The teres (TEH- reez) minor muscle lies right below the infraspinatus on the shoulder blade and has a similar attachment to the back of the head of the humerus (figure 5.28). The teres minor helps the infraspinatus rotate the arm outward.
The pain pattern for the teres minor is very different from that of the infraspinatus; it refers primarily to a very confined spot on the back of the shoulder in the area of its attachment to the humerus. Pain from trigger points in the teres minor may not be noticed until after more oppressive problems with other shoulder muscles are dealt with.
Teres minor trigger points can also be the cause of a worrisome numb- ness or tingling in the fourth and fifth fingers. Note that a comparable pattern of finger numbness can also come from trigger points in the pecto- ralis minor. Pain instead of numbness in these two fingers suggests latissi- mus dorsi trigger points (Simons, Travell, and Simons 1999).
Figure 5.26 Arrow shows outward rotation for locating infraspinatus with isolated contraction. It is the same motion as hitchhiking.
Figure 5.27 Infraspinatus massage with a ball on a wall
Figure 5.28 Teres minor trigger point and referred pain pattern
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 113
The place to find teres minor trigger points is right at the upper lateral border of the shoulder blade. See “The Shoulder Blade” section above for instructions detailing how to find the lateral border. As you rotate your arm outward, as you did for the infraspinatus (figure 5.26), feel the muscle bulge up at the outer border at the very end of the motion. To find the trigger point against the lateral border, measure about an inch up from the armpit. The teres minor can be massaged with the same techniques as the infraspinatus. A tennis, high bounce, or lacrosse ball against the wall is the perfect tool: roll it slowly back and forth across the teres minor against the wall (figure 5.29).
If pain persists in the back of the shoulder after teres minor trigger points have been deactivated, consult this chapter’s Pain Guide for the many other muscles that refer pain to this same place. You may also find it important to deactivate trigger points and stretch the pectoralis major and minor muscles.
Subscapularis
The subscapularis (sub- scap- yu- LEHR- us) is an exceptionally powerful muscle lining the front of the shoulder blade (figure 5.30). Visualize this muscle sandwiched between the shoulder blade and the ribs. (In the illustra-
tion, the ribs have been removed and you’re looking through the body to the back.) The muscle’s attachment to the head of the humerus allows it to rotate the arm inward, as if putting something in your back pocket. This attachment also enables the subscapularis to help keep the joint together and the head of the humerus centered in its socket.
You’d think that the subscapularis muscle would be unreachable and untreatable, buried as it is on the front side of the shoulder blade. Actually, it’s surprisingly accessible if you go about it in the right way. This is good news, because the subscapularis is often at the very heart of the problem with shoulder pain. With a frozen shoulder in particular, knowing how to treat subscapularis trigger points can be the key to recovery; without this knowledge, recovery can be a very long time in coming (Simons, Travell, and Simons 1999; Cantu and Grodin 1992; Voss, Ionta, and Myers 1985).
Bernie, age forty- eight, endured pain in his left shoulder for several months. The problem had begun when he tripped and fell while picking up broken branches after a storm. His shoulder ached all the time and woke him repeatedly in the night. He stopped even trying to raise his arm and dreaded putting on his shirt in the morning. He hated the idea of going to the doctor, but the problem wasn’t getting any better. Bernie’s wife gave him a gift certificate for a massage and, to her great surprise, he went. The therapist worked on an extremely tender place under his arm and then showed him how to massage the spot himself. His shoul- der was better right away, which encouraged him to continue working on it on his own. When asked at work three months later how his shoul- der was doing, he realized he’d had no pain in quite a while. To test it, he raised his arm all the way up. “I’d forgotten about it,” he said. “I don’t even think about it anymore.”
Figure 5.29 Teres minor massage with a ball against a wall
Figure 5.30 Subscapularis trigger points and referred pain pattern
Ruth’s shoulder trouble came about in a very different way. At age sixty- seven, she had decided to pursue her lifelong dream of learning to play the banjo. But soon after her first lessons, she began having pain behind her left shoulder whenever she sat down to practice. It hurt just to stick her arm out to hold the neck of the instrument. Luckily, her teacher knew something about trigger points, having had problems of his own. He explained that the position of the left hand when playing a banjo, guitar, or even a violin requires maximum outward rotation of the left arm. To permit this, the subscapularis muscle has to lengthen all the way, which can be a terrific strain if you try to practice too long and the muscle isn’t strong and resilient. “And then you get trigger points,” he told her. After he showed her how to do self- applied subscapularis massage, Ruth was able to continue playing her banjo, pain free, as long as she didn’t overdo it.
