Common Shoulder Pathologies:
The 4 X 4 Approach:

Part I:
Movement Impairments of the Scapulothoracic Region:
Scapular Downward Rotation Syndrome

In our last discussion we introduced the eight topics related to common shoulder pathologies. In this discussion we will focus on the first of eight movement impairment syndromes: Scapular Downward Rotation Syndrome. Scapular Downward Rotation Syndrome is a terminology used to name multiple shoulder pathologies of the upper extremity. Viewing this syndrome as a whole will help you to categorize the following pathologies: supraspinatus or rotator cuff tendinopathy and impingement, rotator cuff tears, thoracic outlet and neural entrapment, humeral subluxation, humeral instabilities, Neck Pain (including or not including radiating pain into the upper extremity), Pain in the levator scapula and upper trapezius muscle, and sternoclavicular joint pain.[1]

Let us first dissect the terminology of Scapular Downward Rotation Syndrome. The name of this syndrome tells you that there is a problem with the downward rotation of the scapula which will include muscle firing of the following muscles:

Downward Rotation of the Scapula:
Levator Scapula
Rhomboids Major/Minor
Pectoralis Minor


This is only the beginning. Many times as therapists we forget how our body works as a complete system. If we look at one movement pattern that is impaired we should also look at the opposing force, in this case it would be upward rotation of the scapula:

Upward Rotation of the Scapula:
Upper Trapezius
Lower Trapezius
Serratus Anterior


Many therapists recognize the two movements of upward and downward rotation as agonist/antagonist, and any time we treat muscles using manual therapies we should remember that the musculoskeletal system works in this agonist/antagonist fashion. We should always remember when one muscle or groups of muscles are working there is an opposing muscle or group of muscles that should not be working. With that said, if there is dysfunction or shortening of muscles that create downward rotation that will also affect upward rotation of the scapula creating an imbalanced scapulohumeral rhythm.

Using the basic concepts of the agonist/antagonist theory we must look at the term force couple. A force couple is defined as two forces of equal magnitude but in opposite direction, that produce rotation on a body.[2] In a nutshell, all six of the previous muscles mentioned must fire in a specific order and against an opposing force, equally. If one of those six muscles fire incorrectly neither upward nor downward rotation of the scapula will occur correctly, creating movement impairment.

Now that we have viewed Scapular Downward Rotation Syndrome from a global perspective, now let us look at the most common pathology related to this syndrome.

We will explore Supraspinatus or Rotator Cuff Tendinopathy and Impingement. The pinching of any structure between the head of the humerus and the acromion is referred as impingement of the shoulder. This may include the bursa, the rotator cuff tendons, or the tendon of the long head of the biceps brachii muscle.[3] Which came first the chicken or the egg, does tendinopathy supersede impingement or vice versa. It is not our job to determine which occurred first, other than for clinical findings, but rather focus on treating both the tendonitis and the impingement syndrome. Do understand that tendonitis and impingement go hand in hand, but are two distinct creatures. The tendon that is inflamed, tendonitis/ tendinopathy, is treated much different than the impingement which is a more global response to the insufficient upward rotation of the scapula causing the humerus to impinge against the coracoacromial ligament.3

When treating many times the doctors referral/ prescription may state “shoulder pain” or “shoulder tendonitis”. As a therapist it will be our job to make clinical decisions, using valid testing methods, to determine what the exact root cause of the pain, inflammation or movement impairment syndrome. These clinical findings will allow the therapist to develop and implement a detailed treatment plan. For example, if a patient was referred, from a medical doctor, with a diagnosis of shoulder tendonitis the therapist needs to know whether it is the long head of the biceps brachii tendon, the Supraspinatus tendon, or both. This is achieved by performing some basic orthopedic assessments such as the following:

Orthopedic Assessment: Shoulder Impingement
Biceps Tendon (long head): Positive Yergason’s Test or Speeds Test

Supraspinatus Tendon: Positive Hawkins Kennedy Impingement Test

Both Biceps & Supraspinatus Tendon: Positive Neer & Welsh Impingement Test

[4] (These orthopedic assessments are referenced in this footnote)

Once the therapist has established what muscles they believe are affected they can begin to develop and implement treatment strategies. We still must think globally, because it may be the muscle imbalance of upward and downward rotation that is creating the impingement, which creates the tendinopathy. At this point the therapist may have pin pointed which tendinopathy is present, but must determine which muscle or groups of muscles are impaired in upward and downward rotation of the scapula. This is where our traditional visual and palpation skills come into play. We must assess the six muscles of upward and downward rotation through a standard visual exam, palpating for muscle tightness and performing Range Of Motion (ROM) assessments using a goniometer to determine movement impairments and functional deficits. Once all the information is collected the treatment plan can be effectively developed using the data that is collected.

Tune in next week to continue this free educational lesson. If you are interested in attending any of our weekend workshops, feel free to check out our website http://www.massagesmart.com/, or tune in each week at http://massagesmart.blogspot.com/ . Don’t forget to subscribe to the feed that will automatically update you when I submit new educational blogs/articles.

