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!

Identfying Shoulder Pain Part 2 – What to Do About It

Additional Disclaimer

Before I continue this post, I would once again like to state that I am not a licensed medical professional and this post is not intended to treat, diagnose or cure any medical injury, disease, cause, condition or ailment.  If you suffer from any type of pain you should seek the cousel of a qualified medical professional.  A partial list of these professionals is located in the second half of the first post.  The information in this blog is given with the intent to educate but not diagnose and I am not liable and do not claim responsibility for any emotional or physical problems that may occur directly or indirectly from the content of this blog.

Now that you know what your own anatomy looks like and how it functions (if you don’t, make sure you read Part 1 first!):

What are some things I can do on my own to address my shoulder pain?

Allowing that you do not have an injury and we are dealing with muscular issues, there are several things you can do.  Again, before attempting any type of self-diagnosis or treatment, if you have pain you should seek out the advice of a qualified medical professional.

Stretches

To even start to begin to correct this, we first have to stretch out the antagonists (chest and front delts) before we can begin to strengthen the posterior chain (rhomboids, etc.).  You can see all these stretches in a previous post here: Stretching Adequately Before/During/After Playing

  1. Doorway or Wall Chest Stretch – will stretch your chest
  2. Scapular Wall Slides – these will activate your lower traps and rhomboids
  3. Arm Circles – be gentle on these
  4. Upper Trap/Levator Scapulae Stretch

    With this exercise you can perform it standing and your non-moving arm can be extended straight down with thumb pointing towards the ceiling for a greater stretch

 Foam Rolling/Self-Myofascial Release

A foam roller cannot take the place of a massage therapist, but if you cannot afford to go, this is your best option. You can cover a wider area with the foam roller, and get more specific with a tennis ball, hitting your own trigger points.  Remember, pain is not necessarily at the point of discomfort, it can be “referred”  from another part of the body.  When you press on a trigger point, you may feel that  pain shoot through the body to where you felt discomfort.  Dr. Perry gives more examples of this in his guest blog post Shoulder Pain Secrets.

Guidelines for foam rolling: roll over the muscle to find the most tender spot.  Once you find it, lay on it for 20-30 seconds until the muscle begins to relax.  Then, roll the entire area.  Repeat if necessary.


Tennis Ball Work

This video from Synergy Athletics tells some of the do’s and don’ts of using a tennis ball. Actual usage is towards the end.

This is a really good description of how to use the tennis ball on trigger points in not only the shoulder but the neck.  As I have just recently found out from Stop Chasing Pain’s Dr. Perry, if you have shoulder pain, there is a good chance your scalences or SCM (or other deep neck flexors) could be too tight, as well.

In any case, this next description of how to use a tennis ball, I actually found on a message board.  I’m sorry that I don’t know to whom I need to give credit for this!
Use the following diagram for an idea of what muscles are being treated.

Image courtesy of http://www.sports-injury-info.com/im…er-muscles.jpg

So here we go.

This is how you treat your (upper) trapezoid muscles.

This is how you treat your rhomboids (down the trapezoids and between the shoulder blades) as well as your infraspinatus. You must squat down to apply pressure. You won’t get enough pressure on the ball if your legs are straight.

This is how you treat your side deltoids (you can do the same with the anterior and posterior deltoids). Put your bodyweight behind it.

This is how you treat the clavicular head of your pectoralis (the upper part of your chest):

Now, this is the tricky part, the side of your neck, the sternocleidomastoid muscle (the one that usually pulls to one side screwing things up.)

For this to work, you need to use the corner of a wall. Furthermore, you need to really drive your bodyweight. This is one of the strongest muscles. Don’t kill it but work on it.


Wanna Free E-Book?

You can’t get much better than this: Mike Robertson put out a  free e-book on Self-Myofascial Release using foam rollers, The Stick AND tennis balls.  It starts with lower body and the upper body tutorials are towards the end, but if you have a foam roller and a tennis ball, you can really work yourself all over with the help of this book. There is even a section on helping the wrist flexors!

Self-Myofascial Release Manual

Strengthening Exercises

As we have just learned, muscles of the upper back tend to become weak and stretched, due to hours of doing things with our arms in front of us, which leads to tight pectorals

Serratus anterior muscle

Image via Wikipedia

(and Serratus Anterior, I forgot to mention).  This means these muscles need to be strengthened and one of the absolute best ways of doing this is resistance training.

Any kind of motion that counter acts the pushing motion (which is what your tight chest muscles are already doing) will help.

These motions are primarily any type of rowing or pulling motion.  If you think of these exercises in planes of motion, you have two choices: horizontal pulling and vertical pulling.

