Whether you pull a muscle, have an overuse injury or strain, or are dealing with any number of issues, one thing typically remains true: You never really understand how much you use your shoulder, hip or knee until you’re dealing with chronic pain or injury.
Shoulder injuries and strains are common for many people, and according to George Russell, a massage therapist and chiropractor in New York City, massage therapy can be ideal for helping those who suffer from shoulder dysfunction.
As massage therapists, Dr. Russell says, you are uniquely suited to assist clients suffering from shoulder injuries. “A massage therapist spends more time with clients, develops more trust with them and often has better manual skills than any neuromusculoskeletal practitioner,” he says. “I want to teach massage therapists to do everything I know that’s in their scope of practice—and one of the few things that leaves out is high-speed adjustments. A massage therapist can effectively address a wide range of shoulder problems.”
Anatomy and Structure
The rotator cuff consists of four muscles— supraspinatus, infraspinatus, teres minor and subscapularis—whose fibers emerge directly from all over the shoulder blade and converge on the humeral head. These muscles are called a cuff because they attach like a cuff to the very outer top of the humerus. “Picture an epaulet on a military jacket,” Russell suggests. When contracted, these same muscles rotate the humerus, which is why the group of muscles is called the “rotator cuff.”
But that’s not all they do, and “rotator” may not even describe their primary function. “It’s true they move the humerus in various ways, especially rotation,” Russell says. “But kinesiology reveals the rotator cuff’s real function—to snug the humeral head into the middle of its shallow socket on the outside of the shoulder blade, no matter where the arm moves in space.”
Like a mortar and pestle, the shoulder joint (like any ball-and-socket joint) functions through roll and glide. When you lift your elbow over your head, the humeral head rolls up in the socket and would roll out and hit the acromion if there weren’t an equal and opposite glide down in the socket. The opposing glide is what keeps the joint from harm, and that glide is the job of the rotator cuff. “The rotator cuff muscles come off almost every surface of the scapula— front, back and top,” explains Russell. “That pattern of attachment suggests that the scapula is the stable end of the muscles and the ‘cuff’ all around the outer top of the humerus is what is moved—in whatever way glides the humeral head to the center of the glenoid fossa.” Think, for example, of a professional baseball player pitching a fastball: The rotator cuff is what keeps his arm from flying over home plate with the baseball. “When Masahiro Tanaka throws his fastball, the rotator cuff pulls the humeral head backward and toward his scapula, gliding the humeral head back into the center of the socket where it belongs,” Russell says.
Instead of starting by releasing spasm and tightness in the rotator cuff, consider the shoulder joint itself as a whole. “In my opinion, all of the common injuries of the shoulder result from shoulder joint misalignment,” Russell says. “The rotator cuff becomes damaged when it tries its hardest—but fails—to glide the humeral head to the center of the socket.” Following are some of the most common shoulder injuries.
A SLAP tear (superior labral tear from anterior to posterior) is a tear of the superior labrum and, often, the long head of the biceps. The labrum is a ring of cartilage that deepens the socket for more controlled movement. In a SLAP tear, the bone rolls up to move the whole arm up in space, but for some reason, the rotator cuff fails to counter the force of that movement so there’s equal glide back into the socket. The labrum is the next line of defense, and it should act like a guardrail on a highway, bouncing the ball back into the socket. “But you can only drive so long against a guardrail before it gives,” Russell explains. Sooner or later, the humeral head will breach the labrum, and it almost always starts at the top and front of the joint, where the ligamentous and joint capsule protection is the least and where the human arm tends to go.
Acromial impingement, shoulder bursitis, and supraspinatus or other rotator cuff muscle tendonitis/tear. All of these injuries have to do with the failure of downward/backward glide, which is also a failure of all the rotator cuff muscles. “Powered by the deltoid, the humerus rolls up to bring the arm overhead,” Russell explains. “If the rotator cuff cannot or does not glide the ball down into the glenoid fossa, the bone eventually hits the acromion, which sits above the humeral head like a carport above a car.” Damage to any structure from the humeral
head to the acromion can result. Eventually, one can expect arthritis as well, since a poorly seated joint doesn’t allow the cartilage surfaces to stay against one another and to be nourished by the joint fluid.
