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CHAPTER 26

Subscapularis Muscle

H I G H L I G H T S : S u b s c a p u l a r i s t r i g g e r p o i n t s (TrPs) E X A M I N A T I O N is e x a c t i n g in its t e c h n i q u e , but


are o f t e n t h e k e y to a " f r o z e n s h o u l d e r " s y n - r e w a r d i n g . A b d u c t i o n o f t h e s c a p u l a i s necessary
d r o m e . R E F E R R E D P A I N f r o m TrPs i n t h e s u b - to reach m a n y of t h e TrPs in this m u s c l e . D I F -
scapularis muscle concentrates in the posterior F E R E N T I A L D I A G N O S I S o f s u b s c a p u l a r i s TrPs
d e l t o i d area a n d m a y e x t e n d m e d i a l l y o v e r t h e includes C 7 r a d i c u l o p a t h y, t h o r a c i c outlet s y n -
scapula, d o w n the posterior aspect of the arm, drome, adhesive capsulitis, and "impingement"
a n d t h e n s k i p t o a b a n d a r o u n d t h e w r i s t . T h i s re- s y n d r o m e . T h e p a in a n d restricted range o f m o -
f e r r e d p a i n p r o d u c e s a d i s t i n c t i v e , easily r e c o g - t i o n of a " f r o z e n s h o u l d e r " a n d of t h e s h o u l d e r of
nized pattern. ANATOMY: medially, the sub- a p a t i e n t w i t h h e m i p l e g i a are f r e q u e n t l y c a u s e d
s c a p u l a r i s m u s c l e a t t a c h e s t o t h e inner s u r f a c e o f by subscapularis TrPs that have been over-
t h e s c a p u l a a n d , laterally, t o t h e lesser t u b e r c l e l o o k e d . T R I G G E R P O I N T R E L E A S E o f this m u s -
o n t h e a n t e r i or a s p e c t o f t h e h u m e r u s . F U N C - c l e requires t h a t t h e patient' s a r m b e gradually
T I O N o f t h e s u b s c a p u l a r i s i s chiefly t o h e l p s e - a b d u c t e d a n d laterally r o t a t e d w h i le t h e v a p o -
cure the head of the humerus in the glenoid fossa c o o l a n t or ice is a p p l i e d o v e r t h e lateral chest
d u r i n g a r m m o v e m e n t s , particularl y a b d u c t i o n . I t w a l l , o v e r t h e s c a p u l a , a n d o v e r t h e p a i n pattern
is a c t i v e in m e d i a l r o t a t i o n a n d a d d u c t i o n of t h e o n t h e b a c k o f t h e a r m a n d wrist. T R I G G E R
arm at the shoulder joint. The SYMPTOMS P O I N T I N J E C T I O N requires identification o f t h e
c a u s e d b y s u b s c a p u l a r i s TrPs are primaril y p o s - TrPs f o r injection b y p a l p a t i o n o f t h e s u b s c a p u -
terior s h o u l d e r p a i n w i t h p r o g r e s s i v e painful r e - laris f i b e r s against t h e s c a p u l a a n d requires a
s t r i c t i o n o f a b d u c t i o n a n d lateral r o t a t i o n o f t h e longer n e e d l e t h a n u s u a l . W i t h p r o p e r p o s i t i o n i n g
arm. ACTIVATION AND PERPETUATION OF o f t h e p a t i e n t , careful t e c h n i q u e , a n d f o l l o w - u p
TRIGGER POINTS in this muscle are often s t r e t c h , injection of t h e TrPs is safe a n d effective.
caused b y c h r o n i c m u s c u l a r strain or sudden T h e p r e s e n c e of s p a s t i c i t y a n d TrPs in patients
t r a u m a t o t h e shoulder. P A T I E N T E X A M I N A T I O N with hemiplegia deserves special consideration.
identifies i n v o l v e m e n t of this m u s c l e by a m a r k e d C O R R E C T I V E A C T I O N S include avoidance of
r e c i p r o c a l limitation of either a b d u c t i o n or lateral p r o l o n g e d s h o r t e n i n g o f t h e m u s c l e b o t h a t night
rotation of t h e arm at the glenohumeral joint and and during the daytime, avoidance of a
an even greater restriction of the combined " s l u m p e d " f o r w a r d p o s t u r e , a n d regular use o f
movement. The humeral attachment of the mus- t h e I n - d o o r w a y S t r e t c h Exercise a t h o m e .
cle is often tender to palpation. T R I G G E R P O I N T

1. REFERRED PAIN pain and tenderness around the w r i s t . 55,61

(Fig. 26.1) The dorsum of the wrist is usually more


Subscapularis trigger points (TrPs) cause painful and tender than the volar surface.
severe pain both at rest and on motion of
the upper limb. The essential zone of the re- 2. ANATOMY
ferred pain pattern lies over the posterior (Fig. 26.2)
aspect of the shoulder (Fig. 26.1). Spillover The connection of the subscapularis to
reference zones cover the scapula and ex- the humerus is the most anterior attach-
tend down the posterior aspect of the arm to ment of the four muscles that form the ro-
the elbow. A diagnostically useful accent, tator cuff; the others are the supraspinatus,
when present, is a strap-like area of referred infraspinatus and teres minor muscles. 4

596
Chapter 26 / Subscapularis Muscle 597

Medially the subscapularis attaches to fossa.7, 14


Because the deltoid muscle at-
most of the inner (anterior) surface of the taches to the proximal portion of the
scapula, filling the subscapular fossa from humerus, during abduction the vertical vec-
the vertebral to the axillary border of the tor tends to pull the head of the humerus up-
scapula (Fig. 26.2). Laterally it passes ward out of the glenoid fossa and against the
across the front of the shoulder joint via a acromion. During abduction, the depressor
tendon that attaches to the lesser tubercle action of the subscapularis contributes a
on the anterior (ventral) aspect of the major force to counteract this upward dis-
humerus and to the lower half of the cap- placement caused by the deltoid. This sta-
25

sule of the shoulder joint, blending with bilizing function of the subscapularis was
the capsule. The location of this attach-
14
substantiated by electromyographic (EMG)
ment to the humerus in relation to the at- activity of the subscapularis that increases
tachment of other shoulder-girdle muscles during abduction from 0° to 90°, plateaus
is illustrated in this volume (see Fig. 29.4) from 90° to 130°, and rapidly diminishes
and elsewhere. The large subscapular
17
from there to 180° as the deltoid no longer
bursa, which usually communicates with exerts an upward displacement force. The 25

the cavity of the shoulder joint, separates subscapularis is active in forward swing of
the tendon of the subscapularis muscle and the arm during walking. 4

the underlying joint capsule medially. 13


Electrical stimulation of the subscapularis
Supplemental References elicits strong medial rotation of the arm at the
shoulder. When a strongly shortened sub-
19

Other authors illustrate the subscapu-


scapularis muscle maintains medial rotation
laris muscle as seen from the front, but
of the arm, it is not possible to fully supinate
partially covered by overlying struc-
the hand of the outstretched upper limb be-
tures. from the front with an unob-
2,16,18,34

cause of the restricted lateral rotation at the


structed v i e w , from below, from the
52,54 1

shoulder. In this way, subscapularis TrPs


19

side, and in cross section.