Horizontal pulling would be things like seated cable rows, 1-arm dumbbell rows, barbell rows, T-bar rows, X-cable crossovers, Face Pulls, etc.
Vertical pulling motions would be things like Pullups, lat pull downs, althernating pulldowns, chin ups, etc.

All of these exercises will be helpful to strengthening the back muscles.  The biggest thing to remember when performing these exercises is to get the form right.  What do you need to remember?  Retract and depress your shoulder blades and keep them that way THROUGHOUT the movement.  This means that when you are doing any kind of pulling motion, when you let your arms extend back, they should not be able to full extend because you still have the bottom of your shoulder blades pinched together.  This activates your rhomboids and lower traps and allows them to do their proper job of stabilizing your shoulder girdle.

For these movements you will have to have equipment of some kind, be it a pullup bar, bands or dumbbells, and that is really the only limiting factors of these exercises.  I have some great links to the kinds of bands I use on my website at http://fluteangel.net/links.htm  if you want to go pick up some.  They are very inexpensive and portable and can come in varying strengths.

Prone Lower Trap Raises

These have to be one of my absolute favorite exercises I had never heard of.  They  look deceptively easy until you try to do them and realize that just lifting your arms without any weight is heavy enough!  In fact, this is such a good idea, I might just do a blog post all about activating the lower traps…

Here is a version you can do at home if you don’t have a bench:

From Neanderthal No More By Eric Cressey and Mike Robertson

Ideally, this exercise is performed face-down with your chest-supported on an elevated flat bench (i.e. longer legs, so that you’re higher off the ground). However, if you don’t have access to such a bench, you can do it bent-over; just make sure that your upper body remains parallel to the floor at all times (no cheating!)

Hold a dumbbell in one hand with a supinated group (the thumb points up at the top of the movement). Begin with the arm dangling below you on the bench. Horizontally adduct (think reverse fly) your arm while maintaining the thumb-up position. At the top, your arm should be at the 9 (left) or 3 (right) positions, and the upper arm and torso should form a 90-degree angle. Throughout the movement, concentrate on retracting the scapulae while keeping it tight to the rib cage (no winging).

Rotator Cuff Exercises

There are an awful lot of these exercises, however, one thing to make sure you realize when performing these exercises is that it’s not about how much weight you can lift.  The SITS muscles are small and if they are causing you pain, they may not only be weak, they areprobably tight and stretched which means you need to be even MORE careful.  1-3 lb. dumbbells will be PLENTLY for these exercises.

The two you probably recognize are internal and external rotation exercises.  Stand perpendicular to a pole with a band attached.  While keeping your elbow tucked in closely to your side rotate your arm inward, pulling the band and then slowly back.  Turn the other way and now you are pulling the band across your body.

Soup Can Pours

In a standing position, start with your right arm halfway between the front and side of your body, thumb down. (You may need to raise your left arm for balance.) Raise your right arm until almost level (about a 45° angle). (Hint: This is like emptying a can.) Don’t lift beyond the point of pain. Slowly lower your arm. Repeat the exercise until your arm is tired. Then do the exercise with your left arm.

Exercise 4

Preventative Measures

Gerald Klickstein’s book The Musician’s Way: A Guide to Practice, Performance and Wellness is an excellent book on just those subjects.  In Chapters 12 and 13 (and reposted on the blog) he mentions 12 Habits of Healthy Musicians:

The Twelve Habits of Healthy Musicians by Gerald Klickstein
1.  Increase playing or singing time gradually
2.  Limit repetition
3.  Regulate hand- or voice-intensive tasks
4.  Manage your workload
5.  Warm up and cool down
6.  Minimize tension
7.  Take breaks
8.  Heed warning signs
9.  Take charge of anxiety
10. Keep fit and strong
11. Conserve your hearing
12. Care for your voice

The Musician’s Way specifies ways in which you can incorporate these twelve habits into your lifestyle. Here are a few highlights:

  • #1: To avert overuse injuries, restrict any increase in your total playing or singing time to a maximum of 10-20% per week (p. 12).
  • #4: Respect your physical limits and ask a mentor for advice before you take on an overload of duties (p. 243).
  • #5: Pages 37-39 present a six-step process for warming up thoroughly and efficiently.
  • #6: Two sections in Chapter 13 – “Balanced Sitting and Standing” & “Meeting Your Instrument” – depict how musicians can form easeful habits. Forty-one photos are included.
  • #7: In solo practice, play or sing no more than 25 minutes before pausing for a 5-minute respite. The Musician’s Way itemizes six restorative movements that help to invigorate breaks (p. 75-82).
  • #8: Injury symptoms can be subtle, as are the social issues that come into play when unwell musicians who are expected to perform need to rest instead. Pages 237-241 untangle these topics.
  • #9: Anxiety doesn’t just scuttle musicians on stage but also impels some to overpractice to the point of injury. Strategies to neutralize anxiety interweave throughout The Musician’s Way and come to the fore in Chapter 7, “Unmasking Performance Anxiety.”
  • #10: Music making requires mental, physical, and emotional vigor. Healthy musicians, therefore, mind their nurtrition, rest, exercise, and other self-care needs much like top athletes (p. 245-246).
  • #11: Strategies that thwart music-induced hearing loss are summarized in my post “Hear today. Hear tomorrow” and fleshed out on pages 277-291.
  • #12: A section titled “Voice Care” encapsulates vocal hygiene under seven headings, the first of which is ‘Drink plenty of water’ (p. 268-277).

