These conditions are typically called tendinitis.  A better term for both of these conditions might be tendon pain or tendinosis, which is the tearing of tendon fibers, due to repeated stress or overload, in the absence of an inflammatory process.  It is important to perform muscle resistance testing to determine which of these muscles are causing anterior shoulder pain.

The long head of the biceps tendon and the subscapularis tendon lie next to each other and general palpation may not be able to determine which muscle is creating the tendon pain.  Even though the pain may be in the same area, the treatment protocol and subsequent stretching are drastically different.

Subscapularis Treatment:

• Follow the shoulder protocol starting with the velvet glove technique.
• You will need to release all the other anterior shoulder muscles—pectoralis major, minor, and subclavius—before you work this muscle.
• Next, follow the specific protocol for the subscapularis including multi-directional friction and eccentric contraction.
• This is an extremely rare injury, as this muscle has a broad, flat, wide tendon, that is very deep and well protected. Although this muscle is almost always tight, subscapularis tendinosis is rare.

Biceps and Coracobrachialis Treatment:

• Start with the basic shoulder protocol and release all of the anterior shoulder muscles.
• The client is supine with the arm supinated, with support under the elbow using a bolster or a towel. Have the client perform a resisted test with the shoulder flexed to 90˚, palm facing up, to pinpoint the injury.
• Follow the rest of the specific biceps/coracobrachialis protocol.
• Continue to reassess and repeat any or all of the protocol until the client is pain-free.

Patient sits on table or treatment stool.

Operator stands behind with the thumb and index finger contacting zygopophysial joints bilaterally with the left hand on the vertex of the head to control motion.

Operator’s left hand introduces forward-bending, right side-bending, and right rotation while monitoring left zygopophysial joint for opening movement.

Operator introduces forward-bending, left side-bending, and left rotation, palpating for opening of the right zygopophysial joint by the operator’s right index finger

Operator’s left hand introduces backward-bending, right side-bending, and right rotation with the right index finger monitoring the right zygopophysial joint’s capacity to close.

Operator introduces backward-bending, left side-bending, and left rotation with the left hand while monitoring the left zygopophysial joint’s capacity to close with the right thumb.

The anatomy and biomechanics of the cervical spine result in five somatic dysfunctions.  The typical cervical segments (C3-C7) have non-neutral dysfunction with either a forward-bending or backward-bending restriction together with a coupled side-bending and rotation restriction to the same side (Type II motion).

At the atlantoaxial (C1-C2) junction, the primary somatic dysfunction is that of restriction of rotation to one side or the other.  While there may be minor forward/backward-bending and side-bending components to the rotational restriction, adequate treatment to the rotational restriction restores the minor movement motion simultaneously.

At the occipitoatlantal (C0-C1) junction, there are two dysfunctions possible.  There will either be forward-bending or backward-bending restriction with coupled side-bending and rotation to opposite side (Type I motion).

The structural diagnostic process starts by identifying levels of palpable deep muscle hypertonicity.  This identifies segments that need motion testing.  The diagnostic and the therapeutic processes seem to be most satisfactory by beginning from below and moving cephalad.

The bony landmark of most value in the typical cervical segment is the articular pillar.  They are palpated in the deep fascial groove between the semispinalis medially and the cervical longissimus laterally.  The paired examiner’s fingers can localize to the right and left articular pillars of any given cervical segment and introduce motion testing.

The typical cervical segment pillar is the size of the examiner’s finger pad.  The identification of the articular pillars begins by first identifying the spinous process of C2 and C7.  The C2 spinous process is the first bony prominence in the midline caudad to the external occipital protuberance (inion).  The spinous process of C7 (vertebra prominens) is the spinous process that remains palpable during cervical backward-bending.  The articular pillars of C2 and C7 are at the same level as the spinous processes.  Placing the examiner’s fingers between the pillars of C2 and C7 puts the finger pads in contact with with C3, C4, C5, and C6.  This provides the ability to localize to any specific cervical segment.  The structural diagnostic process can be performed in patients in both sitting and supine positions.

The cervical spine consists of seven vertebrae that are divided into two distinct regions.  The upper region consists of the occiput, C1, and C2 vertebrae and lower region includes the vertebrae of C3-C7.  Precise movements of the cervical spine require optimal arthrokinematics and osteokinematics and depend on muscle length, strength, and recruitment patterns.  Motions of the cervical spine are comprised of coupled motions.

Neutral mechanics, also known as Type1 mechanics, result in coupled movement of side bending and rotation to opposite sides.  Neutral mechanics occur in the thoracic and lumbar spine.  Non-neutral mechanical coupling, or Type2 mechanics occur when side bending and rotation of vertebrae occur to the same side.

C0 = occiput, C1 = atlas, C2 = axis, C3-C7 = typical

Atlas

The primary movement of the occipitoatlantal articulation (C0-C1) is forward and backward bending.  There is also a small amount of coupled side bending and rotation to opposite sides.  Left rotation of the occiput on the atlas is associated with anterior displacement of the right occipital condyle on the right articular process of the atlas.  As the occiput turns to the left, the occipital condyles are displaced to the left, resulting in side bending to the right.