53 3,43

can indirectly impair function at the hand.


3. INNERVATION
The muscle is innervated by the supe- Although the records of 12 subjects
rior and inferior subscapular nerves, throughout a right dominant golf swing
through the posterior cord of the brachial were highly variable, the mean EMG activ-
plexus from spinal nerves C and C . 5 6
15,26,29 ity of the right subscapularis muscle began
The superior subscapular nerves (usually at takeaway with only 1 5 % of the maxi-
two of them) enter the more horizontal, su- mum activity elicited by manual muscle
perior part of the subscapularis muscle. strength testing. The activity increased to
The inferior subscapular nerve enters the 6 5 % during acceleration, and subsided
more distal part of the subscapularis mus- slightly thereafter. The left subscapularis
cle and ends in the teres major muscle. muscle maintained a moderate amount of
This innervation pattern suggests that the activity during the swing, ranging around
subscapularis muscle is composed of at 3 0 % of the maximum test activity.44

least two compartments, each of which A similar study of men and women pro-
would have its individual endplate fessional golfers reported a very similar
27

zone-an important point when performing pattern bilaterally for women golfers;
motor point blocks or injecting TrPs.
24 however, the male subjects showed activ-
ity on the right side that started with
4. FUNCTION mean takeaway activity at only 1 2 % of
The subscapularis muscle adds to stabil- maximum test activity, increased to 8 0 %
ity of the glenohumeral joint by helping to by the time of the acceleration phase, and
maintain the head of the humerus in the maintained that level of EMG activity
glenoid fossa. It helps to prevent anterior throughout the remainder of the swing.
displacement of the humerus. The left subscapularis muscle in men, like
Acting alone, the subscapularis medially both sides in women, maintained a mean
rotates and adducts the a r m , and helps to
7,29 of approximately 4 5 % throughout all 5
hold the head of the humerus in the glenoid phases of the golf swing. 27
598 P a r t 3 / U p p e r B a c k , Shoulder, a n d A r m Pain

Figure 2 6 . 1 . Referred pain pattern projected from t w o lateral trigger points and a more medial trigger area
(Xs) in the right subscapularis muscle. The essential referred pain zone is solid red; the spillover zone is stip-
pled red. Portions of the second through the fifth ribs have been removed for clarity.

Figure 26.2. Attachments of the right subscapularis muscle, as seen from the front with the arm laterally ro-
tated. Parts of ribs t w o through five have been removed for clarity.
Chapter 26 / Subscapularis Muscle 599

Fine wire EMG recordings of qualita- is strongly synergistic with it. Both the
tive subscapularis muscle activity during latissimus dorsi and pectoralis major also
freestyle swimming in 14 subjects, with a adduct and medially rotate the arm, and
painful shoulder, were compared with a
51
thus can act synergistically with the sub-
previous study of 12 pain-free shoulders. scapularis, but these muscles attach to the
Subjects with painful shoulders showed a trunk rather than to the scapula.
pattern similar to normal subjects until The arm-rotation function of the sub-
the recovery phase, when average activity scapularis is opposed primarily by the infra-
was only half that of normal values. In spinatus and teres minor muscles. However,
this phase, the subscapularis puts the these three muscles work together to hold
shoulder in the painful position of medial the head of the humerus in the glenoid fossa
rotation (which is when strong contrac- during elevation movements of the arm.
tion of that muscle would be painful if it
had active TrPs). The swimmer may be
6. SYMPTOMS
avoiding that pain.
In the early stage of myofascial involve-
The EMG activity of the subscapularis
ment of the subscapularis, patients can
muscle in 15 skilled throwers with shoul-
reach up and forward, but are unable to
der girdle symptoms and chronic anterior
reach backward with the arm held at shoul-
instability of the shoulder was compared
der level, as when starting to throw a ball.
to that of 12 healthy, skilled throwers. In
22

With progression of TrP activity, abduction


healthy subjects, during wind up, the sub-
at the shoulder becomes severely restricted
scapularis muscle exhibited only 5% of
to 45° or less. These patients complain of
the amount of EMG activity recorded dur-
pain both at rest and on motion, and of in-
ing manual muscle testing, but during late
ability to reach across to the opposite
cocking it reached a mean value of 147%
armpit. The patient has often been told that
of the test value. Subscapularis activity
he or she has a "frozen shoulder," adhesive
increased to 1 8 5 % of test value during ac-
capsulitis or "pitcher's arm." When asked
celeration, and still averaged 97% during
about the wrist, the patient often says that
follow-through. The athletes with painful
it is sore and painful in a strap-like area,
shoulders started out with normal values,
especially on the dorsum. Because of this
but reached only one-third of normal val-
referred tenderness, the patient may move
ues during late cocking and half of normal
the wristwatch to the opposite wrist.
values during acceleration and follow-
through. The authors considered this Active TrPs are a major source of the
marked difference in neuromuscular con- pain and limited shoulder motion, espe-
trol to be a factor in producing or main- cially abduction and lateral rotation, in pa-
taining chronic anterior instability. How- tients with hemiplegia. The TrP shortening
ever, they offered no satisfactory also contributes to subluxation of the head
explanation for the marked inhibition of of the humerus.
subscapularis activity and apparently had
not considered treatable myofascial TrPs 7. ACTIVATION AND PERPETUATION
as a possible major contributor to the OF TRIGGER POINTS
problem.
Subscapularis TrPs are activated in the
These studies illustrate an important following ways:
principle: The EMG activation of a mus-
cle can be remarkably different under test 1. By unusual repetitive exertion requiring
conditions compared to meaningful, forceful medial rotation when the sub-
well-learned activity. This effect can be ject is out of condition, as in the over-
very strong in a muscle inhibited reflexly head stroke of the crawl during swim-
by active TrPs in a functionally related ming, or pitching a baseball
muscle. 23
2. Due to repeated forceful overhead lifting
while exerting strong adduction, as
5. FUNCTIONAL UNIT when swinging a small child back and
The teres major most nearly matches the forth, from between an adult's legs, up
functions of the subscapularis muscle and overhead, and down again
600 P a r t 3 / U p p e r B a c k , Shoulder , a n d A r m Pain

3. By the sudden stress overload of reaching tion of the arm. The arm is medially ro-
back at the shoulder level to arrest a fall tated when the hand touches the abdomen
4. When the muscles are stressed by dislo- and performs 90° of lateral rotation of the
cation of the shoulder joint arm at the glenohumeral joint when the
5. At the time of fracture of the proximal hand points laterally away from the body.
humerus, or tear of the shoulder joint Involvement of the teres major, anterior
capsule deltoid, and lower fibers of the pectoralis
6. By prolonged immobilization of the major also can produce some of this limita-
shoulder joint in the adducted and me- tion of lateral rotation, but not as severely
dially rotated position. or consistently as the subscapularis. A
These TrPs are perpetuated by repetitive lesser degree of subscapularis involvement
movements requiring medial rotation of can be detected if the muscle refers pain in
the humerus. A "slumped" forward-head, its characteristic pattern to the back when
abducted-scapulae posture can perpetuate the arm is fully flexed in lateral rotation at
these TrPs by fostering sustained medial the shoulder. This referred pain from sub-
rotation of the humerus. Refer to Chapter 4 scapularis TrPs may be encountered when
of this volume for specific systemic and the arm is placed in this position to stretch
mechanical perpetuating factors. and spray the long head of the triceps. 47