Postural Considerations

As flutists, a good many of us suffer from poor posture, made worse by long hours of playing without being in tune with our bodies.  If you are “stuck in your head” and not paying much attention to your body by being so focused on the music, you may notice that when you finally stop playing, you are sore, tight, hurting, and in terrible posture – slouched to the side, front, or otherwise not upright.

Besides understanding your individual body map and taking the time to be aware of your posture WHILE playing, let me propose a postural alteration.  Many of you may do this, but many of you may not:

When playing, take note of your arm position.  Do your elbows “fly” away from your body?  If so, this puts tremendous stress on the little muscles of the rotator cuff, which are not well equipped to deal with this type of endurance activity.  Let your arms hang from the flute, keeping the elbows closer to the body and also making sure the left arm is really under the flute.  When you sit, make sure you are BALANCED on your sit-bones with your feet FLAT on the floor.   This should help keep you in the proper position while leaving your deltoids and biceps to do the hard work of fighting gravity instead of your little rotator cuff muscles.

Dr. Susan Fain has some great information in her dissertation, and I highly recommend you check it out!  You can also hear the both of us at the National Flute Association Convention in Charlotte this August speaking with Lea Pearson and Karen Lonsdale about pain prevention.

Additional Resources and Articles

By the way, there is an EXCELLENT 5 – article series called Neanderthal No More: Fixing Your Caveman Posture by Eric Cressey and Mike Robertson over at T-Nation.   It can be a bit advanced for some, but if you are looking for a lot of information by people who know what they are doing and you wouldn’t mind a full week’s workout laid out for you, I’d check it out.  Not only does it have a full description of anatomy, it delves into body awareness by asking you to check out your own posture in different ways and then testing it to examine your own posture and movement patterns.  In part 3 they give client analysis – see if you can determine what’s “wrong” with these guys. :)

Please, tell me if this addresses your shoulder pain and if you found this helpful, leave a comment below.  Let us know what pain you are dealing with, what has worked for you and if you have anything to add to the post, let’s hear it!  Look for some guest blog posts dealing more with these issues, soon!

And feel free to link your own articles to this blog, down in the comments section!

Related articles

Foam Rolling

Foam what?  I’m sure most of you have no idea what I’m talking about, but everyone should.  Ever had a massage?  I mean a good, deep tissue massage?  It hurts like mad while it’s being done, you’ll find tight and knotted muscles you didn’t know you had, but when you are done, don’t you feel so much better?  Possibly a bit sore the next day, but much looser, and if you got them frequently, you would probably move a lot more freely, your clothes might fit a little looser due to less knotting of the muscles and water retention and as an added bonus you would probably sleep a lot better.  So why don’t we get massages more often?  Well, cost can be an issue as can having oil/lotion worked into your hair.  We want these benefits….but what do we do?

My friends, let me introduce you to the foam roller; the poor man’s massage.  It comes in varying sizes and lengths but in general, it’s about 36 inches long, looks like a pool noodle but is as hard as a brick.  Roll yourself strategically back and forth over this device and when you are done screaming in pain (especially over the IT band and calves) you will be surprised how much better you feel.
In athletic work, this helps muscles repair, facilitates stretching, promotes joint flexibility and stimulates blood flow/toxin flushing.  In musicians, all of the above are just as true.  With musicians, a tennis ball may be more of your friend, as it is easier to access your upper body muscles.  Please see the attached videos and articles for descriptions.  Rolling out the lats, upper back and thoraic attention will help a lot with musicians, because we tend to slouch over to our instruments and this can roll out our weak/tight muscles.

A note to those who have either low muscle density, are out-of-shape or overweight: you should know that the arms are heavily involved in foam rolling as they support your body weight while you are rolling.  You should also know that foam rolling can be painful and you should be able to distinguish the difference between pain and injury.  If you are not sure, go get a deep tissue massage with trigger point therapy and that will give you a better idea of what to expect.  Foam rolling should never cause bruising.

Other articles you might want to investigate:

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