Injuries of Middle Age: The Shoulders

An aging cohort of affluent baby boomers is extending “middle age” indefinitely, and this population is showing up in clinical settings with a set of problems very well suited to massage therapy.

 by George Russell, May 1, 2024

Among the dilemmas of middle age is the balance between accepting limitation and soldiering on aggressively—the latter, at least in part, being a manifestation of many Americans’, and especially the baby boomers’, obsession with “more.”

At the musculoskeletal level, a cardinal issue contributing to middle-aged injuries is that fascia shrink-wraps to match a person’s habits. The body lays down scaffolding, in the form of fascia, to match long-held patterns of movement and posture.

In this sense, fascia is your history—like the fibrous rings of a tree—but it’s also your destiny because tightly woven fascia makes forming new habits difficult.

Most of the problems people present with in middle age have to do with a loss of the subtle gliding movement that maintains proper joint position and mobility. Frozen shoulder, labral tears, supraspinatus fraying and rupture, acromial impingement, bursitis, arthritis—these are all injuries that have separate features, but what they have in common is a loss of glide in the shoulder joint and the resultant limitations to healthy movement.

Related: Massage for Shoulder and Back Pain

Additionally, the fascia dehydrates and becomes stiffer as we age. Its capacity to absorb stress decreases and the cells that rebuild injured tissue become fewer. If you’ve gone through menopause—and all of the problems of middle age it can cause—you probably experienced the effects of this change. One of the many fabulous things about estrogen is that it keeps our tissues hydrated and supple. Frozen shoulder is an extreme example of this challenge, appearing most often in peri- and post-menopause.

Here, we’ll focus on the shoulders, and, in particular, the roll-and-glide mechanics of a ball and socket joint, as well as the impact of scapular mobility and placement on issues in the shoulder.

Roll and Glide: Movement Basics

The hips and shoulders are ball and socket joints. Think of them being shaped like a mortar and pestle. When you lift your arm, your humeral head rolls up toward the edge of the socket. But unless it also glides back toward the center of the joint, the humeral head ends up pressing against the front structures of the shoulder, and this area is where almost all injuries of the shoulder begin.

Reminder: Whichever way the end of the bone (the elbow) moves, the humeral head must glide in an equal and opposite way to maintain a healthy joint. For example, elbow up, humeral head down.

Problems in the shoulder or hip almost always involve disruption of the glide function.

So, what muscles create the gliding action? The internal and external rotators.

In the shoulder, that’s the rotator cuff. That’s why almost all shoulder problems involve trigger points, functional weakness and mechanical disadvantage of the rotator cuff.

I’ve always thought that the rotator cuff should be renamed the “stability cuff.”

Hips, Shoulders and the Symptom Cascade

In a way, humans are like dogs standing on their hind legs. When our simian ancestors stood up on two legs, the hips and the shoulders evolved in very different ways. We have traded stability for mobility in both sets of joints, but most of all in the shoulder.

The shoulder adapted to maximize range of motion and dexterity, and the hip for stability with motion. Both joints switched orientation by 90 degrees. The benefits of being able to stand on two legs and to move our arms around are obvious.

But most hip and shoulder problems also stem from our evolution.

Gravity tends to take the hips forward in space, which may include an overarched low back. In less flexible people, that tends to be accompanied by hamstring shortness. In people with more flexibility, psoas spasm.

An overarched lower back position pushes the femoral head forward against the front of the acetabulum, labrum and front capsule and ligaments, which can lead to groin pain, limited range of motion and psoas spasm. Ultimately there could be a labral tear, arthritis and complications to the low back and sacroiliac joint regions.

What about the shoulder? These postural asymmetries put stresses on the shoulders by destabilizing and displacing them.

Think about it this way: Forward shifted and/or forward-tilting hips lead to a backward tilting ribcage. The chest ends up collapsed and the neck compressed with the head forward.

Gravity then draws the humeral heads forward. By the time many people reach middle age, they’ve been in this type of position for a long time.

The symptom cascade for shoulders is quite similar to the hips: labral and biceps tendon damage, limited motion, rotator cuff strain, and pain and/or arthritis.

The Benefits of Massage for Shoulder Problems

You don’t need me to tell you that massaging the shoulder muscles—from the biceps to the spine—helps immensely with any shoulder problem. Remember that the arms are like wings. The shoulder muscle attaches to the skull, C1 through T12, and because the latissimus dorsi’s tendon is the tough, diamond-shaped thoracolumbar fascia, you could even say that each arm starts at the opposite iliac crest.

Related: Don't Shoulder the Pain

As a massage therapist, you are already working on all of this, of course, but awareness, intention and sequencing are important and change how the client takes in your work.

The fundamental issue is posture-based joint stress.

Restrictions in shoulder movement generally start with limitations in gliding, a small but crucial movement. Joint limitation cannot be fixed by pushing the arm at end range. If you can restore glide—then release fascial restriction and tension in overworked muscles—your client’s healthy range of motion, and your success rate, will increase dramatically.

Fascial techniques are immensely helpful.

In truth, though, fascia and muscle are often intertwined. Fascia surrounds each muscle and also surrounds all the individual structures of muscles, even into the muscle cells themselves, which have a cytoskeleton, or fibers that separate and connect the parts of the cell.

