Up to twenty muscles are involved in operating the shoulder and all of them are vulnerable
to strain, because the shoulder is such a hard-working part of the body. Shoulder trouble
takes a predictable course. When a shoulder muscle is weakened and made
dysfunctional by
trigger points, associated muscles have to take up the slack. Under the extra burden,
they fall
like dominoes, each acquiring trigger points in turn, until every muscle in the region has
joined the party.
Simple chores become impossible. You can no longer scratch your back, comb your
hair, or reach up to get the cereal off the shelf. If you need two hands for something, you
have to use your good arm to lift your bad one. You may not even be able to reach across
your body to fasten your seatbelt. Constant pain disturbs your sleep and makes your job
miserable. In its fully developed state, shoulder trouble can persist for months, and some-
times for years. (1999: 604-606; Bonica 951)
Diagnosis for this condition usually focuses on the joint: arthritis, bursitis, tendonitis,
rotator cuff injury, adhesive capsulitis, and so on. Another rationale for shoulder pain is the
presumed deterioration of joint cartilage, which X-rays often seem to confirm. Even with
such "proof," it can be a mistake to automatically assume that the trouble is in the shoulder
joint. Trigger points in nearby muscles are often the real source of pain. When trigger point
therapy takes the pain away, this can be hard to dispute. (1999: 544-546, 604-605) Shoulder trouble can be extremely frustrating when therapists don't understand shoulders.
Jeanie, age forty-five, had pain in both shoulders after trying to catch herself during a
fall on the stairs where she worked. Doctors had offered only two options: cortisone
shots or exploratory surgery, both of which she declined. She went through two ineffective courses of physical therapy, and then settled into getting professional massage
once a month. The "feel good" massage was relaxing but did little to relieve her chronic
shoulder pain. She lived with her shoulder trouble for the next fifteen years. In a class on the self-treatment of pain, Jeanie discovered trigger points in all of
her rotator cuff muscles. The massage techniques she learned the first night in class
brought more relief of her shoulder pain than she'd had from any previous treatment.
She had spent thousands of dollars on therapy. She wondered why these trigger points
had never been found.
Trigger points in the four rotator cuff muscles are the most frequent cause of shoulder
pain, loss of upper arm motion and clicking or catching in the joint. When you're able to
manage these trigger points yourself, you may be able to avoid forced manipulation of the
shoulder, steroid injections, and harsh physical therapy. Exercise and stretch, the
75 The Trigger Point Therapy Workbook
mon form of physical therapy for shoulder problems, often yields disappointing results when the rotator cuff muscles are stiff and resistant. The safest and most direct and. effective
therapy for shoulder pain is specific trigger point massage of these muscles. Even
when sur-
gery must be done to correct a genuine structural problem, massage of the trigger
points in
the rotator cuff muscles is vital for eliminating residual pain. (1999: 141-142, 542,
556, 599;
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 76
Supraspinatus
The supraspinatus (soo-prah-spih-
NAH-
tus) is buried in a pocket in the top of the shoulder blade above the scapular spine (Figure 5.15). The word supraspinatus means
"above the spine." At its outer end, the mus-
cle passes under the Acromion to attach to the very top of the head of the humerus. This
attachment gives the supraspinatus great
leverage for helping raise the arm. It also
allows the muscle to help the other rotators
hold the joint together.
The supraspinatus is not the easiest muscle to massage and it's not the easiest to find. Many massage therapists, even quite good ones, don't even try. Nevertheless, this muscle is too important a part of common shoulder problems to ignore. The
supraspinatus can be self-treated if you understand it well enough and are determined to take it on. Supraspinatus trigger points can be at the heart of an otherwise unexplainable
problem.
Erik, age fifty-five, had had a had fall while skiing. Eighteen months later, he still felt
the effects in the outside of his left shoulder and in his left elbow. He couldn't raise his
arm without the most excruciating pain. Sometimes it hurt just to walk across the room with his arm hanging at his side. Playing the piano, something he had always
done on weekends for extra income, had become an unpleasant ordeal. After many tests,
Erik's doctor still wasn't sure what was wrong.
Pressure applied to an extremely tender spot in the supraspinatus muscle of Erik's
left shoulder blade reproduced the pain in his elbow and shoulder. He was shown how
to massage the muscle himself. Within three weeks, by his own efforts—after a year and
a half of misery—his pain was finally gone.