Who You Might See
As might be expected, Russell explains, anyone whose work requires that they have their hands above their heads for long periods of time are prone to rotator cuff injuries. “The rotator cuff is ‘white meat’ muscle. It has no myoglobin, so it can’t burn glucose for energy. It’s like it’s on battery power (glycogen),” he says. “When the battery runs out, the liver needs a half hour to recharge the battery, so if you’re going past that deadline again and again, you’ll get overuse syndromes and fascial adhesions.”
Athletes who throw, too, are more likely to have rotator cuff problems because the rotator cuff is the structure that decelerates the arm once you’ve let go of what you’re throwing. “To throw with any power, you usually rotate your body,” Russell adds. “This means that the rotator cuff often has to work around a corner or at some odd angle because the shoulder blade is very protracted and the ribcage is rotated as well.”
Russell also notes that swimmers are at risk for shoulder problems because of the big range of motion they take their arms through against the resistance of the water, while also rotating their neck and ribcage. “It’s a complex task,” Russell says, “and can lead to rotator cuff strain, especially in the subscapularis, which stabilizes while it also assists internal rotation of the arm as you push the water back with the arm.”
How Massage Helps
“The key thing is that the rotator cuff corrects the gliding junction of the arm and shoulder blade,” Russell explains. “A ball-and-socket joint must balance roll and glide. The bone must be able to have a good gliding range of motion.” Restoring the gliding range of motion, and soothing and freeing overworked muscles that have been beat up by working with the wrong line of pull, is where massage therapy really shines.
To be effective, however, massage therapists need to look at the rotator cuff as the core stabilization system for the glenohumeral joint. “If you accept that, then it’s important to understand that range of motion in the shoulder is more than flexion and extension,” Russell says. “It includes the humerus being centered on the glenoid fossa.” Range of motion, then, involves evaluating the position and fixity of the humeral head itself, and guiding it back to the center of the joint manually. “It will often appear that the ‘pecs are tight,’” Russell adds. “But if you put the palms of your hands on the outside of the humeral head and slowly move it posterior/ inferior-ward, you’ll discover that what you’re seeing is an anterior humeral head.”
How you talk to clients about shoulder problems is important, too. “Up, down and side to side are not useful ways to describe shoulder movement,” Russell says. “Instead, talk about upward and downward rotation, and scaption (protraction and retraction around the ribcage), which are the real motions that go with arm gesture. All of these movements can be actively and passively coached— for example, when the patient is prone.”
Finally, self-care techniques for rotator cuff and other shoulder injuries include ice for inflammation and heat for muscle tightness. If there is focal inflammation, try recommending the use of ice where the inflammation is and heat on any parts of the muscles that are not inflamed.
Russell also recommends an easy assessment protocol to help you and your client assess the efficiency of shoulder movement. Have the client move their arm through a range of motion, standing in front of a mirror, or while supine. “The humeral head should stay centered in the socket in neutral stance and throughout the range of motion,” he says. “If the client elevates the scapula significantly or the humeral head rises up in movement, there is a problem, and this is usually the exact point where the client will report pain. After you treat the muscles and mobilize the humeral head into a fluid neutral position, repeat the exercise and you will probably both see and feel a difference.”
When Massage Is Contraindicated
It is important to exercise caution if the tissues are inflamed, but you should know that you can still work on the parts that are not inflamed. Additionally, if your client has frozen shoulder, proceed slowly. “That is a condition where adhesion is a response to inflammation—if you break it down too fast, it can flare up a lot, so take it easy, and let them know they may be in pain after treatment,” Russell adds.
Helping your clients regain their health and well-being—whether by reducing stress, mitigating pain or better handling the symptoms of chronic illness—is one of the greatest benefits of massage therapy. With a solid understanding of ball-andsocket mechanics, a little education and some basic techniques, you can help your clients with shoulder dysfunction get their shoulders back into a good range of motion, and feel better.
Theory Into Practice