“The scalenes,” said one of the therapists. “I think I could make a really good case for scalene involvement for a number of reasons.”
“I could make a case that the pectoralis minor might be slightly more important,” countered one of the other therapists. “I think this is true because of her scapular position. We could test whether this is correct, but I like the pectoralis minor as a major player.”
“Maybe, but I still like the scalenes,” the first therapist replied.
Since I did not respond, the six participants looked at each other, thinking they must be missing something. After a quiet pause, more muscular influences in thoracic outlet syndrome were explored and debated. When I still didn’t say anything, the flow of ideas gave way to silence.
Before going further, let me explain the context. A few times a year, I conduct an advanced training where six therapists and I see clients together, in the tradition of grand rounds. Most often, as in this case, I have never met the client previously, so the situation is as real as possible. These clients aren’t coming in to be models for educational purposes—they expect results.
When Ms. M., our present client, addressed the group, it was clear she was extremely reticent and seemed a bit unsure about this whole endeavor. That is certainly understandable, as having seven therapists ask questions can feel a bit like an intervention. Still, her hesitant demeanor was significantly more than other clients who have participated in the past.  
After my silence at their suggestions, I challenged my students to recount what Ms. M. shared with us when we asked her how we could help her today. As a group, they recounted the history, with three possible areas of focus. Ms. M. described a nagging ache in the area of the right scapula and upper ribs. She also revealed how she used to have thoracic outlet symptoms, but these were largely resolved by several visits to a physical therapist. Third, she described having annoying tension headaches, but they were episodic and today just happened to be a headache day.
“What are you looking for?” asked one of the therapists. “Are we missing something?”
“You are indeed missing something,” I answered.     “I think you are missing the very reason Ms. M. is coming to see us. Ms. M., could you tell us again, what is the most important result you would like from our session today?”
“I’d like you to work on this annoying pain in my shoulder,” she said, grabbing her upper trapezius and rhomboid. “The headaches come and go and the numbness in the fingers, as I said, has been much better after the physical therapy sessions. This shoulder pain just won’t seem to go away and is really affecting my daily life.”
This was a summation of exactly what she said earlier; nothing had changed, she just restated her goal in a more succinct way. My class, a group of stellar therapists, immediately grasped what she was sharing with us. While interesting for the group, the thoracic outlet symptoms were not her major concern. The ache behind her scapula was.
If you remember, Ms. M. was quite reticent as she spoke to us, somewhere between being a bit fearful but also skeptical. Giving her the opportunity to point out her priorities to my group, restating and reemphasizing them, completely changed her demeanor. She visibly relaxed and was now fully engaged in the process.
After Ms. M. left, my therapists and I had a wonderful and rich discussion about the appointment and the lesson learned. It is paramount that we, as massage therapists, make sure to address the goal of the session, as stated by the client. My group, as I and many other therapists have mistakenly done in the past, can get pulled down the rabbit hole of symptoms we find interesting, but that are not the major concern of the client. The paradox is that this mistake often becomes more likely as the knowledge and treatment abilities of the therapist increase. I have seen this mistake most often occur when a therapist understands that a client’s presenting symptom may originate somewhere else in the body. Unless the client understands this connection, they are likely to feel that the therapist did not address their main complaint.
Saying this, I fully understand there are times when the client’s initial concern may not be the ideal treatment protocol. In those cases, we need to clearly explain our rationale for our approach and make sure the client is fully on board with the choices made. Addressing the client’s main concern gives them a sense of validation, that their priorities are our priorities. When both client and therapist are aligned in that effort, amazing and wonderful things happen.