Download Self Help for Shoulder Pain - Massage Therapy Connections

Shea Shulman
LMT, CMMP, CLT
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DISCLAIMER
The information provided in this document is not intended to be a substitute
for professional medical advice, diagnosis or treatment. Never disregard
professional medical advice, or delay in seeking it, because of something you
have read in this document. Never rely on information in this document in
place of seeking professional medical advice.
Massage Therapy Connections is not responsible or liable for any advice,
course of treatment, diagnosis or any other information, services or products
that you obtain through this document or on our website. After reading this
document, you are encouraged to consult with, and review this information
carefully with your doctor and/or any professional healthcare provider.
HOW TO USE THIS DOCUMENT
It can be very frustrating to look for help, whether from traditional medical
sources or complementary therapies, and being treated as just another
shoulder pain case. The reality is that there can be numerous reasons for
shoulder pain and until you know which ones are responsible for YOUR pain,
it will not be treated appropriately. For this reason, it’s important to work
through all the pages of this document, take the recommended tests, and at
the very least, narrow down the causes of your pain.
Section 1 discusses potential causes of nerve irritation and how to test for
them, and the specific muscles that can be contributing to your shoulder
pain. Sections 2 and 3 will then review what you can do at home to address
your specific issues. You’ll find helpful information on self-care, including
effective massage tools, what trigger points are and how to treat them, and
appropriate stretches. With both sections, it can be helpful to have someone
with you but it’s not essential.
A Table of Contents on the next page will help you sort through the
information and make it easier to refer forward or back to sections for
review.
We love to hear from you with stories, updates or results, and you are
always welcome to ask questions by contacting us at:
[email protected]
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TABLE OF CONTENTS
Section 1: Assessment is your critical first step
Step 1: Rule out or confirm presence of nerve irritation
Test 1: Cervical Compression Test
Test 2: Anterior Scalene Compression Test
Test 3: Pectoralis Minor Compression Test
Step 2: Examine Specific Muscles
Supraspinatus Muscle, Clinical Symptoms
Drop Arm Test
Movement Test
Hand to Shoulder Blade Test
Hawkin’s Test
Infraspinatus Muscle, Clinical Symptoms
Hand to Shoulder Blade Test
Mouth Wrap Around Test
Teres Minor Muscle, Clinical Symptoms
Subscapularis Muscle, Clinical Symptoms
Stretch Test
Deltoid Muscle, Clinical Symptoms
Section 2: Treatment Strategies
Relax These Muscles
Trapezius Muscle, Clinical Symptoms
Levator Scapulae Muscle, Clinical Symptoms
Anterior Scalene Muscle, Clinical Symptoms
Applying Moist Heat
Effective Massage Tools
Trigger Points – How to recognize and treat
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5
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7, 8
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15
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19, 20
Section 3: Stretching
Neck Stretches
Chest Stretch and Anterior Deltoid Stretch
Infraspinatus and Teres Minor Stretch
Posterior Deltoid Stretch
Middle Deltoid and Supraspinatus Stretch
Subscapularis Stretch
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Addendum A: Shoulder Impingement Syndrome
Summary
About Shea Shulman, LMT, CMMT, CLT
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26
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Section 1: ASSESSMENT IS YOUR CRITICAL FIRST STEP
If you are unable to get professional help for your shoulder pain, or your
experience with medical providers has not provided relief, there are steps
you can take at home to help yourself.
It is impossible to eliminate shoulder pain caused by soft tissue if you are
not sure what the exact cause of your pain is. You will read here what
assessments we do in our office for clients with shoulder pain.
Understand that one individual test may not pinpoint the exact cause of your
pain. The following tests together are used to narrow your pain down to one
cause, or you may find that there are multiple components to your pain.
Step 1: Rule out or confirm the presence of nerve
irritation.
If nerve irritation is present, you MUST eliminate this prior to working on the
shoulder. Otherwise, anything you treat on the shoulder itself will yield only
partial results and the pain will return.
