Pain in the posterior shoulder girdle (I’m going to include upper back and posterior neck together) is a very common issue with many people who complain of pain. Unfortunately, many people seem to believe that the pain is just magically there, when in reality, there is an underlying cause and reason for the issues that an individual has. Specific muscles that are stiff or short, specific muscles that are lengthened or inhibited, faulty movement patterns and postural issues are all commonly significant causes of pain, especially in this region. Massage therapy can be a great tool in treating someone with this condition. In a 2003 study in the research journal Spine, a national survey on the most successful treatments used for back and neck pain was conducted. Massage therapy was one of the top 3 most effective studies. As a matter of fact, nearly one third of all complimentary provider visits were for neck and back pain in the year studied.
I am first and foremost a strength and conditioning specialist. Through my many observations working with a multitude of varying clients, a very common trend seems to be hyperkyphotic shoulders (or at least shoulders that are somewhat more kyphotic than normal) and weak upper back musculature with over lengthened tissue. This over lengthened tissue develops poor quality and strains. In our society today, many people sit for a ridiculous amount of time throughout the day, leading to rounded shoulders, stiff hip flexors and a weak and lengthened posterior chain.
In “Muscles: Testing and Function with Posture and Pain,” Kendall and others discuss painful posterior neck muscles in great detail. “The compensatory head position associated with a slumped, round upper back results in extension of the cervical spine.” “The faulty mechanics associated with this condition chiefly consist of undue compression posterior on the articulating facets and posterior surfaces of the bodies of the vertebrae, stretch weakness of the anterior vertebral neck flexors, and tightness of the neck extensors, including the upper trapezius, splenius capitis and semispinalis capitis.” (Kendall, 2005, P.159) With the body’s inherited ability to try to maintain equilibrium, the kyphotic shoulders cause extension at the next joint up. This combination leads to neck pain, shoulder pain and often times headaches.
On top of the tissue creep and adaptations that take place from all of the time sitting with poor posture, many of the same people perform workouts that add fuel to the fire. A disproportionate number of movements that train protraction and internal rotation of the shoulder joint in comparison to the number of movements that train retraction and external rotation of the shoulder joint makes issues worse; as well as useless and harmful exercises such as crunches, which depress the rib cage. With the adaptations that people have developed, a combination of the appropriate corrective exercises and soft tissue work is very necessary. While one or the other may help to a certain extent, it is the combination of the two that is amazingly effective. What we also tend to see a lot is hyperkyphosis coupled with forward head carriage, which features overlengthened lower cervical muscles (splenii, erectors,etc.) and strained upper cervical muscles (suboccipitals). The lower muscles (C3 on down) help extend the head the neck while the upper (C1-C2) rock and tilt the head on top of the neck. They have separate functions for many activities. Weak deep neck flexors allow this situation to remain. The lines of tissue up here are all directly connected with deeper lines through rest of the trunk and body, so when we analyze and coach full body movements, we need to look at head and neck alighment as well. This is often forgotten.
In Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann gets very in depth with specific conditions that can cause neck and upper shoulder pain. Two “syndromes” that are discussed are scapular downward rotation syndrome and scapular depression syndrome. In these conditions, muscle imbalances around the area lead to impaired scapular resting position and motion. One common imbalance is weakness in the lower trapezius and serratus anterior with an excessive pull by the upper trapezius, levator scapulae and weight of the upper extremity. This creates a downward or asymmetric pull on the cervical vertebrae and in turn, neck pain. With the lower traps and serratus not doing their job in assisting with upward rotation of the scap, upward rotation is not fully achieved with shoulder abduction and flexion, leading to improper movement and pain. This also leads to a scapular resting position that is rotated downward excessively, causing specific strains throughout the day, even at rest. This is just the tip of the iceberg. Issues such as this can lead to a host of other problems around the area as well, including acromioclavicular joint pain, humeral instabilities, sternoclavicular joint pain, humeral subluxation and thoracic outlet syndrome. (Sahrmann, 2002, p. 217-224)
There can be a combination of issues, syndromes and imbalances. Ultimately, each individual must be assessed in order to determine what needs lengthening and what needs strengthening. While one individual may have a weak upper AND lower trapezius with over dominant, short rhomboids and levator, another person may have an over dominant upper trapezius, weak lower trapezius AND weak rhomboids. The first individual would need massage work done on their rhomboids and levator and strength work done on their upper and lower traps with real specific exercises. The second person would need lower trap and rhomboid strengthening along with tissue work on their upper traps and probably pecs, lats, etc. It all comes down to the individual at hand. (And of course this all then needs to be taken into account with full body movement patterns)
Another very common malfunction that leads to issues with pain in these areas is faulty breathing mechanics. The diaphragm should be playing a large role in breathing; however, many people have diaphragms that are not doing their job effectively which contributes to poor breathing mechanics and places the burden on other muscles. The problem is that these other muscles that now have to assist with breathing (more than normal) because of the poorly used diaphragm already have big time jobs that they are responsible for. Now they become overused and stressed because of the extra role they must now play. “Inefficient or inappropriate breathing patterns can lead to dysfunction, both structurally and physiologically.” (Rattray, 2000, p. 33)
In Clinical Massage Therapy, Rattray discusses two inefficient breathing patterns. Apical breathing occurs when someone mainly uses the upper chest to breathe. Their lateral ribs move a little and there is not much movement from the abdomen at all. The scalene, upper traps and levator scapulae are overactive and strain as the ribs raise during this faulty breathing pattern. (Note: We do want apical expansion,just not elevation) Paradoxical breathing occurs when someone’s abdomen doesn’t rise as they inhale and the abdominals don’t relax which immobilizes the viscera. With the lack of visceral motion, the scalenes and lateral motion of the ribs have to compensate, which can ultimately lead to excess stress and pain. (Rattray, 2000, p. 34). Poor diaphragm function can also cause low back and spine issues because of the diaphragm’s attachments to the lumbar spine.
In an ideal breathing situation, the abdomen will rise first (we want front, sides and back to fill with air), indicating that the diaphragm is functioning as it should. When the diaphragm functions as is should, the accessory breathing muscles elsewhere can relax when they need to and strain will ultimately be much less. Many sources go as far as to say that diaphragm function is the most important of the whole body. In “Clinical Application of Neuromuscular Techniques,” Leon Chaitow states that “the functional status of the diaphragm is probably the most powerful mechanism of the whole body.” (Chaitow, 2008, P. 78)
In “Fascial Release for Structural Balance,” Thomas Myers and James Earls discuss the importance of the diaphragm and proper breathing mechanics in great detail. “One only has to get the ‘wind knocked out’ by a blow to the xiphoid area to realize how useless the other muscles of breathing are without the diaphragm.” (Myers, Earls, 2010, p. 169)
An interesting discussion of exhalation is found in this section. In our sped up and stressed out Western society, very few people have a contraction free exhale. Exhalation is supposed to be a natural process of elastic recoil in the lungs that does not require any action; however, this is often not the case with many people. This can cause stress in unwanted areas. Another problem with exhalation is the diaphragm failing to fully relax at the bottom of the exhale. Many people retain some tension in the diaphragm at all times (can be an issue with poor breathing mechanics) so it never fully relaxes or expels all of the air. Fixing this problem and getting the diaphragm to relax can help the body neurologically, musculoskeletally and organically. Putting the diaphragm in a better starting state can also help with proper function for each breath (Myers, Earls, 2010, p. 171-172) “Small aberrations in the breathing pattern- repeated so many times per day, so many days in a row, right in the middle of the Deep Front Line and the organic self- can lead to many imbalances. The converse is also true: getting the breathing to take a more balanced path can make diverse problems disappear as the body rights itself.” (Myers, Earls, 2010, p. 172)
They also make some great points about the scalenes and their role in breathing. The scalenes are described as the secondary muscles of breathing; more important than the intercostals. “In breathing, they lift the upper two ribs, or prevent them from being pulled down.” (Myers, Earls, 2010, p. 167) Looking at this statement, it is easy to imagine how the scalenes might be affected with an apical breathing pattern characterized by chest elevation. Interestingly, they say that in dysfunction, the middle and posterior scalenes should be divided from the anterior. They say that the middle and posterior scalenes are paravertebral and act as the “quadratus lumborum of the neck” by creating or preventing/stabilizing lateral flexion of the neck. The anterior scalene runs more interiorly from the anterior tubercles of the third through sixth cervical vertebrae down and forward to the first rib- making it more “the psoas of the neck.” It is designed to pull up on the ribs during inhalation. (Myers, Earls, 2010, p. 168) This could have some important implications when designing a specific treatment protocol as these muscles would likely need to be released in order to develop optimal diaphragm function.
