Upper trap tightness treatment beyond massage

Rather than, and actually in the past, and as I said in the beginning, I was mainly a manual therapist-based person, based doctor, and I would see a problem, I would think, hey, let's just address this tight muscle, because I know that with a lot of people with upper trap tightness, they dig, they dig having that massage, right? They dig manual therapy, they dig ART. It's all good, chills it out, but why does it come back, you know? So that's what I try to figure out first now, and I try to figure out what are corrective strategies first that will work if they're not a first aid person. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery.

And now, your host, Dr. Sebastian Gonzales. Hey guys, this is Dr. Sebastian Gonzales again with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. I am doing a solo podcast today, and this is session 119, and we're going to go over some, maybe some missing links for upper trap tightness, neck pain, shoulder pain, pain over the top part of the shoulder that you might consider some rotator cuff conditions, upper trap tightness, or pain into the mid-shoulder blade region, which is what I call periscapular pain. So I tend to see that when patients come in to see me with this stuff, they tend to spend a lot of time doing mash work on it, which could or could not work, but obviously since they're in to see me, it didn't work for them.

So I'm here to present some of the possible missing links via case presentations today. And if you're a patient, you're going to get a lot from this. If you're a clinician, you might get some from this as well. So hopefully this will help you guys explain some of the stuff you're going to be using in your clinical practice to the patients that come in and ask these questions as well. As you know, in the past podcast, I've said that a lot of this is to scratch my own itch. And if I have a patient with a C5 cervical radiculopathy, then I kind of want them to know all these parts because they're going to be asking these questions.

And if they don't tend to understand the reason behind doing some of this stuff, then they might ditch care and they're like, well, I had a little flare up and this didn't work, right? But as I found that explaining, especially the first story that I'm going to go into here with one of my patients is, I found that as he went through three, three, he was basically a three-time offender of the same exact condition. And it seemed to reduce the exact same way every single time. And it was, it was kind of fun. I mean, he kind of felt silly at the time and he's like, oh damn, it's that again. You know, but he was in excruciating pain at the time.

And then we can reduce them very quickly. So it's, it's nice to see that the patient becomes empowered. And that's what I'm really trying to, to, to present in this presentation today. I'm not going to be bashing on any types of techniques or whatever. I'm going to frame things. And what I usually tell my patients is that we typically have number one, the phase one is a first aid period. And not everybody's in this, at least not when they walk in. Think of a first aid period as being a cut on your elbow. Let's just say right where they, they stick the needle in, they draw blood. That is a laceration.

So you slice it right there. When you extend your elbow, you're going to tear the skin apart and it won't want to heal very quickly. So the way you would treat in a first aid setting, at least for that timeframe, five to seven days, roughly, it's very different than you would, than you would treat someone in that region. And if they've had a past laceration a year ago, maybe they have other considerations that are creating symptoms there. Now, first aid comes first, obviously, but not everyone's going to present that way. Not everyone's going to come in that acute. Sometimes they are. The second thing I like to have people do is to find their supportive systems.

And as you're going to find through case one, you'll, you'll get to understand this a little bit better because he actually presented different phases, both, uh, all three times. The, the third one is present load. Sometimes load is therapeutic. Sometimes it is sometimes you use it too early. And this is when you have people who are just continually repping stuff out and they're like, well, I've done load. I've lifted weights. I've carried things. It hurts. So maybe they need to retract back a little bit to address the first two phases first and then come back into it. And the last phase is really just getting the person to understand these problems.

Because if it happens again, because we know that past injury is a very good predictive measure of future injury. This first person has a cervical radiculopathy consistently, and they've had MRI findings of basically a large herniation up there, but he's able to reduce it. So when you have a structural problem that you find on an image, a lot of times this will give light to what possibly could be happening in the future. Now it's not an indication that actually you're broken. Okay. It just means that if you have that disc injury up high, now you have a little bit altered structure. Okay. A little bit altered structure.

And sometimes it won't tolerate all the same types of load or movements that you might be subjecting it to. So if you subject it to a lot of Natharoxbury headbanging, it probably won't like it. But also to someone who has a perfectly normal MRI, normal MRI won't like that either. But you might be a little bit more triggered. Okay. So if, uh, just to be clear on this stuff again is, you know, I'm not going to bash any techniques because support or the first aid, which is the first part. The second is supportive systems and then load and then empowering the patient. These can be addressed different ways.

So I'm just going to explain how I did it in these cases here. And, um, I've actually beat myself up in the past because I've come from a background of a lot of manual therapy. I thought, Hey, I can fix it with my hands. This is great. We can do this. Like, and I had a lot of good success, but I think I left a lot of the things on the table in regards to patient empowerment because I was hitting that too soon. So what I've found that actually I've, I've converted a little bit and I do a little bit more of, of supportive, uh, strategies such as corrective exercise. And by, by the way, if you're implementing corrective exercise in your practice, or if you're a patient who's gotten corrective exercise and you're like, well, it doesn't change anything.

You might be the wrong one. If you consider like medications, it's like, they don't just blanketly give you a medication. You pick the right one at the proper dosage. Okay. Too much of the dosage might be bad. Not enough won't be good enough. So you should actually, and this is what I experienced in my practice, and you'll hear through these cases is that you're going to hear that you're going to, you'll find a change. You'll feel a change and it might not stick for a very long time. It might stick for a week. We don't know. Everyone's a little different. So I just realized I didn't do the story.

God, what am I going to do in the story here? I'll come back to that one sec. So the dosage is important. So the supportive exercise is supposed to be, where was I? Now I forget where I was at. Shit. Anyways, first aid, supportive, and then load. Load a lot of times can make it feel so it's better too. And we might not have to get nitty gritty with all these corrective exercises. A lot of times you just, you supply some load, the body figures it out. And it's almost like a movement Rolodex. The load, a lot of times, and I'll take you through a case later where we're talking about a loaded carry.

The loaded carry is more than the person really wants to do. Like they're kind of freaking out like they don't like it. And obviously I've mitigated a lot of the risks through the examination to figure out I'm not going to break the person. But sometimes when you get them to do something heavy, it no longer can they cheat the movement. Okay? Your nervous system has strategies of movement. And we found this through like dynamic systems theory. You take a hand away and I hand you a cup, you're going to use the other hand. If I take the second hand away, now you might reach for it with your mouth.

So there's all these different movement strategies that you might have. Now, all of a sudden, if I was to hand you something heavy, you probably, even if I hand it to you in one hand, you're going to put the second one under there. So a lot of movement optimization will kind of come out of that with the load. And as you'll hear in a podcast to come, Guido's probably going to say, if he says what he says in his seminar, the movement will emerge. Okay? So building that, putting that person under a heavy farmer's carry, they can no longer shrug the weight up if that was contributing to their problem.

They can no longer use all the support around the shoulder girdle because it's not going to work for very long. So I like to tell my patients that when you supply this load, although it might seem freaky, we've got to allow the nervous system to go through these Rolodex of strategies. And it's doing it real quickly. It's like, okay, that doesn't work. That doesn't work. Oh, that one works. Maybe these five work. So we'll use that. So we have to allow it to test the system a little bit and challenge it. Now, I guess we'll go into that story right now. Now, I usually take this moment to share a story that's a little bit more entertaining and funny.

But I realized the last time when Cody said, what are you thankful for? You're always bitching about shit. I don't think I'm bitching about shit. I'm just doing observational humor. But either way, though, it made me think. So why don't we do what I'm thankful for this time? And the last time, all I could think of was pistachios. But I am thankful for all you listeners out there. I'm thankful for the people who put out great content. I know it's hard. It's really hard for you guys to do so. And I've been there. Like, there's a lot of crickets out there. There's a lot of trolls. There's a lot of people who will bash you for it.

So for the people who have been very open about supporting the podcast, the videos, the articles, and all the stuff that I'm attempting to change the world with here and help people with, thank you for the support. Thank you for telling me what you think. Thank you for sharing. And thank you for improving all the content. Because I get lost with creating some things. I don't know what everyone wants to hear about. And I don't know if I'm saying things in the right way. So I'm used to speaking a little bit more medically. And I think I could do probably a better job of storytelling and analogies and whatnot.

So thank you for the feedback, everybody. It's been an amazing 100 and now 19 episodes. I'm hoping it's going any better from here. Here we go. Now, getting into the actual story of the patients, I'll first start with the first person who was a three-time offender. Let me explain his case a little bit here. So he had some really severe neck pain and shoulder blade pain that went into about his mid-back region. He couldn't look up or he couldn't turn. And when he came to me, actually, he came from a colleague. And he had the experience at my colleague's office where he said, like, hey, I had this MRI which confirmed a C5 nerve impingement.

I'm freaking out. Maybe I need surgery on this and so on. So my friend did a simple dermal traction. He's lifted the skin. If you don't know what dermal traction is, it's just it's a real easy plug and play. Lift the skin, decompress the nerve as it's going under the skin. And all of a sudden, he's like, oh, my God, it's better. Like, months of pain was reduced with a simple pulling of the skin. And there's no parlor trick in this. It's basically we just unloaded the nerve a little bit. So what we found with that is that we can we have a nervous system problem. We have a nerve-based problem. What created that in the first place, we don't know.

What's loading that nerve, we don't know. That would take a little bit more further investigation. But we found something that can decrease his pain and get it so we can kind of reset him. I know there's a big there's a big push right now for the whole term movement resets, right? Or posture resets or whatever. I don't care what you call it. We got to chill the person out. And that's the first aid period. So with his problem, sure, he had that C5 issue because it went down the shoulder blade, went down to the side of the neck, went partly down to the arm. But it doesn't matter with the structure.

We were able to reduce it. So let's reduce it. So we found that pulling the skin up helped him. And that was what helped him for months. Now, when he finally came into me after being with my colleague, he had a problem again. But he already had all these tools under his tool belt. He had already decompressed the area. He had already reset it, as we say. He did the first aid period. He did five to seven days of that. Then he got to do some corrective exercise. He did some deep neck flexor exercise. He did some thoracic motion exercises. And I won't go into too much of what those were because you can do it many different ways.

But for the most part, these worked for him. But when he came in to see me, he was frustrated. And he's like, look, I did the deep neck flexor stuff. I did the mid-back movement stuff. It didn't work. I'm still hurting. So I grabbed his shoulder around the skin area. And I pulled it up. And he's like, damn, that works again. And I said, I know. So all we're going to do is we're going to chill the system out again. You got a first aid period. You got to address it. Now, so many clinicians out there might be thinking, well, I don't, this wasn't a fresh injury. Sure. But we still have to establish the first aid period because it might be an acute bout of inflammation.

For patients out there now, remember that, think about what this guy's thinking here. He's thinking that the stuff that he implemented at the end of his care last time was going to work in the beginning of his care this time. And it just happened to not. And there's nothing wrong with that because eventually we did get him to that. So he spent about five to seven days unloading the nerve, letting it chill out, giving it a chance. Give a nerve a chance, man. Give a joint or a muscle a chance. Sometimes we just got to let it chill, like that laceration on the arm. All right? Don't stretch. Don't pick the scab.

So he was able to chill that thing out. And finally we got back into the same stuff. And he said, hey, look, deep neck flexor stuff works. This is a corrective exercise, by the way. He did mid-back movement. Hey, that works. He said, good. I feel great. What do we do now? I said, hey, why don't we get in some loading? So I gave him a loaded carry, a farmer's carry. He walks around. He's like, hey, that feels good. I said, cool. Let's do a push-up plank. Hold it real hard, just like a Dan John style, like a really aggressive push-up plank. He's like, hey, that feels good. And I said, great. So let's do this amongst a bunch of other things at home.

So his current rehab at that time was doing some of the corrective stuff as warm-up, doing the deep neck flexor stuff, doing the mid-back movement stuff, doing some loaded carries, deadlift, squatting, pushing, pulling, and unilateral work, or single arm, single leg. So the standard strength conditioning protocol. Now, he came back a couple months later. He said, hey, man, this is the worst. Like, I have neck pain again. I went and played a pickup soccer game, and I was doing headbutts, right? So compression on the neck. It just didn't like it. It triggered it, whatever, right? So he's very, very sensitive on this.

But he's a calm guy, so he's very logical. So going through that again, he's like, hi, I don't know what to do. And like, I'm really concerned that my neck might need surgery soon because it seems like it's just getting worse. So I picked up his skin on his shoulder or around his neck, and he's like, damn, that worked again, didn't it? I said, yeah, it worked. I'm like, are you seeing a process here? Are you seeing a system? Because back, let me retract it again for everybody, is that he tried all the corrective exercises at that point. And it didn't work, right? But he forgot the one thing, at least in his case, which was helpful for unloading and first aiding.

Now, everybody is a little different with their first aiding process, okay? And I'll get to some cases later that had a little bit different first aid process too. So for him, again, we did some first aid, and we found some more this time, actually. We found down that breathing work actually worked for him. We did some face-down alligator and frog breathing, okay? He just put his forehead into his hands and just breathed and chilled, and that helped. The skin grabbing helped. We also did some neurodynamic passive offloaders, which is he was just laying in bed and tilting his head to the side and kind of watching TV, put his arm over his belly and chilled.

Now, patients out there might be wondering, I don't know how to do that. Well, it's not important at this point, okay? Because the offloaders or the resets are different for everybody. So just know that the process is to get the area to chill. The whole system, the whole nervous system is freaking out. Let it chill. Give it a chance. And then we started to implement the same things. We did deep neck flexors. We did, actually, button turns, we call them. So mid-back movement. We also did shoulder packing this time. Shoulder packing, which I will get into a little bit later as well. This is when I actually go next to the person.

I have them do a movement, like bending their head backwards or turning or whatever. And I said, whatever hurts, just pick one. They said, ah, that hurts. So I take their shoulder blade and their shoulder on the front, and I just smash it together like I'm trying to push my hands really hardly together. They just happen to be in the middle of me. So I'm not doing anything else. Just hold them together, and I say, move again. And they say, oh, that feels better. So what this tells me is that there's an aspect of a shoulder blade destabilization. And it's not going to be like the thing's hanging off.

It just means that it's not holding tight enough. Now, an example I usually give with people with this is that I sit in my chair in my office, and I have a skeleton next to me who's on rollers. So I push the skeleton, and I said, who's more stable, me or the skeleton? And they say, well, you are. I said, why? And they said, well, because the skeleton moved. I said, great, cool. Then I have a marble desk, and I push the desk, and I move. And I said, who's more stable? And they say, the desk. I say, great. And I hold their shoulder, and I say, go ahead and move your neck. I say, who's more stable, your neck or your shoulder?

And they say, oh, the shoulder is. I said, great. So you're seeing that if we make the shoulder a little bit more stable, then it will improve your neck, right? So you need to have a stable point of movement. You always have to have a stable point to move from. So that's what shoulder packing is there. So I might chase that down a little bit more with some corrective exercises or loads with them. Now, at this point in time, he went back to all of his corrective exercises, his warm-ups, and he went back to farmer's carries and suitcase carries and deadlifting and squatting and pushing and pulling and so on.

But this time, as he left the office, I told him, I said, next time, what are you going to try first? And he said, I'm going to try that thing. I said, great. Like, call me, text me, email me, whatever. But just know that this past thing that you have, it doesn't mean you're broken, but it means that you're a little bit more sensitive to what's going to trigger you. Now, should he not headbutt anymore? That's a whole different conversation. But I told him this. I said, how reckless is it if I just go run a marathon right now and I haven't been running at all, right? What if I go climb K2 and I've never trained for it?

At least I have it in a year. So you have to expose yourself to this a little bit. So if we want him to do some headbutts again, perhaps we need to expose him to maybe a single headbutt a day, you know, stuff like that. So I'm just being responsible with it. So I'm not telling him that he can't do it anymore. I'm just telling him that we need to be more responsible with what we're attempting to do if it's a probability of triggering for him. Now, another moral story is basically don't jump to surgery here. Although you have some MRI findings or x-ray findings where you have narrowing of spaces and degeneration and arthritis and disc herniations and nerve pinching and so on, like, don't freak, okay?

Actually, the biggest thing of concern is if you have a loss of arm pain or if you're losing dexterity. Those are big problems. So when it's in the neck, though, it's not a big reason to concern unless you don't respond. But I know that in my experience with working with people who want images very soon, they freak out about what's the finding on the image. And it's not always correlated because probably before they had the problem, by the way, this guy had no trauma originally that I know of, that disc herniation could have been there already, right? When he was feeling good. And I know that with my back, and by the way, if you don't know already, I've already recorded a book about my story and how to mentally get ready for success with physical recovery.

My herniation is, by the way, that'll be available soon if it's not already. I'll have it on my site. The idea behind when I kind of actually had an epiphany through there is that I had a disc herniation. I still do. Two or three millimeters. I forget which. I think it moved a little bit. But I had pain in high school around the age of 16 for about eight months or so. And around 35 or so, I had another issue with back pain. I did a re-imaging just to see. And there's a herniation there still, right? Same spot. No problem. Whatever. And thinking about it, actually, I've had more pain-free time.

Like, during the course of that 20 years, I only had, at the most, like a 0.5 out of 10 pain. 10 being the worst. That's probably the highest I've had. So, if you think logic with it, how do we know that the herniation doesn't actually make me feel good, right? I've had more good times with a herniation than I have bad. So, don't jump to surgery on this stuff. Make sure you're not responding to good quality care first before you actually jump into that. Because it's not going to change your tolerances and whatnot. Now, the next person, I went through the same logical algorithm with them, too. First aid, supportive loading, and then getting them to understand.

Now, this person had mainly just upper trap tightness. It wasn't really terrible, okay? It was like a dull ache. It was very, very minor. And she can move her neck around. It wasn't a big problem. It was worse with extension. There was no mechanism of injury. It was just kind of a nuisance. She sat a lot for work. She ran every morning. She hasn't done weight training. And she's around 40 or so. And so, she was told, actually, by someone that her atlas was loose or it was out. And so, she first came in asking, like, hey, do you think you can adjust this? I said, look, give me some time to assess it.

My job during this assessment is to prove or disprove what he said. So, I said, look, feel me out. Let's do this. Let's just try. And she said, cool. So, I built the trust in the beginning with that because I wanted to test to see if any of these other kind of tests that we did with the other guy maybe worked. So, first off, I was thinking, is she a first aid case? She's probably not because she's not ultra sensitive. She's not lit up. She's not a hot case, right? Maybe we go a little bit more supportive with her. And then maybe we progress to load a little bit quicker. And obviously, I did all my orthos, neuros, DTRs, and whatnot.

I screened everything out of red flags, and I didn't find anything. Now, rather than, and actually in the past, and as I said in the beginning, I was mainly a manual therapist-based person, based doctor. And I would see a problem. I would think, hey, let's just address this tight muscle. Because I know that with a lot of people with upper trap tightness, they dig. They dig having that massage, right? They dig manual therapy. They dig ART. It's all good. It chills it out. But why does it come back, you know? So, that's what I try to figure out first now. And I try to figure out what are corrective strategies first that will work if they're not a first aid person.

So, I'll go through and test it all out. I did all my standard testing, range of motion, passive-active, neurological, orthopedic, and also compression and decompression. So, we find a position that is painful. Like, just say, with her, it was looking up. And I kind of pull her up a little bit. And she said, oh, that feels so much better. And I push her down a little bit, and she's like, oh, that's worse. So, we know now that compression was a little bit more triggering to her. And I would test and retest a couple times to confirm. Now, again, could I have given her first aid with this? Yeah, but I think she was beyond that.

So, I don't think it'd be as useful because the first aid period, it doesn't really address stabilization in the area. So, I'd rather give support or an active care strategy when possible and then kind of come back and further treatments and address more of the tissue work. Because I can always do that later. I just want to make sure that I'm empowering the person first. Now, what I did first with her was I tried the skin pull. That didn't work. And I tried a couple different spots, and it didn't work. And I always tell them in the beginning, I said, look, you're not going to offend me if this doesn't help.

So, all I'm looking for is for better, worse, or same. So, do not think you're going to offend me. I want an honest answer because if you're not honest about it, you're going to trick me a little bit. It's going to take me longer to get to where I need to get to, to help you out. So, she said it didn't work. Great, cool, perfect. After that, I had, I just packed her shoulders together again, one of them. And this time, it hurt a little bit more to turn to the right. So, I just held her right shoulder and packed it together. And she said, oh, that's so much better. I said, oh, cool, great. So, I tried the other one.

She's like, ah, it's wishy-washy. Great, cool. So, I'm looking more at the right shoulder as being a thing. So, based upon that, since she's not really a first aid case, and I don't have to be really, she's not really fragile. I thought, let's just dynamically test this by trying to figure out which muscle groupings are really not working extremely well. And this is going through the concept of attractor states, which I will go through with Guido on a further podcast. If you haven't heard Guido speak, he's the shit. So, and I've had a really hard time finding attractor state information for people to understand.

So, I thought I would go through this first here, but I'll let Guido go through it more in detail when I actually have him on. The basic idea is that, you know how, like, everyone says, like, this muscle's on, this muscle's off? Think of that, except for the muscle's not really off. It's just under stiff. It's a tug-of-war. You're allowing the tug-of-war of the tighter muscle to win, and the other one just doesn't have enough stiffness. So, all we're going to do is momentarily change that state, and we're going to improve the stiffness of the one that's lagging. So, I'll usually go for sections first, and with shoulder packing cases, the ones that are responsive to that.

By the way, again, packing the shoulder on created a better stable point for movement of the neck. And this improves, a lot of times, radiculopathy or numbness of the fingers. It does improve some shoulder blade pain. It does improve a lot of other things. So, don't just think this is for neck-based pain or the symptoms like upper trap tightness and so on. But it's always a good thing to check with the upper quarter. Now, with dynamic testing, I'll usually start with the one that is the highest suspicion to me. So, the one I checked on this one first was, I thought, you know what? You know what?

What holds the shoulder blade on? Well, let's go with the serratus interior. Let's try that. Let's just try that one. I'm like, I don't know if it's right or wrong, but she's going to tell me at the end if it improved it or not. So, I loaded her up on that. It's uncomfortable. I tell people in the beginning that you're going to be uncomfortable and you might be a little sore. But this is okay. Don't stretch that stiffness out. It's looking, we're looking to build some stiffness there so it builds support. We're going to support that blade so I don't have to hold it there and walk out of the room with you.

So, we did this. It took about a minute. Okay? She's gassed out. She doesn't like it. I had her do the movement afterwards with her neck. She looked up and also looked to the right. She said, no change. I said, great, cool. That won't offend me. We tried the left. The left one didn't work either. That was another minute or so. So, we've only done about two, two and a half minutes of work so far. And I'm saying the time frame because I want you guys to realize that with corrective exercise, if you do it well, it doesn't need to take forever. Okay? This is all testing and we might add more at the end.

But for the most part, you should have a definitive change if you've done the right dosage and medication. Or in this case, recommendation of exercise. Next, we tried the rhomboids. We gassed those out. Didn't work. I tried the lats. Gassed those out. Didn't work. Took about a minute each. Finally, I thought, you know what? Maybe it's not an actual muscle that's not working well. And let's just try to load a movement. So, in my experience, I like to do a loaded carry because that packs the shoulders down. It does a lot of other things too. So, I tried that. She came back and I handed her two 53-pound kettlebells.

And she's probably only 130 pounds, 140 pounds. She's not that heavy. So, she's grunting and groaning and walking around the room. And like I said in the beginning, we got to make sure that the nervous system has the Rolodex it's going through. So, if I gave her a 20-pound weight, she would shrug it, be talking, be chilling. It wouldn't be a challenge for her nervous system. So, when you start seeing the face grimace and making noises and breathing changes, you know you're on to something. So, she brings it back after about 30 seconds, puts them down. I said, look, immediately look up, look to the right.

And she said, oh, that's so much better. I said, great, cool. We're on to something. Do that twice more. So, we did it and it worked. It helped her. So, next I thought, you know what? Let's go back to a double-arm serratus push-up plank. Let's get that serratus in there again because it locks it down, right? It locks that shoulder blade down real tight. So, we tried it again. Spent about a minute. I pushed her around, really, really stiff plank, and it didn't work. It made her worse. I said, great, let's go back to that loaded carry again. We did another lap around the room. She felt better. So, I said, great, we found your reset here, at least one of them.

So, I'm like, why don't we try something else too? We did an overhead shoulder press. And so, we got a little bit more of the lower trap, middle trap involved. And that felt better too. So, it's funny going through this that in the very beginning, she was telling me she needed her atlas adjusted. And I said, are we on board here? I don't think that's what you need at this point in time. And she said, yes, this feels great. And I said, cool, what are you going to do at home? And she's like, well, I don't have these whites. How do I buy these? And I said, no, you don't need to. I said, carry around.

I'm going to go find two Jansport backpacks. Everybody's got two Jansport backpacks that they had in high school that they don't use anymore because now they're growing up, except for me. I still use when I bring stuff to work. So, go find those and fill them up. Carry stuff. And I mentioned it, I think, in session 118. Maybe it was the last one. Let's check that real quick here. Oh, I did say 118. I mentioned at the very end. By the way, Merry Christmas. I'm recording this about three weeks early. So, I mentioned to Dr. D, I said, hey, is it fair to say that in deconditioned people, if they have wrist, hand, elbow, shoulder, nerve issues, neck issues, or shoulder blade issues, that if they don't get three calluses forming on their last ring and middle finger, then it's fair to say this is going to come back pretty quick?

And he said, yeah. I mean, there's no proof for this. I just say that because if I look at people's hands and I see that you guys haven't had enough load, then it makes me think that that's a missing link in there. And if we've now tested to see if the load is therapeutic, I'm going to know that you did enough by if we have some calluses forming, because that's how the body adapts. You can't cheat that type of thing. Obviously, if you do have calluses forming and you still have problems, maybe there's a missing link in there. Maybe we forgot the first aid. Maybe we forgot the corrective. So, we can just go backwards.

It's not a big deal. So, we found also after that with working with this girl that she couldn't do this all the time because she can't carry heavy stuff all the time, which is fine. I understand that. And I really like to find on people what's a very simple reset you can do that's not going to look like you're like a maniac. All right? You should look normal when you're resetting it when at all possible because you don't want to foster that question from coworkers and friends. It's like, what are you doing? You know, it's like, well, I got this and this and that. It gets really tiring. It's kind of like when you have crutches and everyone wants to talk to you about why.

It's like you've already said this story about 15 times throughout the day. So, you'd rather just not talk about it. So, one that we found with her is that, so we did that push-up again, push-up position, and it hurt again. So, I said, great, let's not carry again. I want you to do one thing. Can you do the opposite of shrugging for me or hold oranges under your armpits? The second one actually worked with her because she couldn't figure out what the opposite of a shrug was. Different cues for different people. So, she held oranges under her armpits. She looked up. She looked right. She felt better.

So, she basically just needed to pack the shoulders down. And she can do it voluntarily. And her first thought with that was that, hey, maybe I need one of those shirts. And I said, the shirts, I don't think you need it right now. You're showing me you can do it by yourself. So, just practice this strategy. And eventually, when you start doing these carries more and more and more, and you start having those calluses for them, your body's going to figure out, hey, I've got to make this change and make it stick. So, I think the moral to this story is that, look at the overall picture here. Now, could we have adjusted her?

Could I have? Would I have helped her? I have no idea, and I'm not even going to bother. Because, until she shows me that the loaded movements are not going to help, then I'm not going to bother. She's already getting better. So, why muddy the water here? And I tell a lot of people with this, too, is that, yeah, can we do this and this and that and so on? And, yeah, sure, we could. But, let's just work. Let's go with what's working right now. And it might change in a week or so. It might change in two weeks. So, as we start to have her go through this loaded carry, we might find that next time she comes back in, she's going to have those calluses for them.

She's got enough load. She's got enough volume. And we're going to see that now there's just one single spot. There's little pinch points you still have, but all the rest of the stuff has gone away. I tell them that this is, the water clears. It's no longer muddy. Once you, when you have a muddy, when you have a muddy water thing, there's a lot of guessing going on. But once you find something, you're going the general direction, I would just stick it. Just keep there. Hold. Let the water start to unmuddy. And then you can see better of what we're working with. It's really tough when the whole area is sensitive.

