Shoulder Pain Secret

Today I have a REAL treat in store for you.  Dr. Perry Nickelston, owner of Stop Chasing Pain, has written a guest blog post for me.

I first found Dr. Perry through his podcast: Stop Chasing Pain.  Dr. Perry is a DC who specializes in using laser therapy to treat people.  When I was doing research on my shoulder pain series, I mentioned it to Dr. Perry and he mentioned to me I might want to include the subscapularis in my posts.  I asked him if he had any particular exercises or suggestions for that particular muscle and he said sure!  The resulting blog post is a gift from Dr. Perry.  If you want to know more about him and what he does, you can find his website at The Pain Laser Center, view his blog at Stop Chasing Pain, listen to his podcast (you can also subscribe on iTunes), watch his YouTube channel, and find him on Twitter and Facebook.  Tell him you found out about him from me and this blog!  Enjoy!

Shoulder Pain Secret

The one place that never hurts, but causes so much misery everywhere else!

Perry Nickelston, DC, FMS, SFMA

I see lots of shoulder pain problems in my clinic. In fact it is the #1 condition I treat. By the time clients see me for help they have been everywhere else you can possibly imagine for therapy. They have had physical therapy, steroid injections, acupuncture, even surgery and the pain still exists. They wonder why?

They hear about my Stop Chasing Pain laser and movement therapy program via referral and always say the same thing on the first visit, “I tried everything else Doc, so I might as well give this a shot. I got nothing to lose.” My response is always the same, ‘Your shoulder pain is not the problem; it is a symptom. Pain is where your problem ended up, not where it started. Once we stop chasing pain and begin fixing the real problem, you will lose that pain.’

Without question the shoulder is the most common injury affecting athletes and is very tricky to treat (Halloween reference not intended), like unless you know the right places to look for dysfunction. Angela reached out to me and asked if I would take a look at her article series on shoulder pain. I was very impressed with her content. It is jam-packed with some terrific information that very few people know. You can learn more than most doctors know about the shoulder when you read her articles.

Yes, I am totally serious. Trust me, I see this stuff in the trenches every day and clients have never seen stuff like this before. So, I highly recommend implementing her strategies.

I suggested adding a section on some often neglected culprits of shoulder pain and dysfunction.  Angela asked if I would like to write a brief post about them myself. So here I am. These points are nasty culprits and very deceiving in their contribution to pain because of referred pain and movement compensation patterns.

You never feel pain where these muscles are located, and yet they can cause debilitating pain in other areas. We end up chasing the referred pain instead of the site of pain so relief is temporary at best. When these muscles are so knotted up and in constant spasm they lose the ability to control movement (stability) and your nervous system kicks in a compensation pattern by recruiting other muscles to do more work. This is a basic primal survival mechanism where your body does anything and everything to avoid pain. It may not be the best thing either.

Your body is not concerned about tomorrow and the negative effects of what it is doing to protect you. It is only concerned with RIGHT NOW! It only cares about what is necessary to keep you functioning in the moment. Before you know it, there is a spiraling domino effect of pain, spasm and dysfunction, making one unhappy person.

What are these two muscles? The subscapularis and the scalenes! Oh what fun these two muscles can be. Trigger points (muscle knots that cause severe pain and movement dysfunction) in these two muscles cause lots of misery. I recently published a Special Bonus E-book entitled ‘The Top 10 Trigger Points Every Health and Fitness Professional Should Know! for my friend Charlie Weingroff and his amazing new DVD Set ‘Training=Rehab, Rehab=Training, and here are a few excerpts relating to these points. Also be on the lookout for my newest DVD coming out this summer entitled, ‘The Top 25 Trigger Points for Maximum Pain Relief!

 

Subscapularis

Subscapularis is one muscle that is very elusive and causes all sorts of problems in function and pain. This is the number one trigger point that is overlooked in most shoulder pain problems.

Sitting on the inside part of the scapula lining up against the chest wall he is deep inside the arm pit. Look at the pain pattern above and notice the intense red in the posterior part of the shoulder. That’s right…he is a primary cause of pain in the rear deltoid. Now a really amazing pain referral pattern of this muscle is chronic wrist pain! Imagine that. I have seen countless people complain of wrist pain and nothing seems to help.         That is an alarm signal for me to check the subscapularis and I always find a trigger point.

The subscapularis rotates the head of the humerus medially (internal rotation); when the arm is raised, it draws the arm forward and downward. It is a powerful defense to the front of the shoulder-joint preventing displacement or subluxation of the head of the humerus.

