Shoulder & Arm Understand Pain By Sophie Xie / October 24, 2016 Subscapularis tear is not the most common type of rotator cuff tear. However, it is the most painful rotator cuff tear.Why?Because the subscapularis muscle is the largest rotator cuff muscle. It provides over 50% of total rotator cuff muscles strength, enabling us to hold and hug our loved ones. Our body usually react strongly to injuries of such important muscle. A tear of the subscapular muscle or muscle tendon will cause a lot of pain, guarding and spasm of surrounding tissues, severe movement limitation, and disability.In this post, I'll help you to understand subscapularis muscle tear, how to test for it, and how to start making things better.Do you know the subscapularis muscle?"Subscapularis" means "the muscle under the scapula or shoulder blade". THe subscapularis muscle is not easy to find. It is hidden under piles of other soft tissues and bony parts, in the deepest part of the shoulder joint. It runs from the underside or inner side of the shoulder blade bone to the front of the shoulder joint.The muscle has some very important functions:Rotate shoulder inwards (shoulder internal rotation)Stabilize head of the humerus by holding it down, allow entire arm to rotate up and reach overheadPassively stabilize shoulder joint during liftingPrevents shoulder joint from dislocating forward; prevents shoulder impingementInjury to the subscapularis muscleMost injuries that can cause damage to the subscapularis muscle are traumatic and high-force.Direct impact injuries leading to subscapularis tear include: Football or rugby injurywrestling or boxing injuryFalling off high places and landing on shoulder or with arm outstretchedWorkplace and car accidentThese injuries are very likely to involve more than one damaged tissue. Initial examination and imaging may be inconclusive due to massive swelling, widespread pain and muscle guarding. It takes a lot of anti-inflammatory med, muscle relaxer med, resting, icing, compression for usually 3-5 days to calm down the acute reaction of our body. At that time, you may feel more specific pain patterns and symptoms.Repetitive high-force movement can also lead to overuse injury and tear to the subscapularis muscle. High-risk activities are:Baseball pitchingVolleyball and tennis ball playingRepetitive lifting of heavy weights and pieces of machineryThose suffering from overuse of the subscapularis muscle would have experience fluctuating and worsening symptoms over the course of weeks and months.Diagnosis: How do you know? How do you know? If your doctor saw a tear within the subscapularis muscle on an MRI scan, they will be able to tell you information like a full or partial tear, the size of tear in percentage and, of course, the location of the injury.Based on your lifestyle and severeness of the injury, they may make a recommendation for either surgical repair or physical therapy rehabilitation, or both.However, most diagnosis is not straightforward like that.If you live in the US, you doctor will likely to prescribe 6 weeks of physical therapy before ordering an MRI. (You might get a X-ray scan to rule out fracture. However, you cannot see muscle tear on a X-ray)Why? First, the MRI scan is very expensive often with a packed schedule. Your insurance will most likely to refuse to pay for an MRI scan unless suspecting something severe.Second, early MRI imagines are not accurate enough to worth the effort. MRI imaging can be easily blurred by swelling, which most people has a lot early on in the diagnosing and treatment period.Thirdly, Most people with minor muscle tear or injuries would experience significant improvement in shoulder condition with proper education, treatment and exercises over a period of 3-4 weeks.So, how do you know if the subscapularis muscle is the victim here? Check out this list of symptoms and pain patterns: Severe pain in the injured shoulder, especially on the underside and backside of the shoulder joint, underside of the upper arm, and over the shoulder bladePain at base level when shoulder is at rest next to your bodyUnable to tolerate lying on the injured shoulder, or even flat on the backSevere increase in pain when trying to lift shoulder and arm up, especially from the sideSevere increase in pain when directly pressing on the subscapularis muscle from under the armSharp intense pain when trying to push on your stomach with the injured armInjured side shoulder blade may be resting highly than the other side due to muscle guardingInjured shoulder may feel better resting in a slingBest early treatment for subscapularis muscle tearWhether you know for sure what's causing your pain, you should take actions to care for your injured shoulder at home while waiting for treatment or diagnosis.1. Taking your medsI see many patients trying to tough it out with a good intention to protect their body from the side effects of medications. And for some people, this situation cannot be helped due to other health issues.In my opinion, it is highly beneficial to take those pain meds and muscle relaxers as prescribed by your MD in the first 3-5 days following the initial injury.Dragging or lingering inflammation and muscle spasm often prevent proper healing from starting promptly. You may stop the medication as soon as you see less swelling and can feel individual parts of your shoulder and arm.2. Diligent with icing, heating, and compressionFor the first 72 hours, making sure you use only ice for the injured shoulder 10 mins every 1-2 hours. You can use frozen peas for the job. However, to cover a larger area with consistent cryotherapy effect, you may consider investing in a larger gel based ice pack. If you are an athlete, or in a shoulder-heavy profession, you may also consider getting an ice pack with manual compression pump. If your body enjoy heat better, you may start to introduce heating pad after initial 72 hours slowly. THe best place to apply heat is not directly over the injured muscle. Use heat on your neck and upper back for 15-20 mins twice a day to reduce muscle guarding, improve pain, rest and function.2. Do passive shoulder motion exercisesIn order to prevent rotator cuff injury turning into chronic shoulder issue such as frozen shoulder syndrome, you should start moving it early.Shoulder pendulum is a great exercise to start on as soon as you can tolerate some gentle movements. Images via hep2go.com Use your healthy arm for support, lean forward so that your shoulder and arm is hanging down in front of youMove your trunk, so that your arm is moving in a circular motion. Repeat moving the arm clockwise and counterclockwise for 10-20 times each.Then use the same technique to swing your shoulder from side-to-side, and front-to-back, 10-20 times eachRemember, Do not initiate the swing by actively moving the muscles in your shoulder. They should remain relaxed.Repeat exercise 3-5 times per dayThank you for reading, and I hope you find this post helpful.Recommended readings:Biceps tendinitis: Pain in the front of your shoulder explained5 exercises to improve shoulder impingement pain in 8 weeksHow to improve posture with these 3 on-the-go exercisesGot Shoulder impingement? What are you impinging on?Simple self test to find out if you have shoulder impingementNeck and shoulder pain? 3 clinically proven stretches for pain reliefCarpal tunnel syndrome? 3 foolproof tests to find causes of hand numbnessLike what you just read? Share this post via our social media buttons! 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