“Oh my gosh, I haven’t been able to raise my left arm above my head for five years,” said the man seated next to me on a recent flight to Seattle once he learned I was going there to teach my Releasing the Rotator Cuff workshop. “It’s a good thing I’m right-handed!”

“My wife’s shoulder really bothers her,” said the hotel shuttle-bus driver upon arrival. “She has trouble brushing her hair and teeth. She doesn’t want to go to the doctor because she’s afraid he’ll tell her she needs rotator cuff surgery.”

“Both my mother’s shoulders are messed up,” said the front-desk clerk at the hotel when he learned I would be presenting in the hotel’s conference room. “It started with her right shoulder. Her doctor sent her to physical therapy. It didn’t help and then her other shoulder started hurting!”

I hear complaints like the ones above all too often. I also hear, “I tried massage, but it didn’t help.” Well, if the massage therapist does not have the specific skill set, odds are massage therapy won’t help all that much.

Of note: before we dive in, my comments above are not a dig at physical therapy. I’m privileged to know and work with many outstanding physical therapists. However, if the clinic uses a paradigm that emphasizes exercise, chances are the rotator cuff issue will not improve. As John Gibbons, DO, says, “Lengthen before you strengthen.”

The Slippery Subscap

The subscapularis (or subscap) is a difficult muscle to palpate, and—let’s face it—one that most clients don’t enjoy working, although they will enjoy the benefits. As one client said to me, “It feels like you just shouldn’t be there.” He certainly appreciated his pain-free range of movement after the session though!

Before we discuss palpation and strategies to make subscap work more palatable for the client, let’s review the anatomy. The subscapularis is a thick muscle with a broad tendon that covers the anterior scapula and reinforces the shoulder joint. This muscle functions to stabilize, internally rotate, depress, and adduct the humeral head in the glenoid fossa. Attachments are the medial border of the anterior surface of the scapula and the lesser tubercle of the humerus.

This sturdy muscle provides 50 percent of the strength of the rotator cuff. The subscap plays a vital role in joint centration, depressing the humeral head (along with the other rotator cuff muscles) during abduction of the shoulder joint, and counteracting the powerful force of the deltoid. Weakness of the subscap—or as I like to think of it, disruption of its ability to function at full capacity—can lead to anterior glide syndrome as the larger internal rotators drive the humeral head anterior, which often leads to impingement syndrome. Another important function of the subscap is its eccentric activity, protecting the shoulder joint during external rotation.

The scapula rests on the serratus anterior and subscap, which move across one another as the scapula moves. Working on these muscles assists the scapula to glide on the thorax.

The shoulder joint follows the scapula, and increasing scapula stability and mobility leads to increased glenohumeral joint function. Skilled comprehensive work on the subscap is essential for recovery from rotator injuries.

Trigger points refer across the shoulder blade, down the arm, and around the wrist.

Palpation: Find the Right Spot

I’ve discovered that approximately 80 percent of therapists in my workshops think they’re on the subscap when they’re on the latissimus dorsi/teres major. It’s an easy mistake to make and easily correctable. The reason for this common error is because therapists attempt to enter the subscap too far inferiorly, which causes the ribs to block the therapist, and they mistake the fat lat for the subscap.

The best place to enter subscap territory is the central portion of the muscle. Bear with me while I use this analogy. I live in beautiful Austin, which is in central Texas. Dallas is north and San Antonio is south. If I try to enter subscap in the San Antonio area (south), I’ll most likely mistake latissimus dorsi for subscap. If I enter in the Dallas area (north), I’ll probably hit the tendon, which is fine if that’s where I want to start. I prefer to enter through Austin (central), though, which puts me in the less sensitive central belly, and I can glide superior or inferior from there. (That’s assuming the client’s scapula is not superglued to the thorax, which it often is. More about that later.)

Staying with this analogy, substitute your cities for mine. Begin your entry into the subscap from your city. Dive under the pec major with your fingers to get your medial placement first, and only then gently press your fingertips toward the scapula. The medial placement is crucial; pressing posteriorly too soon causes the fingers to slide laterally, and you’ll wind up on the lat.

Verify your location by sliding your fingers laterally to feel the lateral border of the scapula. If you are lateral to the lateral border of the scapula, you are on the latissimus/teres major, not subscap. This should be your mantra: To accurately palpate the subscap, my fingers must be medial to the lateral border of the scapula.

Solid Principles for Working the Subscap

There are many effective manual therapy techniques for working with the noble subscap. Align yourself with solid principles when choosing techniques. As engineer Harrington

Emerson famously said, “As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.” Following are a few of the principles I follow.

1. Start with the muscle in a shortened state.

2. Pin and Rock. Your first encounter with a stressed myofascial unit should be gentle and nonthreatening. Passively shorten the muscle and gently pin it with multiple fingers for a broad, dispersed pressure. Then, add a slow rhythmic rocking of the joint. Rocking stimulates a parasympathetic response. After all, we are rocked for nine months. (In fact, the first nerves to myelinate in the human fetus are the vestibular nerves, which sense movement. The first thing we are conscious of is that we are moving beings.) Be patient—wait for the tissue to soften and yield before moving to the Pin and Move protocol. Come back to this Pin and Rock maneuver whenever you sense guarding in your client.

3. Pin and Move. When you meet an area of dense fascia, trigger points, tender points, or just plain snarly tissue, integrate active movement. Active movement takes it to the brain by involving the central nervous system, creating longer lasting results. Fascial layers and actin and myosin myofibrils glide across each other as the muscle goes through its shortened, neutral, and stretched states.

4. Work the muscle(s) from as many different positions as possible—supine, side-lying, prone, and even weightbearing. This comprehensive approach can yield tremendous results.

I think of the subscap as the psoas of the shoulder because of its sensitivity, the feeling of vulnerability it evokes in the client, and its propensity to stimulate a sympathetic nervous response. Positional release and rocking are two excellent strategies to make subscap work more palatable for the client.

The least invasive and easiest way to warm up the subscap is to place your finger pads on it while the arm is abducted and externally rotated. Then, adduct the arm by letting it lie in a comfortable position across your client’s chest (Image 1). This puts the muscle in a slack position (using the principle of positional release). Later on, you’ll take the humerus through a range of motion.

Pin and Rock

Gently rock your client’s shoulder while your fingers are gently pressing on the subscapularis, working your way inferior to superior. Rocking is calming and a great way to “introduce” yourself to a muscle. The hand that is rocking the shoulder is the working hand. The hand that is on the subscap is simply exerting a gentle pressure. Do this Pin and Rock technique until you feel some melting in the tissue. Perform it on as much of the subscap that is accessible. Notice whether the scapula is glued to the rib cage. If it is, hopefully it will be more freely movable at the end of your work.

Once you have felt some melting of the tissue, you can add small circular movements with your fingertips as you continue to warm up the subscap. Do this with the muscle in a neutral state or, if your client is too sore, a slack state. Try to get as much length and width of the subscapularis as you can.

There have been many clients on whom I could just do simple rocking for several sessions. “Ungluing” the subscap and freeing the scapula to glide on the thorax can take time. Honor your client’s pain threshold. This builds rapport and trust.

Pin and Move

Take the shoulder through both passive and active range of motion while releasing trigger points and knots. Active movement allows you to work through the muscle layers, but begin with passive movement to teach your client the movement pattern, and then allow your client to do it on their own. Keep in mind that most people with rotator cuff injuries have limited range of movement, but active movement is essential for release of stubborn trigger points and knots. Movement choices include (1) internal and external rotation, (2) abduction/adduction, and (3) any movement of the shoulder joint!

Always ask your client what movement they think would work best. You might find that some clients will not be able to tolerate supine subscap work for a variety of reasons. Or, your client may be ticklish, have large breasts, be heavily muscled, or have a glued-down scapula that makes access to the subscap a challenge. You should start these clients in the side-lying position.

Subscap Precautions

When working on the subscap, please remember to be mindful of:

• Breast cancer/lymphedema: (Note: this is a precaution specific to subscapularis work. Align yourself with an oOccupational tTherapist with an expertise in working with breast cancer patients.)
• Hypermobile shoulders

• Shoulder replacements

Final Thoughts

Keep in mind that the shoulder joint is complex, and there may be underlying joint pathology that should be assessed by a doctor. The practitioner is encouraged to always use sound clinical judgment when making decisions about their ability to help each individual. Be sure to refer clients to a qualified professional when the need arises.

Let this article be a stepping-stone to developing a finely honed and exquisite skill set for freeing the slippery subscap. Let’s add to world peace, one shoulder at a time!

Resources

Fernandez de las Penas, Cesar, Joshua Cleland, and Peter Huijbregts (Eds.). Neck and Arm Pain Syndromes. Churchill Livingstone, 2011.

Osar, Evan. Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction. Aptos: Lotus Publishing, 2012.

Sahrmann, Shirley. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. St. Louis: Mosby, 2011.

Trundle, Terry. Rotator Cuff Syndrome: From Impingement to Post-Operative Rehab (Digital seminar). 2009.

images

Image 1. The client actively moves the humerus toward her ear in abduction while the therapist works the superior section of the subscap in the supine position. Keep in mind that abduction is usually limited with rotator cuff injuries; work to increase range of movement while respecting limitations.