Do you now have, or have you had in the past, ANY tingling or
numbness in the fingers or hand on the same side as the affected
shoulder? Often, people ignore occasional numbness or tingling in their
hand or fingers. However, this is 100% confirmation of nerve irritation. If
you had it in the past, it could be gone, but it is more likely that you still
have nerve irritation, only to a lesser degree.
Perform the following compression tests.
These tests should be completed even if you have not had any numbness or
tingling in your hand or fingers. These compressions tests should be held
for 5-7 seconds.
Test 1: Cervical Compression Test
This is best done with a partner as shown, but you
can easily perform this test on yourself. Just use
moderate pressure to push directly down on your
head.
If you feel any sensation down the arm or in the
hand during this test, it means that there is nerve
irritation at the root of the nerve. This can be
caused by many things, including a bulging disc or
osteoarthritis.
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In these cases, it is especially important to treat the neck muscles. The
neck muscles will tighten in response to the problem and in return they put
MORE pressure around the nerves.
Test 2: Anterior Scalene Compression Test
This test is also best performed by a partner, but again, you can do this
yourself.
1. Relax the arm on the affected side and
turn the palm face up.
2. Find your pulse on the front of your neck
above the clavicle (collarbone). You will
not only feel the pulse, but should also
feel a cord-like tendon behind your finger
or thumb.
3. With mild to moderate pressure, use your
thumb, index or middle finger (whichever
is easiest for you) to apply downward
pressure to the tendon. You will somewhat roll under the top of the
clavicle.
If you feel sharp pain at the compression site
or anything down the arm or in the hand
(especially tingling, numbness or an increase
in the symptoms you already have) it means
this test is positive and that the anterior
scalene muscle in your neck is irritating the
brachial plexus of nerves that innervates your
shoulder, arm and hand.
Neck Scalene Muscles
The arrow points to Anterior Scalene Muscle
Be sure to complete the following test even if this test or the previous test
was positive. You will want to retest all areas after you have relieved
pressure from the nerve.
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Test 3: Pectoralis Minor Compression Test
Pectoralis Minor Muscle
Perform this last test for nerve irritation. As before, relax the arm with the
palm up. Have a partner apply pressure (directed towards your back) to the
tendon of the pectoralis minor muscle. You can also do this yourself; you
will feel the tendon behind your thumb move when rolling your shoulder
forward. Numbness, tingling or an increase in current symptoms is a
positive finding for nerve irritation by the pectoralis minor muscle.
Look at how the brachial plexus of nerves (in yellow)
courses beneath both the anterior scalene muscle and
the pectoralis minor muscle (shown
with arrows) before entering the arm.
Both muscles are very susceptible to
tension, especially in cases of
forward head posture where the
head sits in front of the body and the
shoulders are rounded to the front.
Forward Head Posture
When nerve irritation is present, the muscle testing described below may not
produce accurate information. Therefore, if any of the previous three tests
were positive, you will need to first work on relaxing and stretching your
neck (see pages 16 and 22).
If the previous tests were negative, your next step is to
examine specific muscles to help determine which are
responsible for your shoulder pain.
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Step 2: Examine Specific Muscles
This section examines five muscles that can be responsible for shoulder pain.
You’ll learn where these muscles are, what symptoms they can produce,
where the pain patterns typically are, and in most cases, how to test for
their involvement.
The Supraspinatus Muscle. This muscle initiates bringing your arm out to
the side and stabilizes the shoulder joint from the top.
Clinical Symptoms:
•
•
•
•
•
•
Pain bringing the arm out to the side. The pain
is typically felt at the top of the shoulder.
Pain with everyday activities, such as brushing
your teeth.
You may have a snapping sensation or sound
with shoulder movement.
You may have a painful “catch” when you move
your shoulder.
Pain may be felt on the outside of your elbow
Compression on the muscle in the spots below
is painful.
Supraspinatus Muscle
The red areas show typical pain patterns from the supraspinatus muscle.
