October 11, 2005
Complete Massage Plan for Subscapularis Injury |
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A tight subscapularis muscle is the most implicated in rotator cuff injuries. Learn how to assess this hidden muscle, mobilize it, release it, stretch it and prevent a recurring injury to the subscapularis.
The rotator cuff is named for the “cuff” of tendons from four muscles attached side by side at the head of the humerus. The acronym many students and professionals use to remember the rotator cuff muscles is SITS – which stands for supraspinatus, infraspinatus, teres minor and subscapularis.
The subscapularis is one of the most commonly indicated muscles responsible for shoulder pain. Its origin is the subscapular fossa and it inserts in the lesser tubercle of the humerus. The action of the subscapularis muscle is medial rotation of the humerus and stabilization of the glenohumeral joint. While its location between the scapula and the ribs may seem like an impossible location to address, there are techniques to evaluate and work with this muscle.
In an article in the August 2004 edition of Massage Today, Ben Benjamin, PhD, states, “The subscapularis muscle is the muscle we use for forehand strokes in racquet sports, as well as for a tennis serve. It is one of the primary muscles used in swimming, hitting or throwing a ball. When the subscapularis is injured, we have trouble getting dressed or lying on our side to go to sleep.” An inability to raise the arm fully overhead can be a sign of a tight subscapularis.
Specialized Assessment Tests
The Lift-Off Test assesses the function of the subscapularis muscle. In a sitting or standing position, the client rests the dorsum of his/her hand on their back in the lumbar area. Inability to move the hand off the back by further internal rotation of the arm suggests injury to the subscapularis muscle.
The Belly-Press Test is a modified version of the Lift-Off Test. This is useful for a patient who cannot place his/her hand behind their back. In this version, the client is supine, places his/her hand of the affected arm on the abdomen and resists the examiner's attempts to externally rotate the arm.
Upper Arm Medial Rotation Resistance Test can be performed with the client sitting or standing. This test is done with the client’s elbow at his/her side and the elbow bent at a 90-degree angle. The client medially rotates the arm while the practitioner provides manual resistance. If this test induces pain or a re-creation of their symptoms, then it is positive for subscapularis involvement. If this test is negative but the practitioner still suspects subscapularis injury, this test can be adjusted to more intensely focus on the subscapularis. The adjustment would stretch the subscapularis prior to the application of resistance. This is done by having the client’s arm laterally rotated before the practitioner provides manual resistance against medial rotation.
Mobilization Technique
The Institute for Integrative Healthcare Studies’ Deep Tissue Massage manual by Dr. James Mally, ND, teaches subscapularis massage to increase shoulder girdle range of motion. Dr. Mally outlines the following massage steps:
1. Have the client lie on their side with his/her arm overhead.
2. Stand in front of your client, facing his/her upper body. Hook your arm closest to the client's head under his/her top arm so that it is supportive, the heel of your hand pressing on the superior border of the scapula and your fingers hooked on the medial border of the scapula.
3. With your hand closest to the client's feet, press into the axillary border of the client’s scapula and hook your fingers on the medial border of the scapula.
4. These instructions will have the practitioner contacting the scapula on all three of its sides.
5. Once your grip is secure, go through a complete shoulder range of motion by circling with the scapula. This rotation moves the scapula over the ribs.
6. Be sure to keep your client’s arm over his/her head while performing this technique.
7. This will stretch the pecs in front and press the scapula into the ribs, massaging the subscapularis effectively.
8. If you don’t have the client’s arm overhead, you may get slapped in the face. This positioning will also feel firmer to your client.
9. Make sure to hold the drape with the heel of your hand on the axillary border of the scapula.
Soft Tissue Release
The Institute for Integrative Healthcare Studies’ Sports Massage manual describes a technique to manually address the subscapularis.
1. Client is supine with his/her arm abducted at about 45 degrees.
2. Stand next to the client on the same side as his/her raised arm. With the practitioner’s outside hand, hold the client’s wrist so that the forearm is at a 90-degree angle to the massage table.
3. Place the pads of your (practitioner’s) fingers into the anterior aspect of the client’s scapula. This is done just inferior to the axilla.
4. If your client is female, it may be appropriate to ask her to hold her breast out of the way with her opposite hand.
5. While pressing in to the subscapularis, move your fingers in a superior direction while simultaneously actively abducting your client’s arm overhead.
6. When moving the client’s hand over his/her head, make sure to also laterally rotate the humerus, (this will bring his/her hand above their scalp, not above his/her face).
