Editor’s note: The following article was adapted from Myofascial Release Therapy by Michael J. Shea, PhD, and Holly Pinto (North atlantic books, 2014).

Myofascial release offers the possibility to restructure past somatic experience and to reform or create a new structure. When the client’s contact with the world is thwarted by orthopedic injury, shock/trauma, stress, and so on, the inner world of the body becomes distorted. A central focus of myofascial release is to rearrange these distorted myofascial patterns. Let’s take a look at how this work can be applied to a client’s shoulder and arm issues.

Clavicle, Coracoid Process, and Sternum
The client should be in a supine position. Image 1 shows the therapist palpating either end of the clavicle. Place your thumb, or the pisiform bone surface of both hands, on the opposite ends of the individual clavicle and compress inferiorly and medially. Repeat slowly, in unison with the breath, until you feel the clavicle soften and release.
Next, palpate the coracoid process. Use the pisiform surface of your hand or thumb to compress posteriorly until its range of motion has increased. If it does not release, use your opposite hand to distract the distal end of the clavicle or alternate compression of each (coracoid process and clavicle) until a release occurs (Image 2).
To work the sternum, place the heel of your hand over the xiphoid process, but not directly on it. Place the heel of your opposite hand over the sternum above the angle of Louis (the junction between the body and the manubrium of the sternum). Slowly compress both hands posteriorly and together. The release is obtained when the bone feels more resilient and has increased mobility.

The Work: Clavicle, Coracoid Process, and Sternum
Client Position: Supine
1. Palpate each end of the clavicle by pressing inferiorly and medially.
2. Do this in unison with the breath until a release is felt.
3. Palpate the coracoid process posteriorly until the range of motion increases.
4. Place the heel of your hand over the xiphoid process and the heel of your opposite hand over the angle of Louis, and press posteriorly until the range of motion increases.

Subclavian Muscle
The release of the subclavian muscle is a favorite technique. In Image 3, the therapist has placed a clavicle on the client, pointing to where the subclavian muscle is in relation to the rest of the skeleton. As you can see in Image 4, the client is in side-lying position, while the therapist’s thumb forms a wedge between the clavicle and first rib, and his opposite hand holds the shoulder around the deltoid. The key to this technique is to elevate the shoulder you are working on toward the ear, thus elevating the clavicle. This will allow you much deeper access into the subclavian muscle.
Start your pressure right at the sternum between the clavicle and first rib. Move the shoulder up and attempt to hook your thumb under the clavicle as though you were going to stretch the periosteum of the clavicle. Move half an inch at a time along the underside of the clavicle, and in the first several inches, you will feel what appears to be a tight band—the subclavian muscle. As you apply pressure, which in this case can be 5 to 10 pounds, you will feel that ligament begin to soften. Do not stop there. Continue your search under the clavicle, moving distally, very slowly, until you reach the coracoid process.
This is a good stretch for the clavipectoral fascia, and as you get closer to the coracoid process, you will run into the conoid and trapezoid ligaments that attach the clavicle to the coracoid process. With your thumb or your fingers forming a wedge between the coracoid process and the clavicle, maintain a static pressure until you feel those ligaments start to stretch (Image 5). Do not forget to use the opposite hand to elevate and slightly circumduct the shoulder while doing this. It is as though you are using the clavicle as a stick shift and you are attempting to find the right gear that will allow the release. Some coordination is needed between your right hand and your left hand.
Make sure you observe the before and after position of the clavicle. With any technique around the trunk, ribs, or clavicles, always ask the client at the end of the technique to take a slow, full breath into the area that was just worked. This will allow for a much greater release, and again will allow the client to develop an internal awareness of any changes that have taken place. It is especially important because of the connection the lungs and pleura have to the first rib. The subclavian artery is between the clavicle and first rib. Whenever the subclavian muscle is tight, it will obstruct the subclavian artery. The vertebral artery branches off the right and left subclavian arteries and weaves its way up into the head through the transverse processes of the cervical vertebra. The vertebral artery then branches off to form three other arteries: the basilar, cerebella, and meningeal. If you suspect cerebral vascular insufficiency is present in a client, it will be well worth your effort to free the subclavian muscle.

The Work: Subclavian Muscle
Client Position: Side-lying, with knees flexed 45 degrees
1. Using your thumb, form a wedge between the inferior aspect of the clavicle and first rib at the sternum.
2. With the other hand, elevate the shoulder toward the ear.
3. Search for tight bands moving medially from the sternum toward the coracoid process.
4. Do not forget to use the opposite hand to elevate or circumduct the shoulder while doing this.
5. Cue the client to take slow, deep breaths into the area that was just worked.

