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Subscapularis: Overlooked and Under Treated

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By: David Kent, LMT, NCTMB

The subscapularis is often neglected and/or undertreated as a cause of posterior shoulder pain with restricted range of motion (ROM). According to Travell and Simons, “differential diagnosis of subscapularis TrPs includes C7 radiculopathy, thoracic outlet syndrome, adhesive capsulitis and ‘impingement’ syndrome.”[1]In this article, I will review how to determine when the subscapularis muscle is responsible for causing shoulder pain and restricted ROM, as well as review its anatomy, function, trigger-point patterns and treatment options.

Intake and health history forms will help you identify some common factors that may contribute to the formation and perpetuation of trigger points, as well as the shortening of the subscapularis muscle. According to Travell and Simons, some of these factors include the following:

  • Repetitive movements that involve medial rotation, such as swimming the overhead stroke, playing tennis or pitching a baseball;
  • Repeatedly lifting boxes or other objects overhead with both arms extended;
  • Reaching backward to break a fall;
  • Soft-tissue stress when the shoulder joint is dislocated;
  • A fracture to the proximal humerus or trauma to the shoulder joint capsule;
  • The immobilization of the shoulder in an adducted and medially rotated position over a long period of time, such as when the arm is in a sling; and
  • Prior surgeries and procedures.[2]

Taking a photo of your client in front of a postural analysis grid chart is an effective method of evaluating, documenting, educating and ultimately showing a client his or her postural progress over a series of treatments. For example, a constant slumped, forward-head, adducted-scapulae posture will perpetuate trigger points and the shortening of muscles, like the subscapularis, by continually keeping the humerus in a position of medial rotation.3 [Photo 1]





Trigger Points: When trigger points are present in the subscapularis muscle, they produce referred pain “in the posterior deltoid area…down the posterior aspect of the arm, and then skip to a band around the wrist.”4 [Photo 2] Remember that referred pain is a symptom; we want to address the cause. So intake forms, postural analysis evaluations, range-of-motion and orthopedic assessments, and being familiar with trigger point patterns are all helpful to designing and implementing a customized therapy plan. But treating a trigger point is only part of the solution. We need to avoid a recurrence in the future. It is therefore necessary to demonstrate to your client which muscles need more lengthening and which ones need more strengthening so that all of the joints are properly aligned and moving through their full range of motion.

Anatomy: The subscapularis is one of four muscles that make up the rotator cuff, along with the supraspinatus, infraspinatous and the teres minor muscles. In my dissection seminars, I always highlight the subscapularis, which is the most anterior of the rotator cuff muscles. [Photo 2] It is a thick triangular muscle that attaches medially on the anterior or costal surface of the scapula on the subscapular fossa; it forms part of posterior wall of the axialla. Laterally it attaches on the lesser tubercle of the humerus and the lower half of the shoulder joint capsule.

Actions: The subscapularis is primarily responsible for medially rotating and adducting the arm. It also helps to hold the humeral head in the glenoid cavity. To check for shortening in the subscapularis it is necessary to evaluate both abduction and external rotation.

Abduction: According to Travell and Simons, when evaluating a shoulder with restricted abduction, it is first necessary to determine if the restriction is being caused by the inability of the scapula to move on the rib cage, the humerus to properly articulate in the shoulder (glenohumeral) joint, or a combination of the two. The difference can be easily determined by placing your hands on the client’s scapula to prevent its movement while asking the client to abduct his/her humerus. [Photo 3] When the subscapularis is involved, it restricts glenohumeral movements like abduction and lateral rotation, but it does not restrict scapular movements on the rib cage. If scapular movements are restricted, it is necessary to evaluate muscles that run from the torso to the scapulae like the pectoralis minor, serratus anterior, trapezius and the rhomboids.5

Lateral Rotation: When checking lateral rotation at the shoulder, adduct the arm by placing the elbow at the side. Bend the elbow 90 degrees to show the amount of rotation at the shoulder joint. [Photo 4] The arm should be able to laterally rotate 90 degrees. In addition to the subscapularis, other synergistic muscles like the teres major, latismus dossi and pectoralis major also adduct and medially rotate the arm. These muscles must also be evaluated and treated. Keep in mind that the antagonistic muscles are weak and over lengthened, so they need strengthening. Muscle movement charts can aid in quickly identifying the muscles involved and show the normal range of motion for the muscles and joints being evaluated. [Photo 5]

Treating the subscapularis: While there are many different approaches to treating the belly of the subscapularis muscle, I find one particularly effective; however, with this method some clients may only be able to tolerate static pressure versus movements, such as with-fiber or cross-fiber techniques.

