Simplified Methods for Rotator Cuff Management

This article is presented as a practical and uncomplicated approach to management of the shoulder’s four rotator cuff muscles. The purpose of this article is to make it possible for any desiring healthcare professional to become skilled in the application of trigger point and myofascial therapy of these muscles. The key to successful therapy, and long-term elimination of pain, is to restore adequate blood circulation to the trigger points. When adequate blood supply is reestablished, muscles can replenish the energy necessary to allow complete relaxation and recovery. When a trigger point is fully relaxed, it ceases to exist. Relaxed, replenished muscles are soft and supple and can be bent, twisted, elongated or compressed without pain or limitation. Strength, flexibility and endurance are qualities of recovered muscles.

Myofascial Release

Myofascial release is performed by applying sustained tensil force over restricted fascia. According to Brukner & Khan, the aim of the procedure is to breakup abnormal cross-linkages. This occurs in collagen fibers and limits the ability of connective tissue to elongate. It is thought that cross-linkages form as a result of an inflammatory response to acute or overuse injury. This is a primary reason that muscle and fascia needs movement during the rehabilitation phase.
The term release indicates a prolonged lengthening of tissue, as distinguished from a stretch that may or may not lead to long-term change.
For those who follow the CPT code standard, myofascial release is now billed under 97140 – Manual Therapy Technics.

Trigger Point Therapy

All muscles have some degree of flexibility. The amount of flexibility is influenced by size and shape of the muscle, its diameter, location and type of muscle fibers. When muscle fibers are injured, there is local disruption of the relaxation mechanism. The muscle fibers lose their ability to relax and lengthen. This results in sustained muscle contraction. The unrelenting contraction causes a biomechanical pressure buildup inside the muscle bundle. The affected muscle fibers become oxygen starved and energy depleted, because the flow of blood is shunted around the pressure barrier. The resultant pain, dysfunction and shortening are reflexly maintained as long as blood flow is delayed. This area of involuntarily shortened muscle is referred to as a trigger point. They feel like knots or small, ropey lumps in the muscle. A trigger point feels hard to the touch and painfully tender if compressed. Muscles containing trigger points become weak, inflexible and lack the qualities of endurance. Trigger point therapy is the art of locating, and extinguishing or inactivating, trigger points. Like myofascial release, trigger point therapy is presently billed under 97140 – Manual Therapy Technics.

Anatomical Review

For those of you who have been out of graduate school as long as I have you will appreciate the following thumbnail refresher.
The rotator cuff is a musculotendinous complex of four muscles around the shoulder [glenohumeral] joint. My review will very briefly highlight each of the four muscles.

The subscapularis is the only anterior cuff muscle. It originates on the inner surface of the scapula and inserts into the lesser tubercle on the anterior aspect of the humerus. It acts chiefly as an adductor and internal rotator of the arm at the shoulder. Subscapularis trigger points will refer pain to the posterior aspect of the shoulder. In my experience, this muscle is more acutely involved in frozen shoulder than the other cuff muscles.

The posterior cuff muscles begin with the supraspinatus muscle, which originates in the supraspinatus fossa of the scapula and inserts into the greater tubercle of the humerus. It acts to abduct the arm and to pull the head of the humerus inward toward the glenoid fossa.

Supraspinatus trigger points present as a deep ache around the shoulder concentrating in the mid-deltoid. The ache often extends down the arm to focus over the lateral epicondyle. According to Drs. Travell and Simons, the localized shoulder ache of supraspinatus trigger points often mimics subdeltoid bursitis.

Next is the infraspinatus muscle, which originates at the infraspinatous fossa of the scapula and inserts into the greater tuberosity of the humerus. Its major action is to externally rotate the arm at the shoulder, and to stabilize the head of the humerus in the glenoid cavity. Most authorities agree that intensely deep referred trigger point pain, located in the front of the shoulder, originates from the infraspinatus muscle.

The last of the four cuff muscles is the teres minor muscle. It originates from the dorsal surface of the axillary border of the scapula and inserts into the lowest impression on the greater tubercle of the humerus. It acts to rotate the arm laterally with some minor adduction.

Dr Janet Travell, White House physician during John F Kennedy’s presidency, likens pain from teres minor trigger points as sharp and deep. The referred pain can be confused with subacromial bursitis according to Dr. Travell.

Protocol

Dr Andrew S Bonci, Chairman, Department of Diagnosis at Cleveland College estimates that as much as eighty percent of our pain syndromes come from muscle. It is important to remember, however, that successful treatment must be directed to the target muscles’ offending trigger points, rather than where the pain is felt. You’ll find the following on the healthcare segment of our educational website www.intracell.net, “If you look for the cure at the site of the pain, odds are very good your search will be in vane.”

As you well know myofascial and trigger point therapy offers several treatment options — from hand massage to trigger point injections. My purpose is to share with the healthcare professional a simple, practical and effective method of rotator cuff management.

Let us start with a well known fact – warm muscle out-performs cold muscle. Every healthcare professional knows this is true. Any athlete will verify this as fact. Yet, few healthcare professionals apply the obvious during treatment. Remember, in muscle physiology you learned the importance of enzymes. You learned that enzymes are substances that allow your muscles to more effectively and efficiently contract and relax. Unimpeded enzyme delivery allows muscle to more readily convert food into energy. Enzymes help make muscle more pliable and flexible, hence insulating muscle from injury. It is recognized that enzymatic reactions will double if muscle temperature is increased by 10°. This is referred to in physiology as the Q-10 Effect. My point is – always warm the target muscle prior to myofascial and trigger point therapy.