As can be seen by looking at all of this wonderful literature, proper breathing mechanics with a properly functioning diaphragm are a big deal not only when it comes to neck and shoulder pain, as we are focusing on with this paper, but for the entire body and many of the processes that occur with it, both neurologically and musculoskeletally.
In conclusion, there are multiple factors that come into play when it comes to working with neck and upper back pain. Some of the most important factors that I found through research and experience have been discussed here. Cervical stresses from postural and structural adaptations, specific muscle imbalances around the shoulder girdle and neck and breathing dysfunction are all very commonly found in individuals with neck and shoulder pain and are very important to assess and address with massage treatment. As mentioned earlier, while massage treatment can help tremendously with specific issues that are found, proper exercises to strengthen weak or malfunctioning areas are just as important so that bad movements and postures can be stopped in order to prevent a recurrence of the issues that were treated. If a massage therapist is not qualified to prescribe and coach the proper exercises and/or stretches, a qualified strength and conditioning professional should be referred to ensure ultimate outcomes for the client. If we continue to research and see more and more benefits and successful treatments with soft tissue therapy and proper exercise/movement, we can help many more people get rid of chronic pain for good! Hopefully, this project can be a nice start towards a bigger library of research information.
If I get enough interest, I will post the case study report as well. Breathing mechanics continues to draw my interest and the more I learn about it, the more intrigued I become. I am finally taking the first two Postural Restoration courses dealing with pelvic and breathing disoreders the next couple of months and am excited to get even more in depth with things.
Chaitow, L., & DeLany, J. (2008). Chapter 4- Causes of musculoskeletal dysfunction. Clinical application of neuromuscular techniques (2nd ed., p. 78). Edinburgh: Churchill Livingstone/Elsevier.
Earls, J., & Myers, T. W. (2010). Chapter 7- The abdomen, thorax, and breathing. Fascial release for structural balance (pp. 167-172). Chichester, England: Lotus Pub. ;.
Kendall, F. P. (2005). Chapter 4- Neck. Muscles: testing and function with posture and pain (5th ed., p. 159). Baltimore, MD: Lippincott Williams & Wilkins.
Rattray, F. S., Ludwig, L., & Beglin, G. (2000). Chapter 4- Non Swedish massage techniques. Clinical massage therapy understanding, assessing and treating over 70 conditions (p. 33). Toronto: Talus Inc..
Sahrmann, S. (2002). Chapter 5- Movement impairment syndromes of the shoulder girdle. Diagnosis and treatment of movement impairment syndromes (pp. 217-224). St. Louis: Mosby.
Wolsko, Peter M., Eisenberg, David M., Davis, Roger B., et.al (2003). Patterns and Perceptions of Care for Treatment of Back and Neck Pain: Results of a National Survey. Spine. Feb 2003, vol 28-issue 3, 292-297. Retrieved Feb 8, 2011 from http://journals.lww.com/spinejournal/Abstract/2003/02010/Patterns_and_Perceptions_of_Care_for_Treatment_of.18.aspx.