7. Raising the client’s arm stretches out the subscapularis underneath the practitioner’s fingers.
Stretches
According to David G. Simons, MD, Janet G. Travell, MD, and Lois S. Simons, PT, in the book Myofascial Pain and Dysfunction (Vol.1), there are some very specific stretches that can help lengthen subscapularis muscle fibers.
Circumduction: Perform circumduction by swinging the arm with the client leaning over and arm hanging down. The client may wish to add weight in the hand to provide some traction. Attempt to laterally rotate the arm and make a wide swing.
Doorway Stretch: Stand in a narrow doorway with the forearms flat against the door facings to anchor the forearms and step forward through the doorway to stretch the muscles. One foot is placed in front of the other with the forward knee bent, the head held erect and the gaze focused straight ahead. The client should stretch the musculature to the point of comfortable tension (without pain) and hold that position for several seconds. The doorway stretch stretches the subscapularis when the forearms are in a lower hand position (elbows dropped and hands level with ears) and in the middle hand position (with the elbows at a 90-degree level of flexion).
Corrective Action
According to Simons, Travell and Simons, correcting postural stresses is an important step toward preventing subscapularis pain.
Stop Slumping: Clients must learn to avoid a slumped posture in which the head is forward, the scapula is abducted and the arm medially rotated.
When Standing: The client can hook his/her thumb in the belt or on the hip when standing for extended periods of time to prevent the arm from remaining close to the side.
When Sitting: When in a sitting position for an extended period of time, advise the client to stretch his/her arm up and back behind the head. In a vehicle, an armrest will help hold the arm in some abduction to avoid a completely shortened position of the subscapularis.
There are many options for addressing the subscapularis muscle. Once properly assessed, this tightened rotator cuff muscle can be released with mobilization, massage, stretching and postural adjustments. The need to understand the specialized location and action of this muscle dictates why the descriptions for accessing this muscle are so specific. Once comfortable working with the subscapularis, practitioners will receive a lot of positive feedback from clients with rotator cuff problems.
Recommended Study
Deep Tissue Massage, Sports Massage
Posted by Nicole at 09:58 AM
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Five Energy Tips to Keep You Going |
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We can all use a substance-free boost to manage the demands of a hectic life. Incorporate some or all of these energy-stimulating techniques into your daily routine to keep illness at bay and maintain a steady stream of vigor.
Our bodies are intricately designed to maintain health and overcome illness. The body naturally seeks homeostasis both on a physical and energetic level. Electromagnetic and subtle energies give our bodies life and form the foundation of our well-being.
Chakras and meridians are two systems in which these forces are contained. The chakras form the body’s energy centers while the meridians form the body’s energy pathways. Both emit electromagnetic energy and light. The key to energy medicine is to keep these systems open and balanced so that our life force (qi) can support, shape and animate our physical body.
Both scientific research and personal experiences reveal that energy medicine has the potential to affect every aspect of our being – from healing trauma to balancing emotions. The fundamental law of energy medicine states when our energies are vibrant and balanced, so are our bodies. An increasing number of bodyworkers are enhancing their treatments by incorporating subtle energy work into their sessions. As this trend grows, it becomes more evident that these energies are intelligent, responding positively to intention and touch.
With a few well-chosen energy techniques, bodyworkers and their clients can maintain their vitality and reverse an illness at its onset. In her book, Energy Medicine, Donna Eden offers five useful tips for maintaining your energy systems and nipping an oncoming illness in the bud. The first four techniques can be performed on yourself for daily maintenance, while the last technique requires a partner’s assistance.
1. Separating Heaven and Earth
Rationale: This exercise opens the meridians, expels toxic and stagnant energies and stimulates fresh energy to flow through the meridians and joints. Do this exercise when you start to feel sick. If you do healing work, it moves out any energy you may have picked up from a client and helps to center restorative energy in the lower abdomen.
1. Stand erect with hands on the thighs, fingers spread.
2. Take a deep inhalation through the nose, circle arms out and bring hands together in the prayer position at the heart. Exhale through the mouth.
3. Take a deep inhalation through the nose, while separating the hands: one arm stretches straight above the head with the palm facing up toward heaven; the other arm stretches straight down to your side with the palm facing toward the earth.
4. Visualize that you are pushing something up to heaven and down to earth through the palms. Hold your breath in this position for as long as it is comfortable.
5. Release the breath through the mouth and return the hands in the prayer position. Repeat, switching arms. Do one or more additional lifts on each side.
6. Come out of this pose by bringing both arms down, allowing your body to bend at the waist. Hang there with your knees bent slightly as you take two deep breaths.