Application

Subscapularis: I was much more aggressive in the treatment of subscapularis trigger points, prior to helping rehabilitate my own frozen shoulder. [There’s no greater learning experience – believe me.] I prefer to inactivate subscapularis trigger points while the patient is standing. The patient’s involved arm hangs limp by the side. I passively abduct the arm about 10° to 20° and slide the treating thumb into the posterior axillary fold. The thumb is gently oscillated around the inner surface of the scapula until the primary trigger point is located. In my experience I have noted more trigger point formation along the axillary border of the scapula. A couple 30 second sessions of ischemic compression to the primary trigger point usually affords temporary release. An understanding thumb with a short nail will ensure fewer profanities from the recipient.

Supraspinatus: Of the four cuff muscles, I have found the belly of the supraspinatus to be the least symptomatic-probable. When there is active involvement, it seems the tendon insertion into the head of the humerus is the major culprit. This is especially true if the pain pattern mimics bursitis. When you have a patient who activates localized shoulder pain while carrying a briefcase or suitcase, your odds suggest insertion trigger points of the supraspinatus. Also, dominant side trigger points will bring complaints during shaving, combing hair or brushing teeth.
The tendon is investigated while the patient is standing with support to the opposite shoulder. Make sure the patient’s arm hangs loose and relaxed. Their weight is transferred to the contra-lateral side. Instead of thumb palpation the target tendon insertion is investigated with the TriggerWheel. The one quarter inch treating surface will both locate and inactive the offending lesion. When the TriggerWheel locates the trigger point – continue the rolling ischemic compression for about 30 to 45 seconds. On a pain scale to 10, use a pressure of 5. Your goal is good pain – not ouch pain.
Trigger point investigation of the muscle belly occurs with the patient seated. To inactivate trigger points of the muscle belly, I prefer a rolling ischemic compression with the TriggerWheel. Use short back-and-forth strokes to locate and inactivate the trigger points.

Infraspinatus: I have never evaluated symptomatic shoulder pain, without finding complications of infraspinatus trigger points. Also, complaints of chronic suboccupital and posterior neck pain often reveal the culprit to be located in the infraspinatus fossa. Patients will often identify this pain as being most severe during rest. While working with two major league baseball clubs, I found the infraspinatus muscle to be the major source of nagging shoulder distress in major league pitchers. Both of the club’s trainers independently concurred with my clinical findings. I never evaluate neck or shoulder symptoms, without a very close look at the infraspinatus.

Trigger Point investigation of the infraspinatus muscle begins with a seated patient. This short, flat muscle is usually very taut and its trigger points are extremely sensitive. Again, I locate and inactivate these trigger points with a TriggerWheel. The 1/4 inch rounded treating surface will locate and extinguish both latent and active trigger points. Successful Temporary intervention is usually completed in 30 to 45 seconds. Reduction of localized and referred pain, increased shoulder motion and reactive hyperemia, are signs of successful intervention.

I strongly suggest that you receive trigger point therapy of the Infraspinatus muscle before you provide it to your patients. On a pain scale of 1 to 10, treat with a 5 or less. Remember, it isn’t necessary to hurt the muscle in order to help the muscle.

Teres Minor: This fourth member of the cuff functions in concert with the infraspinatus. Although their origins and insertions are virtually the same, they do not share a common nerve supply. According to Travell, localized posterior deltoid pain, “the size of a silver dollar”, is usually referred from teres minor trigger points. Clinically, I have observed supraspinatus trigger points without teres minor involvement, but never the reverse.
There is considerable difference in trigger point and myofascial management of the teres minor vs the infraspinatus. I approach the teres minor muscle with the patient standing, while the non-involved shoulder is braced against a wall. It is important that the patient’s weight be transferred to the non-involved side. Have the patient elevate the target arm, while flexing the elbow so that the forearm comes to rest on top of their head. [If the patient is unable to assume this posture, then I simply drape the target arm over my shoulder and expose the axilla as much as possible.]
With the patient properly positioned, offending teres minor trigger points can be quickly located and extinguished with an Intracell Stick. I prefer the 17” Executive Intracell model – but any Stick model will work. The instrument is held with both hands and passed over the suspect muscle. Progressively deeper passes allow the Intracell Stick to search and locate contracted muscle bundles. The resultant release takes 30 to 60 seconds per lesion. Best results are obtained when the provider’s hands are close together and only 4 to 6 spindles are being used.
By the way this patient positioning affords an excellent opportunity to evaluate other posterior muscle lesions that often occur in concert with rotator cuff diagnoses. Included are the teres major, latissimus, long head of the triceps and posterior deltoid muscles.

Worth Remembering

I would like to close by sharing with you a real life story. It has nothing to do with the rotator cuff, but hopefully its message will mean as much to you as it did to me.

I was consulting by phone with an 80 yof who lives in California. She was suffering with grade 3 sciatic neuralgia that was hampering her twice- weekly golf match. That’s correct — and she, also, pulled her cart and walked every step. Self-administered Intracell Stick therapy to the iliotibial band not only relieved her symptoms but, also, improved her golf game. She was ecstatic!

I asked her to share with me her secret of such a prolonged, productive life. In essence these are her remarks, “You don’t stop living because you grow old – you grow old because you stop living. Just because you have a pain, doesn’t mean you have to be a pain.”