Superficial Fascia of the Arm
The fascia of the arms is continuous with the cervical fascia and is often overlooked. As seen in Image 6, you may have the client lay prone, and her head can be turned in either direction. You can experiment with the head position by turning it to the opposite direction and seeing if that shortens the arm you are working on, and vice versa. Take your fingertips right over the attachment of the deltoid muscle in the upper arm and get ahold of as much of the superficial fascia of the arm as you can. While you are moving down the arm inferiorly, several inches at a time, you can have the client lift her head and slowly turn it one way and then the other. Alternately, you will also have her bend her elbow slowly toward the side of her body and back, as well as dorsiflexing the wrist and hand.
What is really effective about this technique is that you can work down the entire length of the arm. While around the elbow, it is convenient to work the fascia off the olecranon process. Below the elbow, you can get much more deeply into the interosseous membrane of the forearm. While working deeply in the forearm in this manner, have the client roll her arm very slightly back and forth, or pronate then supinate the forearm, but very slowly so it does not throw your fingers out of position. Although Image 7 does not show it here, you can certainly keep going right down over the retinaculum of the wrist. It is here that you would be more active with wrist flexion while you are working that fascia. This technique is found to be particularly beneficial for anyone who has had a whiplash injury and was the driver of the car. The numerous ways in which back problems occur from lifting can also be addressed very nicely this way. Remember that the fascia of the arm goes in four basic directions when they meet at the shoulder girdle: to the temporomandibular joint (TMJ), to the scalenes, to the upper trunk muscles, and to the lower trunk muscles. You will really enjoy this particular work as a way of finishing any work done on the trunk, neck, or head. As an alternative, you can have the client turn her head slowly while you are working the arm. This will assist the cervical fascia to release.
These techniques are effective for local problems in the arm or as a way to finish up neck work.

The Work: Superficial Fascia of the Arm
Client Position: Prone
1. Fingertips begin in the posterior deltoid muscle, moving superficial fascia down the arm inferiorly several inches at a time.
2. The vector is in and down the arm.
3. The client lifts her head, slowly turning one way or another, as well as dorsiflexing the wrist and hand.
4. While around the elbow, work the olecranon process and deeply into the interosseous membrane of the forearm.
5. Have the client roll her arm back and forth slightly.
6. Use an elbow while working the forearm, if necessary.

Clavipectoral and Deltoid Fascia
In some respects, these techniques are the same as those of the superficial fascia of the arm. However, these flexors of the arm tend to be the most problematic. You may start with your fingertips or elbow at the head of the humerus, very close to the coracoid process (Image 8, page 90). The deltoid is stretched while the client has her palm down on the table and periodically moves her elbow toward the side of her body and back out. Tell the client to imagine she has a dime under her elbow, and she is trying to slide that dime toward her body and back out. This way, she does not have the temptation to lift her elbow and rotate it in order to move it toward her body. This type of movement gives greater access to the deeper fascia of the arm and thus the entire body. As before, only move several inches at a time, then give the client a break and occasionally ask her to take a breath into the area you just worked.
Spend time around the anterior deltoid as well as the middle deltoid, because this is where the fascia will usually bunch up. The direction of movement is from the top of the shoulder down toward the elbow, and you can spend several minutes on each deltoid. You can even “clean” some of the tissue off of the distal end of the clavicle, as well as over the coracoid process, if it is buried with a lot of tissue that has resulted from injuries to the upper girdle. The important thing with this technique is to keep the arm and hand as flat as possible on the table. This requires the client to keep some degree of tension in her arm to maintain this position. The tendency is for the arm to pop up when pressure is applied over the head of the humerus. You can use your opposite hand to hold down the wrist if you need to. When you ask the client to move her elbow in and out, have her make small movements. She does not need to move any more than an inch or two at a time. The movement should be done slowly to affect the deeper fascia and the interosseous membrane. You can work down into the biceps or laterally over the edge of the humerus. Another option is to pin the pectoralis tendon in the glenohumeral joint, have the client rotate her shoulder laterally, and then stretch her arm down toward her foot (Image 9). Wait for a softening and then return to neutral and disengage.

The Work: Clavipectoral and Deltoid Fascia
Client Position: Supine
1. Fingertips begin in the deltoid muscle, moving superficial fascia down the arm inferiorly, several inches at a time.
2. The client can imagine she has a dime under her elbow and is trying to move it toward her body and back out.
3. Use your fingertips or elbow.
4. Spend some time working in this area.
5. Pin the pectoralis tendon.
6. Have the client rotate her arm laterally and stretch it toward her feet.
7. Wait for a softening and return to neutral.

