Think about all the things human beings can do with their hands. The diversity is truly awesome, particularly in sports and the arts. In our world of rapidly proliferating technological devices, human hands and fingers are called on daily to manage subtle, new operations. All of these widely varied actions of the hands depend directly on the strength of the shoulder joints and their ability to move freely.
Moving the arm into an infinite variety of positions requires extremely fine coordination among all the muscles involved. There are twenty- four muscles that affect the function of each shoulder, including the scalene muscles in each side of the neck. Tight scalenes can cause compression of the nerves and blood vessels that supply the shoul- ders, arms, and hands (Davies 2006). 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 seat belt. Constant pain disturbs your sleep and makes your job miserable. In its fully developed state, shoulder trouble can persist for months, and sometimes for years (Simons, Travell, and Simons 1999; Bonica and Sola 1990).
Shoulder trouble can be extremely frustrating when therapists don’t understand shoulders and don’t fully treat the muscles that move the joints. Pain from trigger points and the resulting joint dysfunction can last for years. Some people get lucky and the pain goes away due to limited use, but often the range of motion remains very limited. In other cases, like Jeannie’s, the pain persists for years.
Figure 5.19 Serratus posterior
superior referred pain pattern Figure 5.20 Serratus posterior superior massage with the ball on a wall (hand on opposite shoulder)
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 107
Jeannie, age forty- five, experienced pain in both shoulders after trying to catch herself during a fall on the stairs where she worked. Doctors 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, Jeannie dis- covered trigger points in all of her rotator cuff muscles. The massage techniques she learned in class brought more relief from her shoulder pain than she’d had from any previous treatment. It took her several weeks to unload all of the muscles harboring trigger points, but in the end she had full range of motion and no more pain.
Diagnosis for shoulder conditions usually focus on the joint: arthritis, bursitis, tendinitis, rotator cuff injury, adhesive capsulitis, and so on. Adhesive capsulitis is just one of the many labels that doctors apply to the problem known as frozen shoulder syndrome. Adhesions are made from a fibrinous glue that develops over time into more permanent collagen and then ultimately into scar tissue. This process usually takes place after tissue injury or surgery. Although it is possible for adhesions to form in the glenohumeral joint of the shoulder, it usually takes months or years of immobility for them to develop and some people never get them. Even then these adhesions may be released by slow, gentle, pain- free manipulation of the joint by a trained manual therapist. Some orthopedic massage therapists are trained to perform a mortar- and- pestle- like technique to gently massage and stretch the deep fascia inside the joint. Before this technique is done, all of the muscles of the shoulder are massaged and the trigger points released (Waslaski 2012). You can release the trigger points yourself, and, by doing so, you will improve your range of motion, greatly reduce your pain, and also reduce the likelihood that you will develop true adhesive capsulitis. It’s easy to understand the importance of a healthy ball- and- socket joint in positioning the hand and arm for a virtually unlimited variety of actions and operations. Movement of the ball in the socket is the essential action in the shoulder, but movement of the shoulder blade is just as important, if not more so. Think of the shoulder blade as a kind of platform for a crane, the crane being the arm. The shoulder joint is the place where the crane swivels to maximize the range of motion of the arm; the shoulder blade, lacking the restriction of liga- ments, moves freely on the back. To gain this freedom requires an elaborate arrangement of the powerful muscles on both the front and the back of the trunk harnessing and controlling the shoulder blade. Of the twenty- four muscles involved with the shoulder, seventeen attach to the shoulder blade. All of them have an effect on the posi- tioning and function of the shoulder complex. Just like a cascade of dominoes, many muscles can become involved when there is a significant imbalance in one (Davies 2006).
The four rotator cuff muscles are the most frequent cause of shoulder pain, loss of upper arm motion, and click- ing or catching in the joint. The rotator cuff is made up of the tendons of these four extraor-
dinarily important muscles that cover the inner and outer surfaces of the shoulder blade. Tendons are the strong fibrous end of the muscles that anchor them to the bones. When there is an issue at the tendon, it is likely that the problem is in the corresponding muscle (Davies 2006).
When you’re able to manage the trigger points in these muscles yourself, you may be able to avoid forced manipulation of the shoulder, steroid injections, and harsh physical therapy.
Exercise and stretching, the most common form of physical therapy for shoulder problems, often yield 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 surgery 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 (Simons, Travell, and Simons 1999; Danneskiold- Samoe, Christiansen, and Andersen 1983).
Of the twenty- four muscles involved with the shoulder, seventeen attach to the shoulder blade.
Be sure to read chapter 3, Treatment Guidelines to learn how to do the massage.
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 5.21). The word “supraspinatus” means “above the spine.” At its outer end, the muscle passes under the acromion and crosses over to attach to the outer side of the 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.
Pain in the outer shoulder will tempt you to expend energy massaging the deltoid muscle. Deltoid massage is easy, feels great, and may even do some good, but it won’t fix your shoulder pain if it’s coming from the supraspinatus. Supraspinatus trigger points can be at the heart of an otherwise unexplainable problem.
Erik, age fifty- five, took a bad 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, became an unpleasant ordeal. After many tests, Erik’s doctor still wasn’t sure what was wrong. A knowledgeable friend applied pressure to an extremely tender spot in the supraspinatus muscle of Erik’s left shoulder blade, repro- ducing 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 at rest as a deep ache in the outer side of the shoulder (figure 5.21). Occasionally, pain spreads to the outer side of the upper arm and forearm and into the wrist (not shown). It can be 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 misdi- agnosed as bursitis (Simons, Travell, and Simons 1999; Bonica and Sola 1990).
