Exercise

The rotator cuff is named for the "cuff" of tendons from four muscles attached side by side at the head of the humerus. The acronym many students and professionals use to remember the rotator cuff muscles is SITS - which stands for supraspinatus, infraspinatus, teres minor and subscapularis. The subscapularis is one of the most commonly indicated muscles responsible for shoulder pain. Its origin is the subscapular fossa and it inserts in the lesser tubercle of the humerus. The action of the subscapularis muscle is medial rotation of the humerus and stabilization of the glenohumeral joint. While its location between the scapula and the ribs may seem like an impossible location to address, there are techniques to evaluate and work with this muscle. In an article in the August 2004 edition of Massage Today, Ben Benjamin, PhD, states, "The subscapularis muscle is the muscle we use for forehand strokes in racquet sports, as well as for a tennis serve. It is one of the primary muscles used in swimming, hitting or throwing a ball. When the subscapularis is injured, we have trouble getting dressed or lying on our side to go to sleep." An inability to raise the arm fully overhead can be a sign of a tight subscapularis. Specialized Assessment Tests The Lift-Off Test assesses the function of the subscapularis muscle. In a sitting or standing position, the client rests the dorsum of his/her hand on their back in the lumbar area. Inability to move the hand off the back by further internal rotation of the arm suggests injury to the subscapularis muscle.

The Belly-Press Test is a modified version of the Lift-Off Test. This is useful for a patient who cannot place his/her hand behind their back. In this version, the client is supine, places his/her hand of the affected arm on the abdomen and resists the examiner's attempts to externally rotate the arm. Upper Arm Medial Rotation Resistance Test can be performed with the client sitting or standing. This test is done with the client's elbow at his/her side and the elbow bent at a 90-degree angle. The client medially rotates the arm while the practitioner provides manual resistance. If this test induces pain or a re-creation of their symptoms, then it is positive for subscapularis involvement. If this test is negative but the practitioner still suspects subscapularis injury, this test can be adjusted to more intensely focus on the subscapularis. The adjustment would stretch the subscapularis prior to the application of resistance. This is done by having the client's arm laterally rotated before the practitioner provides manual resistance against medial rotation.

Mobilization Technique The Institute for Integrative Healthcare Studies' Deep Tissue Massage manual by Dr. James Mally, ND, teaches subscapularis massage to increase shoulder girdle range of motion. Dr. Mally outlines the following massage steps: 1. Have the client lie on their side with his/her arm overhead.

2. Stand in front of your client, facing his/her upper body. Hook your arm closest to the client's head under his/her top arm so that it is supportive, the heel of your hand pressing on the superior border of the scapula and your fingers hooked on the medial border of the scapula.

3. With your hand closest to the client's feet, press into the axillary border of the client's scapula and hook your fingers on the medial border of the scapula.

4. These instructions will have the practitioner contacting the scapula on all three of its sides.

5. Once your grip is secure, go through a complete shoulder range of motion by circling with the scapula. This rotation moves the scapula over the ribs.

6. Be sure to keep your client's arm over his/her head while performing this technique.

7. This will stretch the pecs in front and press the scapula into the ribs, massaging the subscapularis effectively.

8. If you don't have the client's arm overhead, you may get slapped in the face. This positioning will also feel firmer to your client.

9. Make sure to hold the drape with the heel of your hand on the axillary border of the scapula.

Soft Tissue Release The Institute for Integrative Healthcare Studies' Sports Massage manual describes a technique to manually address the subscapularis. 1. Client is supine with his/her arm abducted at about 45 degrees.

2. Stand next to the client on the same side as his/her raised arm. With the practitioner's outside hand, hold the client's wrist so that the forearm is at a 90-degree angle to the massage table.

3. Place the pads of your (practitioner's) fingers into the anterior aspect of the client's scapula. This is done just inferior to the axilla.

4. If your client is female, it may be appropriate to ask her to hold her breast out of the way with her opposite hand.

5. While pressing in to the subscapularis, move your fingers in a superior direction while simultaneously actively abducting your client's arm overhead.

6. When moving the client's hand over his/her head, make sure to also laterally rotate the humerus, (this will bring his/her hand above their scalp, not above his/her face).