  1. Place the client in a supine position.
  2. Stand facing the client at level of client’s shoulder.
  3. In the palm of your non-treating hand, cradle the scapula while using your fingertips to secure the vertebral border of the scapula; abduct the scapula.[Photo 6]
  4. Position the fingers of the treating hand against the belly of the subscapularis muscle. [Photo 7]

NOTE: Some clients may be ticklish, but this is easily overcome by using the client’s hand during the treatment. Have the client place his/her hand on the ticklish region while you treat the area between his/her fingers. [Photo 8]

  1. Drape the client’s arm across his/her chest (adduction) to shorten the muscle. [Photo 9]
  2. Press the fingers of your treating hand down toward the table and into the subscapular fossa.

Before the session ends, advise your client that he/she will receive the most benefit from your therapy session by actively engaging in self-care stretching techniques, such as the doorway stretch, which will further help improve muscle length, and create and maintain balance in the shoulder. [Photo 10]

You have now identified several factors associated with subscapularis pain and discomfort with the help of assessment aids and tools like intake forms, charts and postural analysis photos. Continue to study and broaden your skills with hands-on seminars and DVD programs. And to share your tips and experiences in the treatment room, please drop me a line at [email protected]

For more information related to this month’s topic, check out “Charting Your Progress: Visuals for Success” (February 2008) and “Getting Comfortable with Postural Analysis” (July 2008) online at

David Kent, LMT, NCTMB


David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit or call (888) 574-5600 for more information.

1-5 Simons DG, Travell JG, et al. Myofascial Pain and Dysfunction: The Trigger Point Manual, volume 1, 2nd ed. Williams and Wilkins: 1999.

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Safety Protocols: The Carotid Artery

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By: David Kent, LMT, NCTMB

Regardless of your modality and whether you perform massage on an outcall basis, in a clinic or spa, or in another setting, it is always important to be aware of circumstances in which massage may not be beneficial for your client or when it might be necessary to take extra precautions during a session. For example, a client enters with cervical pain and limited range of motion, complaining of pain along the length of the sternocleidomastoid muscle, as well as temporal, frontal and orbital headache symptoms consistent with trigger points in that muscle. In this situation, treatment will likely consist of working very close to the carotid artery; therefore, it is extra important to understand the anatomy and the body’s physiological responses around this region, so that you can ensure your massage produces positive outcomes. In this article I will discuss two conditions that require taking extra precaution when working around the carotid artery: plaque build-up in the carotid artery and a condition called Carotid Sinus Hypersensitivity (CSH). Plaque Plaque is made up of fat, cholesterol, calcium, and other materials found in the blood. Over time, plaque hardens and subsequently clogs the arteries, which decreases blood flow through the arteries to the heart and the brain. This is called atherosclerosis. In my full-body dissection seminars, I always remove a portion of the carotid artery; then I cut and peel away the arterial wall to reveal a “tube” of plaque lining the artery. This tube looks like a crudely formed plastic straw that is thicker in some areas than others. When squeezed, the tube makes snapping and cracking noises similar to a piece of plastic braking. I demonstrate this for my students so that they understand why it’s important to administer precise palpation and avoid making contact with the carotid artery during a massage. Palpating an artery that has substantial plaque build-up could pose serious risks to the client. In a worst case scenario, a piece of plaque could break off inside the artery, travel to the brain and cause a stroke. Using appropriate intake forms can help you identify clients who are at risk for plaque build-up. Intake forms should inquire about previous surgeries, health conditions and prescription medications. Some procedures to look out for include carotid endarterectomy:  a surgical procedure for cleaning out the carotid artery and restoring blood flow to the brain. Other related procedures include coronary bypass, stinting or angioplasty. Blood clots are also related to plaque build-up, so look out for medications that include blood thinners and anticoagulants. When red flags come up, heed the warnings—even if a client says he/she has received massage previously. In cases such as these, I will not proceed without a prescription for massage therapy from the physician currently treating the client’s condition. This is a safeguard for everyone involved, and most patients will thank you for your concern and professionalism. If you do not understand something a client wrote on an intake form, make sure to look it up before you proceed. For example, some clients use acronyms to describe their conditions; however, it is important not to assume you know what an acronym stands for. CSH is one such acronym that has multiple meanings. The Carotid Sinus and Carotid Sinus Hypersensitivity (CSH) The carotid sinus plays a key role in regulating blood flow to the brain; it contains baroreceptors that are sensitive to changes in blood pressure. It is part of the internal carotid artery just after it emerges from the common carotid artery, located just above the superior border of the thyroid cartilage (Adam’s apple) at the level of C3; it is attached fascially to the sternocleidomastiod muscle.  SEE IMAGE Carotid Sinus Hypersensitivity (CSH) is an exaggerated response to carotid sinus baroreceptor stimulation. Massaging the carotid sinus stimulates nerve endings, which can cause the heart rate to slow. CSH is the most common reported cause of falls and syncope (fainting) in persons over 65 year of age. In a study of 1,000 people with no history of syncope, dizziness or falls, participants were given carotid massage for an average of 7.3 seconds, in a supine and upright position with beat-to-beat heart monitoring. The study showed that 39 percent of the participants had some form of carotid sinus sensitivity; 24 percent had asystole (absence of cardiac heartbeat) for three seconds or greater; and 16 percent had symptoms, including syncope with carotid sinus hypersensitivity. 1 In rare cases, only 1 percent experiences Spontaneous Carotid Sinus Syndrome: a situation in which the symptoms can be clearly attributed to a history of accidental mechanical manipulation of the carotid sinuses, for example, by taking a pulse in the neck or by shaving. 2 Therefore, it is necessary for massage therapists to be aware of the potential physiological effects when treating in this region. Providing Safe, Effective Massage There are several ways to ensure that you provide safe, effective massage therapy:

  • Use intake forms to screen clients for potential risks prior to performing therapy. Make sure that forms are updated on a regular basis, especially if you haven’t seen a client for several months.
  • Thoroughly review your client’s health history on a regular basis. Ask routinely if your client is under a doctor’s care.
  • Clarify the meaning of acronyms.
  • Look up the unknown before you proceed.
  • Make use of resources like the Internet, textbooks, medical books and medical dictionaries to look up information.
  • Educate your clients by using postural analysis photos and trigger-point charts to illustrate their problem areas.
  • Perform muscle tests to ensure that you working on the right muscle and to help avoid critical structures like the carotid artery and carotid sinus.
  • Integrate orthopedic assessments.
  • Continue to expand your knowledge by investing in DVD programs and other continuing-education programs that review the specifics, such as anatomy,  contraindications, precautions, trigger points, safe therapy techniques, etc.
  • Take live seminars to continually hone and refine your hands-on techniques and reinforce anatomy

Treating in the sternocleidomastoid region can be a safe and satisfying experience for the client as long as you take the necessary steps to ensure you are palpating properly and precisely. Always proceed with caution. To share your tips and experiences in the treatment room, please drop me a line at [email protected] And for more information about keeping it simple in your day-to-day practice, be sure to check out my other articles at David Kent, LMT, NCTMB David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit or call (888) 574-5600 for more information. 1Kerr SR, Brayne MS, et. al. Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls. Arch Intern Med 2006; 166(5):515-20. Institute for Ageing and Health, University of Newcastle upon Tyne, England. 2 Wijetunga MN, Schatz IJ. Carotid Sinus Hypersensitivity. Click here to download a printable version for this article with photos.

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Questions with Direction – Practice Building Tips

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By David Kent, LMT, NCTMB

One of the most challenging aspects of being a massage therapist is trying to build a thriving practice with repeat clients. So, it’s no surprise that many therapists have felt the crunch with the recent downturn in the economy. And, unfortunately, services like massage therapy are often among the first things to be cut from one’s budget in times of economic crisis.

Therefore, it is now more important than ever to convince your clients to stay the course with their massage therapy sessions. This article will show you how asking some simple questions can ultimately lead to repeat clients, whether you work in a spa, outcall, seated- or clinical-massage setting. Soliciting a client’s feedback by way of asking thorough questions will better help you understand you client’s needs and deliver results. But even more important than asking the question, is listening and responding to the information your client provides.