Supraspinatus trigger points are to blame for the clicking or popping that is sometimes felt or heard in the shoulder joint. The muscle is kept so tight that the head of the humerus is prevented from gliding smoothly in its socket. The popping stops when the trigger points are deactivated (Simons, Travell, and Simons 1999).
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, tendinitis, or inflammation, tennis elbow is often just referred pain from myofascial trigger points that can 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 (Simons, Travell, and Simons 1999).
Figure 5.21 Supraspinatus trigger points and referred pain pattern
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 109
Causes
The supraspinatus is commonly overloaded during a onetime incident of extreme exertion, such as moving a large couch or carrying heavy weight like boxes or suitcases. The supraspinatus muscles have to work extraordi- narily 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. So can a large, strong, eager dog that can’t be broken of pulling on the leash (Simons, Travell, and Simons 1999; Hagberg 1981).
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. Review finding the landmarks in “The Shoulder Blade” section above. Find the superior angle and the spine of the scapula. If your hand is in the right place, your fingertips will be contacting the top edge of the scapular spine and the heel of your
hand will be on your collarbone. To verify that you’re touching the supra- spinatus, begin to raise your arm forward and a little to the side. Just as your arm starts to move, you should feel the muscle contract and bulge up under your fingers. If not, move your finger slightly to the outside.
Trigger points occur in two places in the supraspinatus (figure 5.21). One is in the belly of the muscle, just below the superior angle of the shoul- der blade. It is easy to confuse this trigger point with one in the levator scapulae, so palpate carefully. If massage feels really good, you are likely to be on the levator. The second trigger point is about two inches farther out, near where the muscle dives under the acromion, the bony point of the shoulder. The trigger point is right in the bony V formed by the scapular spine and the collarbone, which come together at this spot. This point can be acutely tender, just like a bruise. Try to make the massage feel comfort- able, not to the point of squinting your eyes or grimacing.
The sensitivity of the fingers is helpful for locating trigger points in the supraspinatus, but massage with the fingers is not worth the strain. The Thera Cane or Backnobber are better tools (figure 5.22). 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. With either tool, the opposite hand in the bow gives you the greatest leverage for digging into this deeply situated muscle.
It’s conceivable that you’ll need some help in dealing 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.
Infraspinatus
The infraspinatus (in- frah- spih- NAH- tus) covers almost all of the shoulder blade below the scapular spine (figure 5.23). 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
Figure 5.22 Supraspinatus massage with the Thera Cane (opposite hand in the bow)
be raised above the level of the shoulder. The infraspinatus is also a strong participant in keeping the head of the humerus in its socket.
The infraspinatus is one of the most frequently afflicted muscles of the body. It’s capable of ending an athletic career, as illustrated by Kim’s story.
Kim 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 tendinitis, 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 con- cerned 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.
Symptoms
Paradoxically, though located behind the shoulder, infraspinatus trigger points are the most common source of pain in the front of the shoulder (figure 5.24). This pain usually feels like it’s deep in the joint and may travel some distance down the biceps. Extreme tenderness in the anterior deltoid and the bicipital groove in the head of the humerus can lead to an erroneous diagnosis of bicipital tendinitis. Pain can also shoot down the outer side of the shoulder. Occasionally, the trigger point just inside the medial border of the shoulder (figure 5.25) will refer pain to the back of the neck and to the upper back next to the shoulder blade, all the way down the upper arm and forearm, and into the entire thumb side of the hand. When pain is referred to the forearm it tends to promote formation of sat- ellite trigger points in the hand and finger exten- sors, compounding pain and other symptoms in the hand. It is also possible to develop hyperhidrosis, or excessive sweating, within the referred pain zone and even down into the hands (Simons, Travell, and Simons 1999; Pace 1975).
Other symptoms of infraspinatus trigger points include weakness and stiffness in the shoulder and
Figure 5.23 Infraspinatus trigger
points for shoulder pain Figure 5.24 Infraspinatus referred pain pattern
Figure 5.25 Infraspinatus medial border trigger point with referred pain pattern
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 111
arm, which can cause your shoulder and arm to tire easily. Both inward and outward rotation of the arm are restricted, making it difficult to move the arm in any direction. 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 bra. You struggle getting your 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. Even reaching up to comb your hair or brush your teeth may be painful (Simons, Travell, and Simons 1999; Sola and Williams 1956).
The internal rotator muscles, the subscapularis, and the pectoralis major can instigate trouble in the infraspi- natus and teres minor. If the subscapularis and pectoralis major are short, tight, and have trigger points, the infra- spinatus and teres minor become overstretched. The latter two muscles then develop a compensation pattern of trigger points. The infraspinatus may be responsible for much of the referred pain you experience, but if you don’t resolve the trigger points and the shortening in the opposite muscles, you won’t solve the problem. Deactivate all of the trigger points before starting a stretching protocol.
It is possible for many of the shoulder muscles to end up with trigger points and soon you’re unable to move the arm much at all. The rigidity of the shoulder imposed by the stiffness of the muscles can give your doctor the idea that you have adhesions in the joint or adhesive capsulitis, which can lead to a recommendation for forced manipu- lation under anesthesia. Nevertheless, this condition, commonly called a “frozen shoulder,” can often be treated very successfully with trigger point massage of the rotator cuff muscles and other associated muscles (Simons, Travell, and Simons 1999).
Causes
Working at a job that requires keeping the arms overhead or out in front for long hours is abusive to the infra- spinatus 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 overload the infraspinatus. Driving a car with the hands on the top of the wheel puts continuous strain