My client pointed to the location of the spot in question, using his left thumb to dig vigorously into his anterior right shoulder. “Right there,” he said. “Man, this is so painful, and it’s been like this for at least a week.”
Wanting me to know exactly where the location was, he guided my hand to the area. Once there, he released his pressure, and I was able to explore the area with careful palpation. The area of most tenderness was one of the anterior tendons of the deltoid. I discerned this from fiber direction and resistive testing of neighboring muscles.
“You can press harder,” he said, “but that’s the place.” Rather amusingly, he nudged my hand away from the spot to dig in again to confirm the sensitive area. “I’m hoping you can get in there and dig out the tension.”
Oh, boy. I surmised that this wasn’t the time to have the “tightness” discussion, but I briefly pondered how to proceed.
“Do you think you could remember exactly how much pressure you were using, if I asked you to do that again later?” I asked.
Placing his thumb yet again on the spot, he said he could.
“Our goal is to get that tender spot to quiet down,” I said. “There are several ways to do that. Think of it like trying to get into a house after losing your keys. You can try the front door, the side door, or the back door. The front door is most often the one that’s locked, so your only option there is to use a lot of force. There are times when the back door affords you several other possibilities.”
“Uh, OK,” he replied, not knowing exactly what that meant for treatment.
“With your permission, let me try some different approaches, because the spot in your shoulder is already pretty mad and direct interventions may make it worse, not better.”
I could tell he wasn’t fully buying into this idea of approaching his pain indirectly, but he relented. Since the affected area was in the anterior deltoid and he had mentioned earlier that forward flexion was slightly limited and uncomfortable, I had an idea of where to begin.
Forward flexion of the humerus also requires upward rotation of the scapula, so I began to explore muscles that create downward rotation and could therefore limit upward rotation.
Broadly, I needed to address muscles that function as antagonists, synergists, and stabilizers. Since some of the synergists were in close proximity to the affected area, I started with the antagonists, muscles that may limit forward flexion and therefore increase the load on the deltoid. Starting first with the humeral attachment of the latissimus, his eyes widened as I zeroed in on the attachment.
“Wow, that’s tender,” he exclaimed. “That’s not the spot, but it is painful.”
Once the latissimus attachment was significantly less sensitive, I moved on to the teres major, which can work in concert with the latissimus. It too was very sensitive but quieted down after a minute or so. Reaching behind his shoulder, I began examining some of the posterior deltoid tendons using a compressive pincer palpation. Finding one that was exquisitely sensitive, I spent about 2–3 minutes getting it to release.
Forward flexion of the humerus also requires upward rotation of the scapula, so I began to explore muscles that create downward rotation and could therefore limit upward rotation, again placing more load on the deltoid. There was some sensitivity at the lower rhomboid but even more at the scapular attachment of the levator scapula. All of these sensitivities were met with some curiosity by my client since he’d previously been unaware of their presence.
Returning to the anterior shoulder, I carefully explored the heads of the biceps and then a few of the other anterior deltoid tendons adjacent to the affected one. “You’re close, but that’s not the spot,” he stated. By the sound of his voice, I could tell he was getting impatient.
“Let’s recheck the tenderness in that spot; you can locate it better than I can,” I said. “See what you find.”
The look on his face was precious—he kept digging around in his shoulder but found nothing.
“I don’t understand how that worked,” he said. “Seems like magic.”
“Not magic at all,” I replied. “The presenting symptom, the one that you were aware of, is a product of many muscular interrelationships. As therapists, our job is not just to have the skills to locate the problem area but also to possess a deep knowledge of the system behind the symptom—how muscles work together to create or limit movement. Make changes in the system, and the outcome changes as well.”
“Like coming in through the back door and unlocking the front door from the inside,” he said.
Exactly.