Symptoms
The main symptom of subscapularis trigger points is severe pain deep in the back of the shoulder (figure 5.30). An ache in the back of the wrist is occasionally present and could be seen as a signature of subscapularis trigger points. Sometimes the shoulder pain extends down the back of the upper arm (not shown). You may also have an extremely tender spot on the front of your shoulder where the troubled subscapularis has been continuously pulling and jerking on its attachment to the humerus (Simons, Travell, and Simons 1999).
The pull of the four rotator cuff muscles must be in balance in order for the shoulder joint to operate smoothly and freely. A subscapularis muscle weakened by trigger points allows the supraspinatus to pull up on the head of the humerus unopposed, jamming it against the acromion. A clicking or popping noise when you move your shoul- der indicates probable trigger points in the subscapularis or the supraspinatus, or both (Simons, Travell, and Simons 1999; Lippitt and Matsen 1993).
Subscapularis trigger points also keep the muscle from lengthening, reducing the shoulder’s range of motion and restricting rotation of the arm in either direction. This makes it difficult to reach above your head, across your body, or up behind your back. The disabling pain and stiffness caused by subscapularis trigger points are commonly mistaken for bursitis, arthritis, bicipital tendinitis, rotator cuff injury, and adhesive capsulitis (Simons, Travell, and Simons 1999).
Causes
A sudden unprepared overloading of the shoulder muscles, such as might occur during a fall, is especially likely to make trouble for the subscapularis. Your shoulders are more vulnerable to this kind of accident when you’re an older person, overweight, or simply out of shape. Another common cause for the development of subscapularis trigger points is prolonged immobilization of the shoulder for healing of a broken arm. Stroke victims who have lost the use of an arm often develop subscapularis trigger points because of inactivity. Recovering from a tear to the rotator cuff can make trigger points in the subscapularis, as can the initial injury. Dislocating the shoulder can also cause trigger points (Simons, Travell, and Simons 1999).
Trigger points commonly develop in the subscapularis when you overexert yourself during exercise or sports activity without proper conditioning. Lifting a child overhead and then swinging her down between your legs and up again will activate subscapularis trigger points. Fitness enthusiasts, swimmers, tennis players, and ball throwers of all kinds are in special danger of abusing their subscapularis muscles. Pitchers who have to retire prematurely because of chronic shoulder pain might well be able to return to the mound if their subscapularis and other shoul- der muscles were given some trigger point therapy (Simons, Travell, and Simons 1999).
Treatment
The easiest technique for gaining maximum access to the subscapularis is to sit with the bad arm hanging down between your legs (figure 5.31). Rest your forehead on a table with a folded towel as a pad. This position
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 115
relaxes the shoulder muscles and brings the shoulder blade forward and around the body especially if the arm is held loosely down in between the legs. With the palm surface of your fingers firmly against your ribs, push deep into the slot between the ribs and the armpit. If your hand and fingers are tight against your ribs, the fingertips will press right into the subscapu- laris. Search for exquisitely tender spots deep in the pocket between the ribs and the roll of muscle that defines the back of the armpit. You won’t be pinching this roll of muscle or pressing into it; rather seek the deep valley of the armpit itself. For the uppermost trigger points, search very high in the armpit and aim up at the joint itself. When you find a trigger point, treat it with slow, short strokes pressing up toward the ceiling then outwards against the shoulder blade. Travel down the entire length of the muscle. There will be four to five inches, from top to bottom, to search and treat. Don’t over- look points near the bottom end of the shoulder blade as you approach its inferior angle.
Try using your thumb for this technique; you may like it better. As you learn forward, place the elbow of your treatment hand on your knee. This will provide better leverage. Periodically, relax the side you are working on, as it will have a tendency to tighten up in defense. Keep your arm down,
hanging loosely in between your legs. If you’re unsure whether you’re touching the subscapularis, contract it by strongly rotating your arm inward. Inward rotation is when your elbow is turned outward. This technique was the primary therapy my father used to treat his own frozen shoulder, as described in chapter 1. Although many other muscles were involved, the subscapularis was the heart of the problem. Give subscapularis trigger points ten to twelve strokes several times a day. If pain wakes you up in the night, have another massage session; it should cut the pain enough to let you get back to sleep. Don’t overdo it; the armpit can get quite sore.
Continue daily massage until you can no longer find trigger points. Significant relief can come right away, but complete deactivation may take as long as six weeks. Trigger points that have been in place for months or years will require a great deal of attention. Because they are usually soft, you probably won’t be aware of the clusters of lymph nodes here; however, if you feel a firm bump larger than a pinto bean that does not go away in a couple of days, it is wise to have it checked out by a doctor. See the section “Contraindications: Reasons to Be Cautious” in chapter 3 for more details about lymph nodes. You’ll quickly discover that long fingernails will keep you from effectively self- treating your subscapularis muscles. Fingernails grow back. Make the sacrifice.
