Subscapularis Tendinitis: Identification and Treatment, Lecture notes of Animal Anatomy and Physiology

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n previous articles I discussed what I call the Essential Principles regarding the nature of injury and the healing process. These principles are especially helpful in recognizing and treating those difficult-to-identify, elusive pains that plague clients. Parts 1 and 2 of this series on the shoulder dif- ferentiated two specific “rotator cuff” injuries — infraspinatus tendinitis and supraspinatus ten- dinitis — and discussed effective treatment regi- mens appropriate for each injury. (See the June/July 2004 and August/September 2004 issues of Massage & Bodywork .) This article, the third and final part of the tril- ogy, applies the Essential Principles to another common, and commonly misidentified, shoulder or rotator cuff injury: subscapularis tendinitis.

The Nature of Injury at the

Subscapularis Muscle

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he subscapularis muscle is attached to the undersurface of the scapula, sandwiched between the shoulder blade and the ribs. Its tendon attaches to the humerus on the lesser tubercle. The subscapularis muscle-tendon unit is difficult to visu- alize because the tendon goes through the body from back to front. This muscle helps you open jars, hug someone, lift things, clap your hands, throw a ball, and complete the forehand and serving actions in tennis. The subscapularis is by far the strongest of the four rotator cuff muscles. If a client has a shoulder injury, there is a 70 percent to 85 percent chance it is the sub- scapularis tendon. In people under age 40, it is the most frequently injured structure in the shoulder. Yet subscapu- laris tendinitis is the shoulder injury most likely to be missed by the healthcare professional. Before I understood how to assess this problem, it was the most perplexing shoulder injury imaginable. One likely reason for this con- fusion is that the subscapularis is such a strong muscle that, unless it is severely injured, it does not test positively during the most commonly used test to locate this injury. Once I learned some auxiliary testing positions to avoid this difficulty, I was able to accurately assess this injury. When the subscapularis tendon (A and B, above right) is injured, some of its fibers are strained and torn; this lesion usually occurs at the tenoperiosteal junction (the point of attachment from tendon to bone). Fibers in the muscle belly will rarely tear. Subscapularis tendinitis can occur in an instant if a strenuous action is performed before the muscle is warmed up and ready. With a good warm-up, the muscle-tendon unit is more pliable and can absorb stress more easily. Overdoing an activity after a period of inactivity makes a person vulnerable to this injury. Lifting something heavy, throwing a stone into the middle of the lake with all of your strength, or simply

reaching into the back of the car to lift a heavy bag and pull it toward you — any one of these can cause a subscapularis injury.

Pain as a Signal

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ubscapularis injury can make its appearance slowly over time or in an instant if there is an overt acci- dent. When it appears slowly, a person finds that lifting the arm up high or putting on a shirt hurts. Or, after playing tennis for a while, serving brings on pain in the shoulder or down the back of the upper arm. If the injury becomes really severe, even opening a jar or door will be painful. Throwing a ball can also bring on this injury, as this is the main muscle used in pitching — both overhand and sidearm. Many pitchers suffer from this injury. Overuse is a major factor, and it is often dif- ficult to know the exact cause, because the pain is often not felt until several days after the strain occurs. Pain from this injury can be felt anywhere in the upper arm area and is often not felt where the tendon attach- ment is located. Pain can be referred down as far as the wrist if the strain is severe. Even though the tenoperiosteal junction is the site of most subscapularis injuries, the pain is generally felt in the back of the upper arm in the area of the triceps muscle. When the tear is in the muscle, which is rare, pain is felt under the shoulder blade.

Scar Tissue and Chronic Pain

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his injury may become chronic, coming and going with the amount of exertion performed. Each new

Lenni Armstrong illustration

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Subscapularis muscle Subscapularis tendon upper half (A)

Subscapularis tendon lower half (B)

From this new starting position, have the client pull toward the abdomen. Each test variation stretches the muscle a little bit and progressively puts more stress on the tendon. This principle is important to keep in mind while testing all tendon injuries.

Test 2 — Passive Elevation First, say to the client, “Raise your arm above your head.” You ask the client to do this by herself so you can get an idea of the extent of the injury. If the client has great difficulty in lifting the arm, you will know to go very gently as you perform the next test. Now place one hand on the elbow and your other hand at the back of the same shoulder to stabilize the joint (see Test 2).

Test 2 — Passive elevation

Push the arm back diagonally until you come to the very end point of the range of movement. If there is still no pain felt, give the arm a slight jerk in the same direc- tion. This jerk places extra stress on the injured struc- ture and is always done at the very end of the range of motion. The client should be totally relaxed while you passively test the arm.

