My main goal for writing this article is to bring to your awareness to a complex that I feel has great influence on the body, is not easily understood and often either not treated at all or miss treated. I also hope to stimulate you to think outside your comfort zone of techniques, from what you are currently utilizing.
Dysfunctions of this complex can have serious detrimental effects on the functionality of the body, in general the cervical structures, the anterior and posterior thoracic structures. These dysfunctions can pose global effects on posture, and overall systemic function.
Acute and chronic dysfunctions here have the potential to affect the spinal orthopaedics of the cervical, thoracic and lumbar vertebrae, musculoskeletal function, respiratory function, cardiac function, digestive functions, neurovascular functions, Lymphatic functions, CNS and more.
Dysfunctions to this complex occur from various reasons:
MVA’s where the drivers arm is placed either on the steering wheel, resting on the door, seat belted shoulder or the opposite non belted shoulder, side, front, rear MVA impacts, FOOSH (Fall On Out Stretched Hand) forwards, backwards or to the side, dislocations, AC separations, contusions, fractures of the upper extremity, Adhesive Capsulitis, immobilization of the extremity, MMA injuries, holding the leash of a large dog etc…
Postural imbalances can develop from obesity, psychological pathologies, and emotional issues. Flexed forward posture or military posture can develop from work related improper lifting techniques. We see these postures in occupations such as – UPS delivery person, water delivery person, construction/labourer, auto-mechanic and don’t forget massage therapists and chiropractors, amongst others. It’s a wonder that this SMMCC complex tolerates our influences on it.
This complex consists of tissues not limited to the following:
Superficial and deep cervical fascia, deep thoracic fascia, Submandibular and digastric fascia, SCM, endothoracic fascia, pleura, mediastinum, clavicle, upper 3 ribs, manubrium and sternum, AC joint, various joint capsules and ligamentous articular structures, musculature of the cervical and upper thoracic area, neurovasculature and viscera.
Indirectly this SMMCC complex has influence on diaphragm function, iliopsoas, lumbar vertebral coupling motions, digestive function, gait and joint and muscular complaints of the lower extremity. Now I’m not saying that if your patient complains of knee pain and they’ve been diagnosed with OA that you only treat the SMMCC… that would be wrong…. but that you look at the global posture and ask yourself if you can see the connections. In many cases you will.
Below is a quick review of some of the anatomy of the area and influences it has on this complex.
This first pic is the basic anatomy, a lateral view that illustrates just how close things can get within this small area. Here we have just the musculoskeletal structures and not much else. We can see the sternoclavicular joint capsule, interclavicular ligaments, costoclavicular ligament (aka rhomboid ligament) and the subclavious muscle.
Costoclavicular ligament
In “Disorders of the Shoulder: Diagnosis and Management 2nd Edition” by Lippincott, this ligament is described to have both anterior and posterior sections with a bursa between them. The anterior fibers resist excessive upward rotation of the clavicle and that the posterior fibers resist excessive downward rotation.
Subclavious muscle
As it runs from beneath the clavicle over the first rib, the subclavious muscle attaches medially onto the 1st rib. Fibres and fascia of subclavious blend/attach to and become structures, such as the SC ligs and capsule, costcoclavicular lig., anterior and medial scalenes, mediastinum, external intercostal fascia and muscles and endothoracic fascia amongst others.
Trigger points located within the subclavious muscle can regularly refer to the anterior arm and lateral forearm into the thumb, index and middle fingers. I’ve found many times that TP’s within this muscle are overlooked by therapists. TP’s here may be confused with Thoracic Outlet Syndrome or Carpal Tunnel Syndrome & can contribute to the development of TOS.
The Clavicle
There are a number of movements that can become dysfunctional when the clavicle is involved with cervical or thoracic injuries. These dysfunctions can cause pain/tension cycles in many of the surrounding structures and can persist if not recognized by the manual therapist.
The clavicle plays an intimate role with thoracic respiration. With inhalation the clavicle rolls posterior-superiorly and with exhalation the clavicle rolls anterior-inferiorly. These movements must be restored if functional respiration is to be returned.
The sternal end of the clavicle, separated by a complete intra-articular disc. Meniscoid impingements of this disc can actually be heard when the patient or therapist moves the extremity. Besides the numerous injuries that can occur to the MSAK here, dysfunctions of the SC joint can also be due to arthopathies such as Rheumatoid and Osteoarthritis, Ankylosing spondyloarthritis, Tietze’s Syndrome (costochondritis), Friedrich’s Disease (avascular necrosis) and infection.
The sternomanubrial joint (Angle of Luis)
This angle is also the landmark for the 2nd rib attachment. You can see in this picture what possible influences dysfunctions at the second rib attachment at this angle can have on structures posterior to it.
In this next pic, I’ve included the neurovasculature. Missing is the lymphatic, adipose tissue and connecting fascia, which when inserted, make for very close quarters.
In this cross sectional picture, we truly get a sense of just how close packed all the structures are. Missing is the fascial connections to all the tissues. Once tolerance to stimulus in one structure decreases, you can see how it will affect the tissues not only next to it, but how it can affect all the tissues.
One muscle that is overlooked is the ommohyoid muscle. You can see it as it just overlaps the brachial plexus where the neurovasculature bundle has its upper, middle and lower trunks. Remember that this muscle is always affected in MVA injuries. (Insert submandibular pic)
Connections to 1-5 ribs and beyond!
This complex has been shown to have connections to not only the first rib, but that it also has influence on not only ribs 3-5, but also the entire thorax and the humerus. Way over at the coracoid process, the clavicle has connections via the conoid and trapezoid ligaments (coracoclavicular ligaments.) These blend to become the pectoralis minor, biceps short head, coracobrachialis muscles.
Pectoralis minor attaches to ribs 3-5 muscularly. Fascially, it has connections that reach far inferiorly into the rectus sheath and beyond.
Indirect connections
It’s quite obvious, to me at least, that dysfunctions of the front of the body play a significant part in the majority of our patient’s complaints of posterior thoracic discomfort and pain. In some specific cases, the pain is being caused by an injury to posterior structures, but in a majority of the cases I’ve seen, the anterior structures are to blame.
If you discover a coupling dysfunction at T3, is it a complete treatment to just treat the soft tissues around the area? Are we doing a service to our patients by just concentrating on massaging the erectors, rhomboids, trapezius and posterior cervical musculatures?
What of the anterior structure? Why not treat those first? Allow the body the opportunity to sit in a correct posture and allow the posterior structure a vacation! They have, in many cases, been over worked and underpaid! That’s why they are cranky! They need a vacation!
In our course we discuss these and many more topics concerning how one small tissue can have disproportionally large effects on the rest of the body.
Conclusion
As always, I hope that I have been able to serve you in some way with this information, be it a completely new perspective into your patients, be it some new thoughts about how to approach a treatment or provide you with a review and acknowledgement that what you are doing, as far as I’m concerned, is having an amazingly positive impact in improving the quality of life for your patients.
Earn and Learn!
If you are interested in learning more about how to apply LASTechniques to the shoulder, here’s where you can learn!