Axis

The geometry and orientation of the C0-C1 and C1-C2 articular processes appear to dictate the type and amount of motion available at the atlantoaxial joint.  The primary movement here is rotation. (There is no intervertebral disc between C1 and C2.)

Typical Cervical Vertebrae

Intervertebral discs are found between two typical vertebral bodies. At the posterolateral corner of each vertebral body is a small synovial joint called the uncovertebral joint of Luschka.  These joints are found only in the cervical region and are subject to degenerative changes that    occasionally encroach on the intervertebral canal posteriorly.  Flexion, extension, side bending, and rotation are all permissible in the typical cervical vertebrae; lateral flexion and rotation are always facet controlled.  Side bending in one direction will always be coupled with rotation in the opposite direction (Type 1 mechanics).

Optimal muscle lengths and recruitment patterns are critical to the performance of cervical motions to allow the ideal ratio of coupled motion to occur.  The muscles of the cervical region can be classified into two distinct groups according to the relationship of the attachment of the muscle to the axis of motion of the cervical spine.  The intrinsic muscles of the cervical spine located close to the axis of motion are felt to control precise control of motion during movement.  The extrinsic muscles of the cervical spine are located farther from the axis of motion and provide power to the motion but not necessarily precision of motion. A balance of participation between these two groups is critical for precise and pain-free motion of the cervical spine.

Cervical Flexors

The function of the intrinsic cervical flexors is to produce forward sagittal plan rotation or ‘rolling’ of the cervical vertebrae.  The muscles producing the sagittal rotation motion in the upper cervical region are the rectus capitis anterior and rectus capitis lateralis.

In the lower cervical region, forward sagittal rotation is produced by the longus capitis and longus coli.  The longus capitis and longus coli are also active in protecting the anterior structures during forceful extension motions.

The function of the extrinsic cervical flexors is to add force to the flexion movement and produce flexion motion associated with forward translation of the cervical vertebrae.  The muscles contributing to the forward translator motion in the cervical region are the sternocleidomastoids and the anterior and medial scalenes.  Commonly, these muscles are dominant during flexion movements.  The dominant effect of the extrinsic muscles can result in a faulty movement pattern of anterior translation of the head and cervical spine with diminished anterior sagittal plane rotation.

 Cervical Extensors

The function of the intrinsic cervical extensors is to produce sagittal rotation or backward ‘rolling’ of the cervical vertebrae.  The muscles attributed to producing the posterior sagittal rotation in the upper cervical region are the rectus capitis posterior major and minor, the oblique capitis inferior and superior, and the semispinalis capitis,the spelnius capitis, and the longissimus capitis.

The muscles in the lower cervical region that produce posterior sagittal rotation are the semispinalis cervicis, the splenius cervicis, and the longissimus cervicis.

The function of the extrinsic cervical extensors is to produce extension with posterior translation of the cervical vertebrae.  The muscles attributed to producing this posterior translator motion in the cervical region are the upper trapezius and levator scapulae.  A common faulty recruitment pattern can include greater recruitment of the extrinsic cervical extensors during cervical extension, and can be best observed in the prone or quadruped position. 

Cervical Rotators

The intrinsic cervical rotators produce rotation about a vertical axis.  These muscles include the rectus capitis posterior major, the oblique capitis inferior, the oblique capitis superior, and the splenius.

The extrinsic cervical rotators include the sternocleidomastoids, the scalenes, the upper trapezii, and the levator scapulae.  These muscles all have the action of rotation but also the simultaneous action of   lateral flexion.  If these muscle groups are dominant during rotation, the precision of movement about a vertical axis may be compromised.

The therapist will often observe rotation with concurrent lateral flexion, complaining of pain when the lateral flexion occurs, and pain-free ROM when concurrent lateral flexion is avoided.

The therapist may also observe rotation with simultaneous extension.  This faulty movement pattern may be an indication of dominance of the sternocleidomastoid and its influence as an extensor of the upper cervical spine over the poorly recruited intrinsic cervical rotators which would maintain motion about a vertical axis.  The actions of the upper trapezius and levator scapulae can also contribute to cervical extension during rotation.

In addition, the therapist may observe cervical rotation with simultaneous flexion and/or forward translation of the head and neck.  This faulty movement pattern may be an indication of dominance of the anterior scalenes, the middle scalenes, and the sternocleidomastoids during the movement of rotation.

Manually guiding the patient’s pattern of rotation is often necessary.  A frequent intervention is to instruct the patient to turn the head and neck easily to reduce the magnitude of muscular contractions and encourage a more appropriate muscle recruitment pattern.  Strong muscle contractions, especially of the extrinsic rotators can add compression to the cervical spine structures.

In addition, the ‘extrinsic’ upper trapezius and levator scapulae are attached from the cervical spine region directly to the scapula and clavicle.  The clinical significance is that single arm movements can result in compensatory motion of rotation of a cervical spine segment or several segments.  Even the passive stretch of the trapezius and levator scapula (arms hanging at your side) will influence the ROM during active cervical motions, especially rotation, which can result in pain.