The "X"s represent the areas where pressure into the muscle can produce sharp pain.
The supraspinatus muscle can be found by feeling for the ‘spine’ of the shoulder blade
and moving to the depression directly above that boney spine.
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Assessment Testing for the Supraspinatus Muscle
There are four different assessment tests for this small but very important
muscle that can cause shoulder pain!
Drop Arm Test
You will need a partner for this test. Have your partner passively lift your
arm out to the side, which means you should not help with this movement.
Once the arm is shoulder height, your partner should release the arm. If
the arm immediately falls, it indicates a tear or significant inflammation in
the supraspinatus tendon. If the arm does not drop, see if you can slowly
lower it. If you find it difficult to slowly lower the arm, it could indicate a
lesser degree tear or inflammation in the supraspinatus tendon.
If the Drop Arm Test is positive, you should consult your Physician.
Movement Test
In front of a mirror, bring both arms out
to the side and above your head at the
same time. This picture shows
significant restriction of the right
shoulder; it simply won’t go any higher
unless the whole shoulder lifts to assist
the movement.
Restriction felt on the affected side,
and/or a compensation made by lifting
that shoulder to perform the movement
is a positive finding. By doing this facing a mirror, you can observe if your
affected shoulder is lifting up – something that can be difficult to feel without
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seeing it. If both arms can perform this movement without lifting your
shoulder, the test is negative.
The Movement Test may also be positive if you have subacromial bursitis.
The two conditions may coincide. Have a partner apply pressure in the
subacromial space on the side of the shoulder as shown. If it is painful, it
could indicate bursitis. If there is a positive result (pain) with pressure in
the subacromial space, treatment includes working on relaxing and
stretching all heads of the deltoid muscle.
Two pictures showing where to find the subacromial space
Hand to Shoulder Blade Test
Good Side
Bad Side
With a healthy shoulder, you should be able to touch your shoulder blade
with your fingers. If you have shoulder tightness on both sides, compare
the affected side to the unaffected side.
This test can indicate a problem with the supraspinatus or the infraspinatus
muscle, or a combination of both. Other muscles, such as the anterior
deltoid and subscapularis, may also have shortening or trigger points if this
test is positive. However, they are likely secondary to the first two muscles.
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A positive finding is when reach on the affected side is lower than the
unaffected side. Remember, this positive finding means the supraspinatus
muscle is involved, but it may not be the only source of your shoulder pain.
Hawkin’s Test
Elbow Flexion and Abduction
Internal Rotation
Have a partner passively bring your arm into elbow flexion and abduction
(out to the side) to 90 degrees as show. Next, your partner will internally
rotate (bring the hand downward) the arm at the shoulder.
Pain at the end of the test indicates inflammation in the supraspinatus
tendon, which may be a result of Shoulder Impingement Syndrome.
If you tested positive on the Hawkin’s Test and would like to read more
details about Shoulder Impingement Syndrome, refer to Addendum A on
page 26.
Now, let’s check another muscle that is also found on the shoulder blade.
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The Infraspinatus Muscle. This muscle laterally rotates your arm (rotates
it outward) and helps stabilize the shoulder joint.
Clinical Symptoms
•
•
•
•
•
•
•
Shoulder pain on the front or side of the
shoulder
Pain is felt when reaching back, as to
put your hand in your back pocket or to
fasten a bra. It may also be felt just
reaching behind you, as to grab
something out of the back seat of your
car.
Pain may be felt when sleeping on the affected shoulder.
Pain may be felt when using that arm to mouse at the computer or
when holding it out in front of the steering wheel when driving.
Pain throwing a ball
Pain may radiate all the way to the forearm and hand on the affected
side, and even to the base of the skull.
Pain is felt when pressing on the trigger points in the muscle as shown
below.
The red areas show typical pain patterns from the infraspinatus muscle.
The "X"s represent the areas where pressure into the muscle can
produce sharp pain. The infraspinatus muscle can be found by feeling
for the ‘spine’ of the shoulder blade and moving directly below that
boney spine.