Test 3 — Horizontal Passive Adduction Standing at either side of the client, place one hand on her elbow and lift the arm so it crosses in front of the client’s body. Now place your other hand on the client’s shoulder blade opposing it (see Tests 3 and 3A). For instance, if your right hand is on the client’s right elbow, place your left hand on her left shoulder blade. Your hands should now be parallel to one another. Squeeze both of your hands together to compress the tendon.

Test 3 — View from the front

Test 3A — View from back

This test compresses the lower part of the subscapularis tendon against the coracoid process.

Healing Injured Tissues

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f the subscapularis strain is mild, a week or two of rest will often eliminate this injury. Unfortunately, most shoulder injuries undergo repeated tearing and poor scar tissue formation, so treatment is needed. Traditional massage therapy alone is not usually an effective treatment for subscapularis tendon injuries. There is often very stubborn scar tissue that needs to be eliminated. However, massage is useful as an adjunct to friction and exercise therapy. Friction therapy, or transverse friction massage, is a very precise form of massage developed by Dr. James Cyriax. It is remarkably effective in treating most muscle, tendon, and ligament injuries. It is ineffective, however, when the structure lies deep within the body and cannot be easily reached with the finger. Friction therapy is done with no oils or creams. One or several fingers are placed on the skin at the exact point of injury. Pressure is applied in one or two directions while a constant back-and-forth action across the painful structure is maintained for anywhere from five to 15 minutes. This approach is somewhat uncomfortable at first, but the dis- comfort diminishes steadily as the treatment progresses. Friction therapy works by breaking down scar tissue that prevents proper healing within muscles, tendons, and ligaments. It also separates ligament-to-bone adhesions and allows normal healing to occur. Friction therapy also increases blood circulation to areas that normally have very little blood supply. It accomplishes this through mild, controlled trauma to the tendons and ligaments. I usually suggest that frictioning be done in one direction only so both the client and the practitioner can rest momentarily between each stroke. The treatment is mildly uncomfortable, but not painful if done properly. With a relatively fresh injury, treatment of subscapularis tendinitis usually shows signs of progress in three to four weeks. For more long- standing cases, treatment may last two to three months. Treatment should be administered twice a week and should be performed in conjunction with massage ther- apy and a prescribed exercise program.

Begin the treatment with 10 to 12 minutes of friction as described below, giving the client and your finger a brief rest after about five or six minutes. Make sure the client doesn’t experience too much discomfort while you’re per- forming friction therapy. In some individuals this tendon can be very tender. Start with very light pressure and slowly increase the force as the tendon becomes hyper- emic and slightly numb. Always observe the client’s facial expression in addition to what she may say. Start as gently as you need to — remember that if you’re overly enthusi- astic, the client may think twice about returning. Following the friction, massage the upper arm and shoulder area. It’s also helpful, if you know how, to work on the subscapularis directly by forcefully gliding your fingers under the scapula. Massage the upper back and neck as well to improve circulation to the shoulder.

1. Location and Friction Technique Place the client’s palm on her thigh while she lies supine. With your thumb, find the coracoid process at the front of the shoulder. Move about one half inch lat- erally to the medial surface of the humerus (just oppo- site it) and medial to the bicipital groove (see Friction1).

Friction 1

Friction 1A The friction is done vertically head to toe because the tendon attaches in a horizontal direction. Apply the friction pressure upward and relax on the down motion.

Accent the friction at the upper or lower half of the ten- don if you are skilled enough to evaluate and palpate accurately. Continue this for five to 10 minutes, taking breaks as needed. If you or the client needs a break from the friction therapy, massage the upper arm for a while, then dry your hand and have another go at the tendon. Treatment will take anywhere from three weeks to three months depending on the severity and length of time the injury has been present.

2. Exercise Therapy If done consistently, this tendon exercise program 1 is very effective. The stretching realigns the scar tis- sue fibers so they heal correctly, and the weight-cali- brated exercises systematically increase the strength of the tendon. This procedure must be performed every day for six to eight weeks for it to be effective. If the client’s personality is such that she will not do it consistently, this is not the program to recommend. In these cases, try giving the client strengthening exercises only. There are five steps to the program: warm-up, stretch, exercise, stretch, and ice. Instruct your client to do the following:

1. First warm up the tendon by circling the arm for three or four minutes. Stand with the arm 3 or 4 inches in front of the body and make big, slow circles in front of you.
2. Stretch the tendon five times for 30 seconds each time. The stretch mimics passive lateral rotation. Lie on a table or bed with the injured arm toward the edge. Keep the upper arm in close to the body with the elbow bent at 90 degrees.

Stretch Now grip a 2- to 5-pound weight and lower the forearm toward the floor into a stretched position (see Stretch). Relax in that position, stretching the subscapularis in the front of the shoulder. Each stretch is held for 30 seconds. Only a slight pull, not pain, should be felt in the shoulder. Rest a moment between stretches and be sure to hold each stretch for the full 30 seconds and repeat five

Coracoid Process

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