Google is a verb...

A client came in on Saturday sent by one of my regular athletes to see if I could help him with a chronic shoulder problem. He'd had manual diagnosis from an Orthopedist, an MRI, neurological tests from the neurologist, physical therapy rehab exercises for several months and still wasn't sure what was goin on. He had very limited ROM in external rotation. He could do pull ups, overhead presses, lateral raises, but was unable to do anything loaded in external rotation. The docs told him that the innervation to the supraspinatus and infraspinatus was defunct (not their term) and recommended the physical therapy which he did religiously until the Rpts sent him off with a shoulder shrug and a general suggestion that he continue on his own.

When I looked at the back of his scapula, there was no there there. The place where the infraspinatus should be was an indentation. Oops!

I told him that I thought this was outside the scope of my practice, which is largely tunin up athletes on the edge of overtraining and getting the schmutz out when they come in already overtrained with some body part gristled up, sore and weakened from the adhesions that tend to accumulate when overtraining or overreaching occurs. But muscles completely evulsed or gone mysteriously missing fall into the domain of MDs.

Hey, there are several reasons type A folks just keep training on a part when it hurts. One is that there's a 50/50 chance the pain/problem will go away. That's true, sometimes stuff works itself out. Often, tho, when it doesn't, it gets worse and dysfunctional. The kind of bodywork needed when that happens I characterize as clinical work. Several types of deep tissue work can be effective. But if the muscle is nowhere to be found and all there is are a few noodles of gristle where the orgins should be, well Houston.....

This client wanted me to work on him anyway, loosen up some tight places and see if anything we could do would have a positive effect. His scalenes were tight as steel bands, sent trigger point pain referrals pin balling into the zones they're known to travel to. So did his sub-occipitals ping into the forehead, but nothing was lighting up that infraspinatus.

Before he left we discussed some ways that his training at home might isolate that muscle to target it most effectively. I suggested that he might try autogenic training to see if some hypnosis asking his unconscious mind to hook that nerve pathway back up would bring healing from within. He lives a long distance from me, so finding local practitioners seemed like a logical next step. Perhaps acupuncture could address it if only the nerve were inflamed. Acupuncture can be effective at calming down inflamed nerves, in my experience, but that wasn't his issue. This wasn't an inflamed nerve, it was a nerve not doin its job and I've never seen acupuncture address that effectively.

I googled. Google is a noun and a verb and a great one at that if you take the time to explore a little. I've always considered my clients my best teachers, so why not use this as a learning opportunity.

I just finished writing the e-mail I sent to him recapping what I found. Now we get to see if these rather unorthodox approaches bring him the hypertrophy he hasn't been able to invoke so far.

Here's exerpts from the letter I sent:

Since we found that your supraspinatus has responded positively to the rehab you did, that is, it has some power when we did resisted side lying lateral raise test on it, it does not look completely atrophied as does the infraspinatus, and you can do pull ups, I went looking for where the nerve that innervates them both branches off since that's the nerve the neurologist found not firing. I found the branch!!**

It is below the scalene surrounded thoracic outlet of brachial plexus that I loosened up with the scalene trigger point body work we did. I still think it is better for you to be a bit looser there where that brachial plexus goes under the clavicle, but it was not where the problem appears to me to be sourced,neither is it at the vertebral level it seems after doing some reading/sleuthing.



If the problem were at vertebral level, both muscles would most likely be atrophied since they're innervated by the same suprascapular nerve. As you can see if you look carefully at the pics above, the place where that nerve separates to 2 distinct branches, one going to supraspinatus and the other to infraspinatus is actually after it has gone under the clavicle and thru the transverse scapular ligament (purple color) on the top of the scapula itself.

This is not only relevant to your visualization of where it needs to solder itself together again, so to speak, as you do the work of rehabbing that infraspinatus, but as you can see from the piece I found below, it could be a possible answer to what happened to it.

"The suprascapular nerve is a motor nerve originating from C5 and C6 nerve roots or upper trunk of the brachial plexus. It passes through the suprascapular notch which is covered by the transverse scapular ligament into the supraspinous fossa where it supplies the supraspinatus muscle. The nerve continues around the lateral border of the spine of the scapular to also supply the infraspinatus. Depending upon where the compression occurs (suprascapular notch or spinoglenoid notch) either both or individual muscles may be involved. It is noteworthy (see below) that after it leaves the suprascapular notch it also passes the subacromial bursa and gives off sensory fibers to the capsular and ligamentous structures of the shoulder and acromioclavicular joint.