So, work on your fixed points. In this case, the shoulder was the fixed point that was the problem. All right? It might be the mid-back. It might be the feet. It might be the core. It might be a lot of things. But for the most part, the quality of movement of your neck or even surrounding areas are dependent upon what they're pivoting off of. And in the next case, you're going to see that we're going to go into actually a golfer who had multiple fixed point issues. And it's very interesting to see that some of the changes, even lower, can help out stuff into the neck, mid-back, upper trap, tightness, and so on.

Now, just to reframe this as well, because I don't talk about this a lot with patients, and I probably should, is that they wonder, well, should I go somewhere else for tissue work? Because I really feel like massage and deep tissue work and adjusting will work. And I say, you know what? It's just, let's unmuddy this water first. And just like the first aid period, just like the supportive strategy period, just like the load period, everything's a little different, you know? And you're going to respond to different things at different times. Now, ideally, what I would want, if we're looking at the shoulder, maybe I want to chill out the pec minor.

Maybe I do some tissue work on it. Maybe I want to chill out the upper trap and the levator, right? Those are cool. But also, I want to increase the stiffness of the other areas that are showing that they're supportive. In total, I think we're looking at a better comprehensive strategy versus doing just one or the other. Usually, in the beginning, I'll start with a supportive strategy, if at all possible, again. Because my idea is that I need to break the people of the thought that they're broken, they need to be fixed by my hands. Now, I'm down with doing the tissue work. I'm down with it. But I do it a little later.

That's just my personal preference. And I find that when people can shoot for a movement-based correction first, they have a better understanding that they're in charge. All right, that they're empowered, and a lot of what they're experiencing is based upon the loads they're putting on the area. Now, the last case here that we're going to go into is the golfer with neck pain after about nine holes. She had upper trap pain. She had mid-back ache, or kind of that burning thing that goes along with the C5 distribution pattern. She also had some neck pain as well. And it lasted for about two, three days after playing golf.

And she loves golfing, so I'm not going to tell her not to golf. But I actually made a mistake in this case, and I should have actually looked a little bit more at the triggering movement first. I should have looked at the swing first, and I didn't. I waited about three days before doing that, but I finally caught word of it. I saw it. And I made the correction, and I'll go into the things that I made corrective-wise in the very end of this case. Now, the interesting part about her case, actually, is that when she came in, she revealed that she had a past 10-year-old label repair on the left shoulder.

She's a left-handed golfer. And she revealed that there was no mechanism, no dislocation. There was nothing that really happened there. It just became the labral tear, and it got repaired. So, at least for me, that's a little bit of an alert to see that there's been the surgical intervention there. And also, too, it got that way over time, which tells me there was probably a process which created that. So, I need to be aware that there's a possibility that has a correlation because it's so close to the area of concern. Now, with her, I tried the same approach just to see. And I don't do it this way, cookie-cutter every time.

It's just what I tend to do on these people. So, I first started with all the history, started with all the neurological orthopedic testing. We did compression, decompression, and tests. Decompression helped her. So, now we're looking at that as something that we need to be considered over the entire first aid period. Perhaps we give her some decompression work. But also, too, I went through the skin pull to unload the superficial nerves. Did it work or did it not? This one worked a little bit on her, but it wasn't extravagant. And I always like to have people have that woe factor. They're like, whoa, oh, my God, that worked?

You know, just like on the first guy, that one was a woe factor. On the second case, the shoulder packing was a woe factor. On this lady, too, the side that was the past label tear, label repair, was a woe factor when she was turning her head and also looking up and down. So, we use that. We use that as the part of the corrective strategy. So, because I also, too, I have a problem with fitting people in these little boxes. I think everyone has their biases. I progressed down the same route that I did in the last person. We tried the serratus interior. We loaded it and tried to change the tone.

We tried that left side and we tried the right. We tried the rhomboids. We tried the lats and then I tried a loaded carry. Funny, it was interesting on her that actually a lot of pushing movements, the push-up plank, which works, I don't want to say just works the serratus, but it has more of a serratus bias. It has other things going on, too. So, that one helped her with flexion, but not extension. I had her do a farmer's carry with heavy load again. That helped out with extension, not flexion. So, she had a couple things going on there. So, it was interesting to see how it changed things, but overall, I can see that the loading and corrective strategy helped out.

So, she had more of a blend. The last person that I spoke about with the case, she really didn't have a lot of corrective stuff. I didn't give her deep neck flexor work or shoulder packing, or sorry, I didn't give her button turns or thoracic mobility. I didn't give her any of that stuff. This one, I gave her a little bit more of the attractor state work because it worked with some things. But also, too, I gave her some loaded movements. I gave her a carry. We also did deadlift that day, too, with a kettlebell. Now, we also did something that was, again, biasing the rhomboids and the traps in the back.

And it was a single-arm dumbbell row. And I have a tendency of treating people not like they're fragile. If they don't show any red flags or triggers in the exam, I try not to treat them as fragile. And sometimes that doesn't help me. And I'm pretty sure there's people in the past that they've gone home and the next day they're so sore that they're like, I don't want to do that again. But they're only sore in certain areas. It's a muscular sore. And if these people are deconditioned, they're probably not used to it. You get someone like a CrossFitter or someone like a strongman, then they're probably going to be used to it and they're not going to freak out.

So probably I could have done a little less because she got sore the next day. But after the soreness dissipated, she was like, holy shit, my neck feels so much better, right? So it was supportive but a little uncomfortable. Now, let me address this at this point too because I've talked about shoulder packing a lot. Is the answer to have your shoulders packed all the time? No. Okay, like I said earlier, I don't want you to look like a freak, like a posture junkie, or someone like a robot when you're actually moving throughout the day. That's not the way to go. You should be able to move freely if you want to.

Now, doing the movements that are emphasizing those muscles or improving the nervous system's grab on that area, they are intended to improve the stiffness, whether the stiffness be with shoulders forward or shoulders back. It's just helpful in all movements. So it's just one way that we like to train that. I just want to make sure everybody understands that, that it's not a long-term fix. And we do find with people with back pain, flexion intolerant back pain, they like to live in extension, and that produces problems later. And this will also produce a problem if you're just sticking with the shoulders back.