Think logically about what can happen when muscle inhibition (deactivation/tone) occurs from the trigger point. The head of the humerus may drift up and back in the shoulder socket causing an impingement (pinching) at the acromio-clavicular joint and priming up for a rotator cuff tear in the supraspinatus muscle. These are common injuries in athletes and fitness enthusiast, so the subscapularis should always be addressed in any recovery program.

Often the only way to reach this muscle is by hand. Stick your thumb or fingers inside the armpit while slightly distracting (pulling the arm forward) while client is in a supine position. I find that slight internal rotation relaxes the muscle and you can get a better pressure. It can be in such spasm that it feels like a golf ball is pushing back at you.

BE CAREFUL! This trigger point can be excruciatingly painful when pressure is applied. It can feel like your arm is being ripped out of the socket. That is a normal side effect feeling of an intense trigger point. That will subside in time.

Tread easy here and be aware of the subscapular nerve that sits in the area. If you apply direct pressure to the nerve there will be a sharp, numb type feeling shooting into the arm. Simply move off the nerve. You cannot damage anything if you mistakenly press on the nerve; it just feels really freaking weird.

Scalenes

 

Located in the anterior part of the neck and having an intricate connection to the first rib, these muscles are relentless in their contribution to pain. Check out my article on first rib fixation syndrome and the relationship to scalene trigger points here FIRST RIB ARTICLE.

An elevated first rib can cause chronic spasm in the upper trapezius muscle and neck. A first rib manipulation is often indicated to alleviate the condition in conjunction with releasing the trigger points.

The nerves of the neck criss cross in and around these muscles as they contour to the arm, so when they get trigger points nerves can become compressed.

That means tingling, numbness and pain. Many misdiagnosed cases of carpal tunnel syndrome (tingling in the hands) and symptoms of cervical disc herniations can be blamed on these trigger points.

I have found these muscles to be the most common cause of pain in the mid-back! Get all the massages you want and back cracks from your chiropractor and it will not help if these muscles are referring pain. Profound relief from years of chronic pain upper back pain can be helped if you look at these points. The scalene muscles rarely if ever feel pain directly. But when you apply pressure to them and they have trigger points, it can be REALLY painful.

A condition known as Thoracic Outlet Syndrome can arise when these muscles are too overloaded. They pinch on nerves and cause pain in the arm with tingling and numbness.

Scaleni are also accessory muscles of breathing. When they are dysfunctional your endurance level will suffer because your breathing is labored and less oxygen gets into the body. You can often increase the endurance of your athletes simply by working these muscles.

These points need to be worked by hand. Be careful not to apply over pressure on the side of the neck. But don’t be afraid to get in there and massage them out. Consult with a healthcare specialist as needed for more hands on intensive therapy. Just by the very nature of you discovering these points for you will go a long way towards getting pain-free.

Now part of the secret to alleviating these issues is to massage and do soft tissue work BEFORE you stretch them out. Stretching knotted muscles only tightens them further (think of stretching a rope with a knot). You feel temporary relief at best and it returns later. So massage first, then stretch, and then you can use the muscle.

Combine these points with the other information already covered in Angela’s post and you will notice improvement. Be patient and diligent. It can take several weeks for symptoms to completely resolve. I suggest consulting a skilled manual therapist is symptoms persist. There is only so much we can do ourselves.

Five suggestions to help:

  1. If subscapularis is very tight check the wrist flexors for weakness. They are actually synergist. And vice versa….if the wrist flexors are always tight test the subscapularis for weakness…remember it can be TIGHT AND WEAK at the same time!
  2. If the neck scalene are tight check the iliopsoas, wrist extensors, and thumb extensors for weakness. These are also synergists of movement.
  3. Start training the neck extensors if your anterior neck is very tight. May have weakness there too.
  4. Train your grip. Strengthening your hand grip will help your rotator cuff.
  5. Check your opposite side hip and glute muscles for tightness or trigger points. The fascial connection can pull on the shoulder and alter mechanics. You will be surprised at how tender this area can be.

The one take away is that lots of things contribute to the shoulder. And the first rule of thumb is that if your shoulder hurts, lots of other things happened prior. Sure, check the shoulder, but also check the hips, and the thoracolumbar fascia. They are big players in the shoulder game. Have fun now! Also feel free to email me with questions. I love this stuff. Thanks Angela for the chance to play on your blog. So much fun!

