Some of you may have experienced weeks where you seem to see the same conditions over and over again. Its as if you should title your work “hip fixing week” or “headache day”. For me, more often than not, it is “pain in my shoulder…fix me” week. Shoulder joints are one of the most treated areas in my practice, which has provided me with a pretty good idea as to some of the common denominators for why they go funky. Obviously, every client is unique and you cannot generalize because each injury or pain condition is its own process. However, recognizing some of the typical traits of shoulder dysfunction can help you assess some areas which can be treated to help restore shoulder function. And by doing this, we can treat a good number of shoulder pain cases.
The condition which is one of the most frequent that I see, and which I want to cover is shoulder impingement syndrome. Although I said that you should not generalize for proper assessment sake, many cases of shoulder pain are due to impingement syndrome. Yes, there are plenty of other conditions which occur in the shoulder, but for the sake of this post, I want to focus on impingement as it is a condition which pops up a lot, and is highly applicable to massage therapy.
Shoulder impingement is something which afflicts many people and is a commonly diagnosed condition by doctors as a reason for their patient’s shoulder pain. The true cause of shoulder impingement can be divided into two categories. The first is structural dysfunction. This is defined as a reduction of the subacromial space which can be due to bone spurs, swelling, or any sort of abnormality which makes the space smaller. These can be genetic or the result of the second category. The second is a functional dysfunction which can be due to instability of the joint/ muscle imbalance or improper mobility of the joint. This secondary dysfunction then results in an impingement syndrome due to inflammation and swelling. This is where we as massage therapists can be effective, and hence where we will focus our attention today.
The functionality of the glenohumeral joint is that of a ball and socket type. It is extremely agile in that it can move in just about every direction including rotation, flexion, extension, abduction and every combination in between. In a healthy shoulder, the entire shoulder girdle must function as a whole in order to create proper movement. This includes complex combinations of glenohumeral joint movement and scapular movement. When these structures work together, they allow for great amounts of mobility while maintaining the stability needed to lift, move and function. However, when these dynamics change and incorrect mobility or improper stability comes into play, this is when impingement can occur.
The most common range of motions affected by shoulder impingement is lateral abduction, or flexion and external rotation. In other words, raising the arm to the side or over the head. This can vary from slight discomfort to the full inability to raise the arm depending on the severity of the condition. Sometimes clients can also have trouble reaching the arm behind the back (shoulder extension with internal rotation). Usually, pain will present in the anterolateral portion of the shoulder and potentially radiate down the anterior or lateral arm. This can vary in intensity depending on the severity of the impingement.
The reason for this motion being affected is to due to the anatomical makeup of the glenohumeral joint and the subacromial space. As the arm is raised, the humerus moves toward the acromion, mildly decreasing the amount of space in between. This action is completely normal and contributes to how much movement can occur within the joint. However, when there is improper movement of the scapula and humerus, the subacromial space becomes narrowed and the structures involved can collide and cause friction. The supraspinatus muscle, which courses directly through the subacromial space can become pinched in between these two structures becoming irritated. This irritation causes swelling and inflammation, and in chronic or more severe cases can cause tearing or fraying to the muscle. Also within this space, is the subacromial bursa which can become inflamed with this dysfunction, adding to discomfort and levels of pain. This is a functional shoulder impingement.
There can be a number of reasons why this can become a problem, but in my experience, the main reason why this occurs is due to limited scapular movement. As I mentioned, the subacromial space narrows as the humerus moves up toward the acromion. Normally, as the arm is raised and the humerus abducts or extends, the scapula rotates up and essentially moves out of the way; keeping the subacromial space open. When scapular mobility is limited, necessary scapular rotation does not occur and the humerus basically collides or rubs on the acromion causing inflammation and pain within the supraspinatus muscle, and possibly the subacromial bursa. This is why raising the arm overhead becomes difficult and painful. This is also why athletes who need overhead motion, such as tennis players, volleyball players, swimmers, and baseball/softball players are prone to this type of injury.
So why is this condition so common?
