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movement. In Image 3, I demonstrate my favorite anterior and middle scalene stretch to create space at the interscalene triangle. SUBCLAVIUS AND THE COSTOCLAVICULAR CANAL In clients with a drooping clavicle, the underlying subclavius muscle can reduce the costoclavicular canal size and compress the brachial plexus against the fi rst rib. Upper chest breathing can exacerbate the problem, as the fi rst rib elevates during inhalation and can get stuck there. A 2015 study published in BMC Research Notes also noted brachial compression from the subclavius posticus muscle, which ties the fi rst rib to the superior border of the scapula. 3 Rather than dig in to the sensitive tissues under the clavicle, I always begin with the subclavius stretch demonstrated in Image 4. This slow, gentle, graded exposure stretch is designed to reassure the brain that it's now safe to move in previously painful positions. C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 103 Subclavius stretch: The client's arm rests on my shoulder, and my right hand's curled fi ngers snake behind the clavicle and brace while my left fi ngers wade in front of the upper trapezius and contact the scalenes where they attach to the fi rst rib. To create space and stretch the subclavius, I simply extend my knees and abduct her arm, allowing my fi ngers to spread open the thoracic outlet. Pectoralis minor: With the client's hand resting on her neck, my left hand grasps her arm, and my right palm braces her scapula. As she inhales and gently pulls her elbow toward the therapy table, I resist to a count of fi ve. Upon exhalation, a counterforce is created as I pull with my left hand and brace with my right hand, feeling for a stretch in the pectoralis minor fi bers at ribs 3, 4, and 5. RETROPECTORALIS MUSCLE IMPINGEMENT Repetitive movements of the arms above the head, common among tennis enthusiasts, may cause friction and overstretch the nerve plexus under the pectoralis minor at the coracoid. The least irritating way I've found to create space here is by stretching the distal fi bers that attach to ribs 3, 4, and 5. Notice in Image 5 that the stretch is directed at a 135-degree angle, which is the approximate pectoralis muscle fi ber angle from coracoid to the rib insertions. Many NTOS studies recommend postural correction, including muscle strengthening and lengthening for double crush complaints. However, there is no consensus in the literature as to exactly which muscles should be targeted. Posture is dynamic and the best results are gained through whole-body strengthening and balancing programs such as swimming, yoga, and martial arts. The bodywork goal is to bring mental awareness to areas of restriction and to teach the client it is safe to move through those previously painful barriers. Notes 1. A. R. Upton and A. J. McComas, "The Double Crush in Nerve Entrapment Syndromes," Lancet 2, no. 7825 (August 1973): 359–62. 2. D. B. Roos, "The Thoracic Outlet Syndrome is Underrated," Archives of Neurology 47, no. 3 (1990): 327–28. 3. J. Muellner et al., "Neurogenic Thoracic Outlet Syndrome Due to Subclavius Posticus Muscle with Dynamic Brachial Plexus Compression: A Case Report," BMC Research Notes 8, no. 351 (August 2015). doi:10.1186/s13104-015-1317-3. Erik Dalton is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfi ng, Dalton has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com. 3 4 A B 5 Interscalene triangle: (A) With the client's head left-rotated, my soft-cupped fi ngers wade behind the sternocleidomastoid and onto the scalene attachments at the transverse processes. (B) By left-rotating and slowly extending the client's neck, I palpate for scalene adhesions and pin and stretch to release.