For many people, this self- treatment technique will be either too taxing or simply impossible when obstructed by a broad chest. A gentle, conscientious partner can often be of immense help. Before working on someone else’s subscapularis, rehearse the technique on yourself; it will make you more compassionate. If a partner is not a viable option for you, purchase a simple, inexpensive massage tool called the Shemala Fingers from www.bodytools.com. They are a weird little pair of rubber fingers, and the smaller one is invaluable for massaging the subscapularis.
Deltoid
The deltoid muscle, if flattened out on a table, would resemble the Greek letter delta, which has the shape of a triangle. On the body, the deltoid muscle completely surrounds the shoulder like a cap. Although the deltoid is technically a single muscle, it has many heads, or sections, that are commonly categorized into three parts: the anterior, posterior, and middle deltoid, on the front, back, and outer side of the shoulder, respectively. Because of this, the deltoid muscle is often spoken of as “the deltoids.”
The deltoids attach to the collarbone, scapular spine, and acromion, the bony point of the shoulder. Their lower attachment is to a slight bump about halfway down the outer side of the humerus. In conjunction with the supraspinatus muscle, the function of the deltoids is to raise the arm in any direction— front, back, and sideways.
Figure 5.31 Subscapularis massage with arm hanging down between legs
Symptoms
Pain from deltoid trigger points is unusual in that it is not referred to distant places but is felt at the site of the trigger point or nearby (figures 5.32, 5.33, 5.34, and 5.35). Pain originating in the deltoids is felt mainly when you move the arm and less often when the arm is at rest. In contrast, pain referred to the deltoids from elsewhere is felt continuously or in relation to activity in other muscles. Moving the arm, as when eating or reaching out horizon- tally, as you do when you reach behind you into the backseat of a car, will make pain in the deltoids (Simons, Travell, and Simons 1999).
Trigger points in any part of the deltoid weaken the shoulder and impair its efforts to raise the arm. Performance in sports or on the job can be seriously degraded. When health care practitioners are unaware of myofascial causes, pain caused by trigger points in the deltoid muscles is apt to be blamed on arthritis, bursitis, or rotator cuff tendi- nitis (Simons, Travell, and Simons 1999; Reynolds 1981).
Deltoid trigger points are often created as satellites of trigger points in the scalenes, pectoralis major, or rotator cuff muscles, all of which send pain to the deltoid area— the front, back, and side of the shoulder. See this chapter’s Pain Guide for the extensive list of muscles that send pain to the deltoid region.
Causes
The deltoids are frequently overloaded in athletic activities that require forceful flexion of the shoulder, par- ticularly swimming, skiing, weight lifting, and ball playing. In the workplace, the deltoid is overused by having to hold heavy tools up to do a job, or by repeatedly reaching up, out, or back, hour after hour. Doing massage profes- sionally or massaging yourself overtaxes the deltoid muscles. Picking up and carrying a baby or small child is a very common way to abuse the deltoids and other shoulder muscles. A shot from a hypodermic needle can set up trigger points as well (Simons, Travell, and Simons 1999; Cailliet 1966; Jonsson and Hagberg 1974).
To reduce repetitive strain to the deltoids, look for ways to change your job that will help keep the elbows down. Typing taxes the deltoids when the keyboard is too high. Good ergonomics dictates keeping the elbows tucked in and the keyboard level with them. Support the elbows whenever possible and try not to sit in chairs that don’t have arms.
Keep in mind that the deltoid muscles must work hard to keep the arms from being pulled from their sockets when you carry or lift heavy weights. They also are likely to suffer during any accident or fall that wrenches, jams,
Figure 5.32 Deltoid trigger
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 117
or pulls on the arms. An impact injury to the shoulder can be expected to set up trigger points in the deltoids (Simons, Travell, and Simons 1999).
Treatment
Using your hands to massage the deltoids will needlessly exhaust them. Use a tennis, high bounce, or lacrosse ball against a wall instead. Turning at an angle to the wall will allow you to roll the ball over any of the three parts of the muscle.
Note that trigger points will be found only at midmuscle in the anterior and posterior deltoids. In the middle deltoid, because of its complex fiber arrangement (figure 2.11), trigger points can occur anywhere from the point of the shoulder to the attachment in the middle of the upper arm. Most of the knots will actually be found in the middle deltoid, because it’s the largest part of the muscle and works the hardest. Lean into the wall and roll the ball from top to bottom and back again, ironing every inch of the muscle’s area.