Symptoms
Pain from supraspinatus trigger points is felt primarily as a deep ache in the outer side
of the shoulder (see Figure 5.15). Occasionally, pain spreads to the outer side of the upper
arm and forearm (not shown). It's exceedingly painful even to start to raise your arm. Putting your arm overhead is next to impossible. It becomes a problem to wash or comb
your hair. These difficulties and the pain causing them are frequently misdiagnosed as bursi-
tis. (1999: 538; Bonica 947-958)
The supraspinatus is also one of many sources of the pain in the outer elbow
known as
tennis elbow. Although commonly given such catchall diagnoses as arthritis,
tendonitis or
inflammation, tennis elbow is often just referred pain from myofascial trigger points
77 The Trigger Point Therapy Workbook
be treated very effectively with massage. Trigger points in the triceps or one of the forearm
muscles are the most usual cause of tennis elbow. Supraspinatus trigger points, being
so far
away and a less frequent cause, are generally overlooked as a source of this common pain.
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 78
Causes
The supraspinatus is commonly overloaded during a onetime incident of extreme exer-
tion, such as moving a large couch or carrying heavy weight like boxes or suitcases. The
supraspinatus muscles have to work extraordinarily hard to keep the shoulder joints from
pulling apart, especially when you carry something like a suitcase with your arm hanging
straight down. Repetitive strain such as working with the arms overhead for long
periods of
time or typing at a computer keyboard with no elbow support can also exhaust supraspinatus muscles. The simple act of swinging your arms while walking can add an intolerable degree of strain on the supraspinatus when it's already in trouble. A fall can also
initiate supraspinatus trigger points. (1999: 542; Hagberg 111-121)
Treatment
You will find the supraspinatus muscle at the top of the shoulder blade, immediately
behind the thick roll of the trapezius muscle that lies on top of the shoulder. Place your fin-
gers between the scapular spine and the superior angle of the shoulder blade (Figure 5.10
shows how to find the superior angle). To verify that you're touching the supraspinatus, begin to raise your arm forward. Just as your arm starts to move, you should feel the muscle
contract and bulge up under your fingers.
Trigger points occur in two places in the supraspinatus (see Figure 5.15). One is in the
belly of the muscle, just below the superior angle of the shoulder blade. The other is an inch
or two further out, near where the muscle dives under the Acromion, the bony point of the
shoulder. The trigger point is right in the V formed by the scapular spine and the collarbone
that come together at this spot.
The sensitivity of the fingers is helpful for locating trigger points in the supraspinatus,
but massage with the fingers is very hard to sustain. It's also difficult to get the pressure
needed to go deep enough, because the supraspinatus can be quite thick. The Thera
Cane is
a better tool, at least as a finger saver, though the knob may be a little large for use in this
narrow spot on children and smaller adults (Figure 5.16). It helps to first guide the knob carefully into place with your fingers, feeling for the superior angle of the shoulder blade- and the scapular spine.
It's conceivable that you'll need some help in deal- ing with the supraspinatus. If so, a partner standing behind you (with you seated) can get to the supraspinatus with paired thumbs, supported fingers, or a Knobble. If you go to a massage therapist, you might ask him or her to try standing at the head of the table and using paired thumbs, with you face down. In this position, it's very easy to use deep stroking massage
on the entire length of the supraspinatus along the scap- ular spine. The trick is to use the body weight to lean in and bury the thumbs in the muscle.
Pain in the outer shoulder will tempt you to
79 The Trigger Point Therapy Workbook
massage is easy, feels great, and may even do some good, but it won't fix your shoulder pain if it's corning from the supraspinatus.
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 80
Infraspinatus
The infraspinatus (in-frah-spih-NAH-tus)
covers almost all of the shoulder blade below
the scapular spine (Figure 5.17). The word
infraspinatus means "below the spine." At its
outer end, the infraspinatus attaches to the
back of the head of the humerus, giving it
the ability to rotate the arm outward, as
when you pull your arm back to throw a ball or prepare to make a forehand stroke with a
tennis racket. Without outward rotation, the
arm can't be raised above the level of the
shoulder. The infraspinatus is also a strong
participant in keeping the head of the Figure 5.17 Infraspinatus trigger points humerus in its socket.
The infraspinatus is one of the most frequently afflicted muscles of the body. It's capa-
ble of ending an athletic career, as illustrated by Kim's story.
She was a thirty-two-year~old professional tennis coach who had lived with pain in both
shoulders ever since she began playing tennis as a child. Diagnosed with rotator cuff
tendonitis, Kim had had numerous steroid injections and was going for physical therapy
almost weekly. Despite the treatments, pain kept her from-playing much of the time.
She was very concerned that several of her young players were developing shoulder pain
very similar to her own. "I make them play through the pain just like we were told to
do at their age," she said. "I'm afraid they'll end up as tennis cripples like me, but I
don't know what else to do. They want to play so badly."
