Your Temporomandibular Joint , is the most used joint articulation in the body. Your TMJs (jaw joints) are involved with eating, talking, breathing and, probably most importantly, expressing your feelings and emotions. When things go wrong with your TMJ, it is known as Temporomandibular Disorder (TMD). (1)

TMD is a common condition, signs of which appear in up to 60–70% of the population.(1) The peak incidence is seen in adults aged 20–40 years. Women are at least four times as likely to suffer from the disorder.(3) TMD can be annoying and persistent or acutely disabling.

Treatment of the jaw for pain, clicking and locking can be challenging. We often get referrals from dental specialists for patients with prolonged or acute temporomandibular pain and restricted movement.

Anatomy

The Temporomandibular Joint (TMJ) complex consists of two joints on either side between the skull and jaw bone. There is small fibrous shock absorbing disc within the joint that needs to shift correctly for normal pain free jaw movements such as opening and closing your mouth, yawning and chewing. There are many small muscles that are involved in ensuring smooth, precise TMJ movement, and can contribute to increased strain in the joint.

Symptoms

You may or may not experience jaw pain or tenderness with TMJ dysfunction. The most common symptoms include:
• jaw clicking
• grinding
• limited jaw opening, or jaw deviation while opening
• an inability to fully clench your jaw. (1)

TMD sufferers are often teeth grinders or clenchers. TMD can cause jaw headaches, ear pain, dizziness and neck pain. Some TMJ patients report pain or inability to eat, talk or sing. Tinnitus or ear ringing can be associated with TMJ dysfunction.

Causes of TMD

Successful management of TMD involves identifying and managing contributing factors.1 It is important to distinguish between muscle related causes of TMD and intra-articular disorders of the joint itself. TMJ pain may also be caused by referral from the neck or more remote areas. Muscle related disorders are the result of tension, fatigue or spasm of the masticatory (chewing) muscles, whereas intra-articular disorder stems from mechanical or inflammatory disruption of the joint itself.
Soft tissue dysfunction is the most common cause of TMD. Teeth grinding, clenching and abnormal posture, stress and anxiety, may all contribute to masticatory muscle pain and spasm. Cognitive and psychiatric disturbance, such as depression and anxiety, and autoimmune disorders, fibromyalgia and other chronic pain conditions are also frequently associated with TMD and may be a part regional pain syndrome.
Intra-articular causes of TMD include internal joint derangement, osteoarthritis, hypermobility and traumatic injury. Inflammatory conditions, such as rheumatoid arthritis may lead to internal joint derangement. Articular disc displacement from the normal position is the most common joint related cause of TMD. In our experience careful assessment often reveals stiffness in the joint gliding.(2)

Treatment

Physiotherapy has been shown to be effective in the management of TMD, especially with regards to improving joint range of motion.(4)
Behaviour modifications, including improving sleep hygiene, stress reduction and elimination of bad habits such as teeth clenching and grinding, are particularly important.
A careful, comprehensive assessment of the joint and the muscles that control movement: some which are internal and difficult to access is essential to find and treat the dysfunctions that cause pain and disordered movement. Close examination of the neck, upper back and posture is also important in order to get best results. A structured home exercise program is essential.

If you have pain or disturbed movement in your jaw area or persistent headaches, you need to have an TMJ assessment as part of a comprehensive treatment approach. At Northwest Physiotherapy Group we look at the whole body to find and treat the main contributors of your pain.

