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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 91 SCIENCE OF NERVES pressing hard into them can often reduce their tightness (Image 4). They are close to the skin at this point, so it doesn't take much pressure to produce beneficial therapeutic results. The second potential cause of DSN pathology involves localized areas of tightness in the upper-back muscles and potential myofascial trigger points that may constrict small branches of the nerve. There are numerous treatment techniques that can be helpful in reducing tightness in the upper back, such as static compression, broad cross-fiber methods, stretching, and deep longitudinal stripping methods. A broad contact surface can be used for more general applications, and if there are small, localized areas of tightness, a small contact surface pressure can be used during these techniques (Image 5). The third potential problem leading to DSN pathology is irritation of small cutaneous neural fibers between the scapulae as a result of scapular winging or postural challenges, such as upper-thoracic kyphosis and medially rotated shoulders. This variation affects the small cutaneous nerves the most, and addressing these seems most effective with light pressure, superficial skin stretching methods such as those described as myofascial release, or dermoneuromodulation. Place the hands on the upper back and stretch and pull the skin in various directions (no lotion or light lotion works best). More than likely, the client will feel a reduction in symptoms with one particular direction more so than others (Image 6). Once that direction is noted, simply pull the skin with light pressure in that direction and hold it for a minute or two. In addition to any manual treatment techniques performed in the clinic, it will be very helpful to encourage the client to reinforce good posture and frequent movement to help mobilize the tissues. None of these strategies alone are likely to be the sole solution. More likely, you will find some unique combination of approaches that may work differently for each client. Also, there are many more techniques that could be used than those I briefly mention here. So, next time you have a client who comes in complaining of pain between the shoulder blades, consider the possibility of dorsal scapular nerve involvement as you take the history, go through your physical examination, and design their ideal treatment plan. Notes 1. H. E. Sultan and G. A. Younis El-Tantawi, "Role of Dorsal Scapular Nerve Entrapment in Unilateral Interscapular Pain," Archives of Physical Medicine and Rehabilitation 94, no. 6 (2013): 1118–25, doi:10.1016/j.apmr.2012.11.040. 2. P. Shilal et al., "Aberrant Dual Origin of the Dorsal Scapular Nerve and its Communication with Long Thoracic Nerve: An Unusual Variation of the Brachial Plexus," Journal of Clinical Diagnostic Research 9, no. 6 (2015): AD01–2, doi:10.7860/JCDR/2015/13620.6027. 3. D. G. Lee and M. C. Chang, "Dorsal Scapular Nerve Injury After Trigger Point Injection into the Rhomboid Major Muscle: A Case Report," Journal of Back and Musculoskeletal Rehabilitation 1 (2017) : 1–4, doi:10.3233/BMR-169740; A. Saporito, "Dorsal Scapular Nerve Injury: A Complication of Ultrasound-Guided Interscalene Block," British Journal of Anaesthesia 111, no. 5 (2013): 840–1, doi:10.1093/bja/aet358. 4. H. E. Sultan and G. A. Younis El-Tantawi, "Role of Dorsal Scapular Nerve Entrapment in Unilateral Interscapular Pain." Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. Superficial pulling and stretching of the upper back muscles can reduce tugging on branches of the DSN. 5 6 Utilize small contact surface stripping or static compression to the upper back muscles.