After a massage therapist showed Kim how to self-treat her shoulder with a tennis
ball against a wall, she became free of shoulder pain for the first time since the age of
fourteen. She felt that the best part about the new trick was that she could pass it on
to her students.
Paradoxically, though located behind the shoulder,
the infraspinatus is the most common source of pain in the front of the shoulder (Figure 5.18). This pain usually
feels like it's deep in the joint and may travel some dis- tance down the biceps. Pain can also shoot down the outer side of the shoulder. Occasionally, pain is referred to the back of the neck, the inner border of the shoulder blade, and the forearm and hand (not shown). When pain is referred to the forearm, it tends to promote for- mation of secondary trigger points in the hand and fin-
ger extensors, compounding pain and other symptoms
in the hand. Many hours can be wasted rubbing all these places, when you don't realize that the problem
Figure 5.18 Infraspinatus referred may be infraspinatus. (1999: 552-554; Pace 1975: pain pattern 107-113)
81 The Trigger Point Therapy Workbook
Other symptoms of infraspinatus trigger points include weakness and stiffness in the
shoulder and arm, which can cause your shoulder and arm to tire easily. Both inward and
outward rotation of the arm is restricted, making it difficult to move the arm in any direc-
tion. Since arm rotation is necessary for reaching behind you, it becomes impossible to reach
up behind your back. A woman can't fasten or unfasten her brassiere. A man struggles get-
ting his jacket on or off. Lying on the afflicted shoulder is painful. Lying on the opposite side
is painful as well, because the weight of the afflicted arm pulls on the infraspinatus. (1999:
556; Sola 1956: 91-95)
Dysfunction of the infraspinatus typically causes the other rotators to tighten up in an
effort to compensate, which tends to overload them too. All four rotators end up with trigger
points and soon you're unable to move the arm at all. The rigidity of the shoulder imposed
by the stiffness of the muscles can give the impression that you have adhesions in the joint.
(An adhesion is a fibrous band connecting parts that are normally separate.) Nevertheless,
this condition, commonly called a frozen shoulder, can often be treated very successfully
with trigger point massage. (1999: 552-558) Causes
Working at a job that requires keeping the arms overhead or out in front for long hours
is abusive to the infraspinatus muscles, since they have to stay contracted to keep the arms
up. Repeatedly reaching back in work or play can leave the infraspinatus in a shortened
state and full of trigger points. Accidents, falls, and many kinds of sports activity can over-
load the infraspinatus. Driving a. car with the hands on the top of the wheel puts continuous
strain on both the infraspinatus and the supraspinatus, since they work together to
keep the
arms up. (1999: 556; Baker 35-44)
For the same reason, working at a computer keyboard without elbow support easily
exhausts both muscles. Keeping your hand on the mouse out to one side can be the
cause of
your chronic shoulder pain on that side, since this position requires nearly maximum out-
ward rotation of the arm and continuous contraction of the infraspinatus. Study your activi-
ties to discover other ways an infraspinatus muscle may be involved in an habitual overload or repetitive strain, related to its function in outward rotation of the arm.
Treatment
The infraspinatus, being on the outside of the shoulder blade, is an easy muscle to treat with self-applied massage. Confirm its location by feel- ing it contract and bulge as you put the arm into outward rotation (Figure 5.19). The Thera Cane works well for infraspinatus massage (Figure
Chapter 5
—
Shoulder, Upper Back, and Upper Arm Pain 825.20). You may like a ball against the wall even
better. When you exert pressure on infraspinatus
trigger points, the pain reaction takes awhile to
wake up, so don't conclude too quickly that you have no problem there. It may take several sec- onds of deep massage before you feel the charac-
teristic exquisite tenderness. One minute of
83 The Trigger Point Therapy Workbook
The infraspinatus is an especially sneaky mus- cle. You'll rarely experience pain in the infra- spinatus itself. You'll find yourself rubbing away at the front or outer side of your shoulder, forgetting that infraspinatus trigger points are almost always the cause of pain felt there. You won't know the infraspinatus is the culprit until you press on it. Be wary of exercising and stretching the infraspinatus or any of the other shoulder muscles until the trigger points have been taken care of. Trigger points in the infraspinatus are unusually irritable, making stretching counterproductive as therapy. A therapist may insist on the need for exer- cising the shoulder, but the weakness and stiffness that seem to be the problem are actually part of the
protection the trigger points are trying to provide.
Muscle strength comes back when trigger points are
deactivated. Exercise and stretching are helpful for getting your range of motion back, but
not until the trigger points are gone.