References

1. https://physioworks.com.au/pain-injury/jaw-pain-tmj-pain/tmj_dysfunction/
2. https://www1.racgp.org.au/ajgp/2018/april/temporomandibular-dysfunction
3. Sharma S, Gupta DS, Pal US, Jurel SK. Etiological factors of temporomandibular joint disorders. Natl J Maxillofac Surg 2011;2(2):116–19. doi: 10.4103/0975-5950.94463. Search PubMed
4. Ahmed N, Poate T, Nacher-Garcia C, et al. Temporomandibular joint multidisciplinary team clinic. Br J Oral Maxillofac Surg 2014;52(9):827−30. doi: 10.1016/j.bjoms.2014.07.254. Search PubMed

She is a mum in her early 40s who had been suffering a 5 year history of neck, shoulder pain and headaches. The headaches were at the base of her skull and would occur twice weekly and last for several hours. While there were no features of migraine, Mrs P found the headaches quite debilitating, as often her neck and shoulder pain would worsen with them.

Her neck movement was severely restricted also, finding it hard to reverse the car, check blind spots and also to look up with activities like hanging the washing and reaching up to cupboards. Mrs P played netball and found shooting in netball was also painful, and so she had stopped playing. In fact, her enjoyment of life had really taken a hit. She couldn’t enjoy playing with her young daughter as she wanted. She was frustrated and felt down.

She was otherwise in good general health.

Mrs P had also tried other practitioners, including other Physios, with no long term help.

Examination Findings

On initial assessment, we found lots of unhappy areas in Mrs. P’s body that could contribute to her problems. Most notably she had neural tension in all 4 limbs and through the upper cervical spine. This had to be treated first to ensure she responded well to further manual therapy and her results would hold.

There were several muscles in the neck, shoulders, jaw and lower back that were tight and in a protective state, as well as joints in the neck and thoracic spine. The main movements that were restricted were neck rotation (we haven’t shown these for privacy reasons), shoulder internal and external rotation, shoulder abduction and passive neck flexion/rotation. The last test has been shown to correlate well with the incidence neck related headaches.

Below are the pictures of limb range before and after nerve clearing. All tests are performed to the first point of resistance/muscle guarding.

Problem Solving Process

Through a systematic process of treatment trials and clinical reasoning, we narrowed down to a list of 15 structures that were affecting Mrs P’s neck and shoulder movements. With further treatment we narrowed down further to the primary contributor to Mrs P’s condition. This was a segment in her upper neck which was essentially ‘’stuck” (C2) and not gliding to the right as it normally should. There was a secondary contributor in her left shoulder (infraspinatous).

Treatment to this structure made significant changes to Mrs P’s movements, and all other problematic structures.

Results

Over a period 4 weeks (interrupted by Covid!), Mrs P’s movements returned to an optimal state. Concurrently her headaches ceased, her neck and shoulder pain resolved and she was able to finally enjoy playing with her young daughter, as well as move normally and return to netball without pain!

We gave Mrs P strategies to manage her condition long term, including postural, strengthening and motor control exercises, as her posture affected her neck tension and head position.

Postural Corrections

These postural corrections were made for Mrs P, as the corrected position reduced strain and tension on the primary contributors in the neck. Thees new postures will require practice and awareness over time to become natural postures. Mrs P was shown how to check for tension in her neck and whether she was in the correct posture.

Mrs P was overjoyed and quite emotional with her result. She felt that after so many years, she had finally found an approach that worked. She felt confident in her body, and empowered to prevent the condition recurring. She was relieved and excited about enjoying her upcoming holiday, finally being painfree.

This is an example of how a thorough, whole body, systematic problem solving approach can work well for persistent long term musculoskeletal problems.

In this article, we will demystify some of the symptoms you may experience if you are going through menopause — because the more prepared you are, the more you can mitigate the risk of chronic pain and injury in the years following. Healthy aging is key!

What Is Menopause?

Menopause occurs when the body stops producing eggs and the hormones associated with reproduction are dramatically reduced. If you haven’t menstruated in 12 months, then you have entered menopause. It can begin in women as early as their 40s, however the period of fluctuation in hormones can be anywhere between 4-6 years. For some, this has minimal effect except for an end to monthly menstruation. However, for 80% of women this change in hormone production levels (especially in estrogen) will cause symptoms throughout the whole body.