One way to organize your questions is to make use of the wide-range of forms available for these purposes. In fact, your questions will, to a degree, be directed by the information you obtain using forms. I have my clients complete intake forms prior to therapy; these help me develop targeted questions to clarify my knowledge about their health history, their specific areas of pain, the stresses in their life, the ergonomics of their activities of daily living (ADLs), medications they are taking, and to identify any precautions or contraindications before the session begins. Using intake forms helps me develop goals for the client’s current and future sessions—which is also useful in persuading my clients to commit to ongoing treatment.

There are various types of questions; however, this article will focus on two primary categories: general and those related to a client’s pain. General questions are great for helping you understand your client’s expectations, no matter what kind of practice you have.

General questions:

  • Question: What are your goals for today’s session?

Reasoning: If you don’t ask this question, you won’t know if a client wants a relaxing Swedish massage or a vigorous sports massage that integrates stretching. This is also important so that you are responding to your client’s needs and not responding to your perception of your client’s needs.

  • Question: What areas you would like me to focus on today?

Reasoning: This question also relates to the question above. At one time or another, we’ve all probably had an experience with a therapist that seemingly ignored the very thing that brought us to therapy in the first place. When you ask this question, it is very important to listen closely to the answer. When you listen to the client and deliver results, it increases the odds that your client will reschedule and/or refer others.

  • Question: Have you received massage therapy before?

Reasoning: Regardless of the client’s answer, this is the ideal time to communicate to the client how you will perform the session. For new clients, you might advise the client to disrobe to his/her level of comfort and then discuss draping techniques. For veteran clients, you might ask if they’d like you to do something extra special, such as incorporate essential oils into the session.

  • Question: If you have received massage therapy previously, please tell me where you received it, by whom, and which treatments were the most beneficial?

Reasoning: This information can help you understand how to adapt the session to the types of massage therapy that have produced positive responses for the client in the past. You might also ask the client what he/she thinks makes a great massage—and then do what you can to meet the client’s expectation.

  • Question: What type of pressure do you prefer?

Reasoning: Keep in mind that levels of pressure are subjective for each client; what you perceive as light pressure and what the client perceives as light pressure could be entirely different. It is important that you check in with the client at the start of and during the session.

  • Question: Have you ever had any negative effects and/or experiences from receiving massage in the past?

Reasoning: People respond to massage in different ways. Some people get ill or are sore for several days after they receive a deep massage. This is where intake forms and questions can be very useful. Some questions might include what medications the client is on, if he/she bruises easily, what the client’s diet is like, as well as questions related to general health and exercise.

  • Question: Is there anything else that I should know?

Reasoning: I intentionally keep this question open-ended so that the client can add additional information at their discretion. It is up to me to connect the dots. I am frequently amazed by how many clients will tell me about a traumatic accident and/or major surgery in the past that they didn’t mention previously.

Questions about Pain:


  • Question: What other healthcare providers have you seen recently and for what?

Reasoning: This question immediately informs you if your client has seen a doctor or if the client has self-diagnosed. I can then quickly perform a postural analysis (See my article, “Getting Comfortable with Postural Analysis” in the July issue of MT), check range of motion, and perform relevant muscle tests and orthopedic assessments to determine if it is appropriate to proceed or if the client needs to first follow up with a physician.

  • Question: Have you tried different healthcare practitioners over time? If so, which one(s) provided the most relief? What did they do and how long did the results last?

Reasoning: Understanding more about the treatments a client has sought for pain relief will give you insight into how you can best help him/her. For example, if the client sees a chiropractor on a regular basis, you might suggest that he/she schedule an appointment with you immediately before the appointment with a chiropractor for maximum results.

  • Question: What do you do for pain relief?

Reasoning: I am always surprised by how many people buy topical pain relievers at a drug store. Why should the drug store get the money? Consider selling topical ointments in your practice. Integrate a topical into the therapy session and then send the client home with a sample. The next time the client buys a topical ointment, it might just be from you.

  • Question: What aggravates your condition?

Reasoning: If the client reports increased back pain when standing or straightening after bending down, it might indicate lumbar and hip flexor or extensor involvement. A muscle-movement chart can help you determine exactly which muscles to assess. Trigger point charts are useful for educating clients about referred pain. Additionally, using the postural analysis information combined with photos helps show the client how stressed or shortened muscles have contributed to the formation of trigger points. This further leads into a discussion of how a series of treatments can be beneficial.