The humeral attachment of the sub-


8. PATIENT EXAMINATION scapularis (Fig. 26.2) is often very tender to
Lateral rotation is a prerequisite for full palpation due to secondary enthesopathy
elevation (abduction and flexion) of the when there is chronic TrP involvement of
humerus; TrPs in the subscapularis muscle the muscle. To examine this attachment,
restrict lateral rotation. the arm is placed by the side and laterally
When examining a shoulder with re- rotated as the patient tries to bring the el-
stricted abduction, one of the first questions bow behind the plane of the back. This ro-
that should be answered is the freedom of tates the humeral attachment to the front of
scapular mobility as distinguished from the shoulder, where it can be more readily
glenohumeral movement. This difference palpated (Fig. 26.2).
can be detected by placing the hand on the To eliminate articular dysfunction as a
scapula to note its movement as the arm is contributing cause of the patient's pain, the
abducted. Involvement of only the sub- glenohumeral and acromioclavicular joints
scapularis muscle restricts glenohumeral should be examined for restriction of nor-
movement, but does not restrict scapular mal joint play, and also the wrist articula-
36

movement on the chest. Restriction also of tions, if the patient's pain includes that re-
scapular mobility makes one think of addi- gion. If this type of movement restriction is
tional TrPs in the pectoralis minor, serratus present, it should be released. Unrestricted
anterior, trapezius, and rhomboid muscles. range of motion of the arm also requires nor-
When only the subscapularis muscle is mal mobility of the sternoclavicular joint.
shortened and taut, abduction and lateral
rotation at the shoulder are reciprocally 9. TRIGGER POINT EXAMINATION
limited; one movement can be traded for (Figs. 26.3 and 26.4)
the other, which is easily demonstrated. If To determine the most useful diagnostic
the patient has moderately active sub- criteria, Gerwin, et al. tested the reliabil-
21

scapularis TrPs, abduction of the arm at the ity with which four experienced and
glenohumeral joint is limited to about 90°, trained examiners could identify five char-
and when the forearm hangs down, the acteristics of TrPs. The four consistently re-
shortened muscle tends to medially rotate liable characteristics were the presence of a
the arm. No lateral rotation of the arm at taut band, the presence of spot tenderness,
the shoulder joint is possible in the ab- the presence of referred pain that is felt at
ducted position. However, with the arm a distance from the point of stimulation,
adducted by placing the elbow at the side and reproduction of the subject's sympto-
and with the elbow bent at 90° to show matic pain. Determination of the presence
shoulder joint rotation, the forearm can or absence of a local twitch response (LTR),
swing outward to nearly 90° of lateral rota- although very helpful diagnostically when
Chapter 26 / Subscapularis Muscle 601

observed, was reliably identified only in Figure 26.4C, illustrating the increased ac-
the most accessible and readily palpated cessibility of the subscapularis by abduct-
muscles. The subscapularis is one of the ing the scapula.
more difficult muscles to examine reliably To reach the TrPs frequently located
for LTRs. along and superior to the lateral margin of
There are two common lateral TrP loca- the muscle, the palpating finger slides into
tions and a medial trigger area in the sub- the space between the serratus anterior,
scapularis muscle (Fig. 26.1) The most ac- which lies against the chest wall along the
cessible lateral TrPs are found in the back of the finger, and the subscapularis
relatively vertical fibers which lie inside muscle, beneath the finger on the underside
the lateral border of the scapula on the ven- of the scapula (Fig. 26.3). To reach the su-
tral aspect. Lange identified only this
31
perior TrP area, the finger is directed cepha-
more accessible site. The other lateral TrP lad and toward the coracoid process of the
region lies superior to the first and is more scapula to locate a large firm band of mus-
difficult to reach. It lies in the nearly hori- cle fibers in the TrP area. Sustained, light-
zontal bundle of fibers that extend across to-moderate pressure on an active sub-
the scapula (Fig. 26.2). The third location scapularis TrP will reproduce the patient's
is the trigger area along the vertebral bor- posterior shoulder and scapular pain, occa-
der of the scapula where the subscapularis sionally with a referred twinge in the wrist.
muscle attaches to the vertebral half of the Local twitch responses are sometimes seen.
inner (ventral) surface of that bone. A ten- When detected, LTRs are more likely to be
der spot that refers pain from this part of felt with the palpating finger than seen, and
the muscle may represent enthesopathy they are strongly confirmatory of (but not
secondary to primary midfiber TrPs. essential for) a TrP diagnosis in this muscle.
When the patient has become fully re- In thin supple patients, more direct con-
laxed, the examiner first abducts the arm of trol of the scapula is obtained if the exam-
the supine patient away from the chest iner hooks the fingers of the nonpalpating
wall to the onset of tissue resistance, to 90° hand directly around the vertebral border
if possible. Patients with marked shorten- of the scapula and pulls the scapula later-
ing of the subscapularis muscle due to very ally, away from the midline of the body.
active TrPs may not tolerate abduction of In patients with severe subscapularis in-
the arm beyond 20° or 30°. Figure 26.3 volvement, deep tenderness in the muscle
shows the relationship of the subscapularis is usually so exquisite that the patients can
muscle to the scapula, the latissimus dorsi, tolerate only very light digital pressure on
teres major and to other adjacent muscles. the muscle. Normal subscapularis muscles
If the arm cannot be abducted sufficiently palpated in this way are not tender. How-
for examination, sufficient release of the ever, an inadequately trimmed fingernail
subscapularis may be achieved by using on the palpating finger will cause confus-
the hold-relax or the contract-relax tech- ing severe skin pain. The skin should show
nique (see Chapter 3, Section 12). Ade- no fingernail marks following palpation.
quate abduction (lateral displacement) of Palpation for tenderness in the sub-
the scapula is necessary to bring the ven- scapularis trigger area of enthesopathy on
tral (inner) surface of the scapula and its the ventral aspect of the vertebral border of
subscapularis muscle within reach for pal- the scapula is complicated by two facts.
pation. For most examiners and subjects it is un-
Next, the examiner grasps the latissimus reachable anterior to the scapula when ap-
dorsi and teres major muscles (Fig. 26.3) in proached from the lateral border of that
a pincer grip (Fig. 26.4A and B) and locates bone. It is also very unlikely that one can
the hard edge of the scapula with the tips palpate the subscapularis muscle along the
of the digits. Traction must be maintained vertebral border of the scapula. The exam-
on the humerus to abduct the scapula ade- iner must palpate through a relatively thick
quately (arrow in Fig. 26.4B shows direc- trapezius muscle, the rhomboid muscle
tion of pull). The phantom finger "C" in layer, and the serratus anterior muscle,
Figure 26.4B locates the same portion of which all attach along that border of the
the subscapularis as is being palpated in scapula and are also subject to enthesopa-
602 Part 3 / Upper Back, Shoulder, and A r m Pain

Coracobrachialis
Biceps Deltoid
Pectoralis major

Triceps

Latissimus
dorsi
Teres major

Subscapularis

Serratus
anterior

Figure 26.3. Relation of the subscapularis muscle (dark red) to the surrounding muscles (lighter red) when the
scapula (shown as a vertical white line) has been pulled away from the chest wall by the examiner (compare
with Fig. 26.2).

thy. In this region, tenderness to palpation activity in other shoulder-girdle muscles.


alone does not identify which muscle is re- When the subscapularis TrPs become suffi-
sponsible for it. ciently active, the pain-induced restriction
of motion at the shoulder joint becomes se-
vere. Then, functionally related muscles
Related Trigger Points quickly become involved (Section 5), so
When there is moderate TrP involve- that many, or most, of these muscles de-
ment of the subscapularis muscle, the pa- velop active TrPs. Motion at the shoulder is
tient's arm movement may be restricted by then "frozen." Autonomic trophic changes
this muscle alone without associated TrP are likely to follow.
Chapter 26 / Subscapularis Muscle 603

Figure 26.4. Examination of the subscapularis mus-


cle. A, pincer grasp of the latissimus dorsi and teres
major muscles demonstrates the inaccessibility of
the subscapularis with the scapula in its usual rest-
ing position. B, same grasp as in Part A, with the
scapula pulled away from the chest wall (arrow) to
make the subscapularis muscle more accessible for
palpation. The dashed line indicates where the
thumb is pressed against the bony edge of the
scapula. The phantom finger, " C , " shows how far the
finger position in Part C extends beyond the edge of
the scapula to palpate the subscapularis muscle.
C, direction of the finger movement to reach the
most cephalad of the two trigger point areas near
the lateral border of the scapula.
604 P a r t 3 / U p p e r B a c k , Shoulder, a n d A r m P a i n

The pectoralis major tends to develop good reason to expect that a major etiologic
these additional TrPs early, probably due to factor is being overlooked. The two criteria
the restriction of its normal range of mo- commonly used to diagnose "frozen shoul-
tion. The teres major, latissimus dorsi, and der" also identify two key effects of active
the long head of the triceps brachii are of- subscapularis muscle TrPs. Unfortunately,
ten next to develop additional TrPs. The the available literature indicates that TrPs
anterior part of the deltoid soon becomes are rarely considered when making the di-
involved. When TrPs occur in all these agnosis of "frozen shoulder." The same lit-
muscles, none reach full length and can se- erature and clinical experience suggest that
verely limit all movement at the shoulder. TrPs may be a major factor in producing
the symptoms, which is why the subject is
10. ENTRAPMENT reviewed here. To better understand the
No nerve entrapments have been attrib- source of "frozen shoulder" symptoms,
uted to this muscle. two issues are considered: adhesive cap-
sulitis and myofascial TrPs.
11. DIFFERENTIAL DIAGNOSIS Adhesive Capsulitis. Recent literature
Rotator cuff tears, adhesive capsulitis, frequently describes and treats "frozen
C radiculopathy, a thoracic outlet syn-
7 shoulder" as if it were synonymous with
drome, or an impingement syndrome can what is commonly identified as adhesive
cause shoulder pain that is not due to sub- capsulitis. Other authors treat the two
scapularis TrPs. On the other hand, sub- terms as explicitly synonymous. Most pa- 49

scapularis TrPs can mimic these conditions tients with "frozen shoulder" will respond
and must be considered, if any of them are to nonoperative treatment. Weber et al. 45 60

suspected. The subscapularis is one of the observed that spontaneous recovery usu-
four muscles that contribute to the myofas- ally occurs within 30 months. Other au-
cial pseudothoracic outlet syndrome, thors also found that it usually is self-lim-
which is considered in Chapter 18 and in ited, but approximately 1 0 % of patients
Chapter 20, Section 11. The major contri- had long-term problems. 40

bution of subscapularis TrPs to the pain


and restricted range of motion of the shoul- Some authors consider arthrographic
der in hemiplegia is often overlooked and findings to be diagnostic of adhesive cap-
is discussed in this section. The "frozen sulitis.
33, 37,
The arthrogram contrast
38

shoulder" is covered in detail below. medium shows that the normally rounded
outline of the capsule is replaced by a
"Frozen Shoulder" squat, square contracted patch. The redun-
The descriptive term "frozen shoulder" dant fold at the inferior portion of the
is not a specific diagnosis and frequently is joint, which normally hangs down like a
based only on the presence of a painful pleat, is obliterated. More recently, Rizk et
5

shoulder that exhibits restricted range of al. identified restrictions of joint volume,
49

motion. The term has been identified with serration of the bursal attachments, failure
several categories of disease: neurologic to fill the biceps tendon sheath, and partial
(hemiplegia, shoulder-hand syndrome ),
49 57 obliteration of subscapular and axillary re-
idiopathic (an idiopathic c a p s u l i t i s ), 20,57,59 cesses. These findings associate adhesive
rheumatologic (periarthritis or periarticu- capsulitis with the long head of the biceps
lar a r t h r i t i s , acromioclavicular arthri-
10,30 brachii and the subscapularis muscles.
t i s ) , and adhesive capsulitis, which has
5,38
The procedures recently reported for
characteristic objective f i n d i n g s of un-5,49
treatment of the adhesive capsulitis cate-
known etiology. The label "frozen shoul-
57
gory of "frozen shoulder" include forceful
der," when presented as the diagnosis that manipulation to release adhesions (usu-
accounts for the patient's symptoms, serves ally under general anesthesia, some-
35,45,60

as a warning that the patient is in need of a times with only local anesthesia ), force- 20

more specific diagnosis. ful extension (pressurization) of the


When so many authors agree that the capsule, (sometimes to the point of
20,40

cause of a disease is enigmatic, there is rupture ), division of the subscapularis


