Identifying and Correcting Perpetuating Factors
Shoulder pain doesn’t just happen. There are numerous perpetuating factors that can set up a condition of muscular imbalance and overload. Some of these, such as dysfunctional breathing, may seem unrelated but are actually extremely important (and common). Identifying and correcting perpetuating factors is what makes the difference between fixing the same problem each week and setting your client on a new, pain-free direction.
Possible perpetuators are very numerous. Some of the most common include:
Muscles are made to collaborate in an environment of relative balance and stability in the body. Postural distortion may occur due to anatomical variations such as a leg length discrepancy. Actual leg length differences are estimated to occur in approximately 18% of the general population, so this situation is not uncommon. LLD may cause issues with the QL, spinal erectors, glutes and shoulders, and any persistent patter of unilateral pain could be due to this situation.
Individuals with hypermobile ankles may exhibit an extreme tendency to pronate. This causes the ankle to collapse medially and tends to cause anterior (head forward) posture in the upper body. This situation can be corrected with extra support in the midfoot and forefoot.
Chest breathers overuse small muscles such as the pectoralis minor and scalenes to assist in expanding the rib cage. This causes many problems, and can set up shoulder and head neck pain.
There are many other factors that must be considered in a person’s lifestyle. Workstation ergonomics, sleep position, nutrition, stress must be considered. Be observant and read the Apropos of All Muscles chapter in Travell & Simons for extensive coverage of these issues.
Medications can be a powerful and unsuspected perpetuator of pain in the body. Few people are aware of the extensive pain-related side effects from many drugs. Some of the most common, like the statin family of drugs, have extensive muscular side effects and patients are often unsuspecting. Take the time to look up side effects for drugs.
Serratus anterior is misunderstood and overlooked by most manual therapists, despite its central function of stabilizing the scapula during all arm movements. In CTB we have come to recognize it as the hidden key to scapular positioning and hence, shoulder pain and movement dysfunction.
When a client has rounded shoulder posture (a.k.a. upper crossed syndrome) the shoulders are protracted and the scapular stabilizers do not have normal resting length/tension. Serratus anterior is a primary scapular stabilizer and tends to adaptively shorten and defacilitate. This, along with pec minor adaptively shortening results in the chronic protraction of the scapula. This misalignment of the shoulder will alter the scapulohumeral rhythm and then also impact the glenohumeral motion.
However, unlike pec minor, serratus anterior is a broad muscle that has many digitations and the muscle fiber directions can span more than 120 degrees! Some fibers protract/abduct the scapula. The low fibers upwardly rotate the scapula. The lowest fibers attaching to the 12th rib can be very vertical and capable of depressing the scapula. In addition, the highest fibers attaching to the first rib can produce scapular elevation. There are a lot of different motions possible by this one muscle!
The serratus anterior attaches to the ribs and to the medial border of the scapula. Because of its wide span of fiber directions, it is antagonistic to many other scapular stabilizers including: low trapezius, mid trapezius, high trapezius, rhomboids, and levator scapula. It is in length/tension relationships with all these muscles. That’s why most therapists fail to get a release of taut fibers in these other scapular stabilizers, particularly in the interscapular area. They are not addressing the antagonist, serratus anterior, the hidden key.
If serratus anterior is locked into protracting the scapula, the interscapular muscles (mid/low trap, rhomboids) lock into a lengthened position. The neuromuscular system “locks down” the muscles by purposefully creating taut bands (trigger points) in the muscles to provide stability without having to expend energy. Trigger points are metabolically stagnant. No ATP is then required to keep the static posture. The body basically creates a “fake ligament” with the trigger points. It is a strategy that makes sense and has been pointed out by renowned osteopath and author, Leon Chaitow. Many massage therapists and bodyworkers endlessly strip this interscapular area with as much gusto as they can muster (and their clients can handle), to no avail. Taut bands in the antagonist muscle, serratus anterior, must be released for these interscapular muscles to change.
Another important but overlooked issue with the serratus anterior concerns its referral pain. It projects referral along the lateral border of the scapula, down the posterior arm to the last 2 fingers, but most importantly right into the belly of the low trapezius near the inferior angle of the scapula. Low trapezius referral projects upwards into the mid trap, rhomboids and upper trap. So referral pain generated by the serratus anterior reaches all its antagonists via satellite referral! This is a phenomenon (an agonist referring pain over its antagonist) Chuck Duff has termed “reciprocal referral”. Muscle dysfunction in reciprocal referral situations can quickly spiral into severity, but can be addressed effectively if one understands this relationship. Referral pain originating in the serratus anterior can also cause posterior neck pain and even migraine headaches via satellite referral through the low trapezius.
As if all that wasn’t enough, the serratus anterior is also an accessory breathing muscle. Because of its rib attachments it is recruited to assist in expanding the rib cage on inhalation. Thus dysfunction in the serratus anterior can be caused by dysfunctional breathing. If a person doesn’t adequately use their diaphragm to breathe, the serratus anterior is recruited to do more work than which it was designed. This overload causes trigger points to develop and cascades into shoulder pain and dysfunction.
Serratus anterior has so many fiber directions and relationships; to antagonist scapular stabilizers, shoulder posture, reciprocal referral and breathing. Through many years of clinical experience, we have come to see it as the hidden key to shoulder pain and dysfunction. Some of the fibers are deep to other muscles and structures and inaccessible via palpation. Even these fibers can be influenced by the penetrating vibration of the Muscle Liberator making it the perfect tool to treat serratus anterior.
A lot of people who are experiencing chronic pain, especially those who are suffering from certain conditions including Plantar Fasciitis, Thoracic Outlet Syndrome, Carpal Tunnel Syndrome, and several others do their best to find the best pain management solution.
As such, some have resolved to move as minimum as possible, believing that the less action they make, the less pain they will face. Well, the opposite may actually be true. In fact, there is a recently introduced discipline these days, in the form of movement therapy. Movement Therapy is a whole lot like physical therapy. However, it involves several other aspects, such as introducing functional strength and corrective exercise, with a focus on manual therapy. Treatment through touch.
This type of therapy will work towards strengthening muscles, which in turn, improves muscle support provided towards the rest of the body. As you simply allow the muscles in your stomach to lose their strength, you might end up suffering more injuries, including back pain, neck pain, as well as migraines. This is because the muscles in your stomach also help in supporting your back.
Movement therapy also works in increasing endurance so that people who are suffering from these types of pain can still continue working on their everyday activities. As such, it is also proven to increase the stability of the joints, thus decreasing the events of falls, as well as the pain that is linked with swelling of joints.
It also increases flexibility in the joints and muscles of the body. Exercise also fosters the release of natural hormones in the body, the endorphins, which are the ones responsible in relieving pain. The exercise involved also makes an individual feel even better regarding them, thus helping to alleviate instances of depression that most people who are dealing with chronic pain usually deal with. As an added feature, it also helps individuals to maintain the recommended body weight. This factor also reduces pain.
There are a lot of conditions that can benefit from a movement therapy rehabilitation session. For example, those who are dealing with frozen shoulder, whiplash, sprains/strains, and others, are helped accordingly. In fact, almost all conditions that can cause pain can certainly be given treatment by simply implementing the right combination of techniques involved in movement therapy.
There are a lot of methods used in movement therapy. You definitely need to explore all of these methods, including their different combinations until you are able to select the best ones for your specific condition. However, it is highly recommended to take advantage of the assistance of a professional who can help you out. A movement therapist can help you in this regard, giving you the right solution for your specific need.