Teres Major and Minor
Place your elbow just slightly inferior to the axillary border and just inferior to the acromion. Pause and sink to an appropriate depth. Your vector or line of drive is on the coronal plane toward the midline. Instruct the client that when you happen upon a tender or tight spot, you will pause and allow her to slowly internally and externally rotate her shoulder (Image 10). This is like a pin and stretch, and is very effective in treating those attachments. Glide slowly along the axillary border. Once you have reached the inferior angle, lighten your pressure and come off. You can repeat this three or four times, or as the client can tolerate. This release can be used for any shoulder problem.

The Work: Teres Major and Minor
Client Position: Prone, with arm hanging off the table at a 90-degree angle
1. Face away from the head and place your elbow on the coronal line of the axillary border, just inferior to the spine of the scapula.
2. Search for tight tissue.
3. Ask the client to internally and externally rotate her shoulder.

Subscapularis Muscles and Pectoralis Minor
Begin work on the subscapularis by approaching the axilla directly on the coronal plane of the body with the client in a supine position and her arm at a 90-degree angle. Palpate with the pads of your fingertips against the rib (Image 11). Press into the ribs to mobilize them, and at the same time, follow the ribs around posteriorly at an angle toward T4. When your fingers cannot go any further, you have bumped right up against the subscapularis. At this point, ask the client to extend her arm over her head very slowly while you hold the subscapularis. Remember to have her take a breath when she brings her arm down. Another option is to have her take her arm up to the ceiling, and horizontally adduct her arm to her chest. This puts her scapula at your fingertips.
To release the pectoralis minor, turn your hand around and enter into the axilla at the coronal plane, as before, and slide your fingers over the ribs toward the manubriumas (Image 12). When your fingers cannot go any further, you have contacted the pectoralis minor. Then, repeat the same procedure as before: ask the client to extend her arms slowly over her head and occasionally have her take a breath into the point of contact. It is not unusual for the client to report a burning sensation, which is indicative of the fascia stretching. You should not usually repeat the axilla work more than two or three times. Remember, this is a very sensitive area, so go slowly yet firmly.
The brachial plexus is sometimes entrapped by the pectoralis minor, causing numbness, tingling, and weakness down the arm. Make sure a medical professional has ruled out any pathologies of the thoracic or cervical spine. This technique is very effective for anyone who has a shortening of the pectoralis minor from trauma, poor posture, or repetitive motion injuries.
Many students start too low and end up stretching the serratus anterior. Aim your hand directly into the axilla at the mid-coronal plane of the body. Keep the pads of your fingers against the ribs. Always motion test the ribs you are on before you proceed. Press into the ribs very slowly with several pounds of pressure. If they feel hard and resistant to the pressure, they are stuck. Maintain a firm pressure on them and ask the client to breathe into your point of contact. Within two or three cycles of respiration, you should feel the rib start to move. Then, continue moving the tips of your fingers around in the direction described above. If the client reports sensitivity, ask her to breathe into the point of contact. Repeat this procedure several times. Each time, see if the client can reach even higher over her head. As she returns her arm down to the starting position, have her inhale again as you lighten up your contact.
This work is very effective for neck and shoulder problems because it opens up the clavipectoral fascia and deep cervical fascia.

The Work: Subscapularis
Client Position: Supine, with arm at 45 degrees
1. Approach the axilla on the coronal plane and gently make contact with the ribs.
2. Mobilize the ribs to check for movement.
3. Angle your fingers down and slightly inferiorly toward T4, feeling for the border of the subscapularis.
4. Ask the client to extend her arm over her head.
5. Another option is to horizontally adduct the client’s arm, and the scapula will begin to abduct.
6. This will make it easier to come into contact with the anterior surface of the scapula.
7. Ask for a breath and wait for a softening.
8. Friction can be used when indicated.
9. Ask for breath when coming out of the release.

The Work: Pectoralis Minor
Client Position: Supine, with arm at 45 degrees
1. Approach the axilla on the coronal plane and gently make contact with the ribs.
2. Mobilize the ribs to assess for movement.
3. Angle fingers up and over toward the manubrium.
4. When fingers cannot go any further, you are in contact with the pectoralis minor.
5. Ask the client to extend her arm slowly over her head.
6. Occasionally ask for breath into the area of contact.
7. May repeat two to three times.
8. This is a very sensitive area. Enter mindfully.