Inspection of the shoulder may show atrophy of either or both the infraspinatus and supraspinatus muscle....

Treatment of the suprascapular injury is directed at rehabilitation (strengthening and flexibility) of the supraspinatus, infraspinatus, and scapular rotators. During the rehabilitation phase, movements such as cross-body adduction, forward flexion, and external rotation which creates tension on the suprascapular nerve should be carefully monitored.1 Spinal adjustments will help in improving homeostasis to the area. Black and Lombardo1 state that while improvement may occur in one to two months, it may take six months to a year for full return of function. Repeat EMGs will show reinnervation of the involved muscles. At times, surgical decompression may be necessary. Before sending an athlete back to full activity, it is essential to achieve maximum strength of the involved muscles since the infraspinatus supplies 90 percent of the external rotation power of the shoulder and the supraspinatus is important in creating compression stabilization of the humeral head in the glenoid cavity during elevation.

References

Black, K.P.; Lombardo, J.A. "Suprascapular Nerve Injuries with Isolated Paralysis of the Infraspinatus." Amer J of Sports Med, 1990; 18(3):225-228.
Vegso, J.J.; Torg, E.; Torg, J.S. "Rehabilitation of Cervical Spine Brachial Plexus and Peripheral Nerve Injuries. Clin in Sports Med, 1987; 6(1):135-158.

compression at the level of the spinoglenoid notch would be expected to affect only the infraspinatus;"

So from that tidbit we get that it could have come from a compression at the spinoglenoid notch or it could have torn there. You did hear a pop didn't you say?. The next bit is interesting because it offers another option as a source of compression. A cyst arising from a torn labrum where the jello has oozed out into the spinoglenoid notch, thus causing atrophy only to the infraspinatus. Maybe the pop was the labrum tearing. Perhaps a new MRI would show this if done as suggested below. I included the link because you want to look at the source which has more pics. I don't know if there's a minimally invasive laser type surgery that could be done to remove the cyst, if there is one, impinging on that nerve.

Even if there is no minimally invasive surgical intervention for it, it is worth seeing if your insurance would cover this kind of MRI in case this is pertinent.

This location of the possible impingement/rift changes the nature of what you are invisioning as the core of the healing to that nerve that you are trying to invoke. If a fluid filled cyst is the cause, it would probably behoove you to include some good quality glucosamine/chondroitin which provides building blocks for connective tissue repair in your supplement intake. Maybe some anti-inflammatories would help dry it up too. If you don't want to offend your liver with longer term use of NSAID types, try Sam-e as an alternative. These supplements cost you a bit, but if they don't effect a possible cyst that you might not even have, they are still good supports for tendon healing as are Omega 3 fatty acids. This is where acupuncture might be helpful too, if you could find someone who understands what he's/she's trying to do with it.

Idea being to shrink the cyst while doing the side lying l flyes, using some kind of prop to push that arm up beyond where you can actually lift it now, then use the muscle and your visualization of that nerve kicking in to lower it controlling the eccentric. I think at this point it is important to choose an exercise that isolates this muscle from others in its action chain, thus eliminating the possibility that the others are taking the load and and allowing the infraspinatus to stay atrophied. DB side lying l flye with elbow anchored at waist is a great infraspinatus isolation ex. Start with body weight only till you can achieve full ROM in both concentric and eccentric. You might have to use a wooden spoon with a long handle to push it all the way up at first, then lower it without the assist of the prop. If this works you should be able to lift it higher and higher as you proceed and it gets stronger by targeting it with eccentrics only at first, since that's all you got. Work with it. Concentrate. No one has more at stake in getting this muscle hooked up again than you do so this is your training theme for the next 8 months to a year and it's your research project as well. You might want to lay off the pull ups, in case the labrum is torn and supraspinatus still a bit weak, substitute lat pull downs instead. You don't have to hang the full weight of your body from those rubber bands aka rotator cuffs, when doing pull downs. You can control the ROM.

Perhaps the acupuncture might help, but let them know where the impingement probably is, in the glenoid fossa not at the spine. Look a these pics, read this material and the web site link. Think about it. Then if you have questions, call and we'll talk. I don't want to be the only one doing this homework though. I've already spent several hours of my time on this for you, but it does change the flavor of your work on it so is well worth considering, IMO.

Here's the link to the info on Paralabral cysts: