Key Points

• Rotator cuff issues can vary from mild strains to severe tears, posing treatment dilemmas.

• Massage can play a key role in conservative treatments if the therapy is well-designed and targeted to the client’s individual presentation.

The intricate structures of the tendons and muscles in the shoulder play a pivotal role in the function and stability of the joint. When they are compromised, daily activities like reaching for something on a high shelf or getting a restful night’s sleep can become painful challenges for your clients.

Shoulder pain that interferes with mobility and quality of life can often be traced back to one culprit: rotator cuff disorders. We look at key treatment strategies in this second part of our two-part series on rotator cuff disorders. In the previous installment (Massage & Bodywork, September/October 2023, “Put Your Shoulder Into It, Part 1,” page 24), we looked at the structure and function of the rotator cuff muscles, along with common evaluation strategies.

Rotator cuff disorders represent a range of conditions affecting the tendons and muscles of the shoulder joint. The supraspinatus, one of the primary tendons, is commonly involved and can suffer from tears or inflammation. This is often due to overuse or acute injury, which leads to pain and restricted movement.

Similarly, the posterior cuff, comprising the infraspinatus and teres minor, plays a crucial role in external rotation and stabilization. Injuries to the posterior cuff often develop due to strong eccentric loads from decelerating the arm at the end of throwing motions.

On the anterior aspect of the shoulder, the subscapularis muscle, responsible for internal rotation, can also become compromised. Disorders in this muscle may result in sharp pain at the front of the shoulder, especially during pushing or lifting actions. Due to shoulder mechanics and other synergistic muscles, subscapularis injuries are the least common, as other, stronger shoulder muscles aid this muscle in its primary actions.

The four rotator cuff muscles can sustain injuries as a result of various mechanisms and causes. It’s essential to understand that each muscle requires a unique treatment strategy. Unfortunately, many individuals are diagnosed with a “rotator cuff tear” without clarifying which specific muscle(s) are affected. These vague descriptions can result in generalized treatments that may be less effective. An accurate assessment is the key to tailoring treatments to ensure optimal client results.

Rotator cuff issues can vary from mild strains to severe tears, posing treatment dilemmas. Treatment choices range from noninvasive methods to surgical procedures. Noninvasive treatments include physical therapy, massage, heat or cold applications, and nonsteroidal anti-inflammatory drugs (NSAIDs). These therapies are meant to reduce pain and inflammation and improve mobility. These conservative treatments can successfully aid healing and restore functionality for those with less severe injuries or at high surgical risk.

Surgery is recommended for more severe tears or when conservative treatment fails to bring relief. It involves repairing the torn tendon and, in some cases, removing bone spurs or inflamed tissue. While surgery can provide a definitive solution to the structural problem, it also comes with inherent risks and requires an extended recovery period. Ultimately, the decision between conservative treatments and surgery should be individualized considering the severity of the disorder and the patient’s overall health, activity level, and treatment goals.

New studies indicate that conservative treatments may perform just as well as surgical strategies for some problems.¹ Massage can play a key role in conservative treatments if the therapy is well-designed and targeted to the client’s individual presentation.  

Traditionally, massage is lauded for its ability to reduce hypertonicity and help restore overall biomechanical balance. New research indicates that massage can also play a major role in pain management, which can speed the return to function. Interestingly, certain studies hint at the potential of soft-tissue manipulation to boost fibroblast activity, aiding in tissue repair. Even with more significant rotator cuff tears, massage is beneficial in treating surrounding tissues and restoring optimum function.

Treatment Strategies

Following are a few examples of how the rotator cuff might be treated with massage—a diversity of techniques is suitable for addressing these challenges. In the November/December 2022 issue of Massage & Bodywork (“The Ladder of Engagement,” page 20), I presented the ladder of engagement concept. The following treatments follow those protocols. The techniques described here are not rigid sequences, but flexible methods tailored to the problem. I will highlight each method’s ladder of engagement level and offer tips for optimal effectiveness in real-world clinical situations.

Deep Stripping to Proximal Fibers of the Supraspinatus

Treating a supraspinatus injury with massage is challenging. Often, tears occur close to the musculotendinous junction. This area is hard to reach by touch because it’s positioned beneath the acromion process. Nonetheless, there are alternative methods to address strains in the supraspinatus. When this muscle tears, other shoulder soft tissues usually compensate, becoming tight or dysfunctional. These areas should also
be treated.

This technique is beneficial to reduce hypertonicity in the supraspinatus. It also reduces pain in the muscle, making it appropriate for pain management. This technique is most effective with the client in a prone position with their arms at their side. However, if the client is more comfortable in another position, such as sidelying, that also works. The supraspinatus treatment area is relatively small, so the technique is most effective when performed with a small contact surface—the thumb, a fingertip, or a pressure tool, for example.

• Position your thumb in front of the trapezius, targeting the more proximal fibers of the supraspinatus near the spine edge of the supraspinous fossa. 

• Apply a slow, deep stripping technique on the supraspinatus muscle, moving laterally (Image 1). As you move laterally, the space for your pressure application will get narrower as the clavicle and scapular spine converge near the acromion process. 

• Don’t ride up over the top of the acromion process with your pressure; this can be uncomfortable for the client.

This technique is a Level 1 in the ladder of engagement. However, incorporating passive, active, and resisted eccentric shoulder movements allows you to adapt the method to the ladder’s higher levels. For guidance on making these adaptations, refer to the previously mentioned article in the November/December 2022 issue. Keep in mind that as treatment advances and the client’s function pain improves, the higher ladder levels become increasingly effective.

Active Engagement Stripping to the Infraspinatus and Teres Minor

This technique is a Level 3 or 4 on the ladder of engagement. It’s particularly beneficial in the later stages of rehabilitation, but I often find it valuable when applied earlier.

• Have the client lie prone on the treatment table. 

• Raise their shoulder to a 90-degree angle of abduction. The technique will begin with the target muscles (infraspinatus and teres minor) in a shortened position so the shoulder is laterally rotated. This position employs an isometric contraction of the posterior rotator cuff muscles. 

• The technique can be more effective with an increased load on those muscles, so the next step is to increase the load during the eccentric phase of the movement. Place your hand on the dorsal side of the client’s wrist/hand region. Instruct them to hold the position as you press toward the floor. 

• Next, instruct the client to slowly let the contraction go as you gently press their hand/wrist toward the floor, moving the shoulder in medial rotation (eccentrically). 

• As the client moves their arm in medial rotation, perform deep stripping on the infraspinatus and teres minor muscles (Image 2). These muscles are small, so use a small contact surface like the thumb or fingertip. Perform this action multiple times until you have covered the entirety of the infraspinatus and teres minor muscles. Scan the QR code on this page for a video of this technique.  

Compression with Active Engagement on Subscapularis

The subscapularis muscle is not often strained, making it a somewhat overlooked area. Its location makes direct palpation difficult, as most of the muscle is tucked away from easy access. Nevertheless, issues like the vulnerability of the distal subscapularis tendon to impingement and the presence of active trigger points in the muscle belly highlight the need for its treatment.

• Position the client supine on the treatment table. 

• Grasp the client’s wrist gently with one hand, slightly elevating their arm away from their torso.

• With the other hand’s fingertips, apply steady pressure onto the subscapularis muscle (Image 3).

• Ask the client to move their arm slightly inward (medial) and outward (lateral). Ensure pressure is maintained on the muscle during this motion, as it enhances the therapeutic effect.

When the client performs these rotations autonomously, without resistance, it generates a moderate contraction of the subscapularis, qualifying the method as a Level 3 technique. Introducing resistance manually or using resistance bands can escalate the technique to a Level 4 application. For a better understanding, refer to the accompanying video demonstration on page 31.

The Role of Stretching in Treatment

Integrating stretching into massage therapy can significantly enhance treatment outcomes for rotator cuff disorders. Regular stretching can improve the shoulder joint’s flexibility and range of motion, helping restore normal function and reducing the risk of further injuries. When combined with massage, stretching can restore normal shoulder mechanics and reduce the discomfort from soft-tissue injury or the resulting muscle hypertonicity.

General Treatment Protocols

There are essential cautions and contraindications to using massage for rotator cuff treatment. Keep the following warnings in mind when treating this region.

• Acute inflammation—The affected area may be inflamed after an acute injury. Massage during this period can worsen this inflammation. Wait until the acute phase subsides before starting massage treatment. Keep in mind that inflammation may not be readily visible when it is in deeper tissues, like the distal supraspinatus tendon. A detailed history is essential to determine the age of the injury.

• Severe tissue damage—In cases of significant tears or ruptures of the rotator cuff tendons, massage may not be appropriate. An accurate assessment will help you evaluate the severity of the condition. Severe conditions require a referral to another health-care provider.

• Postsurgical caution—For those who have undergone surgery, the area needs adequate time to heal before massage is considered. Massage can be beneficial in postsurgical rehabilitation. However, use precautions with any postsurgical treatment and do not work near any incision site until it has had appropriate healing time.

• Bursitis—Inflammation of the subacromial bursa (bursitis) can worsen with direct massage. Learn about potential signs of subacromial bursa involvement to ensure massage techniques do not further aggravate an irritated bursa.

• Bone abnormalities—Issues like bone spurs or abnormal bone growth can be underlying causes of rotator cuff disorders. Massage does not provide relief in these cases and could worsen the condition. Bone spurs are not likely evident with physical examination and will need diagnostic procedures like an X-ray or MRI to identify. If you are suspicious of a condition, referring the client to another provider for further evaluation is wise.

• Infections—Sometimes, a rotator cuff injury is associated with other pathologies and may involve potential infections in the area. Any infections in the shoulder area, including skin or deeper tissue infections, should be considered when developing a plan of care. 

• Neurological symptoms—If the client exhibits neurological symptoms like numbness, tingling, or weakness in the arm, there is likely neurological involvement, and it should be appropriately evaluated. Pressure on irritated nerves can significantly increase symptoms, so be cautious.

• Pain threshold—Always work within the client’s pain threshold. Excessive pressure can exacerbate pain and further injure the tissue. More pressure is not always beneficial, and it does not necessarily mean you are more effectively accessing “deeper” tissues. Harder pressure might access more tissues, but it can also cause more tissue injury or neural irritation. For this reason, knowing the physiological effects of your treatment methods is important. 

Be sure to maintain open communication with the client throughout the massage session. Adjust the technique or stop altogether if they experience sharp pain, discomfort, or any unusual sensations. 

Enhance the Recovery

In the realm of rotator cuff disorders, there is no single approach that works. Personalized treatment plans tailored to an individual’s unique circumstances and needs are most effective. Massage therapy, with its diverse range of techniques, offers significant potential as a primary treatment method and as a complementary modality that enhances the care of rotator cuff disorders. 

Note

1. Anssi Ryosa et al., "Surgery or Conservative Treatment for Rotator Cuff Tear: A Meta-analysis," Disability and Rehabilitation 39, no. 14 (July 2017): 1357–63, https://doi.org/10.1080/09638288.2016.1198431; Umile Giuseppe, “Correction to: Conservative Versus Surgical Management for Patients with Rotator Cuff Tears: A Systematic Review and META-analysis,” BMC Musculoskeletal Disorders 22, (September 2021), https://doi.org/10.1186/s12891-021-04525-w.