Now, on her third day of care, I started to see the light. I started to see that she felt good when not golfing, but she felt painful after golfing again. At least for a day, it was dissipating a little bit. I was like, what's going on? What's going on with your golf swing? And for those of you who don't understand rotational sports, when you're looking at a ball, especially if the ball is on the ground like a golf ball, you have the body moving around the head, which still produces rotation in the neck, although your neck's not moving. It's relatively moving about the body. It's a wringing out effect.

So there's a lot of neck rotation with that. And so I kept thinking, well, we got the shoulder thing. The shoulder thing's improving it. But there's a lot more going on, too. I forget who came up with the saying, but when you're buying a sports car, you want to pad your budget for some brakes. And with rotational sports, we need to make sure that we're building the braking system, too. And one of the important parts is the posting points. In golf, we're looking at the front side leg, the posting leg. People who golf might call this type of deficiency a slide when you slide out past. I think it's a slide.

Or is it sway? Either way, one's front leg, one's back leg. But you're going to go past that post point, and you just have a weak posting point. And remember in the beginning where I said, what's more stable, me or the skeleton, me or the desk? It's relative. But in this case, if you're trying to impact a golf ball, you need to make sure that you're stuck to the ground. So use ground contact forces. Now, when I was watching her swing, she had neck pain during each swing. So what I thought we should test is work on her contact points on the ground. And in this case, let's just build some resiliency in the hip.

So we did a lot of hip stuff. I actually took her through a series of exercises that help out with that. And one of them is a, I call it a frozen skater. It's basically a single leg RDL without moving because I wanted to load into that hip versus getting sloppy. I take them through a movement and base one later. And then we did some stuff with bands. I wanted to post up onto that side, hold it, and I'm going to slowly pull her out of it with the bands so she has to control the movement. So I wanted her brain to start to get that connection with the posting leg. I had her do that. Didn't tell her anything else.

Gave her the club back and had her swing. She's like, oh, my neck feels better. So what's that tell you? We didn't do anything actually to the shoulder in that case. I didn't coach any other parts to the swing because I'm not a swing coach. I'm not a golf instructor. I don't know all that stuff there. But I do know movement. And when it comes to ground contact, if you have a sloppy ground contact, it's really hard to put quality movement through your swing. So emphasizing the ground contact point on the front leg on her worked. And keep in mind that when we did the corrective stuff for the hip, I attempted to not address the shoulder or neck at all.

When she did the frozen skater, which is the single leg RDL posing, basically, there's really not any shoulder work at all. I don't give her any weight. She's just holding body weight until she fatigues out. With the band and stuff, I had it around her hip. So I was mainly trying to work from the belly button down. So part of the reason why I do this, and there are more efficient ways to do everything at once. I could have gave her something to hold on to. Part of why I do this is, again, because I need to make sure the person is on board with the idea. Because a lot of times, and I go into this in my back book, and I'm sure I can make another book based upon other conditions.

But it's very common for people to go back to the idea of, well, I have this disc herniation, or I have this stenosis, or I have this arthritis, or I have narrowed space, or I'm out, or I'm old, or whatever the heck it is. It's easy to go back to that. But I think when you show them, I feel that when I've been able to show them that they're able to reduce their symptoms with other parts working better, they're more on board with the entire idea of the body as a unit. You can't separate it into parts. We can have first aid processes, but ideally, to get back into the sport and the stuff that you like, you have to treat the body as a unit.

And that's why, getting back into the third phase of load, we just have to go through the basic stuff. If you're not squatting, add a squatting. Maybe you want to be trained how to squat, but add a squatting. Add a deadlift in. Add a carry in. Carries are probably one of the easiest, safest things to add to people, especially double-handed carries like farmer's carries. It's so easy. I mean, if you consider if you're a runner and you have a hip drop or knee issues, just add a carry in. All right? If you're trying to improve how your shoulder locks onto your body, put something heavy in it, you're not going to let the weight win.

And your shoulder packs itself on. There's almost like this, I believe there's this neurological pathway. It's like a triggered system that when something gets in your hand and you're gripping it, all of a sudden that links up everything within that limb. And it's kind of like a software pattern telling your body that, hey, there's something heavy in your hand. Link it up. Stiffen up. Don't let this thing drop. Don't let it pull you over. Right? So that's why I use that callus rule. So use some heavy stuff. And it doesn't have to be heavy all the time. Just expose yourself slowly to some load.

And just to reiterate again, the steps of the process here is first aid. First aid's great. First aid's awesome. Bandages are great. Braces are great. Tissue work, stretching, they're all cool. They're great. But they're first aid stuff. Ice and heat, they're all first aid. All right? But when we have a cut on our arm, we don't treat it the same way after the scab heals up. We treat it differently. So a lot of people stick within that first aid process. When their neck hurts, they chill it out. They first aid it. And they don't progress forward. That's one of our purgatories there is that it will trigger sooner if you don't build the supportive systems.

And just like this lady in the last case, she had that past labral repair. And it didn't look like anyone had addressed rehab around the actual shoulder blade or the things correlating to helping that area out. So my responsibility is to get her to feel that there's a correlation there and get her to buy into the idea that she has to do some rehab to buffer the area. All right? It's like you're paying your payroll, right? And you have this bank account that's almost tapped out every single month. It's really stressful. Build a buffer in there. You can still have the same up and down amplitude, but build a buffer.

So do the first aid, but do more. If you don't have someone who can give you a nice recommendation for supportive care, find one. Okay? Like I said, throughout these stories, if you're doing the right exercise at the right dosage, you will feel an immediate change within a minute or so. Again, it might not stick. It might stick for some people for two days, some people for two weeks, but it's going to have a response. Okay? After that, get into some loaded movements. It doesn't have to be balls to the wall. And I don't want you to think CrossFit and Olympic lifting. I want you to think that. Just think you have to have something, right?