The Musculoskeletal Impacts Of Menopause

Migraines/headaches

High levels of estrogen can trigger headaches and migraines in some women. The good news is that declining levels of estrogen post-menopause can reduce headache frequency overall. However be mindful that as your hormone levels fluctuate during menopause, your headaches may be triggered more often in the short-term.

Bone health and osteoporosis

Bone density in women is strongest during their 20-30s and estrogen levels are especially important in maintaining this. However, as estrogen levels drop, bone loss increases, with an average of 10% bone mass lost in the first five years post-menopause. This means the risk of osteoporosis is far higher in women after menopause, making bones frailer and more prone to fractures, especially in the spine, wrist, and hips from falls.

Muscles

Estrogen provides a protective effect on muscles, which is why women typically suffer less muscle strains than men throughout their lives. Unfortunately the reduction of estrogen during menopause leads to a decline in both muscle mass and strength, which means you may experience more pain or sustain injuries more frequently even though your level of activity hasn’t changed. Not only that, but it can also cause weakness in your core and pelvic floor muscles and lead to instability, poor posture, and even incontinence.

Joint pain and inflammation

Estrogen has been shown to help reduce inflammation in the body. If you already have a pre-existing inflammatory condition such as arthritis or a tendinopathy, this can become exacerbated post-menopause and cause more pain and restriction in your daily activities.

How To Minimise The Effects Of Menopause

Maintaining a good level of physical activity has been shown to counteract many of the negative musculoskeletal effects of menopause. This can be walking, swimming, cycling, gym classes, Tai Chi, strength training, pilates — just remember that consistency is key to reap the benefits to your health. If you can do some form of exercise for 30 mins most days of the week, then you are on your way!

Bone density can be maintained by ensuring adequate calcium and vitamin D levels in the body for bone production. Regular weight-bearing resistance exercise (i.e. exercise on land involving weights) also stimulates bone strength as well as counteracts the muscle loss that occurs menopause and aging. If you are experiencing specific weakness of core and/or pelvic floor muscles, consider getting a specific assessment and exercise program prescribed by a physiotherapist.

For most people, exercising more and being aware of your body changes will go a long way to attenuating the worse symptoms associated with menopause. However, if your symptoms persist and impact your quality of life, menopausal hormonal therapy may be an option to help adjust to the sudden decline in estrogen levels. This is best discussed with your GP to ascertain whether this is the right option for you.

If you are suffering from muscle aches and pain, we can help get you moving pain-free and prescribe an exercise program to keep you there despite the hormonal fluctuations in menopause. The earlier you start, the easier it is to keep the gains as your body undergoes these significant changes!

References

Introduction to Women’s Health APA Lecture Series

Bondarev, D., Laakkonen, E., Finni, T., Kokko, K., Kujala, U., Aukee, P., Kovanen, V. and Sipilä, S., 2018. Physical performance in relation to menopause status and physical activity. Menopause, 25(12), pp.1432-1441.

Chidi-Ogbolu, N. and Baar, K., 2019. Effect of Estrogen on Musculoskeletal Performance and Injury Risk. Frontiers in Physiology, 9.

She had suffered some trauma to her head and neck region when she was 15 years old, and she had traced the start of her problems to after this event.Mrs D suffered with 2 migraines a month generally, but lately she had been experiencing headaches on a daily basis around this. Her symptoms were usually aggravated by stress.

Her headaches and migraines were in similar areas, usually around the left eye and into the back of the skull on the left, and she had associated pain into her left shoulder and the top of her arm.

Mrs D had been under the care of a neurologist, and had seen other Physios and Chiropractors with good but short to medium term relief only.Her good result was:

What we found

1. Reduce or eliminate the constant headaches.
2. Reduce migraine frequency, duration and intensity.
3. Feel less stiff in the neck and shoulders.
4. Improve energy levels.

We took Mrs D through a whole body assessment, because we know through experience and research that where your pain is may not be where the cause of your problem is.

