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.