This week we look at Supraspinatus Impingement. An oft cited issue in the shoulder that results in pain in the anterior shoulder.
The dreaded word you don't want to hear with shoulder pain is impingement. When citing impingement, I am talking about supraspinatus impingment, (one of the four rotator cuffs) where the tendon becomes caught (or impinged) under the 'acromion process'. This usually results in pain in the anterior (front) aspect of the shoulder and any movement involving raising of the arm, either directly in front of you or to the side, results in acute pain and an inability to hold the arm for any length of time.
This condition often has a 'slow onset' which means it creeps up on you. Various anatomical influences can affect this space and we will mention these later. but this pain is usually that niggling pain in the fleshy part of the anterior shoulder, that starts as a niggle and gets worse and worse with time - especially if it's untreated.
Anything that impedes the sub-acromial space through which the supraspinatus passes can cause this syndrome. This can come from spurs that form on the acromion that presses on the tendon when the arm is raised, or even variations in the shape of the acromion bone itself. A thickening of the coracoacromial ligament which runs from the coracoid process to the acromion also creates a narrowing of this vital space. Injury to this tendon or thickening through injury or even through underuse of the arm in a certain position is a contributing factor. If we don't move our arms through a range of motion that includes overhead positions and extension, the ligaments can calcify and/or 'thicken', creating less space. We will discuss this more in a later article on Separated Shoulder.
Often this condition does present without specific injury and when this occurs there are certain muscles that can be addressed to help assist with creating space. Anatomically, this issue is brought about by tightness in the Pectoralis Minor and/or the Medial Head of the Biceps Brachii which connect directly to the coracoid process. We talked about the coracoid process last week as the anterior connection of scapula. This bony protuberance is the connection for the Pec Minor and Biceps tendons. Tension in these muscles rotates the bony protuberance (which is connected to the scapula in the back) forward, thus impinging the supraspinatus tendon which runs directly underneath the coracoid process itself.
This is where Pectoral and shoulder flexibility are paramount. I see this type of issue so often in people who train heavily with weights without complimenting their chest and arm workouts with shoulders and back. Too much tension in the anterior muscles draws the corocoid process down and rotates the scapula forward. Its the forward posture of the shoulders that you can notice on some people. This results in the supraspinatus being pinched and If a muscle is being pinched, it is unable to fully contract and when you ask it to work, it hurts. Too much emphasis on pushing without pulling results in a disproportionate amount of pull in one direction - this compromises posture and function.
So when a condition is brought about by incorrect posture and not the actue injury, trauma or ligament thickening, often if you can release the pectoralis minor and/or biceps brachii, you can achieve a lot of reduction in the irritation. Creating space for a muscle to function is a great deal of the remedial work that I do. So when I work on pectorals and my clients complain of the pain - it is to get rid of that tension to allow other muscles to work properly that is the point of that massage. I'm not pushing on the pain, but working on muscles to reduce the amount of restriction that is causing the pain.
Effectively, any movement of the arm requires the head of the humerus to be sitting as securely as possible in the glenoid cavity. Without the head sitting securely in the socket, any action is going to be impeded. It's not just the contraction of muscles that is important, but also their ability to act as a 'brake' to prevent dislocation or injury from 'ballistic' movements. If the intricate balance between opposing forces isn't maintained, the whole connection doesn't work. For example, when we throw we would hit ourselves in the leg the downward momentum of the exertion. This is where the shoulder is truly interesting as it incorporates so many of these muscles in any given action with 'push and pull' being constantly tweaked and arranged to ensure the humeral head staying in connection with that glenoid fossa.
This is also where the rotator cuff act heavily as brakes against other sorts of movements. So in sports, when these actions are repeated, often tension can be created by an imbalance within the rotator cuff itself. That interplay between the 4 main muscles that contain this insecure connection is vital to ensuring proper function. Hence, working on the subscapularis can effect and help assist with an overused supraspinatus or muscle that is being asked too much of. This balance is important to understand. We often begin to rely on these small muscles to work hard when we are involved in repetitive motions so it is important to address all 4 of them whenever you are dealing with an issue in one of the group.
So when that niggling pain in the anterior deltoid starts to make itself known when moving your arm, lifting shopping bags or even when you sleep on it. Don't brush it off. Often this is the first warning sign that there is an imbalance. If we get to the issue early, it is so much easier to nip the bad habit or misalignment in the bud. Stopping it from becoming too chronic is paramount for with every minor misplaced pain, there often comes small compensations and changes in alignment or muscular activation to avoid the pain. Unfortunately this doesn't help address the underlying issue of why it is happening. Get it early.