Perry Nickelston, DC, FMS, SFMA

stopchasingpain@gmail.com

 

My Thoughts

Dr. Perry brings up some great points about these lesser known muscles, and I know that he hits on several conditions common to flutists (Carpal Tunnel and Thoracic Outlet Syndrome).  I especially enjoyed the part about the Scalenes and how not only can they cause pain in the arms/hands, they can interfere with breathing, something very important for musicians and athletes alike.

I know that this post may be a bit over the heads of some of my readers in regards to anatomy, but I hope you will go back and re-read it, understanding how YOUR muscles work and just what may be going on to cause that tingling in your hands, or numbness, or pain in the shoulder.

Dr. Perry gives several alternatives to what traditional doctors may say is causing you pain.  This is why I suggest seeing the several different types of medical professionals if you are dealing with any kind of pain or injury.    I HIGHLY recommend listening to Dr. Perry’s podcast, checking out his blog and website and look him up on Facebook!  He has some great things there.  While I know he is not posting things to deal with musicians specifically, it never ceases to amaze me how so much of what he sees and deals with are common problems in not just musicians, but athletes and office workers.

If you have experienced these types of pains, please leave a comment to help others know what worked for you!

Thank you so much for your post Dr. Perry!

Shoulder Pain Part 1

One of the most common ailments among musicians, especially flutists, is shoulder pain.  I myself suffer from it due to a myriad of reasons.  Sometimes it can be helped, sometimes not, but most of the time there is hope for us that we do not have to play in pain.  Before we can attempt to fix the problem, we have to correctly identify the source of the pain and just what might be going on.  Let’s do a little body mapping. :)

Most of the pain that flutists complain about (and myself personally experience) comes from what we call the left shoulder.  If we’re to get specific about it, most of the pain usually originates from the rear of the shoulder in the muscles of the rotator cuff and the rhomboid, specifically.

The Culprits

If you look to the left you will see the muscles that lie on top.  If you look to the right, these are the muscles that lie underneath.  Look at this picture, can you identify exactly where your pain is?

The Victims:

Where you probably experience pain the most


Rhomboids


These lovely little muscles can be the source of a LOT of pain for people.  As you can see, the connect the inside of your shoulder blade to your spine, and their job is to cause the blades to retract, or come together.  Pinch your shoulder blades together and that’s the rhomboids doing their job.

When your chest muscles are too tight, these guys can get stretched and weak.  When this happens, you might get a sharp pain that can travel through your shoulder and even down your arm.  You might even have a knot here.

Teres Major/Minor/Infraspinatus/Supraspinatus


With the exception of the Teres Major, these muscles make up the rotator cuff.  I’m sure you’ve heard of it before, but had no idea what it does.  It does a lot of things, but for our purposes here what you need to know is how it works so you can play your instrument.  The rotator cuff muscles main job is to lift and rotate your arm and keep your shoulder stable within its socket.

For flutists, this is why the left shoulder tends to hurt more than the right shoulder, because we bring our left shoulder up and rotate it in front of us to be able to play.  This is the job of the rotator cuff muscles.  As you can see, they are very tiny muscles, and holding up an instrument for a long time, especially when their assisting muscles such as the lower traps and rhomboids are already stretched out and weak puts a great strain on them.  Compound that with overactive traps and chest muscles and you have a recipe for disaster just waiting to happen.

Actually, this will show you exactly how the shoulder blades.  As this video is playing, put your hands on the muscles that are moving and do the movement yourself.  Do you see how your own body works?

The Antagonists:  The ones partially causing the pain!

Pectoralis Major/Minor

These muscles may be less thought-of as contributing to the problem of shoulder pain but may in fact be the main cause.  Most Americans now spend a large part of their day in front of their computers, sitting and driving.  What do all these have in common?  The arms are in front of the body.  What main muscles bring the arms forward?  The pectorals.  Of course we have assistance muscles such as the front deltoids, so do this with me:

  • Put one hand on your chest, near your shoulder.
  • Bring your other arm in front of your body and feel which muscles move

You probably notice that the front of your shoulder tightens and so do your chest muscles near the shoulder joint.

Now, exaggerate that motion.

  • Put both arms in front of you like you are typing
  • Squeeze your arms in towards your body
  • hunch your shoulders and slouch your upper body

Does this resemble how you might look after spending too long at the computer, or driving?  If you hold this exaggerated position for long, things will start to hurt.  You’ll notice pulling in your rear delts, and your chest will get sore.