49
Chapter 26 / Subscapularis Muscle 605

tendon, 40
resection of inflammatory syn- spasm of the subscapularis, with trigger
ovium between the supraspinatus and points, accompanies frozen shoulder from
subscapularis attachments, excision of
40
the outset." The "frozen shoulder" litera-
the coracohumeral ligament, 9
arthro- ture often refers to the importance of trying
scopic excision of the rotator interval of conservative therapy first and frequently
the capsule or release of the anterior cap-
9
identifies physical therapy or physical
sule. The reports by these authors indi-
59
therapeutic techniques as an essential part
cate that, to them, the source of the irrita- of that conservative t h e r a p y .
35,45,57,59

tion that caused the adhesions being The reason the shoulder becomes so
treated remains enigmatic. painful and "frozen" when a patient devel-
Many of the above-listed procedures ops subscapularis TrPs is that so many
implicitly or explicitly identify the bursae other shoulder-girdle muscles also become
and or tendons of the supraspinatus and involved, adding their pain patterns and
subscapularis muscles as being closely as- restriction of movement. The other TrPs
sociated with the adhesive restriction of are easier to identify than are subscapularis
joint movement. Rizk, et al. reported
49
TrPs and are often inactivated with at least
treatment of 16 patients with idiopathic temporary improvement; but until the pri-
adhesive capsulitis by arthrographic dis- mary cause (subscapularis TrP involve-
tention and rupture of the joint capsule. ment) is identified and corrected, symp-
Only those patients whose posttreatment toms will persist.
arthrograms showed iatrogenic capsular Specific identification of subscapularis
tears at the subscapular bursa or at the TrPs as a focus of therapeutic attention is
subacromial bursa experienced sudden re- rarely mentioned in the literature, and no
lief of pain during the procedure. Among controlled research studies could be found
the 3 patients not experiencing sudden re- that specifically addressed the TrP compo-
lief of pain, two had a distal bicipital nent of "frozen shoulder." Many clinicians
sheath rupture, and one had subscapular agree that subscapularis TrPs can be re-
rupture. The coracohumeral ligament also sponsible for the symptoms of "frozen
has a muscular relationship because it at- shoulder" and can be simply and effec-
taches to the rotator cuff in conjunction tively treated. 8,32
However, in the current
with the supraspinatus tendon. 13
climate of managed health care, clinical
When restriction persists after the success is not sufficient; competent re-
inactivation of TrPs in muscles that search substantiation is essential.
could be responsible for the restricted In addition, it is quite likely that TrPs in
range of motion, or if there is arthro- the supraspinatus or subscapularis mus-
graphic evidence of adhesive capsulitis, cles can be a major factor in the develop-
the antifibrotic medication, Potaba® ment of adhesive capsulitis. The supra-
(aminobenzoate potassium-a member of spinatus muscle, as noted in Chapter 2 1 , is
the B vitamin complex) manufactured by prone to develop enthesopathy or enthesi-
Glenwood, Inc. may be administered. Its tis. Since the humeral tendinous attach-
effectiveness is related to adequate ment region of the subscapularis is not so
dosage (12 g/day taken as 0.5 g capsules accessible to direct palpation, its tendency
or tablets in divided doses either four or to develop enthesitis is not so well recog-
six times daily) and to sufficient duration nized. The humeral attachment of the sub-
of medication (usually a minimum of 3 scapularis tendon lies in close approxima-
months). tion to the subscapular bursa. As noted
above, adhesions within the subscapular
Relation to Trigger Points. The primary bursa were identified as a major compo-
symptoms of "frozen shoulder"—pain in nent of adhesive capsulitis. It is possible
the shoulder region and restricted range of that a chronic enthesitis of the subscapu-
motion—are also primary symptoms of ac- laris muscle adjacent to its bursa could in-
tive subscapularis muscle TrPs. Lewit 32 duce an inflammatory reaction that could
voiced the observation of many clinicians then induce fibrosis of the bursa which re-
skilled at identifying TrPs that "painful quires forceful manipulation, inflation of
606 P a r t 3 / U p p e r B a c k , Shoulder, a n d A r m P a i n

the bursa, or arthroscopic surgery to release of the subscapularis muscle in patients


it. In this case, this stage of fibrosis could with painful hemiplegic shoulders. Range
be prevented by prompt recognition of the of motion improved markedly: 4 2 % for lat-
subscapularis TrPs when they first de- eral rotation and 2 2 % for flexion of the arm
velop. Treating these acute TrPs promptly at the shoulder. All patients indicated less
and effectively would prevent much subse- pain in the original arc of motion but still
quent pain, disability, and expense. had pain at the new extremes of range of
Similar considerations apply to supra- motion. The effect of block lasted 3-5
spinatus TrPs and enthesitis of the supra- months. This treatment would also
spinatus tendon in the region where it serendipitously inactivate the active loci of
blends with the joint capsule. Both the TrPs in motor endplates that were injected.
subacromial bursa and the coracohumeral Botulinum A toxin has been success-
ligament lie in close approximation to this fully used for treating spasticity in upper
region of supraspinatus attachment. limb muscles of patients with strokes. It 6

Well-designed research studies explor- has several potential advantages over phe-
ing the TrP component of "frozen shoul- nol. Its toxicity is specific to motor end-
der" should help improve recognition of plates, it has no effect on sensory nerves so
one important etiology of this condition it is not prone to painful sequelae, and it
and help to resolve much of the enigma as- should be equally effective for treatment of
sociated with it. spasticity and TrPs in the subscapularis
muscle. Most patients with hemiplegia
The Subscapularis Muscle in Hemiplegia who have shoulder pain and restricted
A very common and distressing problem range of motion suffer spasticity, TrPs, or
of patients with hemiplegia is pain and both conditions in the subscapularis mus-
loss of range of motion at the shoulder, cle. Both conditions need therapeutic at-
which are usually attributed to spasticity, tention and both respond to the same treat-
but which also are cardinal features of sub- ment. Botulinum A toxin is administered
scapularis muscle TrPs. by much the same technique as that used
One study reported an attempt to iden-
28 for phenol block when primarily con-
tify the source of shoulder pain in patients cerned about spasticity, and administered
with hemiplegia by testing the degree of as- by looking for active loci to inject when
sociation of variables and by injecting 28 primarily concerned with TrPs. For either
patients with a local anesthetic in the sub- condition, this toxin is effective only when
acromial area where they complained of it is injected where endplates are located.
pain. The author made no mention of TrPs, Although clinicians skilled in the iden-
but reported that patients with better sen- tification of TrPs are impressed with how
sation tended to have lateral shoulder pain commonly subscapularis TrPs in hemi-
with radiation to the arm (Fig. 26.1). The plegic patients are a major contributor to
pain was related most to loss of motion and both their pain and loss of shoulder range
NOT to spasticity, subluxation, loss of of motion, no controlled research studies
strength, or sensation. The subacromial in- of the clinical effectiveness of this thera-
jection resulted in moderate to marked re- peutic approach were found. Research
lief in nearly 5 0 % of cases ("dramatic" re- studies conducted by experienced clini-
lief in some cases), suggesting that in those cians who are trained in how to identify
cases, the source of pain had been ad- and treat TrPs are urgently needed.
dressed. Dramatic relief may have been
28

the result of injecting a region of 12. TRIGGER POINT RELEASE


supraspinatus enthesopathy, and the fail- (Fig. 26.5)
ure of relief in other cases may have been Joint play should be restored if it is re-
the result of having overlooked a con- stricted in the glenohumeral, acromiocla-
tributing TrP in the subscapularis muscle vicular, and sternoclavicular joints. 36