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Assessment Testing for the Infraspinatus Muscle
Hand to Shoulder Blade Test (see page 9)
If your hand can only get to your lower back pocket in this test, it is an
indication that the infraspinatus is involved. Remember, a positive result on
this test also indicates involvement of the supraspinatus muscle.
Mouth Wrap Around Test
Good Side
Bad Side
Try this on both sides and compare unaffected to affected side. Turn your
head 45° to the opposite side. Try to reach your hand around the back of
your head to touch your mouth.
If you can only get to your ear, it indicates the infraspinatus is involved (and
possibly the middle deltoid muscle). If you are unable to hold the arm up to
perform the test, it indicates the supraspinatus muscle is a problem. If you
can only reach the back of your head, the subscapularis muscle is likely at
fault. We address the subscapularis muscle starting on page 12.
There are other muscles located around the shoulder blade that also
need to be tested. Let’s look at two more.
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The Teres Minor Muscle. Like the infraspinatus muscle, this muscle
laterally rotates your arm to the outside and helps stabilize the posterior
part of the shoulder joint. In this picture, you can see how close they are to
each other!
Clinical Symptoms
•
•
•
Deep, aching shoulder pain
Pain that is felt on the back of the shoulder
Pain when pressing upon the trigger point in the muscle
There are no special tests, but this muscle often has an active trigger point
when infraspinatus is the main source of shoulder pain.
The red areas show typical pain patterns from the teres minor muscle.
The "X" represents the area where pressure into the muscle can produce
sharp pain. The teres minor muscle attaches to the shoulder blade on
one side and the head of the humerus bone on the other end. Feel for
the outside edge of the shoulder blade and move your thumb just outside
of that edge to see if a trigger point there produces sharp pain.
The Subscapularis Muscle. This muscle sits
under your shoulder blade and internally rotates
your arm (rotates it inward) and helps stabilize
the front of the shoulder joint.
Clinical Symptoms
•
•
•
•
•
Pain when reaching back, as to throw a
ball
Pain down the back of the arm
In severe cases, it can causes symptoms
Subscapularis Muscle
of a frozen shoulder
Pain at the wrist
Pain when pressing upon the trigger points in the muscle (you can do
this by lifting your arm and pressing your thumb into the underside of
the shoulder blade)
The red areas show typical pain patterns from the
subscapular muscle. The "X" represents the areas
where pressure into the muscle can produce sharp
pain. However, because this muscle lies flat
underneath the shoulder blade, it can be difficult to
reach these trigger points on your own and you may
need professional help.
Assessment Testing for the Subscapularis Muscle
Stretch Test
Have a partner passively bring your arm out to
the side as shown and then rotate it backwards.
Make sure this is a passive movement, meaning
you do not help by lifting your arm or rotating it
yourself! Pain felt with the rotation indicates
involvement of the subscapularis muscle.
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There is one more muscle to assess that can be involved in shoulder pain.
This muscle is not a rotator cuff muscle.
The Deltoid Muscle. This muscle has three heads:
the anterior (front) deltoid, middle deltoid and
posterior (back) deltoid. The three sections form a
“cuff” over the shoulder. All three sections bring the
arm out to the side. The anterior head helps flex,
adduct (bring towards the body) and internally rotate
the arm towards the body. The posterior head helps
extend the arm backwards and laterally rotates the
arm to the outside.
Deltoid Muscle
Clinical Symptoms
•
•
•
•
•
Pain may be felt on the front, on the side or on the back of the
shoulder, depending upon which head is affected.
You may have a painful “catch” in the shoulder, especially with trigger
points in the anterior and middle portions.
You may have pain that is mistaken for Arthritis
There is pain when pressing on the muscle’s trigger points
Deltoid trigger points are often secondary to other active trigger points
in the shoulder
Note that the trigger point in the posterior deltoid muscle can trigger pain
when actively rotating the arm backward in the same position as the stretch
test.