The answer to this question cannot be pinpointed to one thing. However, realizing that scapular mobility is an important factor in this condition leads us to look at why scapular movement can become limited. I think an easy line can be drawn from poor conditioning and posture to a higher prevalence of shoulder impingement. There is an epidemic of poor posture today and one of the main forms comes in is a forward shoulder posture. This chronic shoulder placement does two things to the shoulder girdle. First, it causes or is the result of, hypertonicity in the pectorals, latissimus dorsi, teres major, subscapularis and serratus anterior, which all limit and lock down the movement of the scapula and humerus. In further progressed cases this can sometimes even lead to a scapula which is adhered to the ribs and has hardly any movement at all, causing even less range of motion. This does not allow the needed movement of the scapula to rotate out of the way of the humerus as it abducts or extends. Second, anterior posture is usually paired with weakness in the lower trapezius muscle which is a key contributor to active upward scapular rotation (along with serratus anterior and upper trapezius). Both of these factors combine to limit scapular mobility and open up a person to developing an impingement in the shoulder.
Once this environment is present, the chances of an impingement syndrome are certainly increased. This is especially true if that person begins doing more activities which require range of motion over the head. This could be picking up tennis as a new hobby or maybe deciding to do some remodeling and spending a day painting. Either way, the lack of mobility will potentially cause irritation as the use of the arm and shoulder in the overhead position occurs. This being the case, irritation of the supraspinatus muscle will happen and impingement symptoms will occur. Now, just because some inflammation develops does not mean it will turn into a full impingement syndrome; that is determined by the longevity and chronic nature of the shoulder working in this manner. In other words, the first time this irritation occurs it will probably not last long, and the pain will subside fairly quickly. It is the repeated irritations and chronic poor mechanics of the scapula which will eventually lead to more acute and painful symptoms, and potentially lead to a more severe injury like a supraspinatus tear or bone spurs.
So how can we treat shoulder impingement syndrome?
This is where we as therapists can apply what we know to help the condition. A traditional treatment prescribed by a doctor would be physical therapy and potentially a steroid injection. While these may be needed in certain circumstances, they are certainly not the only option and usually do not treat the actual root cause. The most important thing we can do to treat shoulder impingement is to increase the ability of the scapula to move using manual therapy. By doing so we are allowing for the subacromial space to be maintained and the impingement of the supraspinatus tendon to not develop. This involves mobilizing and lengthening shortened structures which may have been shortened for a long time. These include serratus anterior, latissimus dorsi, rhomboids and pectoralis minor. The most important of these may be serratus anterior which, not only has the ability to protract the scapula leading to anterior shoulder placement but also firmly holds the scapula against the ribs. This limits its ability to lift away from the ribs causing decreased movement.
We should also do manual mobilization to the scapula itself to make sure the scapula is lifting off the ribs properly. There are many techniques out there for this and I encourage you to look them up to pick your favorite. The main focus of this technique is to gain proper scapular mobility and allow for movement in the scapulothoracic “joint”. Many times this the only effective way to truly gain this mobility. It can actually be quite difficult to apply when lack of movement has been chronic for a long time. No matter how hard it is, this is an important step which should be emphasized.
Once we have increased scapular movement, we can focus on lengthening the structures which limit the actual glenohumeral joint mobility. These include subscapularis, teres major, pectoralis major, and brachialis. Once these are released, increased mobility should be present and pain should be diminished. At this point, the shoulder girdle should be sitting further posterior and not locked into an anterior position. Also, the range of motion in the shoulder will be increased (sometimes dramatically) with more flexion and abduction being possible without pain. The shoulder will feel stable and free when raised over the head and your client will consider you a massage genius.
I will note that because of the painful characteristics of impingement syndrome when it is acute, it is important to gain mobility of the scapula first. If we try to treat the glenohumeral joint before gaining scapular mobility, we may cause more irritation of supraspinatus which will not feel good for you client. Once the range of motion of the scapula is increased and inflammation has subsided in the supraspinatus muscle, direct treatment can be applied to the supraspinatus to help break up any scar tissue or adhesion created by the chronic irritation and inflammatory process.
Another Note: If pain continues even after 3 or 4 treatments there is the possibility of a supraspinatus tear which will need to be diagnosed with an MRI. Even if there is a small tear, these same treatments will still be fine to do since all we are doing is creating correct function of the shoulder. We would, however, need to limit the direct treatment to the supraspinatus itself until the tear is healing. We would also consider limiting overhead movement of the shoulder in order to limit aggravation of the tear.
Additional Resources: Certainly a stretching regimen would be applicable for this condition. Here are some links to the stretches which would be good for post-treatment and for ongoing maintenance.
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