(or in the supraspinatus muscle). To release subscapularis trigger points


A pair of s t u d i e s reported the suc-
12,24
(TrPs) using spray and release, the patient
cessful use of phenol for motor point block lies relaxed in the supine position. The op-
Chapter 26 / Subscapularis Muscle 607

erator first applies a few initial sweeps of crease in volitional range of motion, but
spray (Fig. 26.5A) and then abducts the they were apparently unaware of TrPs.
arm by taking up slack as it develops, hold- Osteopathic techniques are often ap-
ing the arm in the neutral position between plied to release tight muscles in a general
medial and lateral rotation. This provides sense, but are rarely identified for the pur-
an opening in the axilla for entry of the pose of releasing TrPs in a specific muscle.
spray. The operator continues to laterally Two techniques could be helpful for re-
rotate the arm to the position of Figure leasing TrP tension in the subscapularis
26.5A as slack develops and then abducts muscle, but likely would be more benefi-
it to the position of Figure 26.5B; the cial if they were modified to more effec-
vapocoolant spray is again swept upward tively release the subscapularis muscle.
over the fold of the axilla (Fig. 26.5B). The One is the Spencer technique as illustrated
patient's body weight helps to fix the with abduction and lateral rotation, and42

scapula. Further subscapularis range of the other is the integrated neuromuscu-


motion is gradually obtained by additional loskeletal technique for the upper limb and
abduction and lateral rotation of the arm. shoulder, subject prone. 58

The operator places the patient's hand suc- When other shoulder muscles also are
cessively under the head, then under the involved—especially the teres major, latis-
pillow, and finally over the head of the bed simus dorsi, pectoralis major, and anterior
(Fig. 26.5C). To achieve the full effective- deltoid—the full range of abduction and
ness of the spray in this position, the pa- lateral rotation at the shoulder may be
tient's body is turned and supported suffi- blocked until these other muscles are re-
ciently in a relaxed position to sweep the leased. When full lateral rotation is ap-
vapocoolant over the dorsal surface of the proached during abduction, the unaccus-
scapula, including its vertebral border. tomed shortening may cause shortening
In cases of severe involvement and activation (reactive cramping) of the
great sensitivity to muscle activity and supraspinatus muscle, an antagonist of the
stretch, it may be necessary to begin re- subscapularis. This activation of the
lease with the shoulder submerged in supraspinatus latent TrPs may cause sud-
tepid water where the load of gravity is den, severe pain referred to the shoulder,
removed and small movements are well but can be prevented or relieved if the
tolerated. supraspinatus muscle is promptly length-
Other noninvasive techniques for re- ened and sprayed.
lease of taut bands in the subscapularis One may think of the release of these
muscle include trigger point pressure re- successively activated muscles as unravel-
lease, deep massage to taut bands that can ling the history of the condition, much as
be accessed, hold-relax and contract- one unwinds layers of a bandage, with the
relax, and other methods of myofascial
56
subscapularis as the initial layer.
manipulation as described by Cantu and In hemiplegic patients, spray and re-
Grodin. Application of vapocoolant or ic-
11
lease are likely to provide only temporary
ing can precede any of these techniques. benefit in the acute phase, or if there is
Nielsen described treatment of sub-
39
resting spasticity. There is no contraindica-
scapularis TrPs by using stretch and spray, tion to the application of spray and release
and Lewit described release using grav-
32
several times a day, and it can provide
ity-assisted postisometric relaxation. much relief of pain. After several months,
Chironna and Hecht 12
reported two and with no resting spasticity, TrP release
cases of shoulder pain with restricted can lead to lasting relief of pain and to per-
range of motion that they ascribed only to manent improvement in the range of shoul-
spasticity which they successfully treated der motion.
with motor point block of the subscapu- Spray and release are followed at once
laris muscle using phenol. They noted that by hot packs, then by active range of mo-
their treatment (which incidentally would tion exercises, and finally by the middle
effectively inactivate TrPs in that muscle) hand-position of the In-doorway Stretch
inexplicably resulted in immediate in- Exercise (see Fig. 42.9).
Figure 26.5. Stretch position and spray pattern (ar- cle. The involved side of the chest can be turned up,
rows) for trigger points in the subscapularis muscle. away from the table, sufficiently for the spray to cover
A, initial stretch position. B, intermediate stretch posi- all of the skin that overlies the subscapularis posteri-
tion that is reached as the taut bands of the TrPs par- orly, but with the body supported in a way that does
tially release. C, full stretch of the subscapularis mus- not lose full relaxation of the patient.
Chapter 26 / Subscapularis Muscle 609

13. TRIGGER POINT INJECTION If pain remains after the inferior TrPs
(Fig. 26.6) along the lateral scapular border have
been inactivated, the lateral TrP in the supe-
If trigger point (TrP) tenderness, pain, rior region shown in Figure 26.1 may be re-
and restriction of movement remain after sponsible. These TrPs lie in the thick band of
noninvasive treatment by spray and re- fibers that arch across the middle of the mus-
lease, precise injection of the active TrPs cle and attach to the vertebral half of the
may be effective. The patient lies supine in scapula. These fibers are shown between the
the same position as that used for vapo- posterior cut ends of ribs four and five in Fig-
cooling, with the arm abducted. If suffi- ure 26.2.
cient abduction is not available to provide The TrP injection is followed immediately
room for performing the injection, TrP re- by spray and release, and then a hot pack to
lease techniques should be applied to pro- warm the skin over the subscapularis.
vide it. The patient's hand is placed under When a patient with hemiplegia has a
the pillow, or with the wrist at shoulder subscapularis muscle with both spasticity
level (Fig. 26.5A), if that is as high as it will and active TrPs, this is one valid indication
go. The patient's body weight holds the for injection of the motor endplate zone with
scapula in position after it is pulled later- botulinum A toxin while looking specifically
ally (Fig. 26.4B and C). The active TrP site for TrPs (identified by LTRs and/or EMG ac-
to be injected is located and fixed between tivity characteristic of active loci of TrPs as
the fingers. A 6- or 7.5-cm (2 1/2- or 3- described in Chapter 2). This injection
inch), 22-gauge needle is inserted between should be done under EMG guidance with a
the examiner's fingers into the depth of the Teflon-coated hypodermic needle specifi-
axillary fossa (Fig. 26.6). The needle is di- cally made for botulinum A injections.
rected parallel to the rib cage and cepha- The medial trigger area requires special
lad, toward the face of the scapula, directly consideration for injection. Unequivocal
into the TrPs identified by palpation. The determination that subscapular tenderness
needle is always inserted through the skin along the vertebral border is caused by en-
caudal to the TrPs being injected and di- thesopathy of the subscapularis muscle is
rected cephalad to avoid encountering the difficult. The tenderness also could be in
rib cage, which can easily happen in this the middle trapezius, lower trapezius,
location. A similar injection technique is rhomboid, and/or serratus anterior mus-
described and illustrated by Rachlin. 46
cles through which one must perform the