What we did

Summary of assessment findings:

1. Muscle tension/knots in many of the neck and shoulder muscles on both sides.
2. Adverse nerve tension in the upper limbs.
3. Stiffness in many joints around the neck, thoracic spine and lumbar spine.
4. Restricted passive neck flexion/rotation test, worse to left.
5. Weakness in the deep neck flexors and scapular stabilizers.
6. Poor pattern of shoulder movements, left worse than right.

We trialed treatment on the the unhappy muscles and joints that we had found on the initial assessment, and used a single test movement(passive flexion/rotation of the neck) to measure the response of each intervention. we also monitored other key movement tests related to Mrs D’ condition, especially shoulder and neck range/quality of movements.
From this we made a list of structures that had made good changes to Mrs D movements tests.

We then worked on that list to narrow down further the main dysfunctions that were contributing to Mrs D’s condition. This involved a process of elimination and clinical reasoning.

We finally narrowed down to the left infraspinatous muscle in her shoulder, that was continuing to make differences to all of Mrs D’s relevant movement signs. Working to release this muscle also improved the stiffness in many of the neck joints.

Results

The graph below shows the improvement in Mrs D’s key movement tests over the course of treatment, which involved 7 x 1 hr treatment sessions.

The objective improvement matched improvements in Mrs D’s symptoms:

1. General headaches were largely eliminated between migraines, except for times of high work related stress. In these cases headaches were much less severe, and of shorter duration.
2. Migraines were also less frequent, less severe and shorter duration, on average 1 very 4-6 weeks.
3. Mrs D was very satisfied with her results, feeling more energetic and more in control of her condition. she had simple tests she could use to self monitor her body, to know when muscle and joint tension was increasing, and a range of strategies that she could use to manage her condition long term.

Why was the left shoulder contributing to Mrs D’s condition?
The left shoulder had a large trigger point/knot in the infraspinatous muscle. This was adding to the level of noxious input to her central nervous system, sensitising the main receptor nuclei(trigemeni cervical nucleus) in the brainstem that trigger headaches. Reducing tension in this muscle reduces the level of this noxious input, thus making it harder for a headache/migraine to be triggered.

This shoulder dysfunction related to weakness to of the shoulder stabilisers, poor posture in sitting at her desk, and poor movement control, problems we addressed as part of a long term solution for Mrs D.

This case study highlights the importance of looking beyond the neck in the management of headaches.

It is unlikely that such a result would have been achieved by treatment of the neck alone, as the shoulder release work improved the neck stiffness when re- assessed immediately afterwards.

There are several different types of headaches with different causes, and it is well accepted in clinical settings as well as in research findings that the neck can either cause or contribute to the pain of headache. But if structures like tight muscles and stiff joints in the neck can contribute to headaches, why can’t similar structures further away from the neck, such as in the shoulders or thoracic spine, contribute to headaches? And how can this be explained if it is possible?

In our experience at NWPG, more remote regions can contribute to headaches, and we have examples of clients that have had significant improvement in frequency, duration and intensity of their headaches when other remote contributors have been found and treated.

But first, let’s look at one of the more common contributing areas of headache, the neck. Understanding the contribution of the neck will open the door to understanding how remote areas can contribute to headaches.

Cervicogenic Headaches

Cervicogenic headache is a type of headache with distinct signs and symptoms that has been classified by the International Headache Society, an organisation that researches and classifies all types of headaches.

Headaches are generally classified as Primary or Secondary. Primary headaches occur without an identifiable source within the body or CNS(Central Nervous System). Examples are migraine, tension and cluster headaches.

Secondary headaches arise from an identifiable source, such as the eyes, sinuses or neck, or potentially other musculoskeletal regions.

Cervicogenic headache (CGH) is a secondary headache, and research shows that it makes up for 15-20% of all chronic and recurrent  headaches. (1)

The good news for sufferers of CGH is that there is scientific evidence that it can be treated effectively once it is recognised and diagnosed (2).

