Top Overlooked Cause of Shoulder Pain
Updated from 9/24/2020
The relationship between chiropractors and shoulder pain is similar to the inseparable pairing of peanut butter and jelly. Our shoulders often bear the brunt of poor ergonomics and repetitive stress, a shared experience between chiropractors and their patients. While some patients engage in activities contributing to shoulder issues, most exhibit degeneration within the rotator cuff. Remarkably, over half of individuals aged 60 and above have been found to have either a partial or complete tear in one or more rotator cuff muscles. It is noteworthy that a significant number of these tears specifically affect the subscapularis muscle. Regardless of who is suffering and the etiology, there is a roadmap to identify and treat as dysfunction.
Learn to identify a subscapularis tear.
Watch how to treat the subscapularis.
Give your patients the best rehabilitation exercises for subscapularis dysfunction.
How to Evaluate the Subscapularis
The subscapularis is hard to say, find, spell, and, until now, even more challenging to assess.
The subscapularis is a frequently overlooked generator of shoulder symptoms. Even the gold standard, MRI, demonstrates a paltry sensitivity of 51.6% and specificity of 77.2% for partial-thickness tears. (1) Imaging is imperfect, and orthopedic testing is inconsistent. The most common test, The Lift-Off Test, is not typically positive until at least 75% rupture of the subscapularis tendon. (2)
Fortunately, a new systematic review provided some clarification for assessing the subscapularis:
“The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.” (3)
Bear Hug
The patient places the affected hand, palm down, on the unaffected shoulder. The clinician attempts to lift the patient's hand upward, off their shoulder, while the patient resists. Pain or weakness is suggestive of subscapularis or biceps muscle involvement.
Belly Press
The standing patient places their hand on their abdomen and aligns their forearm on a frontal plane (i.e., Napoleon style). The clinician attempts to lift the patient's hand/arm away from their abdomen while the patient resists. Pain or weakness suggests subscapularis or biceps muscle involvement. AKA Napoleon test
Time to put this into action! ChiroUp subscribers can review these and hundreds of other tests in your Clinical Evaluations Library.
How to Treat the Subscapularis
In-office treatment should consist of soft tissue manipulation of the subscapularis. Remember that the subscapularis muscle originates on the undersurface of the scapula and attaches to the lesser tubercle of the humerus. The actions of the muscle include shoulder internal rotation and glenohumeral stabilization.
Remember, if you are stripping the subscapularis and reproduce pain, numbness, and tingling, extending down the arm—you’re on the wrong spot! Be cautious of the neurovascular bundle occupying the same real estate in the armpit.
Soft tissue manipulation includes ischemic compression of trigger points and myofascial stripping parallel to the muscle fibers. Movement stripping may be performed by contacting the muscle trigger points and applying pressure while passively abducting and extending the humerus. Clinicians should recognize the presence of sensitive neurovascular structures in this region and be judicious when performing STM.
How to Stretch the Subscapularis
Subscapularis Stretch (Doorway)
Stand in an open doorway with the hand of your affected arm grasping high on the doorframe. Lean into the doorway until you feel a stretch in your shoulder. Buckle your knees to increase the stretch. Against the resistance of the wall, attempt to push your hand into the doorframe for 7 seconds. Relax and step into the doorway to increase the stretch. Lock into this new position and repeat three contract/ relax cycles twice daily or as directed.
Subscapularis Stretch (Broomstick)
Begin standing with your affected arm positioned as though you are balancing a tray of food behind your ear. With your unaffected arm, grasp the end of a broomstick and slide the broomstick under your affected arm so that you can hold the other end with your hand. Leverage up with your unaffected (front) arm to create a stretch on your affected shoulder. Attempt to rotate your affected arm upward against your resistance for 3-7 seconds. Relax and use your unaffected arm to leverage the broomstick upward, further stretching your affected shoulder. Repeat three contract relax cycles twice per day or as directed.
How to Strengthen the Subscapularis
Stand with your affected arm tucked into your side, elbow bent 90 degrees, and forearm pointed forward. Grasp a piece of exercise tubing attached to a firm object, then slowly rotate your arm toward your stomach to stretch the tubing. Once your hand touches your stomach, return to the start position and repeat as directed. Try to keep your elbow tucked into your side throughout the exercise.
If you want an in-depth perspective on the assessment and treatment of the subscapularis, here are some other ways to expand your knowledge base.
Subscapularis Syndrome Webinar
The Shoulder & Chiropractic Care Podcast Episode
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Brockmeyer M, Schmitt C, Haupert A, Kohn D, Lorbach O. Limited diagnostic accuracy of magnetic resonance imaging and clinical tests for detecting partial thickness tears of the rotator cuff. Arch Orthop Trauma Surg. 2017;137:1719- 1724. Link
Barth JRH, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22:1076-1084. Link
Dakkak, A., Krill, M. K., Krill, M. L., Nwachukwu, B., & McCormick, F. (2020). Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review. Sports Health: A Multidisciplinary Approach, 194173812093623. Link
