The most common cause of shoulder pain is a problem with the rotator cuff muscles and tendons of the shoulder. You may have heard of these muscles before in conjunction with injuries to baseball players, tennis players, golfers or other athletes. The truth is, these injuries affect most of us to one degree or another.

The diagram above shows two pictures of the rotator cuff tendons and muscles. They are small in size as far as muscles go. They are extremely vulnerable to injury for five reasons.

1. Despite their small size, these muscles provide the primary means of stability to your shoulder joint. They are working hard with any movement your arm makes.
2. These muscles are inadequately strengthened by most fitness and sports exercise regimens, thus they are not properly conditioned.
3. Most of us lack coordination in the joints of our shoulder, neck and upper back region as a result of poor posture and repetitive motions. This results in a continual friction and abrasion to the rotator cuff muscles and tendons.
4. Previous shoulder injuries treated only with rest and medication were not properly rehabilitated and are prone to re-injury until properly conditioned by corrective exercise and deep massage.
5. The blood supply to the rotator cuff muscles starts to atrophy somewhat in people over the age of 40.

These problems present a truly unique opportunity for the massage therapist. With proper training, you can have the best tools for the non-drug or non-surgical treatment of these injuries, as they respond very well to exacting soft tissue work and exercise. So, really no other health care practitioner has an advantage over you here.

Although there are many causes of rotator cuff problems, one very interesting and common cause is impingement. Understanding impingement is critical to being able to successfully treat rotator cuff problems. Impingement exists when shoulder joint structures get pinched as the arm is raised. The structures that can get pinched are the subacromial bursa, the supraspinatus tendon and the tendon of the long head of the biceps brachii. These important structures are located in the subacromial space.

The subacromial space is located underneath the coracoacromial arch. This arch is a bridge-like structure spanned by the coracoacromial ligament, which runs between the acromion process posteriorly and the coracoid process anteriorly.

Why do structures of the subacromial space get pinched? This occurs for basically two reasons. First, the height of the subacromial space might be decreased. This could be due to a bone spur growing off the undersurface of the acromioclavicular joint, or sometimes the acromion itself might be hooked and projecting downward into the subacromial space. Secondly, the proximal humerus can fail to glide inferiorly in the shoulder joint socket as the arm is raised. If the proximal humerus does not glide downward, it will rise up when the arm is raised and the tendons and bursa will be pinched between the humerus and the coracoacromial arch. The humerus can fail to glide downward either because the rotator cuff is weak or the shoulder joint capsule is tight in its posterior and inferior portions.

The weakness in the rotator cuff and tightness in the shoulder joint capsule can be treated with therapy. Bone spurs and the actual anatomy of the acromion cannot be changed, but better movement and control of the shoulder joint can make them less of a factor in impingement. Correcting the factors causing impingement will have a huge positive effect in the client with rotator cuff problems.

How do you correct these factors?

• Use neuromuscular and myofascial techniques to treat adhesions and trigger points in the muscles and tendons of the rotator cuff. When these muscles and tendons are free of adhesions and trigger points, they will be stronger and function much better in their important job of stabilizing the shoulder joint. They also will not be a source of pain.
• Learn techniques to increase the flexibility of the shoulder joint capsule itself.
• Comprehensively strengthen the rotator cuff muscles and also the key scapular stabilizers such as the lower and middle trapezius, the rhomboids and the serratus anterior. Strengthening the scapular stabilizers will prevent a secondary impingement, which results from a lack of the control of the scapula as it glides along the chest wall.

Treating the rotator cuff in this manner allows you to provide a service to your clients they cannot easily get elsewhere. Most people still have these problems treated with rest and medication, which provide no long-term benefit in preventing re-injury. Thus, you provide a much-needed service and all that is required of you is to acquire the necessary skills. I hope this will wet your appetite for learning about this interesting area.