How do I know if I have Cervicogenic Headache?

CGH is defined as pain that occurs in the neck or occipital (back of head) region but may spread forward to the side or front of the head. It is generally aggravated by neck movements or sustained neck postures, eg sitting at a computer or driving.

You may also experience one or more of the following characteristics:

1. The pain is generally dull and not throbbing or piercing.
2. It is generally one sided but you may also experience shoulder pain on the same side.
3. May be eased by massage or external pressure over the neck.
4. There may be a history of trauma to the head or neck/shoulder from a fall or car accident.
5. You may be able to feel tension/tightness in the muscles at top or bottom of the neck, and there may be “lumps” in the muscles that may be tender to touch
6. You may notice stiffness or even pain when you turn your head to one side.
7. CGH is more common in females. 

What Causes CGH?

The pain of CGH is thought to be of somatic origin, ie arising from joint capsules, ligaments or muscles in the neck, especially the upper cervical segments C1-3. These structures are innervated by sensory nerves that detect excessive load or inflammation. When these nerves are stimulated, impulses are sent to the brain (noxious input) where these signals are processed. If these signals (noxious input) exceed a safe threshold, then the brain perceives there is a problem, ie it cannot maintain balance in the body. It then sends an output signal to our conscious awareness that there is a problem and we need to address the underlying cause. The pain of a headache is an output signal from the brain that the body is out of balance.

So why do these structures become irritated?

Well it is usually as a result of joint stiffness or muscle tension developing, ie dysfunction.  Why does this occur? This is a slightly more difficult question to answer, as there may be several factors involved. One of the main factors is poor neck and back posture, which may be accentuated in sitting, especially at a poor workstation . There may also be muscle imbalances or weaknesses in the upper body that may lead to neck pain and headaches, such as weakness in shoulder blade retractors , elevators or deep neck flexors. Finally there may be degenerative changes in the facet joints or discs of the neck which can cause inflammation and hence irritation of sensory nerves.

Dysfunction in the upper cervical segments may give rise to neck pain, but could also give rise to pain in the back, side or front of head. Pain can even be transferred to the eye socket, jaw or temple region. Pain that originates in one part of the body, in this case the upper cervical segments, but is felt in other regions is called Referred Pain. The headache pain of CGH is a type of referred pain, and usually originates in the cervical segments C1-3. This region of the neck has nerve connections with nerves that supply the head and face (Trigeminal Nerve) and so the brain can misperceive the origin of this pain, ie the brain sends the signal to us that the pain is in the head when it is actually originating from the neck. This is similar to Sciatic pain, which is leg pain referred from the lumbar spine (low back) usually secondary to disc bulge or prolapse.

There are characteristic referral patterns that relate to the specific segments that pain is arising from in CGH. 

O- C1: a band of pain around the head much like head band/sweat band.
C1-2: an arc of pain over the head between each ear.
C2-3:  pain radiating for the back of head/occiput into the eye/orbital region.   

So if you have pain in any of these areas, there is a good chance that you may have Cervicogenic Headache.

Can Other Areas of the Body Contribute to Headaches?

From our experience the answer to this question is a resounding “YES”!

There is a growing body of evidence (4,5) that suggests “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint. “

This is called the Regional Interdependence Model of musculoskeletal dysfunction. Put simply, it is the theory that the body is interconnected, and impairments or dysfunctions in one region can influence other anatomically remote regions.

We have a few case studies on clients who have had significant remote contributors to their headaches. Finding and treating these made a big difference to their headaches.

How can remote dysfunctions contribute to headaches?

If we consider that all dysfunctions in the body( tight muscles, joints that are stiff, nerves that do not glide, altered movement patterns, etc), are detected as noxious input by the brain. When the total level of all these inputs exceeds a safe level, then the brain may perceive there is a problem and create a warning to signal to the individual. This warning signal may be in the form of a headache.
This is called the Accumulative Strain theory of Musculoskeletal Health.

