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Shea Shulman LMT, CMMP, CLT 1 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] 2 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 3 3 3 4 5 6 6 7 7, 8 8 9 10 11 11 12 13 13 14 15 15 15 16 16 17 18 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 21 21 22 23 23 23 24 Addendum A: Shoulder Impingement Syndrome Summary About Shea Shulman, LMT, CMMT, CLT 25 26 26 3 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. 4 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. 5 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. 6 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. 7 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 8 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. 9 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. 10 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. 11 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. 12 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. 14 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. 15 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. 16 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. 17 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. 18 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. 19 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. 20 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. 21 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. 22 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 23 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]