7. Slowly roll up to standing position one vertebra at a time. Roll the shoulders back.
8. Bring palms to cover the navel, close eyes and meditate for as long as you like.
2. The Hook Up and the Three Thumps
Rationale for the Hook Up: The Hook Up brings two major energy channels into balance: the governing channel (runs up the center of the back/spine) and the conception channel (runs down the center of the front of the body). The Hook Up strengthens the auric field, connects energies that flow from the front to the back of the body, bridging the energies that flow from the back to the front of the body.
1. Place one thumb or middle finger on the forehead between the eyebrows. Place the other thumb or middle finger in the belly button.
2. Pull slightly upward on the skin of both points. Close the eyes, take a deep breath, exhale and relax. Hold for about two minutes or until you sigh or take a deep breath naturally.
Rationale for the Three Thumps: Tapping specific points on the body will affect the energy field by sending electrochemical impulses to the brain and releasing neurotransmitters. The Three Thumps address fatigue, increase vitality and keep the immune system strong in the midst of stress. The specific locations for thumping are: Kidney 27, the thymus gland and the neurolymphatic reflex points for the spleen.
Thump Kidney 27 Points: boost energies in all meridian and increase concentration. Kidney 27 is the last point on the kidney meridian and its stimulation is indicated for adrenal exhaustion.
1. Place fingers on the clavicle and slide them toward the center. Find the bumps where they end, drop down about one inch and move slightly outward approximately one inch. There is a slight indentation on these points.
2. With palms facing these points, cross hands over one another. Rest the middle finger on these points.
3. Tap and/or massage these points firmly while breathing deeply — in through the nose, out through the mouth. Continue for about 20 seconds or 25-30 taps.
4. Boost the effects of thumping Kidney 27 by hooking the middle finger of one hand in the navel and resting the fingers of the other hand on the Kidney 27 points. Pull upward with the navel and hold for two or three deep breaths.
Thump the Thymus Gland: stimulate all energies, boost immune system and increase strength and vitality.
1. Move fingers down about two inches from Kidney 27 points and into the center of your sternum.
2. Breathe deeply while tapping the thymus point with the four fingers of each hand for about 20 seconds or 25-30 taps.
Thump the Spleen Neurolymphatic Reflex Points: lift energy, balance blood chemistry and strengthen the immune system (remove toxins, fight infection).
1. Find these points by moving fingers down from the thymus, out at the level of the nipples and straight down to beneath your breasts. Then move them down over the next rib, just below the breasts.
2. Tap firmly with several fingers for about 20 seconds or 25-30 taps. Breathe deeply in through the nose and out through the mouth.
3. Massaging Neurolymphatic Reflex Points for Each Season
Rational: Each organ has corresponding neurolymphatic reflex points. Massage re-energizes these points by removing toxins from the muscles. Blood, lymph and the corresponding meridians are stimulated.
Neurolymphatic Reflex Points for Fall Immunity: work the lung and large intestine points to boost immunity during fall.
• The Lung Reflex Points: Front lung points are located in the second, third, and fourth intercostal spaces close to the sternum; back lung points are located between the second, third and fourth transverse processes of the spine. Place the fingertips in the intercostal spaces lateral to the sternum and massage briskly for about 15-30 seconds. For the back, use two tennis balls side-by-side on the floor; lay down with the tennis balls just under the fourth transverse process, then roll back and forth covering the reflex points along the spine.
• The Large Intestine Points: Points are located from the transverse processes of the second, third and fourth lumbar vertebrae to the crest of the ilium. Locate these points and use your fingertips to massage the triangular area for about 15-20 seconds.
4. The Crown Pull
Rationale: Energy naturally accumulates at the top of the head. When this energy does not exit out the crown, it becomes stagnant, often causing headaches and mental fatigue. The crown is the gateway to the higher energies of heaven. This exercise opens the crown chakra, releasing mental congestion and refreshing the mind.
To Open the Forehead:
1. Place thumbs at the temples. Place fingertips on the forehead just above the center of the eyebrows.
2. Slowly and with some pressure, pull fingers apart, stretching the skin. Breathe deeply in through the nose and out through the mouth.
3. Place fingertips at the center of the forehead and repeat the stretch. Breathe.
4. Rest fingertips along the hairline above the forehead. Stretch laterally with the fingers. Breathe.
5. Repeat each of the stretches one or two more times.
To Open The Crown:
1. Place fingertips about two inches down from the center of the crown. Slowly and with pressure, pull down. Breathe deeply in through the nose and out through the mouth.
2. Place fingertips at the center of the crown and pull them apart. Breathe.
3. Place fingertips about two inches down from the center of the back of the crown. Slowly, pull apart with the fingers. Breathe.
