Melvin's Painful Shoulder

By Whitney Lowe
[Clinical Apps]

Melvin is a 29-year-old male client complaining of shoulder pain that has gradually worsened over the last three months. He is physically active and his primary hobby is kayaking, although he does a number of other activities as well. He has a busy work schedule as a veterinarian, so his occupational activities are also physically demanding.
Several months ago, Melvin began feeling pain in his shoulder following a long period of training in preparation for a kayak competition. He describes the pain as primarily in his anterior shoulder region, but claims it is sometimes difficult to pinpoint exactly where the pain is coming from. A number of different activities give him the greatest discomfort, such as reaching overhead, reaching out and lifting, and combing his hair. His primary goal is to get back to a healthy level of activity both at work and in his recreational pursuits. He has regularly used massage for conditioning and relaxation, and wants to know if massage is a good strategy to help him with this complaint.
Key Considerations
We’ve determined Melvin’s key area of pain to be in the anterior shoulder region, so that’s where we’ll focus first. Where a person is feeling pain is not always the primary source of the problem, but it is the best place to begin your investigation.
Melvin described his pain as located in the anterior and lateral region of the shoulder. The inclination may be to consider primarily the anterior and middle deltoid muscles, along with the pectoralis major and minor, as these are the primary muscles in the region where the pain is reported. Yet, we must not fall prey to a common trap of being captivated by our lens of bias. A person’s lens of bias (and we all have one) is the perspective resulting from your learning and experiences.