So what do I do if I think I have CGH, or suspect other areas may be contributing to my headaches?

The good news is that there is scientific evidence that CGH can be treated effectively with Physiotherapy (2, 3). Research has shown that cervical manipulation and specific exercise can reduce the frequency, severity and duration of CGH when compared to placebo treatments (sham treatments), and that these results are maintained at 1 year follow up.

Determining if remote areas are contributing to your headaches requires a systematic whole body problem solving approach, called Ridgway Method. This is a method we practice at NWPG. It is important with this approach to assess a good objective measure of upper cervical dysfunction to determine if other areas of the body are contributing to headaches. The cervical flexion/rotation test has been shown to be a valid measure of musculoskeletal contribution to a headache (1). This means, if this test is restricted in a headache sufferer, and we can change it by treatment to dysfunctional areas of the body, those areas may be contributing to the headache symptoms.

Physiotherapy may also have a role in the treatment of other types of headache, such as tension headaches or migraines, as these headaches may have a cervical or remote musculoskeletal component, ie neck, spinal or other dysfunctions may contribute to pain inputs to the brain which can make you more susceptible to headache.

So if you think you may have CGH, or other areas in your body that may be contributing to your headaches, book in for an assessment at Northwest Physiotherapy Group

The initial consultation (1hr) includes a comprehensive assessment of cervical and spinal posture, range of movements, muscle strength and imbalance tests, nerve tests and passive spinal segmental mobility tests to determine the cause of your headaches and any possible musculoskeletal factors that may contribute to them. We will treat all associated dysfunctional areas to restore balance to your musculoskeletal system.

Simply call our rooms on 9370 5654 to book your appointment, or send us a request through our website.

References

1. T. Hall*, K. Robinson(2004): The flexion–rotation test and active cervical mobility comparative measurement study in cervicogenic headache. Manual Therapy 9 (2004) 197–202
2. Gert Bronfort, DC, PhD,a Willem J.J. Assendelft, MD, PhD,b Roni Evans, DC, Mitchell Haas, DC,c and Lex Bouter, PhDd (2001). Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
3. Journal of Manipulative and Physiological Therapeutics 24:(7)2001.
4. Niere K, Robinson P (1994): Determination of manipulative Physiotherapy outcome in headache patients.
5. Manual Therapy 1997: 2(4):199-205.
6. Wainer RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther(2007); 37(11): 658-660.
7. Sueki DG, Cleland JA, Wainner RS(2013): A Regional Interdependence Model of musculoskeletal dysfunction: research, mechanisms and clinical implications. J Man Manip Ther 21(2):90-102

Just pause and take a breath.

What was it like? In through your nose or mouth, relaxed or tense, from the diaphragm or chest?

Our mouths are designed for eating and talking, breathing is a primary responsibility of the nose.  You can use your mouth as a backup when you are exercising hard or if our nasal passages are congested but efficient effective breathing is in and out through the nose.

I started researching breathing because I was instructed by my wife to stop snoring. I realised I was mouth breathing and began a breath training program which has greatly improved my capacity to nose breath at night. My wife is a lot happier now.  

Why is it so important to nose breathe?

There are very convincing reasons why nose breathing is essential for our health.

When we breathe through our nose we release a gas called nitrous oxide from our paranasal sinuses. This does a number of things:

1. It sterilizes the air we breathe in and assists airway opening to allow  more air to get to our lungs.
2. It also enhances our performance in sport and bringing up blood from the lower lobes of the lungs to get better oxygenation to the blood and to our tissues.
3. Nose breathing can improve the transport of oxygen from the lungs to the blood by 5 to 15%.