Biceps and Extensor Compartment of the Forearm
Image 13 shows the therapist using a broad, soft fist to stretch the bicep. Your ability to move from a broad surface to a smaller surface depends on the tool you are using. Fingertips or knuckles allow you to do some detail work on individual spots of the fascial bag that are stuck. With a slight switch in the position of your hand to fist or elbow, you can take that release into a much broader plane of fascia. This is called organizing the fascia. As with the preceding techniques, keep the client's arm and hand as flat as possible on the table so the technique can be more effective, and use the same type of elbow movement as before. Now it will be a little more challenging for the client to flex her elbow in and out since you are applying more pressure close to the elbow.
Once you get below the elbow, place the point of your own elbow on top of the extensor compartment and very slowly move straight down several inches at a time toward the wrist. Image 14 illustrates where your elbow is to be placed. This is a very strong action, because the motion you are asking the client to make is extending the wrist up. In this case, ask the client to focus on pointing her fingertips toward the ceiling. Remember, do not hold this as a static stretch—ask her to relax her hand occasionally. The closer you get with your elbow to the wrist, you need to think about whether you are going to switch tools and use your fingertips and knuckles to go over the retinaculum and carpal bones. In some cases when working with large wrists, you can continue right on over the wrist with your elbow and you need not be afraid to use a lot of pressure. This work is particularly beneficial for any driver in an automobile accident and for the increasing number of repetitive motion injuries that occur in the wrist and the elbow, especially among clients who work at a computer.

The Work: Biceps and Extensor Compartment of the Forearm
Client Position: Supine
1. Use your fist from deltoid to elbow, moving from a broad surface to a smaller surface when necessary.
2. Once below the client’s elbow, use the elbow point on top of the extensor compartment.
3. Move inferiorly down several inches at a time while asking the client to flex and extend her wrist.

Extensor Retinaculum of the Wrist and the Flexor Compartment of the Forearm
These techniques are especially beneficial to those clients who have had repetitive motion injuries to the wrist and forearms. In Image 15, the therapist is pressing down directly on top of the carpal bone with the flat portion of his knuckle. Another option is to use six fingers. The client has her hand lying flat on the table. The elbow is also flat on the table and pronated.
The therapist begins over the retinaculum of the wrist slightly superior to where Image 15 shows, and then gradually works his way down into the wrist and hands. Start on the midline of the forearm, or actually, in between the radius and the ulna. This work has you start on the midline, get contact with the tissue over the bone by touching into the bone, and then add a second vector by spreading the tissue laterally away from the midline. As you spread the tissue down into the wrist and away from the midline, you can also ask the client to bend her elbow in toward her body slowly and then back out. This will have a very big effect on the interosseous membrane, as well as the carpal tunnel. This is another area of the body where the superficial fascia and deep fascia of the body merge at the surface or outer layer of the body. People with chronic upper girdle problems have rarely had work done below the level of their elbows. You must remember, however, these fascia are interconnected, and most everyone has experienced falls on their hands and wrists at some time in their life.
The interosseous membrane is an excellent entry point into work for the whole arm, shoulder girdle, neck, TMJ, and trunk.
In Image 16, the therapist is working on the flexor compartments of the forearm and also the interosseous membrane. This is a very effective and simple technique, and begins right over the carpal tunnel of the wrist and continues all the way up to the elbow. The pressure is deep, firm, and continuous for several inches at a time. The client should be reminded to keep her fingers stretched and extended while you are working, and she can also roll her forearm by pronating and supinating occasionally while you are between the radius and the ulna. When you get close to the elbow, you can then ask the client to flex her forearm slightly. This will have an effect on the fascia of the coracobrachialis and biceps muscles. All in all, these two techniques are the ones you may use consistently with clients with upper extremity problems, and especially for TMJ disorder and cervical whiplash. Remember that the driver in every single whiplash case is usually gripping the steering wheel very powerfully, and the point of impact causes a force vector to come through the hands and wrists directly. Again, this is a forgotten element in the treatment of high-velocity impact traumas.

The Work: Extensor Retinaculum of the Wrist and the Flexor Compartment of the Forearm
Client Position: Supine
1. To work the extensor retinaculum, have the client pronate her forearm with her hand flat to the table.
2. Start at the midline over the retinaculum of the wrist.
3. Apply pressure using flat knuckles or fingers, and spread laterally, working down into the wrist and hand.
4. The client can slowly bend her elbow toward her body and back out in small movements.
5. To work the flexor compartment, have the client supinate her forearm with an open palm.
6. Start at the carpal tunnel of the wrist.
7. Apply pressure using fingers or elbow and work up to the elbow.
8. Keep pressure deep and continuous, and move only a few inches at a time.
9. The client can slowly pronate and supinate forearm while you work between the ulna and radius.
10. The client can flex her forearm while you work close to the elbow.

Michael J. Shea, PhD, LMT, has been a massage therapist in Florida since 1975. He completed advanced Rolf training and was an assistant instructor at the Rolf Institute before obtaining a doctorate in Somatic Psychology. He was a member of the Massage Therapy Body of Knowledge Task Force that set nationwide standards of practice for the massage therapy profession. For more information, visit www.michaelsheateaching.com.