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Section 2: TREATMENT STRATEGIES
Nerve irritation must be treated first. There were three tests (pages 46) that helped to determine if nerve irritation is present and as least partially
responsible for your shoulder pain. If you tested positive on any of those
tests, you must first work on relaxing and stretching the neck muscles. It’s
important to understand which muscles that may be involved in neck tension
as well as where the trigger points in these muscles are located. You’ll find
stretching information further down in this document, but it’s important to
know which muscles really need that help!
Relax These Muscles
Trapezius Muscle. The trapezius muscle works to
extend your neck (tilting chin towards the ceiling),
rotate your head to the opposite side, and to bend
your ear to your shoulder on the same side. You can
see how large and comprehensive it is, starting in the
mid-back at the T12 vertebrae and having
attachments all the way to the skull.
Trigger points may be present in the upper, middle
and lower portions of the muscle.
Trapezius Muscle
Clinical Symptoms for Upper Trapezius
•
•
•
•
Pain increases when rotating head to the opposite side
Headache on the same side of the head
Restricted neck range of motion
Severe headaches may occur if the greater occipital nerve is irritated
or compressed
Clinical Symptoms for Lower
Trapezius
• Pain in the middle back between
the shoulder blades
• Pain may be felt at the end of a
deep inhalation or sneeze
• Symptoms can be associated with
tension in both parts of the trapezius
muscle at the same time.
As in the previous trigger point drawings, the red areas show typical pain patterns from the trapezius
muscle. The "X"s represent the areas where pressure into the muscle can produce sharp pain.
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Levator Scapulae Muscle. The levator scapulae muscle works to rotate
the scapula downward, as well as rotate and flex your head to the same
side.
As in the previous trigger point drawings,
the red areas show typical pain patterns
from the levator scapulae muscle. The "X"s
represent the areas where pressure into the
muscle can produce sharp pain. This
muscle lies underneath the upper trapezius
muscle and can be difficult to palpate
without professional help.
Clinical Symptoms
•
•
Pain at the angle of the neck as well as a painful “stiff neck”
Pain when turning head to the same side
The Anterior Scalene Muscle. The anterior scalene muscle works to flex
your neck (as when looking down) and to laterally flex the neck to the same
side (putting your ear towards the shoulder).
This muscle can hold a lot of tension. It is
best not to try to work the trigger point in this
muscle on your own, as the brachial plexus of
nerves runs beneath it (see page 6). Instead,
focus more on working the posterior neck
muscles in the back of your neck and trying to
maintain good posture.
Anterior Scalene Muscles
Clinical Symptoms
•
•
Pain felt in the back of the neck area
Many upper extremity conditions can
develop from tension and/or trigger points in the anterior scalene
muscle, such as carpal tunnel syndrome, epicondylitis, frozen shoulder
or rotator cuff syndrome
To help reduce tension in these muscles, refer to the Neck Stretches on page 22.
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Now that you have more information on if there is nerve irritation
and which specific muscles are likely involved, you’re ready to take
some action!
The following treatment strategies will go for all
affected muscles, unless exceptions are noted.
1. Use moist heat to relax the muscles.
This is probably the easiest step of all!
You can use dry heat, but moist heat
penetrates more deeply. You can stay in
your hot shower longer than usual or use
a moist heating pad. If your shower head
produces good pressure, the percussion of
the water hitting the soft tissue is also
helpful.
Trapezius Muscle
Moist heat is a great resource to help with stiffness and pain in specific areas
related to osteoarthritis, muscle “knots” or trigger points, and most kinds of
cramping or spasms. Moist heat can even help with stiffness from postural
strain. By using moist heat, you encourage tight muscles to relax and
relaxation reduces resting muscle tone.
You can heat for as little as 5-10 minutes just to bring circulation to the area
and start relaxing the affected muscles. Or you may choose to heat longer
before bed. Note that heating pads should be used for no more than 20
minutes at a time to avoid damage to the skin and soft tissues.
