In the First Place

When I was teaching one of the most difficult concepts to get across to the interns was what to do first. If you can remember when you were going through chiro school that was usually a major obstacle for most everyone. On one hand you are chock full of knowledge but on the other hand that abundance of knowledge was often paralyzing because of the seemingly endless buffet of choices. 

To solve this problem, I created a “cheat sheet” that went through the body, joint complex by joint complex, listing the predominant condition and treatment for that joint complex. For the experienced practitioner, through experience, this check list is second nature. But one must remember there was a time when it was the “first time” and for most it was simply the swirl of a million seemingly similar diagnostic choices and treatment options.

One of the areas of attention was the shoulder. The shoulder is considered the second most common complaint, from a musculo-skeletal standpoint, after the lumbar spine. The factors that create shoulder problems could include misuse or overuse, poor posture or trauma from falls, be they landing on the shoulder directly or a closed kinetic chain-type injury caused by a fall onto an outstretched hand (FOOSH). 

Complicating this clinical picture is that the “shoulder” has become a generic-type term used to designate the general area where the arm attaches to the torso. The shoulder girdle is a bit more descriptive and includes the AC joint, GH joint, physiologic scapula-thoracic “joint,” and the 20+ muscles that attach the arm to the torso. And while all muscles are important – some muscles are more important than others. But with this swirl of details – what does one do first?

Figure 1_Glenoid Fossa.jpg

All shoulder injuries involve the four rotator cuff muscles. It is always risky making a definitive statement, but I feel safe stating that all shoulder injuries involve the four rotator cuff muscles. The simple reason is that the mechanical actions (i.e. – flexion, extension, abduction, etc.) of the shoulder joint (gleno-humeral joint) are initiated by the simultaneous contraction of the four muscles as they work to seat the humeral head securely in the superior aspect of the glenoid fossa (Figure 1).

Anything that alters this coordinated function (pain, spasm or injury) either currently or in the near future will present with rotator cuff dysfunction, the most prevalent clinical entity being the myofascial trigger point (MFTP). So what treatment does one do first with most shoulder conditions? The obvious answer is to “treat the trigger points.” 

Figure 2_Rotator cuff.jpg

As a quick review, as stated, there are four rotator cuff muscles (Figure 2). The supraspinatus is involved in abduction of the arm. The supraspinatus is the most frequently injured due to misuse and its poor mechanical advantage. Think of reaching across a car seat, with an extended arm trying to pick up a grocery bag or briefcase. That lifting action produces too much strain on the muscle for most people. 

The second group are involved in external rotation of the arm. The teres minor and infraspinatus are the least developed of the four. The reasons for this are that few people do any pre-hab or preventive type exercises to maintain tone of these muscles. I also believe that because the muscles are out of one’s immediate line of vision, it is an “out of sight, out of mind” situation. 

Subscapularis is the fourth rotator cuff and clinically the most important. My justification for that statement hinges on the Murnagham’s 1980’s quote that “MFTP’s to subscapularis may influence sympathetic vasomotor activity leading to hypoxia of the muscles around the shoulder joint. Lack of O2 leads to cellular necrosis and proliferation of scar tissue.” Janet Travell found subscap MFTP’s caused vasoconstriction resulting in, once again, local hypoxia that could progress to “severely limited joint movement” ultimately resulting in adhesive capsulitis. When you control the blood and oxygen you control all the “good” cards. 

Complicating this fact is that the subscap’s internal rotation of the arm and hands may be the most frequently performed motion of the four in that modern-day man/woman’s days often center around “gathering actions.” Gathering actions are where the hands are internally rotated and objects are brought to the midline. This can lead to overdevelopment of the subscap. Make a quick scan of resting hand positions (palms turned backwards) the next time you are standing in line at the grocery store. This will show the prevalence of this observation. 

Armed with this knowledge one needs to treat all four rotator cuff muscles. Three are pretty easy, the subscapularis is not. Most practitioners would address the infraspinatus, teres minor and supraspinatus with the patient prone or seated and a variety of techniques (Graston, FAKTR, ART, cross-friction, pin and stretch, etc.) all can be effective. But the subscapularis presents a challenge because of its anatomical location on the anterior surface of the scapula. 

Unfortunately, because of time, convenience or lack of knowledge the subscap is often ignored. In the past this has had to do with the lack of study the muscle has received over the years. If one has older textbooks lying around from the early 90’s there is a good chance the subscap received scant mention, if not being completely ignored. 

An effective treatment for the subscap, to break-up the MFTP or spasms within the muscle, is to utilize a three-step pin and stretch of the muscle. 

Step 1 – the patient lies supine with the affected forearm resting across the body’s midline (Figure 3).

Step 2 – the doctor’s superior hand makes a thumb-index (pincher’s grip) grip on the posterior wall of the axilla. The doctor’s inferior hand takes the patient’s wrist and externally rotates the forearm and arm (Figure 4).

Step 3 – the doctor passively (or the patient actively) directs the arm through abduction to 180° of flexion. A useful cue is to have the patient “touch the bicep muscle to the ear.” (Figure 4)

The forearm is brought back to the midline and the process is repeated 6-10 times. The pincher grip pressure in the axilla is to patient tolerance, using a thumb pad, not thumb tip (Figures 5 and 6). This simple pin and stretch technique will release the subscap. Interestingly the perceptive patient may feel an immediate “rush” of blood as the circulation comes to flood the shoulder. 

Figure 3 (above) - the patient lies supine with the affected forearm resting across the body’s midline.      Figure 4 (right) - the doctor’s superior hand makes a thumb-index (pincher’s grip) grip on the posterior wall of the axilla. The doctor’s inferior hand takes the patient’s wrist and externally rotates the forearm and arm

Figure 3 (above) - the patient lies supine with the affected forearm resting across the body’s midline.

Figure 4 (right) - the doctor’s superior hand makes a thumb-index (pincher’s grip) grip on the posterior wall of the axilla. The doctor’s inferior hand takes the patient’s wrist and externally rotates the forearm and arm

Figure 4_pincher andbicep to cheek.jpg
Figure 5_thumb pad correct position.jpg
Correct (Figure 5- left) and incorrect (Figure 6 - above) thumb position when maintaining pincher grip.

Correct (Figure 5- left) and incorrect (Figure 6 - above) thumb position when maintaining pincher grip.

Supportive recommendations for home would include attention to posture and discussion of potential offending activities, particularly the “gathering actions” mentioned above. 

Before PowerPoint, when public discourse was handled in what was called the “oral tradition” the great speakers of antiquity had to memorize their speeches and present without notes or electronic amplification to their audience. One memory device the orators used was to associate the different parts of their speech with their home. 

There would be a front door and as the orator progressed through the home, room by room they had an association with the different parts of the house. The front door and foyer would be the logical entry point to the house and the first place one stepped into the house.

“In the first place” became a classic opening that we can learn from our ancestors that allows one to see through the confusion of too many choices and proceed with a confidence that allows one to maximize therapeutic abilities.

From this perspective the often daunting clinical treatment of the shoulder becomes clearer – attention to the rotator cuff in general and the subscapularis specifically become a logical first step in the road to rehabilitation and recovery.


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Russ Ebbets DC

Dr. Ebbets serves as editor of Track Coach, the technical journal for USATF. He has lectured nationally on sport and health related topics. He has authored several books and been a frequent contributor to PaceSetter Magazine since the 1980’s. He maintains a private practice in Union Springs, NY.

His new book, A Runner’s Guide: 30 Years Off The Road is scheduled to be published October 1, 2019.