One of the most critical aspects of nose breathing is that it controls the amount of carbon dioxide(CO2) we breathe out (different to nitrous oxide). This is a bi product of our normal metabolism. Carbon dioxide acts as a doorway between the blood and the tissues. If we over breathe through our mouth or breathe too fast, that doorway stays shut and prevents us from getting oxygen from the blood to the tissues. However if we breathe in a calm controlled manner that doorway remains open and oxygen flows more freely into the tissues.

The background to nose breathing.

A Russian physician, Dr Vladamir Buteyko researched breathing through his professional life. He found that one of the reasons that asthmatics have problems with breathing is that they tend to over breathe.  A central part of his approach is to teach a relaxed breath pattern that doesn’t blow out (exhaling) too much carbon dioxide. 

Interestingly further studies have shown chronic over breathing correlates with chronic disease states, such as heart disease, asthma and diabetes. Good health is linked to a relaxed breathing pattern.

How to start breathing better

Your breath is a truly amazing thing and integral to life. Take advantage of the power of your breath. All you have to do to begin, is gently inhale through your nose and exhale slowly through your nose, taking mindful small, barely perceptible breaths in and out. This has a very powerful effect on your state by activating our calming parasympathetic nervous system as opposed to being tense and anxious and over stimulating the opposite system -the sympathetic.  How have you felt when you have been angry or tense? Tight and tending to breathe quickly and over breathe?

So by switching to a relaxed nasal breath pattern you can reduce those responses and help your body adapt to stress.

Added benefits

1.    Nose breathing moisturises the incoming air, which improves transference of oxygen in the lungs.
2.    It triggers the release of antibacterial molecules to improve function of the immune system.
3.    Nose breathing brings air to the paranasal sinuses that assist the pituitary gland to regulate body temperature.
4.    It helps regulate sleeping patterns.

Nose breathing is an essential part of life and adds quality and calmness to your life.

Try it, it is a very small  change to your routine for potentially significant benefits to your general health and well -being.

References

1. Powerspeedendurance.com/nose-knows.
2. Breathingretrainingcentre.com/nose breathing.
3. Normalbreathing.com/breathing slower and less.
4. Powerspeedendurance.com/the training effects of nasal breathing.
5. XPTlife.com/breathing articles.

‘Unknown’ and forgotten even amongst health practitioners (trust me I know!!). The subscapularis is a large triangular shaped muscle that lies between your ribcage and shoulder blade. Why an entire blog post about just one muscle? I hear you ask.. From our experience the subscapularis muscle is a common source of pain for many of our clients, both local (shoulder region) and remote pain. Subscapularis also happens to be the muscle that relieved remote pain in my own body and hence is another reason I have chosen to write my first blog post on this incredibly annoying but fundamental muscle.

Subscapularis – What? Where? Why?

The image above to the left shows the subscapularis muscle insertion, the lesser tubercle of the humerus or upper arm bone. The second image on the right shows the muscles origin on the flat surface of the shoulder blade (subscapula fossa).

Ever heard of the rotator cuff? Subscapularis is one of four muscles that makes up the rotator cuff, which creates stability of the shoulder joint. The rotator cuff works similarly to that of the four guy ropes on a tent, should one become too tight or loose the other three are impacted creating an imbalance. As we know any malalignment within our bodies has the potential to produce pain.

The muscle is innervated by nerves travelling out of the neck. 

In our experiences, when subscapularis muscle becomes dysfunctional often it has the potential to lead to a number of other conditions, and very rarely produces local pain at the site of the muscle. Common referral patterns of a tight and unhappy subscapularis muscle include neck, back and shoulder pain, arm and wrist pain and you may also find reduced strength in these areas (Perry, 2018). 

How does Subscap become problematic?

Prone to becoming tight and shortened, this muscle is most commonly accessed by clinicians via the armpit. There are many different reasons why this muscle can become dysfunctional and aggravated. The most common we find is posture… There’s a reason why you were constantly reminded as a child to sit and stand tall!!

