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Treatment Tools

By Debbie Roberts, LMT

About the Columnist
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Ink, Art and Healing

I can assure you they didn't use this as a case history when I was in school. One of the reasons would be it was not very popular to get a tattoo or have permanent make up done in 1988, but the celebrities that we see in the movies and on television have changed all of that.

Demand for permanent make-up has grown exponentially over the past few years thanks to the trend for bold, statement eyebrows like those of Duchess of Cambridge or model-of-the-moment Cara Delevingne. The reason a person may give when warning against a tattoo is exactly the reason many people get one: "it's permanent." Just look at celebrity Johnny Depp. His first tattoo was a Cherokee Indian chief for his ancestral heritage-on his right biceps. He now has 32 tattoos.

My goal here is to bring awareness to this artistry and a field that is growing with enormous numbers and a field that will need our help to restore their postural imbalances to save careers. We will take a very close look at their posturing and how the imbalance happens,learn how to assess the problem, and delve into the education of pain referral patterns with nerve entrapment.

The Need

First, let's look at the staggering numbers from the Statistic Brain Research Institute regarding the amount of traditional tattoos performed in the United States:

  • Annual amount of U.S. spending on tattoos = $1,650,500,000
  • Total percent of Americans (all ages) who have at least one tattoo = 14%
  • Percentage of U.S. adults 18 – 25 who have at least one tattoo = 36%
  • Percentage of U.S. adults 26 – 40 who have at least one tattoo = 40%
  • Total number of Americans that have at least one tattoo = 45 million
  • Number of tattoo parlors in the U.S. = 21,000

massage tatoo - Copyright – Stock Photo / Register Mark Let's explore the client that presented in my office with the chief complaint of numbness and tingling into her thumb and first two digits with no neck or shoulder pain. This client has been a permanent make-up artist for 31 years. She first sought out help through chiropractic care. The physician diagnosed her with carpal tunnel syndrome from a left over car accident that happened in her early 20s. She received treatment for her neck three times a week for more than 36 visits, with a cost of $4,000. She said, "Nothing changed. In fact, the symptoms were worse." Without reading further, how would you assess this client? Go ahead and write down the things you would check. At the end, we will discuss the assessment and treatment plan and see if you might do the same.

To understand the posture, we have to understand the profession. What is permanent makeup and how is it performed? It is a cosmetic technique which employs tattoos (permanent pigmentation of the dermis) as a means of producing designs that resemble make up, such as eye lining and other permanent enhancing colors to the skin of the face, lips, and eyelids. Unlike most artists who can step back from their canvas and take a break, a tattoo artist's canvas is another person. They clamp their arm tight to their side to steady their hand. The clamping motion is so they can rely on stabilizing themselves because the client could flinch or move at any given moment, unlike a stationary canvas. Needless to say, they work in a very poor anterior posture position for hours at a time. Like this client said to me, "I am next to someone's eye, I can't make a mistake." Their work also includes producing artificial eyebrows for people who have lost them as a consequence of old age, disease, such as alopecia totalis, or chemotherapy. She relayed to me she covers unwanted scars like the ones that can be left from a face lift and restores the breast's areola after breast surgery.


First, I looked at range of motion of the neck and asked in each position did anything refer down the arm and into the fingers. Although her neck range of motion wasn't good in any position, nothing reproduced her symptoms. Next, I palpated the forearm tissue and did manual muscle testing to see if anything in the flexors would reproduce her symptoms and the answer was, no. So my next thought was it must be between the neck and forearm which lead me to pectoralis minor, anterior scalene, and the first rib. There the symptoms were reproduced, with abduction of the arm out to the side she experienced the numbness and tingling into the fingers. She then relayed she had noticed it had become increasing impossible to hold her shoulder back in a good postural position. Now we have our starting point to be able to reassess during the treatment.

Let's look at pectoralis minor function and entrapment pattern. The pectoralis minor draws the scapula forward, downward and inward at nearly equal angles. Depression of the shoulder by this muscle stabilizes the scapula when the arm exerts downward pressure against resistance. Since the inward force component is blocked by the clavicle when this muscle contracts, the resultant force draws the glenoid fossa of the scapula obliquely down and forward. At the same time, this force tends to lift its medial border and inferior angle away from the ribs causing winging of the scapula.

This winging is an indication that the antagonist muscle to pectoralis minor which is the lower trapezius is weak and inhibited. This is why she could no longer hold her shoulder back in an anatomical position because of the muscular imbalance that had been produced over the years of performing her craft. The pectoralis minor tension increases the entrapment potential of the C7 and C8 roots that hook over the first rib. Kendal, et al., have described in detail this entrapment of muscular origin noting that pectoralis minor shortening is the most likely cause, aggravated by tension in the biceps brachii and coracobrachialis, and by weakness (or inhibition) of the lower trapezius muscle.


The treatment session started with the client in a side lying position to release pectoralis minor, pectoralis major, upper trapezius, levator, anterior, and middle scalenes. Additional muscles were also treated such as latissimus and subscapularis that help produce internal rotation of the humerus.

Treatment tools: I performed isometrics by cupping the client's anterior shoulder into my hand and having her roll the shoulder forward at a 15% resistance holding the contraction for 8-10 seconds and then having her take a deep diaphramic breath and imagine the shoulder going limp six times through. I did not stretch the shoulder during the relaxation phase after the isometric because it would reproduce her symptoms. I used myofascial release techniques to help with the fascial tension both to the front and the back of the shoulder girdle.

The next part was having her in a supine position with heat on the chest muscles while working on her neck muscles, helping to restore balance and relieve the upward pull on the first rib and scapula. I also used a small device underneath her at each level of her T-spine to help produce thoracic extension and more opening for the chest. I alternated each tool and position of the client three times during the treatment session. There was an immediate difference in her symptoms at the end of the session. She was instructed to do the same techniques at home with the heat, isometrics, something rolled between the shoulder blades to allow the shoulders to fall backwards, and the use of breath and visualization. I asked her to examine what she could change in her work station and habits for better ergonomics. In addition to her homework at work, she needed to take posture breaks after each client, not just when she noticed the numbness and tingling starting to increase.

The use of isometrics in this case was a very important aspect. As stated by Liebenson (1996) in Leon Chaitow's Muscle Energy Techniques book pages 5 and 6, "the benefits of, and the mechanisms involved in, use of muscle energy technique (which he terms ‘manual resistance techniques', or MRT): Two aspects to MRT [i.e. MET by another name] are their ability to relax an overactive muscle and enhance the stretch of a shortened muscle and its associated fascia. There are two fundamental neurophysiological principles that account for the neuromuscular inhibition that occurs during the application of these techniques. The first is post contraction inhibition [also known as post isometric relaxation or PIR], which state that after a muscle is contracted, it is automatically in a relaxed state for a brief, latent, period. The second is reciprocal inhibition (RI) which states that when one muscle is contracted its antagonist is automatically inhibited."

I love the application of isometrics because it seemingly just helps melt any over contracted muscle. It is one of my standard tools in my tool box. Tattoo artists are not alone in this "bent over, curved position" staring at clients all day. There are nail techs, office workers, orthodontics, and of course, massage therapists just to name a few, who are probably experiencing the same kind of discomfort from their working posture. So to all of the above, I recommend seeking the appropriate treatment to help correct postural imbalances and most important, change your habits both during and after working to eliminate the anterior forward roll of the shoulder and possible entrapment by a known villain pectoralis minor.

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