Asking the right questions can help your practice tremendously. I am looking forward to learning how the questions in this article worked for you. I encourage you to read my other articles that can help during these challenging economic times.

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Muscle Movement Charts, Personalized Essential Office Forms™, and DVD programs. Visit or call (888) 574-5600 for more information.

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First Aid Tips For Your Patients – Practice Building Tips

A simple acronym that reminds you how to treat injuries.

By David Kent, LMT, NCTMB

By David Kent, LMT, NCTMB

As a practicing massage therapist, I’m exposed to a variety of clients every day, some of whom suffer from debilitating pain brought on by soft-tissue injury. Sometimes, clients wait weeks, even months, to see me after sustaining a soft-tissue injury because they think that the pain will go away by itself; however, more often than not, by the time they do finally see me for treatment, the pain has progressed to the point that it has impeded on their daily activities.

Depending on the extent of one’s soft-tissue injury, there are steps that can be taken at the time of injury to minimize damage, reduce pain, and help aid in the healing process until the client can make it in for treatment. This article will discuss self-care first aid tips that your clients can apply when they sustain a soft-tissue injury.

Emergencies don’t occur every day, but when they do, there are simple and swift actions that can help improve the odds of a speedy recovery. There is no question that your clients will need this information at some point for either themselves or to help a friend; however, the question is: When they need the information, will they remember what to do?

The answer is yes, and it starts with the acronym R.I.C.E:

  • R – Rest the injured region or limb. Pain is the body’s way of signaling that something is wrong and needs attention. Rest will prevent further injury by not using the affected muscle(s) or joint(s).
  • I – Ice the area as soon as possible after the injury. Cold packs or ice baths will limit swelling. When using ice, be careful not to use it for too long, as this could cause tissue damage.
  • C – Compress the area with an elastic wrap or bandage to reduce swelling.
  • E – Elevate the injured body part. Elevation works with gravity to help reduce swelling by allowing fluid and blood to drain toward the heart.

However, our clients will only remember the acronym R.I.C.E. and its significance if we, as massage therapists, put into practice another acronym: R.E.S.T.

  • R – Repetition is necessary if we are to teach our clients about the importance of self-care.  Most people need to see and hear the information, as well as perform the task, numerous times before it becomes routine. During my sessions, I ensure that my clients have all the information they need via handouts, books, Web sites, and anything else that I think will be helpful. During follow-up phone calls to the client, I review the actions that I would like them to take to expedite and maintain their recovery.
  • E – Education and training are the keys to preventing and treating soft-tissue injuries.   Most clients will take appropriate action once they know what to do, when to do it, how to do it and why they are doing it. Whenever possible, I teach using as many senses as possible, including visual, auditory, kinesthetic, olfactory and gustatory. For example, when I teach a client how to use ice, instead of just talking about it, I demonstrate how to do it so that the client can feel and see the process. Then I allow the client to ask questions as they do it to themselves so they are confident with the process.
  • S – Stretching is another useful aid. (Raising your arms and yawning after getting out of bed in the morning doesn’t count!) When it comes to stretching, it is very important to describe the reasons why it is important, most notably, for injury prevention. Create a stretching routine for each of your clients depending on his or her physical condition and abilities; then demonstrate how to perform each stretch. Taking photographs while the patient stands in front of a postural analysis chart is very useful to show clients distortions in their body. This helps clients understand the stresses being placed on their joints and soft tissues.
  • T – Topicals can help by creating a cutaneous (skin) distraction, which reduces pain intensity and helps the muscles relax during stretching. I hand out trial samples to my clients for their use, and I use topicals to promote my clinic by asking my clients to give samples to friends, family and coworkers. Topicals like BioFreeze and other devices, such as the TheraBand, can also produce additional income for you if you choose to sell them in your clinic.

The educational process empowers clients on many levels. It also elevates your reputation as a highly knowledgeable massage therapist. These self-care skills are practical and will help clients who have sustained a soft-tissue injury get some instant relief from their pain. Thanks to your first aid tips, your clients will know how to help themselves and others when soft-tissue injuries arise, and they will sing high praises about the therapist who taught them.

Got some great first aid tips? Are you selling a fantastic product in your clinic? Drop me a line and share your tips!

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit or call (888) 574-5600 for more information.

David Kent – Massage Today: First Aid (08/2008)