Figure 26.6. Injection of trigger points in the subscapularis muscle along the axillary border of the scapula.
610 P a r t 3 / U p p e r B a c k , Shoulder, a n d A r m P a i n

palpation. Since enthesopathy in each of 14. CORRECTIVE ACTIONS


these muscles would most likely be sec- (Fig. 26.7)
ondary to TrPs in their respective muscle Sleep Position
bellies, each muscle should be examined
for TrPs, and if found, they should be inac- When sleeping on the painful side or on
tivated. Since it may take some time before the back, the patient should keep a small
the attachment area can recover suffi- pillow between the elbow and side of the
ciently from the sustained overload to chest (Fig. 26.7), thus maintaining some
become symptom-free, injection of 0.5% arm abduction and preventing prolonged
procaine or lidocaine into the tender at- positioning of the subscapularis muscle in
tachment area expedites recovery. Injec- a shortened position. When sleeping on the
tion of steroid that could reach the weak- pain-free side, the pillow is moved to sup-
ness-prone lower trapezius and rhomboid port the painful arm in front of the body
muscles is not recommended. If one ( s e e Fig. 22.6). This prevents folding the
wishes to inject the subscapularis trigger arm across the chest in the fully adducted
area along its vertebral margin, one tech- and medially rotated position, which is the
nique has the patient forcefully abduct
41
fully shortened position.
the scapula by placing the hand of the in-
volved side across the front of the body, Correction of Posture Stress
reaching far back on the uninvolved shoul- The patient must learn to avoid a
der. This causes a degree of winging which "slumped" forward-head, abducted-scapu-
usually makes it possible to reach the sub- lae posture (avoiding sustained medial ro-
scapularis muscle beneath the scapula. At tation of the arm). See Chapter 41.
least a 1.5-inch needle is required, but care The patient should hook the thumb in
must be taken to stay clear of the rib cage. the belt or on the hip when standing for
a long period of time to prevent the arm
Ormandy described this technique as
41
from remaining close to the side. Also,
the treatment for the scapulocostal syn- when sitting, the patient should move the
drome by infiltrating a TrP in the sub- arm frequently to stretch the muscle. As
scapularis region of the medial aspect of a passenger in a car, the patient can
the scapular spine. The syndrome was di- stretch by resting the arm across the back
agnosed by pain deep in the shoulder re- of the seat, or by reaching the arm up
gion and upper back that often radiated and back behind the head, or reaching
into the neck and down the posterior as- upward toward the ceiling. When a pa-
pect of the upper extremity to the fingers, tient drives long distances, the subscapu-
with marked tenderness at the medial end
of the scapular spine (a pain distribution
suggesting a composite of TrPs in several
regional muscles, including the subscapu-
laris). The syndrome was generally attrib-
uted to altered posture. After injecting
this subscapular TrP location one to three
times with lidocaine hydrochloride and
steroid in 4 4 0 patients, all of them re-
turned to work. It was not clear what spe-
cific structure or structures the author
thought he had injected with a 1-inch
needle. Clinical experience suggests that
steroid and local analgesic may be more
effective than analgesic alone for more
rapid resolution of enthesopathy that is
no longer being exposed to chronic ten- Figure 26.7. Use of a pillow when lying on the af-
sion. Controlled research studies are fected side at night to prevent sustained shortening
needed to confirm or refute this clinical of the subscapularis muscle. The pillow should be
impression. placed between the affected (right) arm and the
body.
C h a p t e r 26 / S u b s c a p u l a r i s M u s c l e 611

laris muscle generates much referred pain 8. Bonica JJ, Sola AE: Other painful disorders of the
if it remains in the shortened position upper limb. Chapter 52. In: The Management of
Pain. Ed. 2. Edited by Bonica JJ, Loeser JD, Chapman
without movement; a nondominant left
CR, et al. Lea & Febiger, Philadelphia, 1990 (p. 951).
subscapularis muscle is more vulnerable, 9. Bunker TD, Anthony PP: The pathology of frozen
since a dominant right arm is more ac- shoulder. A Dupuytren-like disease. J Bone Joint
tive. Use of an armrest helps to hold the Surg 77B(5):677-683, 1995.
arm in some abduction and avoid the 10. Cailliet R: Soft Tissue Pain and Disability, F.A.
completely shortened position. Davis, Philadelphia, 1977 (pp. 161, 162).
11. Cantu RI, Grodin AJ: Myofascial Manipulation: The-
ory and Clinical Application. Aspen, Gaithersburg,
Home Exercise 1992 (pp. 154-155).
12. Chironna RL, Hecht JS: Subscapularis motor point
The patient learns to passively lengthen
block for the painful hemiplegic shoulder. Arch
the muscle by using the middle and lower Phys Med Rehabil 72:428-429, 1990.
hand-positions of the In-doorway Stretch 13. Clemente CD: Gray's Anatomy. Ed. 30. Lea &
Exercise [see Fig. 42.9). Three cycles of each Febiger, Philadelphia, 1985 (pp. 369, 373).
of these hand positions should be per- 14. Ibid. (pp. 522-523).
15. Ibid. (p. 1209).
formed at least twice daily, preferably after a
16. Clemente CD: Anatomy. Ed. 3. Urban & Schwarzen-
moist hot pack, warm shower, or warm bath. berg, Baltimore, 1987 (Figs. 21, 49).
Circumduction, or an arm-swinging ex- 17. Ibid. (Fig. 50).
ercise with the person leaning over and the 18. Ibid. (Fig. 233).
19. Duchenne GB: Physiology of Motion, translated by
arm hanging down (Codman's exercise), is
E.B. Kaplan. J.B. Lippincott, Philadelphia, 1949 (pp.
very helpful. A weight may be hung from 64, 66).
the fingers or wrist to provide slight trac- 20. Esposito S, Ragozzino A, Russo R, et al: [Arthrogra-
tion. An attempt should be made to later- phy in the diagnosis and treatment of idiopathic ad-
ally rotate the arm and make a wide swing. hesive capsulitis]. Radiologia Medica 85(5):583-
587, 1993.
Rhythmic stabilization of the subscapu- 21. Gerwin RD, Shannon S, Hong CZ, et al.: Interrater
laris muscle (cyclic resisted abduction and reliability in myofascial trigger point examination.
lateral rotation at the shoulder to the limit Pain 69:65-73, 1997.
of pain) increases the tolerance of the mus- 22. Glousman R, Jobe F, Tibone J, et al.: Dynamic elec-
tromyographic analysis of the throwing shoulder
cle to stretch by reflex reciprocal inhibi-
with glenohumeral instability. J Bone Joint Surg
tion, thus improving its range of motion. 50
70A(2):220-226, 1988.
23. Headley BJ: Evaluation and treatment of myofascial
pain syndrome utilizing biofeedback. Chapter 5. In:
SUPPLEMENTAL REFERENCE, CASE Clinical EMG for Surface Recordings, Vol. 2, Edited
REPORTS by Cram JR. Clinical Resources, Nevada City, 1990.
Rinzler and Travell described the man- 24. Hecht JS: Subscapular nerve block in the painful
hemiplegic shoulder. Arch Phys Med Rehabil
agement of a patient with TrPs in multiple 73.1036-1039, 1992.
muscles, including the subscapularis. 48
25. Inman VT, Saunders JB, Abbott LC: Observations on
the function of the shoulder joint. J Bone Joint Surg
26.1-30, 1944 (pp. 14, 15, 21-24).
26. Jenkins DB: Hollinshead's Functional Anatomy of
REFERENCES
the Limbs and Back. Ed. 6. W. B. Saunders,
1. Agur AM: Grant's Atlas of Anatomy. Ed. 9. Williams Philadelphia, 1991 (pp. 73-74).
& Wilkins, Baltimore, 1991:370 (Fig. 6-17). 27. Jobe FW, Perry J, Pink M: Electromyographic shoul-
2. Ibid. p. 376 (Fig. 6-26). der activity in men and women professional golfers.
3. Ibid. p. 371 (Fig. 6-19). Am J Sports Med 17(6):7S2-787, 1989.
4. Basmajian JV, DeLuca CJ: Muscles Alive. Ed. 5. 28. Joynt RL: The source of shoulder pain in hemiple-
Williams & Wilkins, Baltimore, 1985 (p. 385). gia. Arch Phys Med Rehabil 73:409- 413, 1992.
5. Bateman JE: The Shoulder and Neck. W.B. Saun- 29. Kendall FP, McCreary EK, Provance PG: Muscles:
ders, Philadelphia, 1972 (pp. 134, 145- 146, 149, Testing and Function. Ed. 4. Williams & Wilkins,
284-290). Baltimore, 1993 (p. 294).
6. Bhakta BB, Cozens JA, Bamford JM, et al.: Use of 30. Kopell HP, Thompson WA: Pain and the frozen
botulinum toxin in stroke patients with severe up- shoulder. Surg Gynecol Obstet 109.-92- 96, 1959.
per limb spasticity. J Neurol Neurosurg Psych 31. Lange M: Die Muskelharten (Myogelosen). J.F.
61 1):30-35, 1996. Lehmanns, Miinchen, 1931 (p. 129, Fig. 40A).
7. Bonica JJ: Musculoskeletal disorders of the upper 32. Lewit K: Manipulative Therapy in Rehabilitation of
limb: basic considerations. Chapter 49. In: The Man- the Locomotor System. Ed. 2. Butterworth Heine-
agement of Pain. Ed. 2. Edited by Bonica JJ, Loeser mann, Oxford, 1991 (pp. 204, 205).
JD, Chapman CR, et al. Lea & Febiger, Philadelphia, 33. Marmor LC: The painful shoulder. Am Fam Phys
1990 (pp. 882-905). 3:75-82, 1970 (pp. 78-79).
612 P a r t 3 / U p p e r B a c k , Shoulder, a n d A r m P a i n