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2. Use self-massage on the affected muscles or a tool to massage
the muscles. The goal of massage is to further relax the muscles, to
break up adhesions that may have formed in the tissue and to increase
circulation. This should NOT hurt…so more pressure is not better.
Simply try to knead the muscles for 2-5
minutes before going to the next step.
For muscles on the back of the neck and
shoulder, try using a tennis ball to gently
roll around on the
muscle. Or try a
hand-held
massager, like the
one from Pure
Wave shown here.
Pure Wave Massager and similar
models can be found easily on Amazon
3. Use silicone massage cups to eliminate areas where the
connective tissue has become bound down. When there is
dysfunction, the connective tissue will lose its elasticity and the tension
that builds reduces circulation to the area. This is important in
treating the area. You may need a partner to
get to areas you cannot easily reach. If you do
have someone to help you, you could use a
skin-rolling technique instead if you did not
want to purchase the
cups. To perform skin
rolling, gently lift JUST
THE SKIN and roll it across the muscle.
One source for purchasing silicone cups
is http://medicalmassageedu.com/product/volume-14/.
A set of 4 cups can be ordered for
$29.95, or $65.95 that includes an
instructional DVD.
If using the silicone cups, which most people
love, you need to use ample lotion or oil (like
coconut oil) on the area to be treated. Start
with just gentle suction, working all over the
muscle. After a minute or so, increase the
suction a little bit and continue to work the cup
over the affected muscle(s). This time, gently
lift the cup to separate the skin from the
underlying tissue as you work. Spend 2-3
minutes on the area.
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4. Know Your Trigger Points. This step is crucial to address! First,
you need to identify where the trigger points are, using the diagrams
that have been given in this manual. A trigger point is basically a
spasm inside of a muscle “knot” that causes pain. The pain can be
with active movement, or even at rest when the trigger point is very
active. The pain from trigger points can be described as a deep ache.
When you apply pressure to a
trigger point, it is painful. You will
know when you are on one!
However, you do not want to simply
“crush” the knots in your muscles.
As you can see, the trigger point
itself is not very big. That is why
we use just the tip of our thumb in
massage therapy to treat them.
Therapists who use an elbow are
simply damaging surrounding
tissue. Keep this in mind when you
are treating your own trigger points.
Recap: Prior to this step, in preparation for the treatment of your trigger
points, you have:
1. Used moist heat on the area for 5-10 minutes
2. Relaxed your muscles with self-massage or a massage tool
3. Used the silicone cups or skin rolling to eliminate tension in the
connective tissue (fascia) that lies above and around your muscle
fibers.
All work up to this point was to properly prepare the tissue to have
successful trigger point treatment. When trigger points are not treated
correctly, they will either remain painful, or go into a latent state, which we
call “sleeping” trigger points. Sleeping trigger points can be reactivated at
any time. They weaken the muscle and contribute to muscular stiffness.
Improper trigger point treatment is often why pain at first improves but then
returns.
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Treating Your Trigger Points
Ideally, you will purchase a Magic Wand to first
apply vibration to the trigger point. This is a
great tool to have at home as our muscles
respond very well to vibration.
I recommend this device because it has the
correct frequency of vibration to be able to
properly relax a muscle. Walmart sells them
online, as well as many other places.
Apply vibration to the trigger point for 1-2
minutes. This will relax the trigger point and
prepare it for the next step.
Hitachi Magic Wand Massager Beware of cheaper knock-offs! They
are unreliable and not as effective.
Available online at Walmart.com for
under $60.
Apply compression to the trigger point in a stop and go fashion.
What I mean by that is, go in a LITTLE AT A TIME. If you apply a lot of
pressure, fast, the muscle will tighten and you will not have success.
Instead, start by applying just enough pressure to where you feel the first
sensation of pain. Hold it there until the pain subsides and then apply more
compression until you again feel pain. Once again, stop at the first
sensation of pain in the deeper spot and wait for it to subside. After 2-4
compressions, you will notice that the pain is not the same and you can
quickly remove your thumb or tool from the trigger point.