What’s going on here is a chronic muslce imbalance between the front of our bodies and the back of our bodies, called the frontal plane (or frontal chain and posterior chain). What happens is that the muscles bringing the arms forward cause the muscles in your rear shoulders/back to get stretched.  Over time, these rear muscles become weakened due to being in a stretched position for so long and not being contracted.  The frontal chain muscles of the chest/front delt get tight because they are contracted for TOO long.

See how this works?

More antagonists:


The “Shrug” Muscles: Trapezius and Levator Scapulae



As you watch these videos, can you see the motions you use to play your instrument, drive, type, eat, fold laundry, etc. and how doing so much of one movement, and not enough of the opposite can cause you pain?

The jobs of the traps and levator scapulae are to shrug the shoulders upward and the job of the lower traps is to bring the shoulder blades downward.  The traps are actually divided into 3 sections of fibers: upper, middle and lower.  Most people have overactive and/or overdeveloped upper traps.  Please don’t do shrugs, there’s no need.  What you NEED to do are get your lower traps firing, because not only are most people not aware that they are there and have a separate job to do, most people’s lower traps do NOT do their job, which is to bring the shoulder blades downward.

Try this:

  • Roll your shoulder blades backwards
  • Right before they roll forward again, squeeze the bottom of your shoulders together
  • if your shoulders come up towards your ears, you’re doing it incorrectly.
  • Done correctly, you are performing shoulder blade depression and retraction and activating the lower trap fibers and rhomboids.
  • Your chest should stick out and there should be space between your shoulders in front.

Does that feel weird?  If so, good!  You’re probably doing it right!  This position is the first position of good form for all weightlifting exercises.  I’ll cover that in another post, but knowing about it now can save you a world of hurt, just by understanding how these muscles are designed to function.

Now that we know where and why, how do I stop the pain?

There are a couple of things to note.  You have to know is your pain a muscle pain or an actual injury?  If this is something that has been bothering you for awhile, I highly recommend going to see a doctor of some sort first before self-diagnosing.

Who to see

You have a lot of choices, I’m going to name a few for you from which to pick:

General Practitioner

This type of doctor can, of course, tell you if anything else is wrong with you.  Your source of pain could not be what you think it is and it could actually be a nutritional deficiency or other abnormality.  This doctor can also tell you if what you have is an actual injury.  If you have an injury, you may or may not want to take medicines prescribed to you by this type of doctor (such as muscle relaxers) and you may also get prescriptions for further testing such as an MRI or a script for therapy from a Physical Therapist.

Physical Therapist

These people will treat your injury by strengthening the surrounding muscles and rehabbing the injury itself.  (PT’s out there, feel free to chime in here on what else you do!)  They may treat you with various modalities including stretching, light weights, heat, ice, massage or electrical stimulation.  If you have a real injury, this may help.

Massage Therapist/Active Release Technique Therapist

These two are NOT the same, do not get them confused.  A massage therapist also does more than “feel good massage” or Swedish Massage.  Most of the massages I have had in my lifetime were anything but “feel good”!  A massage therapist may provide techniques such as deep tissue massage and trigger point therapy.  They can manipulate the fascia around muscles if it has become stuck, trigger point will release knotted muscles and besides freeing up an injured area of knots, massage will also increase blood flow to the area and increase lymph flow, which takes away waste materials from the muscle.  Trigger points are sometimes thought to be areas of waste materials that have gotten blocked.

ART is different in that you may remain fully clothed and there is a lot more movement.  The practitioner will stretch you and press on different areas while moving your muscles and/or limbs to break down scar tissue. It is particularly helpful in treating overuse injuries.  You can find out more information at http://www.activerelease.com

Personal Trainer

Now, if you have an injury, you must get that rehabbed first, or get a doctor’s note to provide to your personal trainer letting them know exactly what is wrong and what you can and cannot do.  If you are not injured, you may be suffering from either Overuse Syndrome or Muscular Imbalances, either of which can be helped by a personal trainer.

A good trainer will not only educate you in stretches that will help you release the antagonists that may be causing your problems, they will also show you corrective resistance training exercises that will strengthen your weak muscles.  When your rhomboids and rotator cuff muscles (among others) are stronger, not only will you be able to play for a longer time without pain, you can become and stay injury-free!  Add to this the benefits of better body awareness and you have a body that is better prepared to deal with the demands of being an instrumentalist.

As a shameless plug – I have availabilities for in-person and online training so you can get one-on-one training programs designed specifically for you.

See the next post: Shoulder Pain Part 2   for stretches and exercises you can do on your own to alleviate shoulder pain.

(This post was just getting too long! :)

This post is made with the knowledge that I am not a medical practitioner of any sort, and therefore cannot prescribe anything.