34. McMinn RM, Hutchings RT, Pegington J, et al: matic component of cardiac pain. Am Heart J
Color Atlas of Human Anatomy. Ed. 3. Mosby-Year 35:248-268, 1948 (Case 3, pp. 261-263).
Book, Missouri, 1993 (p. 126). 49. Rizk TE, Gavant ML, Pinals RS: Treatment of adhe-
35. Melzer C, Wallny T, Wirth CJ, et al: Frozen shoul- sive capsulitis (frozen shoulder) with arthrographic
der—treatment and results. Arch Orthop Trauma capsular distension and rupture. Arch Phys Med Re-
Surg 114(2):S7-91, 1995. habil 75(7):803-807, 1994.
36. Mennell JM: Joint Pain: Diagnosis and Treatment 50. Rubin D: An approach to the management of myo-
Using Manipulative Techniques. Little, Brown and fascial trigger point syndromes. Arch Phys Med Re-
Company, Boston, 1964 (pp. 78-90). habil 62:107-110, 1981.
37. Mikasa M: Subacromial bursography. J Jpn Orthop 51. Scovazzo ML, Browne A, Pink M, et al.: The painful
Assoc 53:225-231, 1979. shoulder during freestyle swimming. Am J Sports
38. Neviaser JS: Musculoskeletal disorders of the shoul- Med 29(6):577-582, 1991.
der region causing cervicobrachial pain; differential 52. Spalteholz W: Handatlas der Anatomie des Men-
diagnosis and treatment. Surg Clin North Am schen. Ed. 11, Vol. 2. S. Hirzel, Leipzig, 1922 (p.
43:1703-1714, 1963 (pp. 1708-1713). 318).
39. Nielsen AJ: Case study: myofascial pain of the pos- 53. Toldt C: An Atlas of Human Anatomy, translated by
terior shoulder relieved by spray and stretch. J Or- M.E. Paul. Ed. 2, Vol. 1, Macmillan, New York, 1919
thop Sport Phys Ther 3:21-26, 1981. (p. 277).
40. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, et al: The 54. Ibid. (p. 313).
resistant frozen shoulder. Manipulation versus 55. Travell J, Rinzler SH: The myofascial genesis of
arthroscopic release. Clin Orthop 329:238-248, pain. Postgrad Med 2 2:425-434, 1952.
1995. 56. Voss DE, Ionta MK, Myers BJ: Proprioceptive Neuro-
41. Ormandy L: Scapulocostal syndrome. VA Med Q muscular Facilitation. Ed. 3. Harper and Row,
121(2):105-108, 1994. Philadelphia, 1985.
42. Patriquin DA, Jones JM III: Articulatory techniques. 57. Waldburger M, Meier JL, Gobelet C: The frozen
Chapter 55. In: Foundations of Osteopathic Medi- shoulder: diagnosis and treatment. Prospective
cine. Edited by Ward RC. Williams & Wilkins, Balti- study of 50 cases of adhesive capsulitis. Clin
more, 1997 (pp. 778, 779, Fig. 55.26). Rheumatol 22(3):364-368, 1992.
43. Pernkopf E: Atlas of Topographical and Applied 58. Ward RC: Integrated neuromusculoskeletal tech-
Human Anatomy, Vol. 2. W.B. Saunders, Philadel- niques for specific cases. Chapter 63. In: Founda-
phia, 1964 (Fig. 60). tions for Osteopathic Medicine. Edited by Ward RC.
44. Pink M, Jobe FW, Perry J: Electromyographic analy- Williams & Wilkins, Baltimore, 1997, p. 851-899
sis of the shoulder during the golf swing. Am J (pp. 887, 890, 891, Figs. 63.80 and 63.81).
Sports Med 28(2):137-140, 1990. 59. Warner JJ, Allen A, Marks PH, et al: Arthroscopic re-
45. Pollock RG, Duralde XA, Flatow EL, et al.: The use lease for chronic, refractory adhesive capsulitis of the
of arthroscopy in the treatment of resistant frozen shoulder. J Bone Joint Surg 78A(12).1808-1816,1996.
shoulder. Clin Orthop 304:30-36, 1994. 60. Weber M, Prim J, Bugglin R, et al: Long-term follow
46. Rachlin ES: Injection of specific trigger points. up to patients with frozen shoulder after mobiliza-
Chapter 10. In: Myofascial Pain and Fibromyalgia. tion under anesthesia, with special reference to the
Edited by Rachlin ES. Mosby, St. Louis, 1994 (pp. rotator cuff. Clin Rheumatol 14 (6):686-691, 1995.
200-202). 61. Zohn DA: Musculoskeletal Pain: Diagnosis and
47. Reynolds MD: Personal Communication, 1980. Physical Treatment. Ed. 2. Little, Brown & Com-
48. Rinzler SH, Travell J: Therapy directed at the so- pany, Boston, 1988 (Fig. 12-2, p. 211).

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