Treating the Shoulder
By Jenny Richardson
I’d like to bring a clinical perspective into a systematic review on massage for shoulder pain (AMT Blog, November 2017) and perhaps broaden the field of what might be happening in the body when someone has shoulder pain beyond just the standard diagnoses.
Most of us know the common shoulder pain “injuries”: bursitis, tendonitis, rotator cuff tears or impingement, frozen shoulder, AC joint sprain, etc. How often do you have a client arrive at your doorstep for some relief from one of these – often having had the medical treatment of a steroid injection to no or little effect? And you’ve maybe heard how complex the shoulder is and so it is a little daunting, being asked to help someone with pain that is debilitating but hasn’t responded to medical treatment.
Anatomy is my thing – I just love the amazing intricacies of how the body places our muscles to allow us to move and do the incredible things humans can do. Yes, the shoulder joint is complex – but it’s also one of the most fun areas of the body to work with. Did you know that in cadaver dissection, by just cutting a handful of ligaments and dissecting the fascia between the layers of muscle, you can actually separate and lift the shoulder girdle off the rest of the body (yes, I have actually done this)? It’s sort of like a suspended pendulum, one each side, held onto the sternum. It’s very cool.What this means though is that the muscular control of the shoulder girdle and arms is crucial. The muscles provide all the real stability (think big muscles like latissimus dorsi, deltoid, trapezius and the small muscles like the rotator cuff muscles). They also create all the movement in this incredibly mobile joint. And (via the nervous system, of course) they then have to coordinate movement with the rest of the body. If you stand on one leg, your arms will adjust to help balance you. When you walk, the opposing leg and arm should coordinate to propel you forward.
In my clinical experience, keeping this role of the shoulder girdle in whole body movement in mind has helped me think about the big picture of ongoing shoulder pain. I have learned to never treat the shoulder as an isolated unit. And when I read systematic reviews of massage (such as the one discussed in the November blog article), for shoulder pain, I now wonder whether the results for massage would have come out even stronger if the therapist had been allowed to treat the shoulder as part of the whole body rather than just massage the muscles located in that region. I don’t mean giving a general full body massage – I do mean treating specifically, but not confined to local tissues where the symptoms are.
When we were in massage college, we heard “everything’s connected” over and over. But are therapists taught how to think about those connections? That was my biggest question in the first 5+ years of practice: how does this pain/injury connect to other pain/injuries? I wanted a set pattern that I could just apply. Eventually I realised that everything is connected – but it is different for each person based on previous injuries and compensations, based on how they regularly move, sports they play, how they learned to move by watching their parents – and therefore it’s up to me to figure out the patterns. If someone has shoulder pain, definitely massage the muscles of the shoulder – if nothing else, that gives relief as most massage does. But think about how that person uses their whole body and how that might have affected their shoulder. You can do assessments and try to find the patterns – watch them walk especially. If all else fails, work through a range of areas that might be part of the picture. The more history you have for the client, the better picture you get on how THAT PERSON uses their body.
Treatment of Shoulder Pain
I’d like to throw you some thoughts on where “tightness”, “restriction” or other “issues” might be found that can contribute to shoulder pain and restriction of the joint:
- BIGGEST ONE TO CHECK – down the ipsilateral arm. Look for tissue tightness right through the arm – all of these muscles have a pull up into the shoulder that can have an effect.
- Coracobrachialis. A pull from this muscle can often lead to pain up and over the coracoid process and to the top of the shoulder.
- Biceps. Work around the attachment onto the forearm. For someone who does a lot of lifting, this can get very hypertonic and of course has two attachments onto different parts of the shoulder girdle.
- The forearm – tension especially in the anterior forearm, from brachioradialis down to the wrist can have a significant pull right through to the shoulder.
- Triceps can add to posterior shoulder pain – again, think of the attachments – but work the whole muscle.
- Pectoralis major and minor. We probably all recognise this as a contributor to shoulder position. But make sure you work the sternal attachments as well as the lateral muscle bellies. It can be incredibly sore at the sternal aspect – but if you can gently work this until some of that sensitivity is reduced, it can make a much bigger difference to the shoulder than the lateral parts alone.
- Subscapularis. Yes, everyone’s nightmare. But truly a hidden source of shoulder (and neck and arm) pain.
- Anterior serratus. Remember this wraps all the way under the scapula and attaches to the scapula medially. And we use that muscle all day long.
- Latissimus dorsi/thoracolumbar fascia. Remember that this huge back muscle is actually all about movement of the arm into extension. I often massage firmly along the lumbar part of this muscle/aponeurosis to give it the sensory input to hopefully help it to relax – in order to reduce its tension on the shoulder.
- The ligaments directly behind the shoulder joint. These posterior capsule ligaments can get very thick and bound up – and push the shoulder forward. If working the pecs isn’t helping the shoulder to relax back a bit, try lat dorsi and the posterior shoulder capsule. You are only trying to reduce the hypertonicity, not lengthen or stretch any of these.
And a couple of less obvious ones:
- Omohyoid. This little muscle might be a contributor to shoulder pain, due to its attachment to the superior aspect of the scapula – not by direct pull, but maybe by unconscious compensation so that there is protection of the throat. I tend to (GENTLY) follow omohyoid down from the attachment onto the hyoid bone and massage across it just below SCM. Here it stands out from other muscles because the direction of its fibres are different. I do both sides – remember it attaches to a hanging bone, so a pull from one side is going to result in tension on the contralateral side.
- Abdominal scar tissue. Now I know this particular thought gets into all the areas under debate at the moment – and I have opinions in all of those debates. However, try it out, particularly for ongoing shoulder restriction rather than just pain. The most common one I see is left shoulder restriction being affected by scar tissue from e.g. an appendix scar on the right side. If someone has a caesarean/hysterectomy scar, or even laparoscopic scars, or scars on the contralateral hip (or ipsilateral, but contralateral is more common as that is our walking pattern), it really is worth spending some time there to see whether that is part of the tension that is not allowing the shoulder muscles to relax yet. (I will just say that I am NOT talking about stretching fascia. Whether we have an effect through changing the tissue somehow, or more likely through an effect on the nervous system I still believe we can affect the tone and neural sensitivity of the tissue.)
There is a lot of research on massage therapy that indicates that overall massage therapy does not have a benefit for particular issues, or if it does, it is only short term pain relief. This concerns me as I think those studies focus greatly on general massage techniques being applied to the symptomatic area only. What if we learned to think about the connections in the body – in a way that is relevant to an individual client, rather than a “rule”? What if we treated based on those connections? Would that make any difference? I don’t know (yet) how that would show up in controlled research studies – but I do know that in clinical practice, learning to think about a client’s body as a pattern of usage, past history and current issue has helped me help people who are in pain and perhaps who have not yet found something that has made a difference. Just perhaps it didn’t make a difference because the problem was NOT where the symptom was.
About the Author
Jenny Richardson is the owner of Canberra Myotherapy and has been practising massage and myotherapy for 12 years. Jenny is passionate about understanding how the body works and using this to help clients with chronic pain.