For trigger points you cannot reach with your thumb, you can use a tool,
such as the Backnobber pictured here:
A tool is not ideal because of the size of the end
piece that is applied to the trigger point.
However, it is better than not being able to get
to the area.
Backnobber II is available at Walmart, Amazon
and other sites. Priced from $30 to $40.
Stretch the muscle after you have treated
the trigger point. This step is incredibly
important, as you want to restore the
anatomical length in the muscle. In the pages
to follow you will find stretches for each of the
muscles we have discussed.
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Section 3: STRETCHING YOUR MUSCLES
I recommend stretching the affected muscles as you exhale. Try to take a
big, quick breath in and then slowly exhale as you stretch. Why? Because
your muscles relax as you exhale. Repeat each stretch 6-10 times,
depending upon your comfort level. There should be no pain with the
stretches. If there is, go into the stretch more slowly and hold the stretch
at the first level of discomfort as you exhale.
Neck Stretches
If you have nerve irritation, perform each of the following neck stretches:
Neck Flexion
Lateral Neck Flexion
Chin towards
chest
Flex the neck
towards the
unaffected side.
Neck Rotation
Anterior Scalene Stretch
Rotate to both
sides.
Perform only on
affected side.
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Muscle Specific Stretches
Regular shoulder stretches can improve posture, improve function, and
make us feel and look younger. For a lot of us, stress in our lives is
manifested by tightness and hyperactivity of our shoulder muscles. Even
after your shoulder pain is improved or resolved, these are healthy
stretches to continue with on a regular basis.
Chest Stretch and Anterior Deltoid Stretch
Because many shoulder problems arise due to poor
posture and “forward” shoulders, it is important to
stretch your chest and this is a good stretch even if
you didn’t have shoulder pain! It targets not only the
pectoral muscles, but also the anterior deltoid muscle
in the front of your shoulder as well as the muscles in
the front of the upper arm (biceps brachii and
coracobrachialis).
This stretch is appropriate and recommended if you
tested positive on pectoralis minor compression test
(page 5) or found trigger points on anterior deltoid
muscle (page 14).
This stretch is best performed with
your thumb facing up as shown and
your hand in a doorway. Once you are
in place, simply rotate your body away
from the hand to stretch the front of
the shoulder and the chest.
Because the pectoralis major muscle is
a fan shaped muscle, with fibers
running in different directions, start
with your arm below shoulder to
stretch several times. Then move your
arm higher in stages to stretch in different directions.
Pectoralis Major
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Infraspinatus and Teres Minor Stretch
Sitting or standing, raise your arm and pull your
elbow across your chest to bring your scapula
(shoulder blade) further from your spine. The
arm going across can rotate with the thumb down
towards the floor. Hold this position for your long
exhale.
Release and repeat 6 - 10 times.
Posterior Deltoid Stretch
Extend your arm across your chest. Keep your
shoulders and hips facing forward as you hook
your arm under your right forearm, near the
elbow. Gently pull the arm closer to your chest.
When you feel tension behind your right shoulder,
hold for your long exhale.
Release and repeat 6 - 10 times.
Middle Deltoid and Supraspinatus Stretch
You can do this stretch standing or sitting. Throw a towel
over your shoulder. Grab the towel behind your back with
the hand on the affected shoulder side.
Pull the towel bringing your hand up your back while
keeping your affected shoulder relaxed and your hand over
on the opposite side of your back.
Hold for your long exhale. Release and repeat 6 – 10
times.
Subscapularis Stretch
You can do this stretch with a strap (here I’m using
an old karate belt), a broom or some sort of pole.
If using a strap:
Hold the strap with the hand of your affected
side as shown here, then hold the bottom end
of the strap with your other arm in front.
With your exhale, pull gently on the lower end of the
strap, causing your upper arm to rotate backwards.
If using a pole:
Hold the pole as shown to the right.
