes of

trigger points are overexertion in

sports activities, lifting heavy weights with the palm up, and

exercises that strongly flex the

elbow, such as pulling up to a chinning bar. Repetitive strain in the workplace—for example, continuously turning a screwdriver—will exhaust the biceps. Be mindful of any activity that necessitates maintaining a contracted biceps. An example of this is violin playing, which requires the left biceps to be in maximum contraction to keep the hand in position on the fingerboard. Violinists' right biceps often develop trigger points from the continual contracting and lengthening during bowing.

Trigger points may be found in either head of the

biceps at the midpoint of the muscle. Massage the muscle with the supported thumb or rake it deeply with the knuck- les (Figure 5.38). Don't get caught up in massaging the ten- der referral area on the front of the shoulder. Consult this chapter's Trigger Point Guide for all the muscles that refer pain to this area: note that the biceps is low on the list.

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Triceps

The triceps is a long, broad muscle with three branches or heads. The attachment

of the

muscle to the ulna, one of the two bones of the forearm, gives it great leverage for straight-

ening the elbow: the triceps is solely responsible for this function. The attachment of

the long

head of the triceps to the shoulder blade helps keep the arm in its socket. Triceps trigger

points occur at five different sites and evoke five distinct pain patterns.

Triceps number 1 trigger point sends pain to the back of the shoulder and the outer

elbow (Figure 5.39). When bad enough, it can refer pain into the upper trapezius and the

base of the neck (not shown). Although this is the most common triceps trigger point, its

location at the inner edge of the triceps makes it easy to miss. (1999: 667-668) Triceps number 2 trigger point, being- very close to the elbow where the muscle is relatively thin, is also easy to miss. It's one of many sources of the pain in the outer elbow known as "tennis elbow" (Figure 5.40). Pain may extend some distance down the back of the forearm. (1999: 668-669)

Triceps number 3 trigger point in the lateral head causes local pain in the back of the upper arm (Figure 5.41). It has special importance because it can keep the lateral head tight enough to compress the radial nerve, causing numbness in the thumb side of the forearm and hand. (1999: 668-669)

Triceps number 4 makes your elbow hypersensitive to touch, making it unbear- Figure 5.41 Triceps number 3 trigger point and able to rest on a tabletop or the arm of a

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Triceps number 5 refers pain to the inner elbow and sometimes to the inner forearm

(Figure 5.43). Pain at this site is sometimes called "golfer's elbow." (1999: 668-669) When active enough, any of these trigger points can cause pain in the fourth and fifth

fingers. Any of them can also create an oppressive sense of achiness in the back of

the fore-

arm and in the triceps itself. Triceps trigger points can be expected to weaken the

elbow and

limit both its bending and straightening. Arthritis, tendonitis, and bursitis are common explanations for pain referred to the elbow by the triceps when the effects of trigger points

haven't been considered.

Overexertion in sports or the workplace can create trigger points in the triceps, particu-

larly any strong, repetitive pushing action. Simply holding something down for a long, unrelieved period can make the triceps knot up. Sometimes trigger points in the triceps are secondary to unsuspected trigger points in the latissimus dorsi or the serratus poste- rior superior.

A convenient and effective way to mas- sage the triceps is with your knuckles, using a tennis ball to give support to your hand (Figure 5.44). This technique works best on a desktop, a tabletop, a filing cabinet, or even the top of an old-fashioned upright piano. You can also use the ball-and-knuckles trick

against your chest or on your knee. Another

good idea, especially for the outer edge of

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C

6

Elbow, Forearm, and Hand