As massage therapists, our lens of bias may be slanted toward muscular problems because those are what we mainly address. Yet, other tissues such as bursae, joint capsules, ligaments, nerves, or tendons could also be involved. Investigating the potential role these tissues might play in Melvin’s complaint is important.
In Melvin’s situation, we need to investigate key structures such as the pectoralis major and minor, coracoacromial ligament, joint capsule, biceps tendon, and nerves of the brachial plexus, because they are all located in the primary region of his pain (Images 1 and 2).
Assessment and Evaluation
The first and most important physical examination procedure is palpation. Your palpation should never feel like poking or prodding, but gentle and compassionate investigation of the superficial and deep tissues. Palpation is most effective when you visualize the underlying anatomical structures as you evaluate the tissues. Make note of any pain that is reproduced and in what tissues.
When palpating Melvin’s shoulder, we find he has the greatest discomfort on the anterior aspect of his shoulder. The tenderness does not seem to be in the superficial tissues because it is not reproduced with moderately light pressure. The pain does not occur until greater pressure is applied, thereby suggesting it is originating in deeper tissues as opposed to the more superficial anterior deltoid.
The next step is to focus on specific range-of-motion (ROM) evaluations. Active movements are performed first, followed by passive movements, and then resisted actions (manual resistive tests). While it might be helpful to include every motion of the shoulder in each test, that may not be necessary.
It will be more efficient to focus primarily on motions Melvin has already described that cause pain and look at motions that stress other key structures in the anterior shoulder.
In his initial history, Melvin described pain associated with reaching overhead; this motion emphasizes forward flexion or abduction of the shoulder. Paying particular attention to these motions as they are performed with the various active, passive, and resisted procedures will provide more information to work from.
Most of the shoulder evaluation procedures reproduce very little of the pain Melvin was experiencing. He does, however, have pain at the far end of active and passive flexion of the shoulder. The pain is more significant with active movement than passive. There is also some pain felt with resisted shoulder flexion.
After noting which of these tests causes a reproduction of his pain, we can cross-reference these findings with what does not produce pain to see if a clear pattern emerges based on anatomy and biomechanics in the area.
The greatest increase in Melvin’s pain comes with shoulder flexion, and palpation shows pain in the anterior shoulder. These findings call attention to the long head of the biceps brachii (Image 3, page 101). In addition, this muscle-tendon unit is used during active and resisted forward flexion motions of the shoulder. What seems odd is that pain is felt during passive flexion at the end range, as well. If the condition is a muscle-tendon injury, it should not be painful when the muscle and tendon are being passively shortened as they are during forward shoulder flexion. These results follow the findings of our earlier palpation.
However, there are unique anatomical features of the anterior and lateral shoulder region. The biceps brachii tendon is enclosed in a synovial sheath as it courses through the bicipital groove on the anterior humerus. When the shoulder is brought into flexion, especially near the far end range of flexion, the tendon can get compressed against the underside of the acromion process or the coracoacromial ligament. Consequently, this is a unique anatomical situation where a muscle-tendon unit is being stressed (by compression) during a passive shortening movement. Mechanical pinching of the tendon and synovial sheath are producing stress on the tendon, which is why it is also painful during a passive movement.
Due to the nature of his activities and the results from these evaluation procedures (history, palpation, testing), it appears likely that Melvin may be experiencing some type of chronic overuse disorder with the biceps brachii long head tendon or the synovial sheath surrounding the tendon. Chronic overuse of the tendon (tendinosis) is caused by a breakdown in the collagen matrix of the tendon.
The problem could also be in the synovial sheath. Most tendons that have a surrounding synovial sheath are in the distal extremities (wrists, hands, ankles, and feet). The synovial sheath is designed to help reduce friction when the tendon has to make a significant bend across multiple joints. There are very few tendons in other parts of the body that have these sharp angles, but the biceps brachii makes a right-angle turn across the top of the humerus before coursing down the upper arm. As a result, it needs protection from friction against the humeral head or bicipital groove.
Inflammation and irritation sometimes develop between the tendon and the surrounding synovial sheath as a result of overuse. This is a condition known as tenosynovitis. It is similar to tendinosis but with the addition of inflammatory reactions in the tissue, which tendinosis does not include. It may be difficult to determine whether tendinosis or tenosynovitis is the primary problem. Fortunately, for the purposes of massage treatment, these two problems can be addressed in a similar fashion.
Treatment Considerations
Based on the findings from our history and comprehensive assessment, it seems likely that Melvin’s shoulder pain involves a chronic overuse tendon disorder. Now, we should determine if massage is appropriate to address this problem and, if so, how to proceed.
The first step is to determine if there are any reasons we should not perform massage. A chronic tendon overuse pathology should respond well to massage, and there are no significant contraindications in Melvin’s case. It is important to monitor the treatment to ensure there is progress and that no symptoms are being aggravated and no new symptoms or contraindications emerge.
Treatment can begin with superficial work on the deltoid and pectoralis major in order to relax these muscles so that the deeper biceps tendon that lies underneath them may be addressed. A key part of the strategy in Melvin’s case is to reduce tightness in the biceps brachii muscle so it does not pull on the tendon and cause excess friction in the bicipital groove. Deep, longitudinal stripping techniques applied to the biceps brachii are particularly helpful to encourage elongation and reduce chronic tightness in this muscle. Active engagement (AE) lengthening techniques are valuable for addressing the dysfunctions associated with chronic overuse problems. AE lengthening is performed by having the client repeatedly flex and extend the forearm while deep stripping techniques are performed on the biceps brachii each time the forearm moves in extension (Image 4).
This technique is even more effective if there is additional resistance on the biceps from a resistance band, handheld weight, or manual resistance from the therapist (Image 5). The additional resistance recruits a greater number of muscle fibers and allows the stripping technique to address even deeper myofascial layers within the muscle. The additional resistance also reduces the effort the practitioner must expend for deep, effective pressure on the muscle.
Reducing tightness in the associated muscle-tendon unit is of key importance, but the primary pain Melvin is experiencing is likely originating from the biceps tendons and we need to address this tissue as well. Tendinosis is generally treated with deep friction massage, with the goal of stimulating fibroblast activity to encourage collagen rebuilding.
Pressure and movement are the key factors that help encourage fibroblast proliferation. In most cases, friction massage can be performed in a transverse or longitudinal direction. However, when treating the biceps tendon, massage only in a longitudinal direction (Image 6) because it is possible, though uncommon, that deep and vigorous transverse friction could dislodge the tendon from the bicipital groove.
In tenosynovitis, the primary problem is fibrous adhesion between the tendon and surrounding synovial sheath. In this case, deep friction applied directly to the tendon helps break up the adhesion and encourage a free gliding motion between the adjacent tissues. Because there may be some inflammatory reaction associated with this treatment, it is a good idea to be conservative with the friction technique until you find out how the individual client’s tissues respond.
Tendinosis and tenosynovitis are both conditions that commonly linger, so it is unlikely Melvin will see immediate results from just a treatment or two. Although it has been recommended that he refrain from the activities that aggravate his symptoms, he is not able to completely do that in his work. In this case, the goal is to focus on restoration of optimum function while he continues in activity. Now that he understands the type of activities that aggravate the condition, he can attempt to reduce those activities to help the treatment process. It is impossible to know exactly how many treatments will be required to achieve these goals because of individual variables with each client. As treatment progresses, it becomes easier to make estimations on the rate of a full recovery.
In this case, Melvin presented with a shoulder complaint and the cause was not easily identifiable or immediately apparent. The evaluation highlighted how easy it might be to make incorrect assumptions about other, more superficial, tissues being at fault and consequently our treatment would have addressed the wrong tissues and not been successful.
Success in clinical treatment results not from simply applying techniques we’ve learned in a shotgun approach, but by considering the evidence our client presents with and how that fits with recognizable patterns of soft-tissue dysfunction. The conscientious and skilled practitioners who can apply these fundamental concepts most effectively will be the most successful in treating their clients.

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s free enewsletter—and his books, course offerings, and DVDs—at

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