Connecting the Dots

A Key to Massage Integration in the Health-Care System

By Douglas Nelson
[Table Lessons ]

“How is that connected?” she asked. “Does this muscle have something to do with my shoulder?”

“Actually, yes,” I replied. “Remember that this muscle, the latissimus, attaches to the anterior shoulder and therefore could possibly be a player in the pain you are feeling.”

My client, Dr. R., a primary care physician, smiled and shook her head with a little laugh. She seemed to possess the ideal qualities one could wish for in a doctor—an excellent listener, thoughtful, engaging, highly intelligent, and relates well to everyone she meets. She presented to me with pain in the anterior shoulder, which was diagnosed by her doctor as impingement and loss of subacromial space.

When we began the session, I palpated the greater tubercle and surrounding areas related to the impingement. There was indeed notable sensitivity in the area consistent with the diagnosis. She also described referred pain into the deltoid tuberosity, which is also quite typical. I remarked to her how all these presentations fit the picture.

“I think my diagnosis was probably spot on,” she remarked. “But my doctor came to that decision without even touching my shoulder. You know, there is something very comforting when you put your finger right on the area that caused me such grief. That is something I will remember when I see patients as well. It feels enormously satisfying to have the provider palpate the pain.”

A big amen to that. Touch is something that we, as massage therapists, do so often it is easy to forget how powerful it is for the client. After exploring the subacromial area and focusing on the attachment of the supraspinatus to the greater tubercle, I moved to the coracoid process and began exploring the pectoralis minor muscle.

“Wow, that’s surprisingly tender,” she said. “What possessed you to go there?”

“Two reasons,” I explained. “First, when we were talking earlier, I noticed the position of your scapula. On this side (the right), the scapula was positioned anterior in relation to the left, and anteriorly tilted as well. The pectoralis minor can play a significant role in both of these scapular positions, as can the fact that you are right-handed and mentioned having to spend many hours writing and using a mouse. Second, I have read several research articles that explored the relationship between tightness in the pectoralis minor and the presence of decreased subacromial space. Those two factors combined made a compelling argument to explore this muscle.”

“The amazing thing to me is that you went there before I even complained of any discomfort. My pectoralis area has actually been bothering me quite a bit for the last few weeks,” she responded. “I hadn’t remembered to mention it yet, but you got there first!”

“It is kind of the perfect confluence of factors,” I answered. “I always question whether I’m pursuing the right strategy, and I look for several factors to support my decisions. If I see an altered position or movement pattern, what muscles are implicated? When I palpate those muscles, do I feel something unusual and would I notice that if I did not have any prior knowledge of the client’s symptoms? Does what I feel and what I observe match with my knowledge of the research literature? Finally, and most importantly, do these possibilities match the client’s experience? There are a lot of factors in the process, just like there are in your own clinical decision making.”

With that comment, I could see a change in her facial expression, and I hoped I hadn’t said anything wrong. After a moment, she noticed me looking at her.

“With one small and very important exception,” she responded. “As a physician, I have very limited training in musculoskeletal conditions and the dynamics of muscular relationships. It’s a bit frustrating, as musculoskeletal pain accounts for a good many of the patients I see. We doctors tend to focus on the area of pain with little underlying knowledge of the context that created it. I marvel at your ability to connect the dots of how everything works together. That takes a deep knowledge of anatomy, much more in depth than the muscular anatomy we did back in medical school, which was mostly memorization.”

In the time that followed, I explored several more muscles that might play into the pain Dr. R. was feeling. Each time, she would ask me to explain the muscle’s possible role and what she might do in response.

“You know, what you are telling me isn’t all that different than what other practitioners told me to do,” she remarked. “The difference is, they just told me what to do. You explained why, and knowing why changes everything. I could see a world where this kind of work is fully integrated into our health-care system.”

So can I. It can’t come soon enough.


Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit, or email him at