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Pivotal Places: Help for Problem Shoulders

By Thomas Myers

Originally published in Massage Bodywork magazine, April/May 2003.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.




Although the arm and leg clearly have similar layout in bone and muscle, they have significantly different functions -- the leg is designed for stability over mobility, while the shoulder and arm are the other way around.
Shoulders are problematic in humans. There are two principal reasons for this: (1) The human shoulder is designed for mobility, whereas the horse's shoulder, for example, bears most of its weight and is thus designed for more stability. For us, problems of hypermobility, friction and displacement are far more common. (2) As a consequence of our upright spine, the shoulder is yoked over the rib cage in a very precarious manner. Thus, even slight displacements of any of the parts of the trunk -- pelvis, lumbars, ribs, spine, neck or head -- may have a deleterious effect on shoulder function, especially when multiplied over many months or years.

In addition to its mobility and the casual manner in which it is draped over the rest of the skeleton, the skeleton of the arm is attached to the rest of the bony framework in only one place -- the sternoclavicular joint just below your chin. The clavicle attaches to the scapula at the acromion, and the scapula floats from this joint on the back side of the ribs in a sea of muscles. These muscular attachments radiate out from the scapula to the head (upper trapezius), neck (levator scapulae), upper back (rhomboids), lower back (latissimus and lower trap), lateral ribs (serratus anterior) and the front ribs (pectoralis minor). (Some anatomists have called the rhomboids a "muscular joint" for the scapula on the spine, but the fact is that the scapula is jointed to the clavicle on the proximal side and to the humerus on the distal side, albeit these joints are very close to each other. There is no real joint between the scapula and the ribs, or the scapula and the spine.)


The shoulder yoke balances over the rib cage, attached only at the top of the sternum. Muscular balance and using myofascia as pivots are both essential to the success of this precarious arrangement.
Given all of the instability we have detailed above, it is necessary that a few of these muscles act as "pivots" for shoulder movements. These particular muscles are frequent underlying causes for trigger points and dysfunctional movements of the shoulder and arm. For any shoulder problems -- deltoid bursitis, biceps tendosynovitis, a "frozen" shoulder or something down the arm -- or even those without current shoulder problems, these three pivots are worth checking out and treating (sometimes repeatedly, if need be) to get generous, integrated movement at the shoulder.

The three pivots are the subclavius, the pectoralis minor and the teres minor -- but don't let the names fool you. They are neither substandard nor minor in their effects on the shoulder. To be as clear as possible, these pivotal muscles set the position of the shoulder so that the outer muscles (traps, lats, pects, delts, etc.) can do the gross movement of the shoulder and arm. If these underlying core pivots are in contracture, fascially shortened or (rarely) too lax, then the outer muscles have to compensate, overworking or skewing their line of pull. This ultimately leads to a wide array of possible problems, the exact nature of which depend on each individual's patterns of use.


Subclavius
Our first pivot point is the subclavius muscle. Located, as the name implies, under the clavicle, you can find it by feeling under the collarbone. Note that you need to go in well under the collarbone to affect this muscle. The first layer of myofascia encountered is the softer stuff of the clavicular fibers of the pectoralis major. The tougher subclavius is on the underside of the clavicle and usually has a tender or sore feel to it.


The subclavius muscle is a tiny, but crucial, part of the shoulder stabilizing system, preventing dislocation or subluxation of the sternoclavicular joint.
While the arrangement of the subclavius -- running parallel to the collarbone from the first rib -- makes it obvious that this muscle's purpose is primarily to stabilize the loose-fitting sternoclavicular joint, it is nevertheless listed in the books as a depressor of the clavicle. In other words, if you contract it, the clavicle is pulled down. But small stabilizing pivots like this are less about the movements they create than the movements they prevent. The subclavius prevents the shallow saddle of the sternoclavicular joint from being dislodged and limits upward movement of the collarbone.

While you would not want to overstretch the subclavius, as that would leave the joint vulnerable, limited motion of the clavicle affects movement all down the arm. Have your client do a shoulder circle, a big round slow shrug, while standing. If the shoulders have limited upward motion, or do not widen when they go posterior, they could perhaps use some myofascial release or increased mobilization of the subclavius.

With your client supine, and you holding her shoulder forward a bit to passively slacken the tissue, "swim" your fingertips through the pectoralis to the underside of the clavicle near the sternum. Go slowly and carefully -- this can be a brand new area for some. Once situated under the clavicle, work slowly but deliberately outward along the lower surface of the clavicle as the client brings his arm out away from his body and over his head. Stop if the client perceives any nerve pain or involvement. Try it on yourself first, so you know what it feels like.


Pectoralis Minor
The subclavius is part of a sheet of fascia that runs under the pectoralis major from the clavicle down to the armpit. Our second pivot is also imbedded within this sheet: the very important pectoralis minor. This tiny, but crucial, "myofascial unit" (sometimes it is more fascial than muscular, especially if ill-used) runs from the coracoid process distally to the third, fourth and fifth ribs proximally.


The pectoralis minor is in the same fascial sheet as the subclavius, but serves a separate, pivotal function.


You can find the coracoid process by putting your fingertips under your own collarbone and sliding them out until you encounter the little lump after the dip in your shoulder. That bump is the thumb-like (or beak-like -- "coracoid" means crow's beak) projection from the scapula forward under the collarbone. Strum back and forth just below the coracoid process and you may be able to feel the pectoralis minor, running fairly vertical down toward the nipple.