Jeffery B. Wood LMT, COTA/L, B.S.
CEO Therapeutic Touch & Bodywork, Inc.
Lead Instructor Massage Smart: Education in Action
AMTA Heart of Florida Unit Chairman
W.T.I. Massage Therapy Director

*Please note, that this information is informative in nature. Massage Smart, nor any of its counterparts, intend to use this educational information to diagnose or perform soft tissue techniques outside the scope of practice of massage therapy.







[1] Sahrmann, Shirley A.: Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, 2002.

[2] Frankel, VH, Nordin M: Basic Biomechanics of the Skeletal System. Lea & Febiger, Philadelphia, 1980.
[3] Sahrmann, Shirley A.: Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, 2002.

[4] Donatelli, Robert A.: Physical Therapy of the Shoulder. 3rd Edition. Churchill Livingstone, Inc, Philadelphia, 1997.

Common Shoulder Pathologies

Common Shoulder Pathologies:
The 4 X 4 approach

The shoulder is truly an amazing structure. The longer you study the biomechanical components of the upper extremity, the more fascinating it becomes. Truly the most interesting aspect of the shoulder is the simple fact that is; what this structure lacks in stability it makes up in mobility. According to Robert A. Donatelli Ph.D., P.T., “the shoulder is capable of moving in over 16,000 positions, which can be differentiated by 1 degree in the normal person.”[1]

This sounds great in theory, but those 16,000 positions of movement are constantly compromised by our tedious activities of daily living that lead to numerous movement impairment syndromes. For the context of this text, movement impairment syndromes are defined as “localized painful conditions arising from irritation of myofascial, periarticular, or articular tissues. Their origin and perpetuation are the result of mechanical trauma, most often micro trauma.”[2] It is this constant bombardment of micro trauma that leads to some of our most common soft tissue shoulder pathologies.

In this topic of discussion we will look at two major categories of movement impairment syndromes of the upper extremity. The first category focuses on movement impairments of the scapulothoracic region and the second category focusing on the movement impairments of the glenohumeral region. Over the following 8 weeks we will discuss each movement impairment syndrome individually. Below you will see a breakdown of the two major categories with its corresponding movement impairment syndromes.

Movement Impairments of the Scapulothoracic Region

1. Scapular Downward Rotation Syndrome

2. Scapular Depression Syndrome

3. Scapular Abduction Syndrome

4. Scapular Winging Syndrome

Movement Impairments of the Glenohumeral Region

1. Humeral Anterior Glide Syndrome

2. Humeral Superior Glide Syndrome (Abduction)

3. Shoulder Medial Rotation Syndrome

4. Glenohumeral Hypomobility Syndrome

In our next series we will look at the first of eight series of conversations, in regards to movement impairment syndromes of the upper extremity. Scapular Downward Rotation Syndrome is composed of several of our classic shoulder pathologies: supraspinatus or rotator cuff tendinopathy and impingement, rotator cuff tears, thoracic outlet and neural entrapment, humeral subluxation, humeral instabilities, Neck Pain (including or not including radiating pain into the upper extremity), Pain in the levator scapula and upper trapezius muscle, and sternoclavicular joint pain.[3]

Tune in next week to continue this free educational lesson. If you are interested in attending any of our weekend workshops, feel free to check out our website http://www.massagesmart.com/, or tune in each week at http://massagesmart.blogspot.com/ . Don’t forget to subscribe to the feed that will automatically update you when I submit new educational blogs/articles.

Jeffery B. Wood LMT, COTA/L, B.S.
CEO Therapeutic Touch & Bodywork, Inc.
Lead Instructor Massage Smart: Education in Action
AMTA Heart of Florida Unit Chairman
W.T.I. Massage Therapy Director

*Please note, that this information is informative in nature. Massage Smart, nor any of its counterparts, intend to use this educational information to diagnose or perform soft tissue techniques outside the scope of practice of massage therapy.

[1] Donatelli, Robert A.: Physical Therapy of the Shoulder. 3rd Edition. Churchill Livingstone, Inc, Philadelphia, 1997.

[2] Sahrmann, Shirley A.: Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, 2002.

[3] Sahrmann, Shirley A.: Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, 2002.

Common Shoulder Pathologies

Tune in next week for valuable information about common shoulder pathologies.

Massage Therapy: Industry & Consumer Facts

Did you know?

According to the 2007 American Massage Therapy Association Consumer Survery; between August 2006 and June 2007, almost a quarter of adult Americans (24 percent) had a massage at least once in the last 12 months.

The AMTA also states that while the use of massage is growing, the reasons people are turning to massage therapy are also expanding. More and more people recognize it as an important element in their overall health and wellness.

• Almost one-third of adult Americans say they’ve used massage therapy at least one time for pain relief.

• Of the people who had at least one massage in the last five years, 30 percent report they did so for health conditions such as pain management, injury rehabilitation, migraine control, or overall wellness.

• Eight-seven percent agree that massage can be effective in reducing pain.

• Eighty-five percent agree that massage can be beneficial to health and wellness.

Please complete our poll!

This information was collected from the 2007 AMTA Consumer Survey.
http://www.amtamassage.org/media/consumersurvey_factsheet.html