In certain positions and postures the subscapularis muscle can be shortened such as at the desk with use of a mouse, especially with the arm held away from the body. Other repetitive action also have the ability to produce dysfunction such as activities that involve a reaching action behind the back, common in swimming and racket sports.

A fall onto an outstretched hand in most cases will lead to prolonged periods of immobilisation such as a cast on the wrist or a sling for a shoulder injury, but did you know it can also  cause dysfunction to the subscapularis muscle. Once the immobilisation and rehabilitation period are complete, you may still find yourself feeling that things are ‘just not the same since that fall/break/accident’. This could potentially be due to unresolved dysfunction of the subscap. 

Even sleep position, one where you are side lying onto the shoulder, arm outstretched can lead to an accumulation of strain within the subscapularis muscle and resultant issues…. JUST FROM SLEEPING!

… I hear the cogs ticking over now….

How do you know if your Subscapularis needs attending to? 

STEP 1.

• Assess your posture using a mirror.
• Where are your shoulders sitting in relation to the rest of your body?
• Do you have a gorilla’s posture? (arms and shoulder position rolling inwards) 

STEP 2.

• Assess your Range of Motion
• Can you comfortably reach over head or do your shoulders feel restricted and tight?
• Can you complete a Subscap Stretch against wall as pictured below?

STEP 3.

• Identify Weakness using the Lift-off Test
• Leaning on an angle, shoulders resting against and feet slightly forward.
• Place hand behind back palm contacting the wall.
• Press the palm into wall as your body subsequently travels forward. 

If you noticed your posture is looking gorilla-like and/or had difficulty completing steps 2 and 3 it is likely your subscapularis muscle has been suffering in silence… or you have been soldiering on in pain!!

Addressing the subscapularis is relatively easy (unfortunately I cannot promise it will be completely pain free) but following on from treatment you will be sure to notice a difference! The catch, we can not do all of the work for you, if order to achieve long-term and effective results you will need to commit to simple postural correction, strengthening exercise and gain an understanding of how to assess and manage this area in future. If you are interested to learn more or found yourself to have some positive tests, please call our clinic to book your appointment. We are ready to help you!

References:

1. Kenhub (2018). Available at: https://www.youtube.com/watch?v=_NvVjLUL3F4 [Accessed 13 Jun. 2018].
2. Perry, D. (2018). Subscapularis Trigger Points: The Icicles of Shoulder Pain | TriggerPointTherapist.com. [online] Triggerpointtherapist.com. Available at: http://www.triggerpointtherapist.com/blog/subscapularis-trigger-points/subscapularis-trigger-points-shoulder-pain-icicles/ [Accessed 30 May 2018].
3. Vizniak, N. (2012). Muscle manual. Professional Health Systems.

Mrs Z was quite stressed by her ongoing levels of pain and wanted to alleviate the headaches, regain pain free neck movement, to reach forward and overhead pain free with the left arm and to tolerate using the laptop for 30 minutes with no pain increase.

On examination, neck movement was painfully restricted as was forward or overhead reaching with the left arm. Adverse neural tension signs were evident when testing the left upper limb and both lower limbs. Trigger points and muscle tension were palpated throughout the neck and posterior shoulder region particular upper trapezius, levator scapulae and the rotator cuff muscles bilaterally. Palpation of the right psoas muscle deep in the anterior aspect of the abdomen was also exquisitely tight and tender.

Through a process of objective testing to confirm the best approach to treatment, Mrs Z responded to releasing of the tight psoas muscle. Mrs Z had a self reported improvement of 80% on a pain/dysfunction scale after 3 treatments. Releasing the right psoas muscle improved active movement in the neck and decreased the levels of shoulder pain and headache significantly. As an interesting side note, release of the right psoas muscle also improved the trigger points in the neck and posterior shoulder region which was quite remote from the site of treatment.

This demonstrates that based on objective testing criteria and thorough neural release work improvements can be made in areas quite remote from the pain presentation.