Under the Arch: Rethinking Shoulder Pain
The second course I attended today at the ABMP CE Summit on pain was Rethinking Shoulder Pain with Whitney Lowe of the Academy of Clinical Massage, and it opened with one of my favorite subjects: anatomy. I learned several new things about anatomical structures of the rotator cuff as well as step-by-step breakdown of various techniques, some new ones and some old ones.
Whitney first went over the architecture of the shoulder. The shoulder's bony structure isn't very stable on its own. The glenoid fossa is pretty flat, so the joint gets its stability from the connective tissues, the labrum, the joint capsule, the tendons, ligaments, fascia, and the muscles around it. The soft tissues do much of the work of stabilizing your shoulder, and I work with those tissues every day in my Las Vegas massage studio.
Capsular problems most often show up as limited lateral rotation and abduction, two motions worth observing in any shoulder assessment. Frozen shoulder is the example covered from the course outline: fibrous tissue develops on the underside of the capsule and gradually limits the joint.
Then there's the roof over everything. The coracoacromial ligament spans the coracoid process and the acromion process, two projections of the same bone, and together they form the coracoacromial arch, a ceiling over the subacromial space. That space is crowded. The supraspinatus runs through it, and the portion under the acromion has a poor blood supply, which matters for healing, since many rotator cuff tears and cases of tendinopathy involve that. The subacromial bursae sit on top of the supraspinatus, and the course revisited what their function is, past the old belief that they only reduce compression between structures. Whitney noted that sometimes chemicals can leak from the bursae and cause discomfort from the irritated tissues.
Another important point that I hadn't considered is that the long head of the biceps tendon makes a hard 90-degree turn over the top of the humeral head on its way to its attachment, running through a synovial sheath under the transverse humeral ligament, so it takes friction and compression at the bend. When that tendon can't slide well within its sheath, the irritation tends to show up as pain at the anterior of the shoulder, sometimes with tenderness when the tendon is palpated directly.
The back of the shoulder got its own attention in this course. Whitney emphasized that the infraspinatus can hold active trigger points in the middle of the muscle belly that refer pain into other regions, and he demonstrated how deep stripping or static compression can help deactivate them. Throwing athletes and people doing vigorous upper-extremity work often overload the posterior cuff right where the muscle meets the tendon, since those muscles have to decelerate the arm under high eccentric forces at the end of a throw. And even the suprascapular nerve (a motor nerve, but it can still become painful under pressure or irritation partly through the nervi nervorum: the tiny nerve fibers that supply the nerve itself).
The assessment piece of the presentation from Mr. Lowe was practical. Start with history: the quality of the pain, whether it refers anywhere, and when it began. Then watch the shoulder move. You check whether one shoulder sits higher, you watch from the front and the back, and you sort the problem with three kinds of movement. Active movement recruits the muscles and tendons, passive movement takes the muscles out of the equation while compression under the arch can still pinch, and resisted movement asks the client to hold a position against moderate pressure. If there's pain when you let go and the client holds the position, that points toward a muscle or tendon problem, and a pattern with no pain during muscle activity points away from the muscle entirely.
What I'm really taking back to my Las Vegas massage table is the active engagement work. Most clients aren't used to actively participating during a massage, but I do this with my clients all the time. We also do resistance movements where I ask them to hold a contraction against my resistance, then slowly let go while I strip along the muscle, so the muscle lengthens under load and the eccentric action magnifies the pressure. The movement matters as much as the pressure, since it sends information from the proprioceptors and mechanoreceptors back to the central nervous system, and that goes a long way toward reducing pain in the peripheral nervous system.
For the subscapularis, you find the edge of the scapula, flip your fingertips around to the ridge, and feel the muscle pop up when the client resists. Then you can work it while they move a cactus arm between rotations. The one caution is a history of dislocation or instability, where you stop short of full lateral rotation, the position where the joint is most vulnerable. For the biceps, the stripping starts broad with the back of the hand or the palm, narrows to a braced thumb or fingertip, and pairs with resisted engagement and a slow eccentric release over several passes, without fatiguing the client.
Then there's the pec minor, one of my favorite muscles. It attaches to the coracoid process, and when it gets tight it pulls the scapula into an anterior tilt, disturbs scapular mechanics, and can contribute to nerve entrapment problems like thoracic outlet syndrome. There's a bundle of nerves running under it, so caution matters when a client already has neurological sensations. It's a hard muscle to stretch, so the pin-and-stretch techniques handles it. He did a demo with the client lying supine on the massage table. Have the client reach down toward the knee to shorten the muscle, pin the pec minor with your fingertips, then have them shrug the shoulder up toward the ear while you hold the pin or glide along the muscle. They do the moving, and the muscle elongates under your fingers. Doing this about 5 times will ease tension and improve gliding.
Lowe also demonstrated work on the supraspinatus with the client face down on the massage table in a pronated position. This muscle's problems mostly live in the distal portion tucked under the acromion where we can't easily reach, so the strategy is to reduce hypertonicity in the rest of the muscle and take the pull off the tendon. It's tricky, but the movement is intended to coax and lift the upper trapezius out of the way so you can strip the supraspinatus with a thumb or both thumbs.
The infraspinatus and teres minor get slow stripping while the client rotates the arm forward and back into what I call "cactus arms," while adding resistance turns up the neuromuscular engagement. Scapular mobility finishes the picture. Upward rotation depends on the serratus anterior, the mid-trapezius, and their coordinating muscles, and we strip along the border of the scapula with our thumb as the client moves, staying off the edge of the bone. He also introduced tools into demonstrating the technique, but I've tried tools and I don't like them because I can manipulate the tissue as well. Maybe that's just my influence from John Barnes.
Lowe's closing reminder was that we won't use every technique every time, or at every stage of the healing process. What carries through all of it is the person on the table. The entire process is an active collaboration with the shared intention of progress, whatever that looks like at the time. It's a privilege to work with people in pain and vulnerability, the human to human connection is everything, and that's the part of this work that can't be replaced. I am lucky to get to practice this work.
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