Most people that I have do carries on, at least the simple thing for carries, is I have them do, I have them shoot for the goal of about half body weight per hand. If you're 100 pounds, shoot for 50 pounds per hand. And usually that freaks them out. And I say, look, it's going to take time to get there. But just to give you a framework is that you're scared to pick up a 20-pound 20-pound weight, right? You're only halfway there. Can you please pick up a 30-pound weight? Challenge yourself a little bit. Does it hurt? No, it doesn't. Okay? If it does hurt, tell me. Maybe we're not ready for this.

Maybe it's not ready. Maybe we need to do some supportive stuff or some first aid stuff. But at some point, we have to get in there. We have to get in there. If you don't, you're not going to build that buffer. All right? And the last part is that just like case one, the three-time offender, he started to realize that, holy shit, this is the same thing happening over and over again. And I just have to address it in a systematic way. If I do it right, it'll work. If it changed, if it's a different thing, maybe it won't work. But if it's the same thing for him, for him and his body and his situation, it seems like it works and it goes.

Maybe his buffer wasn't enough. And that's why this thing keeps happening. Maybe it was the fact that he did pick up soccer and he did headbutts, right? And he was getting pushed around and he hadn't been doing it for a long time. And he's been honest and he says that he's not as dedicated with his loading as he needs to. By the way, I personally load aggressively about two times a week. I challenge myself two times a week. The other days, I'm just working with patients, picking up kettlebells and other objects. So I still have an aspect of picking up heavy things. But they're not heavy for me, okay?

But it's still that callous building type of example. Now, just to frame it again, just to recap. The idea, if you're going to build a big buffer, I think you should strive for building three callouses per hand, okay? It's going to be on your last three digits. It should get to the point where you feel like, these things are ugly and I don't want to have manly, manly hands. I don't want to have rough hands. Once you get to that point, file them off. You're there, okay? You're probably going to feel a lot better than what you did. If you felt pain throughout the process of creating those callouses, then you skipped a step some more.

If you're not under the care of someone who can guide you through this stuff, you need to be. And eventually, when you get to the part of the loading, I'll be 100% honest with you. I pay a strength coach to come in to work with me, all right? I'm not bullshitting you. And I have people that say, well, maybe I can do this on my own. I said, you could, and I could too. And I know a lot more than you. And I don't mean that to be cocky. I'm just confident that I know more than you as a lay public. Maybe not as a doc, but as a lay public, I know more. And I still pay someone to come in and help me with form and load and confidence and movement.

So, I get it. I get it. It costs money. But if you want to beat this kind of stuff, ask for help and find someone who can help you through that. Maybe your doc is not the right one to help you through load. Maybe they are. I know there's a lot of people who are really good with loading and movement now who also work clinically. But also, too, we have our special skill sets. Some people are only good at first aid. Some people are only good at load. Make sure that you have help to guide you through the process throughout the way. All right? If you do, I think you'll be pleasantly, pleasantly surprised.

Now, if you guys are looking for the show notes on this, I will put them on the website. And you can find them under the search function of, just put 119, 119. That is the podcast number for this one. And tell me what you like or don't like about this podcast. If you have a friend who has neck pain or mid-back pain or tightness of the upper traps and they're always wanting people to massage their shoulders at family gatherings, send this to them. Okay? I have a friend who, he would always have his wife massage his shoulders and his wife's like, hey, can you get, you find something so I don't have to do this all the time because I don't like doing it because our hands hurt, right?

And we found out that him pulling his own skin helped. And I said, hey, look, we just saved your hands. You can do this shit on your own. Now everyone's happy, right? You know, there's things that can help people that they would probably never have thought of. So, send them this to show them that there's other ways to improve this stuff for the long term. Don't hang out in the first aid process. Okay? Now, again, tell me what you guys liked and didn't like about this podcast. I would strongly suggest and urge you, please, please, please, give me some reviews on iTunes because as I've done this now 119 times, I know that even great information, I'm hoping this is useful information for you guys, it doesn't get out to the public and it doesn't get disseminated and shared unless there's reviews and people, good people like you can share them.

By the way, I do see the reviews have been building. Thank you so much for doing them. I'm very appreciative and I read all of them. So, it's really helpful for helping me get this stuff out to you guys and your friends and family and your patients. So, I want to make sure that everyone can help out with that. So, if you're part of the movement movement, move this stuff. Move it. Share it. Put it on your website. Put it on your feeds and your social medias and tell them, hey, this is what's badass information. Share it. Thank you so much. Now, next week, we are getting into the new year, right?

So, what is to come in the new year? We are first going to have, we're going to have Guido or Grant Elliott. I'm not sure yet. Guido is the, he's a badass, a complete badass. But the only thing I've seen is a hang-up for Guido is that he's not, there's not a lot of information out there on the internet. He's like a hidden gem. He's amazing. So, when you hear him speak next year, I want you to take it to heart because he is a complete badass in his field, but he's under the radar. Okay, we're going to learn a lot from him, and I strongly believe if we share more of his information with people who are implementing care or people who are in pain, they're going to feel so much better.

And I can guarantee you that when I took his course, it changed my practice significantly. Crazy shit. It's so good. I've found people with shoulder conditions, I can do a load, a heavy loaded pull, a sled pull, and they're like, oh, my neck feels better. My shoulder feels better, right? I've found people with back pain, if you do a very aggressive load into the glute max and the glute medius region, they feel better immediately. They can walk without pain. And again, this stuff doesn't always stick, but if we continually try to readjust that attractor state, then it's going to stick at some point.

It's going to stick. So don't miss that interview with Guido. I'll talk to you guys next year. Have a good New Year's.