7. Raising the client's arm stretches out the subscapularis underneath the practitioner's fingers.

Stretches According to David G. Simons, MD, Janet G. Travell, MD, and Lois S. Simons, PT, in the book Myofascial Pain and Dysfunction (Vol.1), there are some very specific stretches that can help lengthen subscapularis muscle fibers.

Circumduction: Perform circumduction by swinging the arm with the client leaning over and arm hanging down. The client may wish to add weight in the hand to provide some traction. Attempt to laterally rotate the arm and make a wide swing.

Doorway Stretch: Stand in a narrow doorway with the forearms flat against the door facings to anchor the forearms and step forward through the doorway to stretch the muscles. One foot is placed in front of the other with the forward knee bent, the head held erect and the gaze focused straight ahead. The client should stretch the musculature to the point of comfortable tension (without pain) and hold that position for several seconds. The doorway stretch stretches the subscapularis when the forearms are in a lower hand position (elbows dropped and hands level with ears) and in the middle hand position (with the elbows at a 90-degree level of flexion). Corrective Action According to Simons, Travell and Simons, correcting postural stresses is an important step toward preventing subscapularis pain. Stop Slumping: Clients must learn to avoid a slumped posture in which the head is forward, the scapula is abducted and the arm medially rotated. When Standing: The client can hook his/her thumb in the belt or on the hip when standing for extended periods of time to prevent the arm from remaining close to the side.

When Sitting: When in a sitting position for an extended period of time, advise the client to stretch his/her arm up and back behind the head. In a vehicle, an armrest will help hold the arm in some abduction to avoid a completely shortened position of the subscapularis. There are many options for addressing the subscapularis muscle. Once properly assessed, this tightened rotator cuff muscle can be released with mobilization, massage, stretching and postural adjustments. The need to understand the specialized location and action of this muscle dictates why the descriptions for accessing this muscle are so specific. Once comfortable working with the subscapularis, practitioners will receive a lot of positive feedback from clients with rotator cuff problems.

Water.

Note that attempting to reduce fat in just one part of your body at a time is likely to be disappointing.

Fat reduction works like this: When you try to lose fat through calorie-burning exercises, the reduction occurs all throughout your body. Unlike muscle-building, it cannot be specifically targeted to one region. Also, the reduction in fat will not be quickly apparent because it will not be focused on only one spot on your body. So it's helpful to have a "slowly but surely" attitude.

Here's a program for the period in which you want to lose weight:

Plenty of moderate aerobic exercise, no sweetened liquids at all, and no junk food at all. Preferably no sugar, and as little added salt and processed foods as possible. Eat 3 small-portioned meals/day; do not skip breakfast; and avoid snacks. Limit your calories (better to consult a doctor or nutritionist concerning the amount), and weigh yourself 2-3 times/week. Ignore the sensation of hunger. If you see your weight diminishing at a safe, reasonable rate (1-2 pounds/week), keep it up.

Once you've reached your target weight, increase your calorie intake somewhat. And you can then have small amounts of sweetened foods or junk food on occasion (if at all), along with your regular foods (not instead of them). But keep checking your weight 2-3 times/week.

Avoid crash diets, diet pills etc. Avoid fatty cuts of meat. Walk as much as possible. Bicycling and swimming are good too.

More guidelines:

Don't concentrate on specific foods so much as on a balanced, healthy diet plus exercise. Plenty of moderate exercise rather than intense exercise, which can damage your joints.

Good nutrition means eating what your body needs, while ingesting as few harmful things as possible. It has also been described as getting enough of each of the major food categories (grains, fruits, vegetables, protein, dairy, etc.; plus plenty of water).

This will vary somewhat from one person to another; and I don't believe that there's any universal diet that can be prescribed for everyone. Avoid best-sellers with their perennial fad diets. And think twice before using any dietary supplements or weight-loss pills.

In general, one's starting point can be a menu of whole grains, whole-wheat bread, a good amount of vegetables, some fruits and nuts, fish, lean meats (in not-large amounts), and some dairy. However, this must be tweaked according to one's health, weight and other factors at the outset; and also adjusted over time, as one sees what works for him/her in particular.