Levator Scapula

They attached cadavers and skeletons to machines that would take the arms through an overhand throwing motion, allowing them to look at the stresses on the shoulder joint when different movement dysfunctions were introduced.

So, when presented with a shoulder impingement, check the scapular motion!

Most often, the pain is felt along the medial border of the shins, about 1/3 to 1/2 way up the tibia.  The muscle most commonly mentioned as a cause of this pain is the tibialis posterior, but the muscle just as likely involved is the medial portion of the soleus.  Both muscles run up the medial border of the tibia, but the tibialis posterior muscle dips underneath the soleus very distal to the usual site of pain to attach on the posterior border of the tibia.  So if the pain is higher up than the lower 1/3 of the tibia, this leaves the soleus as the muscle involved.

Tibialis Posterior

When looking into the biomechanics of the area, the tibialis posterior and medial soleus muscles are put under strain when the subtalar joint of the foot falls into over-pronation.  Because a function of the tibialis posterior muscle is to support the medial longitudinal arch and over-pronation involves the collapsing of the arch, this action will cause a rapid stretching of the tibialis posterior.

Likewise, repeated eversion of the calcaneus that takes place with subtalar pronation will increase the strain on the medial portion of the soleus muscle.  Over time, the strain placed on these muscles will be transmitted up to their origins on the tibia, creating strain at the attachments on the periosteum of the bone (periostitis).

The athlete will complain of  pain along their inner shin, and point to the medial border of the tibia.  This pain will increase with activity and decrease with rest.  They will have tenderness or pain on palpation of the distal medial border of the tibia.  If you find one small spot that is the source of all the pain, the athlete should be referred to a physician to rule out the possibility of a stress fracture.

Because pronation increases the stress on the medial musculature, a goal for us is to reduce the causes of pronation.  One of the first things we should address is the footwear of the athlete.  I have built strong relationships with the running shoe stores in my city, and refer my clients to them to find the correct shoe for their gait.  By supporting the medial longitudinal arch, the pronation is reduced and the strain on the medial muscles is eliminated.

With massage, it is easy to focus on the site of injury, but remember that pain is a symptom!  We need to treat the structures that are potentially the cause of the condition.  Tight peroneals will pull the foot into eversion and upon weight bearing, pronation.  Additionally, we want to focus on the lateral gastrocnemius and soleus.  With pronation, the lateral belly of the gastrocnemius will typically hold itself tighter than the medial side.

Besides the muscles of the shin, I also recommend looking at the great toe extension (see my earlier post for explanation), the lateral hamstrings and even the lateral rotators of the hip.  All these can promote pronation by externally rotating the leg and forcing the weight to roll off the inside of the foot when walking or running.

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Foot toe-off

Here’s why:

During normal gait (walking) our body travels forward over our stance leg, and the heel will lift off the ground to help propel us.  As the heel lifts, the body weight shifts forward on the foot and the toes must extend.  The big toe is critical to this action, because the body weight shifts toward the medial forefoot during push-off.

If the big toe cannot extend 65-70 degrees, the forefoot cannot accept this weight shift as the heel lifts.  Because our bodies are great at adapting movement, we will create faulty movement patterns in the foot, shin and hip to compensate for the lack of big toe extension.

First, we will walk with our feet pointed out.  Why does this help?  It allows the body weight to roll off the inside edge of the foot, since it cannot travel along the length of the inflexible big toe.  This gait pattern requires the femur and tibia to stay in an externally rotated position.  To maintain this movement pattern, our gluteus maximus, piriformis, and biceps femoris will  hold in a shortened position.

When the body weight is focused on the inside edge of the foot, it will cause the medial longitudinal arch to collapse and the foot will over-pronate.  Walking in this posture will lead to a shortening of the peroneals, as well as the lateral gastrocnemius and soleus, while also increasing the strain on the plantar fascia and muscles of the medial shin (medial shin splints).

So, if you find a client with limited big toe extension, here are some key muscles needing attention with massage and stretching:

1. Big (great) toe flexors – Flexor hallicus longus and brevis
2. Ankle everters – the peroneals and lateral calf (gastrocnemius & soleus)
3. Hip external rotators – Biceps femoris (including the short head), gluteus maximus and piriformis

Often, the the cause of a shoulder impingement is coming from inadequate movement of the scapula, from a combination of tightness and weakness in key muscles attaching to it.

For proper shoulder flexion or abduction, the scapula must be able to upwardly rotate, so the inferior angle points away from the body and abduct away from the vertebral spine.  In fact, once you raise the arm to 90 degrees, most additional shoulder abduction occurs through abduction and rotation of the scapula.

Try this and see:  Abduct one arm to 90 degrees (straight out at your side) and with your other hand, reach across the front of your body to feel the ribs just below your armpit.  Now abduct your arm above your head.  You should feel the scapula abducting and rotating into your hand.

When looking at impaired movement, we should naturally look to the muscle(s) that perform the opposite movement as a potential source of the problem.  The muscle that performs downward rotation and adduction?  The levator scapula.

Levator Scapula

The levator scapula functions to elevate and downward rotate the scapula by exerting an upward pull on the medial side of the superior angle of the scapula.  This muscle is often short and tight from various causes, such as:  general tension, sitting in front of a computer, or carrying a purse the size of a duffel bag.  When tight, the levator scapula will provide resistance to the normal outward rotation and abduction of the scapula during shoulder flexion or abduction, limiting the ROM.  Since our bodies are great at compensation, the glenohumeral joint will try to make up the missing ROM to allow a full flexion or abduction.  This can cause compression of the supraspinatus tendon (or other structures) under the acromion leading to impingement.

A quick way to see if the levator scapula is tight is to simply look at the client from the back.  If the shoulders appear hunched, or one side is higher than the other, the levator most likely needs to be released.  For a more thorough view, you need to assess the shoulder in motion.

By releasing the levator scapula with massage and stretching, it can improve the ability of the scapula to rotate and abduct, leading to both improved shoulder ROM and decreased stress on the glenohumeral joint for movement.

When the hip flexors, piriformis and QL are short or tight, they contribute to an anterior pelvic tilt (APT) that causes the sacrum to rise superiorly, increasing the distance between the origin and insertion of the gluteus maximus, placing the gluteus maximus in a lengthened posistion.

Try this yourself:  Stand up, and place your hands over your glutes so your fingers on your greater trochanter and thumbs over the lateral border of the sacrum.  Now, tilt your pelvis anteriorly.  You will notice the distance between your fingers and thumbs has increased.

When the gluteus maximus is in an elongated position, the tension can be transmitted inferiorly to its insertion on the ITB.  Thus, an APT can be a major factor when a client complains of a painful ITB.

Many therapists mistakenly work only the area at which the client experiences the pain and attempt to stretch the ITB.  But, this structure is fascia and does not respond well to stretching.  Some therapists extend their protocols to the muscles attaching to the injured tissue, in this case the TFL and gluteus maximus.  Unfortunately, the gluteus maximus is too often in a long position and additional stretching will not help.  To properly address an ITB dysfunction, you must look at the balance of the pelvis.

In my practice, I find good success releasing the TFL, iliopsoas, rectus femoris, piriformis, and quadratus lumborum with myofascial techniques before elongating them with Active Isolated Stretching (AIS) or Muscle Energy Techniques (MET).  In addition, I will perform myofascial work on the lateral thigh to release any adhesions between the ITB and vastus lateralis as well as the patellar retinaculum.