4. Place fingertips at the center of the back of the crown and pull apart. Breathe.
5. Repeat each of these stretches one or two more times.
5. The Spinal Flush
Rationale: The spinal flush works with the lymphatic system, the cerebrospinal fluid system and the reflex points along the bladder meridian. Reflex points on the bladder meridian correspond to every organ in the body. This technique is great for anyone under intense emotional or physical stress. It is best performed with a partner, but if in the absence of a partner, use tennis balls along either side of the spine to work small sections of the back at a time. The points are located from the base of the neck, at about C7, to the bottom of the sacrum, between the transverse processes of the spine. Perform this exercise three times, once for the lymphatic system, once for the cranial-sacral system and once for the organs.
1. Lie prone on a massage table. Have your partner begin at the base of your neck, C7, and massage the points between the transverse process of the spine using the thumbs. Apply strong pressure using your own body weight.
2. Work each point for about five seconds by moving the skin up and down or in a circular motion.
3. At the sacrum, massage the entire area. Repeat the massage.
4. To close, sweep the energies using the flat of the hands, moving from the tops of the shoulders down and off the feet. Repeat once or twice.
The key to performing these exercises is to use your intention to move the energy. The energy follows the mind. Visualizing the energy moving coupled with your intention help you feel the effects of these exercises. When working on a client with any of these techniques, help them to visualize and hold their intention of moving the energy in their own body.
Energy techniques can be used by anyone, anywhere and at anytime. They are easy to use, inexpensive, don’t require complex equipment or instrumentation and have no known adverse effects. Using these tips on a regular basis can be truly healing. Share them with those you love.
References:
Chaitow, Leon. Modern Neuromuscular Techniques, Churchill Livingstone, 1996.
Eden, Donna. Energy Medicine, Penguin Putnam, Inc., NY, 1998.
Osborn, Karrie. “Energy Medicine, A Field of Potential,” in Massage and Bodywork, August/September, 2005.
Posted by Nicole at 09:48 AM
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Book Review: “Pharmacology for Massage Therapy” |
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How does taking Lipitor impact a client's massage? This new book, by Jean Wible, provides massage therapists with essential information about adapting massage based on a client's medication list.
Text: Pharmacology for Massage Therapy by Jean Wible, RN, BSN, NCTMB, CHTP, Lippincott Williams and Wilkins, 2005, 298 pages.
Pharmacology for Massage Therapy provides answers to the typical massage therapist question, “How does my client’s medication list impact a massage?”
Wible connects the often overwhelming subject of pharmacology to the application of touch-based therapy. The common ground both medications and massage share is that each has a physiological effect on the body. Wible, with qualifications as both a registered nurse and a massage therapist, is a pioneer in integrating allopathic and complementary medical modalities into a single perspective.
This text accomplishes the goal of teaching linear reasoning skills to someone without the technical vocabulary of a pharmacist. Organized by body system and/or symptom, Pharmacology for Massage Therapy outlines drug categories and the affect drugs have on the systems of the body (such as the nervous system, respiratory system, gastrointestinal system, endocrine system and cardiovascular system). Additionally, there are specialized chapters covering drugs for pain control, infections, inflammation and allergies, fluid and electrolyte balance, psychiatric conditions, cancer and a variety of over-the-counter supplements.
The first step in grasping the connection between pharmacology and massage is to understand what drugs do and how they work. Each chapter addresses key concepts such as pharmacokinetics (how the drug is absorbed, distributed and excreted from the body), pharmacodynamics (how the drug produces its effects in the body) and pharmacotherapeutics (how the drug is used to treat diseases or symptoms).
The strength of this book is the section discussing massage implications for each drug category. This gives the massage therapist the tools necessary to answer the question: “What does this drug mean for my client within the massage setting?” Using this deductive reasoning model, the massage therapist can logically determine cautions, contraindications, effects on massage and the best massage strokes to use based on the medications his/her client is taking.
Pharmacology for Massage Therapy contains bonus features such as; sidebars detailing adverse reactions and side effects of each drug group, quizzes throughout the text to integrate the information, case studies to understand the application of the material and a drug index at the end of the book for easy reference.
This text underlines the value of massage therapy within a medical setting. Wible’s demonstration of the impact different massage strokes have on people taking various medications highlights a relationship with which every massage therapist should be familiar. This is also an extremely valuable reference tool for bodyworkers and can be used as part of the movement toward fully integrating massage therapy into traditional healthcare.
Recommended Study
Pharmacology for Massage
Posted by Nicole at 09:41 AM
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