Massage Protocols for Restoring Glide to the Shoulder Joint

Here are two ways to mobilize the shoulder, working with the client in a supine position:

With the client’s arm on the table:

  1. Find their humeral head, just beyond the tip of the acromion. If you come in with the palms of your hands from the side, you can be sure you’re on the humerus and not on the acromion or collarbone.
  2. Test the gliding micromovement of the shoulder by springing down just a bit. This is a very small movement. If you do both sides at once, you’re more likely to feel where there is more or less movement.
  3. Start by pressing straight down toward the table, then make your way around to the top of the joint, stopping frequently to push the humerus toward the center of the joint. The shoulder is almost never restricted except in the quarter of the circle between A-P and S-I.
  4. Once you’ve found the spot that feels most restricted to you, continue to spring down gently, as you would with those cabinets that you have to push slightly shut to open. Use low pressure and repeat until you feel some play come into the shoulder.

With the client’s arm at 90 degrees:

  1. Lift the supine client’s arm until it’s perpendicular to the table.
  2. Interlace your fingers around the top of the humerus and very gently draw the humerus away from the midline of the body.
  3. Repeat that gesture several times while moving slowly a quarter of the way around the circle of the humeral head until you are drawing the top of the humerus toward the client’s foot.

How to Work the Muscles Around the Joint

Once the joint’s gliding motion is improved as much as possible, work on the muscles around the joint. Whenever you work on muscles, you are also working on fascia, which is the gristle of the muscle between the skin and the muscle, around the muscle and marbled through the muscle.

The rotator cuff may be a good place to start, especially since it’s what generates the necessary glide in the shoulder to maintain proper mechanics and relieve the symptoms of almost all shoulder dysfunction.

From the rotator cuff, move to the deltoid muscle, which crosses close to the joint so may yield pain upon palpation. That pain is usually coming from the joint itself rather than from the deltoid. By the same token, working the deltoid allows you to affect the joint directly, which may help greatly.

Now, work the scapular stabilizers from the skull to the bottom of the ribcage. Don’t forget serratus anterior, which is well accessed in a side-lying position. In slim/flexible clients, you can get all the way up to rib one or two going through the armpit and moving medially along the rib with the client in side-lying. The fibers run directly along the ribs as opposed to the intercostals, which run in between the ribs and do not move the shoulder.

The upper trapezius and levator tend to be very tense compensators when there are shoulder problems because when you can’t lift your arm you compensate by lifting your shoulder blade to get your arm over your head. But in my experience, the upper trapezius is not usually a direct cause of problems in the glenohumeral joint.

Pectoralis minor can get tense from poor posture, when the chest is caved in and arm placement is in front instead of to the side. Releasing this muscle will bring the shoulders more onto the back than the front, which is crucial for shoulder health.

Pectoralis major crosses the front of the shoulder and can be tight in people with hypermobile shoulders, especially because this muscle provides some support across the front of the joint (remember that when the shoulder loses its glide, it’s almost always somewhere in the quarter circle between S-I and L-M).

On the other hand, a humerus stuck forward mimics tight pectorals major, so if you see the upper humerus forward, you will make faster progress if you release the humerus back and down.

The latissimus dorsi are the back of the armpit. Below the armpit, they angle sharply in toward the bottom of the thoracic spine and the thoracolumbar fascia. Make sure you release them all the way down.

This work is easily done in side-lying position, where you can put the heel of your hand on the low outside of the muscle and push its mass toward the thoracolumbar spine.

Quick reminder protocol to balance the muscles around the shoulder:

  1. Start with the rotator cuff. This group of muscles generates the glide in the shoulder that is necessary to maintain proper mechanics.
  2. Move to the deltoids. Palpation may yield pain, as this muscle crosses close to the joint.
  3. Then, work the scapular stabilizers from the skull to the bottom of the ribcage, including pectorals minor and serratus anterior.
  4. Finish with the pectorals and latissimus dorsi, double checking that the lat, pectorals and trapezius are balanced with each other.

Working the Scapula

The shoulder blade moves in many directions, but it’s important to understand that early anatomists, working on a static, dead body, applied the x/y/z axis of science when describing scapular motion instead of looking at the main movements of the scapula in real life. Elevation and depression do occur in the scapulothoracic articulation, but they’re not the main motions by any means.

The common real-life movements are upward and downward rotation (when lifting and lowering the arm), and protraction/retraction (when reaching forward and when drawing the arm back to stabilize it, like when you lift).

Elevation, depression and anterior tilt (the “transom-window” action of the pectoralis minor) don’t occur frequently in concerted motion, although they do help stabilize and add detail to complex movements, as well as being involved in compensations to poor posture lower in the body and problems with the glenohumoral (true shoulder) joint.

Mobilizing the scapula is something almost all massage therapists do brilliantly. Make sure, though, that you include upward and downward rotation in your sequence, spinning the scapula in both directions as if it were a wheel.

Retraining the scapula is essential for proper humeral placement, since it is the socket, and retraining the ribs and spine may also be necessary since they support and tether the scapula.

In most shoulder injuries, the hips are not seated properly and lead to a lack of support for the shoulder, forcing the muscles to work at bad angles. Massage therapists can help clients effectively manage shoulder injuries that commonly occur in middle age.