Fan your affected arm out to the side such
that it’s in line with your torso, your elbow
pointing 90 degrees to that side with your
humerus (bicep) parallel to the ground.
Pull your lower hand straight forward such
that your upper arm tilts backwards.
You should feel a stretch coming from
underneath that shoulder blade in both of
these methods.
Note: It is important not to bounce into any of these stretches
or apply excessive force.
25
Addendum A: SHOULDER IMPINGEMENT SYNDROME
Let’s talk a little more about Shoulder Impingement Syndrome, something
that could cause a positive result on the Hawkin’s Test. The rounded,
forward shoulder position seen in many people puts the shoulder joint in a
poor biomechanical position. When the
shoulders are rounded, the head of the
humerus (upper arm bone) is internally
rotated and too far forward in the joint
socket. It may also sit too high in the
joint cavity. This position of the
humerus doesn’t work well when you try
to move your arm above your head.
That motion creates a situation where
the rotator cuff tendon and other tissue,
such as a bursa (a fluid-filled sac that’s
needed to prevent friction), gets
pinched. This is called shoulder
impingement.
Over time, impingement can cause the bursa to become inflamed and the
rotator cuff tendon to degenerate and tear. To correct the problem, the
muscles pulling the shoulder forward (chest muscles) and inward (internal
shoulder rotators) need to be lengthened and the upper back muscles need
to be strengthened.
Many people who have impingement syndrome are typically treated with
anti-inflammatory medication, sent to PT for stretching/strengthening
exercises, and told to temporarily avoid any repetitive overhead activity until
the condition settles down. But this condition can often manifest itself
along with other muscle and soft tissue problems that are addressed in this
document.
For that reason, even when your shoulder pain has been diagnosed as
Shoulder Impingement Syndrome and you’ve completed all the treatment
protocols – perhaps even feeling a little better – you may find that the
original pain ends up returning. By looking at the whole picture - including
possible nerve irritation, trigger points, finding which specific muscle(s)
tested positive, we can resolve the pain rather than just relieve it.
26
SUMMARY
As a licensed massage therapist and a Certified Medical Massage
Practitioner, I regularly see clients in pain. Often, these clients have
pursued many other options before coming to see me. In some cases, these
clients have been in pain for months or even years without getting
resolution. Some were even told, “There’s nothing more we can do”.
Through medical massage assessments and treatment protocols, the pain
relief they experience can be a game-changer for their quality of life.
Having the opportunity to help these clients makes my work extremely
rewarding.
While I have personally experienced the success of medical massage in
relieving so many pain issues, I also know that not everyone can see a
knowledgeable medical massage therapist. This document is for those who
really want to understand why they have their shoulder pain and what they
can do to help heal.
Shea Shulman
About Shea Shulman, LMT, CMMP, CLT
Ms. Shulman is co-owner of Massage Therapy Connections in Lakewood
Ranch, FL where she practices Medical Massage full-time. After becoming a
licensed massage therapist, Ms. Shulman has studied extensively with many
renowned instructors and schools, including Erik Dalton (Myoskeletal
Alignment), Art Riggs (Integrative Deep Tissue), Aaron Mattes (Active
Isolated Stretching), and Olag Bouimer (Advanced Sports Massage).
In 2013, Ms. Shulman was introduced to Medical Massage by Dr. Ross
Turchaninov MD(UKR), LMT, Founder of The Science of Massage Institute
and Editor in Chief of the Journal of Massage Science. She completed 80
hours of live class instruction plus hundreds of hours of online study to
receive her Certified Medical Massage Practitioner designation. Recently Dr.
Turchaninov featured Ms. Shulman as the “Person of the Month” in his
quarterly online newsletter.
Ms. Shulman’s passion is not only alleviating pain for her clients. She is
committed to elevating the massage therapy profession by using Medical
Massage knowledge, and to working with the medical community to increase
awareness of this important manual therapy. She can be reached at:
Massage Therapy Connections ▪ 941-755-0406
www.MassageTherapyConnections.com
[email protected]