Often, on yourself or your clients, you may not be able to feel it. The pec minor is often small, stringy and less than buff. A better way to approach is via the armpit. With your client on her back, lift her left arm up with your right to expose the armpit. Kneel or sit by the table and put your hand into the apex of her armpit, then lay her arm back down comfortably by her side, over your hand or arm. Slide, swim, ease your fingers into the space between the leading edge of the pectoralis major and the ribs. Your direction is toward the sternoclavicular joint. Don't poke into the ribs or try to pull the pectoralis major away from the ribs. Just melt your fingers into the space between the two.

When you reach a line drawn between the coracoid process and where the outer edge of the rectus abdominis crosses the ribs, you should encounter the outer leading edge of the pectoralis minor. In some people it will be a distinct muscle, but in others it will feel very slight, sometimes desiccated. In some folks it is plastered up against the posterior part of pectoralis major, in some it is stuck down onto the rib cage. With practice, you will be able to confidently locate it in most of your clients. In the beginning, though, if you are clearly under the pec major, and your fingertips are at the line between the coracoid and the lateral rectus, you can be confident you are on the costocoracoid fascia that contains (and thus affects) the pec minor whether you can feel it distinctly or not.


The teres minor joins the outer edge of the scapula to the back side of the humerus. If the two bones are too closely held together by the teres, the scapula gets dragged along everywhere the humerus goes. This means that the scapula will lose its integreal connection with the spine and ribs.
Having achieved this spot, the pec minor can be worked manually, down toward the ribs or up toward the coracoid. The client can help with either of two distinct movements. One is lifting the arm over the head, opening the armpit and stretching the pec minor and its fascia. This motion is helpful for those who have restrictions in this movement -- reaching up or reaching behind the head. The other motion -- especially helpful for those with anteriorly tilted shoulders, where the shoulder is creeping up over the back of the rib cage -- is to have the client bring the shoulders down and together in the back, in the style of sivasana, or a kind of military squaring of the shoulders. This action will activate the lower trapezius and lat, stretching the pec minor and repositioning the shoulders down the rib cage.

A lengthened pec minor allows the shoulder to sit down on the rib cage properly but still pivot around this essential stabilizing restraint. Whenever we reach forward, we pivot around these two, which is why you will have no trouble finding sufficient work in these pivotal areas on yourself or other massage therapists of your acquaintance ("do me, do me!").


Teres Minor
Our third small, but crucial, pivot is the teres minor -- one of the rotator cuff muscles. Whereas the subclavius acts as the pivot for the clavicle and the pectoralis for the scapula, the teres is a pivot between the scapula and the humerus -- in other words, along the back of the highly mobile glenohumeral joint.

Of the four rotator cuff muscles, teres minor is the smallest. It runs along the underside of the infraspinatus, from the upper portion of the scapula's lateral border to the lower portion of the greater tubercle -- the humeral equivalent of the greater trochanter. If you are into this kind of thing, and I simply can't resist it, the teres minor is the quadratus femoris of the arm. Older French anatomists do not list the teres minor as a separate muscle -- they thought of it simply as a small part, a separate head, of the infraspinatus muscle. Indeed, they do have the same function -- lateral rotation and stabilization of the shoulder.

But with these pivots, we need to consider what motions they prevent, and teres minor prevents medial rotation and abduction and horizontal flexion of the humerus. Or, and here's the rub, if it cannot prevent these motions, it can ensure that the scapula gets dragged along with the humerus. Since these motions are, once again, those commonly assumed by the manual therapist, I expect you will have no trouble finding good examples of tight and painful teres minors among your peers as well as your clients.

Teres minor means "little round" muscle. The "big round" muscle, teres major, can be located easily by simply grabbing the flesh of the back of the armpit. You have both teres major and the end of latissimus between your thumb and fingertips. But right now, it is teres minor that we want, not major, and it can be a bit more elusive, though quite findable if you use these palpatory clues: With your model prone or sitting, locate to posterior edge of the acromion process -- the back part of the tip of the shoulder. If your model's arm is by her side, there will be an end to the crease between the arm and the body. Place your fingers halfway between these two points and strum up and down gently, but firmly enough to be down into the flesh a bit. The teres minor is usually a distinct, twangy, close-to-horizontal cord about the size of a pencil or your little finger. If you think you might have found it but you're not sure, you probably haven't. Once found, it has a very distinct, "oh yes, there it is" feeling.

Pin and stretch techniques are very effective with this stubborn little bugger. Turn the arm into lateral rotation, pin the teres against the scapula from below and outside, and then have your model reach the arm (up to her front if she's sitting or off the edge of the table if she's prone) while turning it inward (medially rotating the humerus).

This combination of flexion, abduction and medial rotation will definitely stretch the teres under your fingers or knuckle. Holding the scapula toward the spine while the client moves can help the stretch, though ultimately the scapula will need to move with the humerus. For best effect, work to release the latissimus dorsi and teres major before working with the teres minor.

Getting these three shoulder pivots progressively present in the client's awareness, mobile, functional and balanced will dramatically reduce the client's propensity for future shoulder injuries and dysfunction. Makes it worth the effort to seek and find these pivotal places for arm integration.


Thomas Myers, Certified Advanced Rolfer(R), L.M.T., N.C.T.M.B., studied directly with Drs. Ida Rolf and Moshe Feldenkrais, and has practiced integrative bodywork for more than 25 years in a variety of cultural and clinical settings. Myers directs Kinesis, Inc., which develops and runs training courses internationally for manual and movement therapies. He served as a founding member of the NCBTMB and as a chair of the Rolf Institute's anatomy faculty. His articles have appeared in a number of magazines, and his book on myofascial continuities, Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, was published in 2001 by Harcourt Brace. Myers retains a strong interest in perinatal and developmental issues around movement. His practice combines structural integration, physiological rhythmic sensitivity and movement. He lives, writes and sails on the coast of Maine.




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