Massage Therapy for Shoulder Pain

Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain

Paul Ingraham • Aug 10, 2016 • 10m read

Trigger points (TrPs), or muscle “knots,” are a common cause of stubborn & strange aches & pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common & yet fairly easy to self-treat with massage — the most satisfying & useful places to apply pressure to muscle. For tough cases, see the advanced trigger point therapy guide.

I avoided adding Spot 14 to this series for many years, because it’s a bit tricky to find. But precision is not required: although there is one specific spot that’s especially good, nearly anywhere under the ridge of bone on the shoulder blade is worthwhile, and often a surprising key to pain and stiffness everywhere else in the shoulder, especially all the way around on the other side, facing forward.

Spot 14 is the site of my best treatment success stories in a decade of professional massage. I tell the whole thing in another article.1 Here’s the short version: my wife’s uncle, tough as an old boot, was laid low by a toothache-like misery in the front of his shoulder, but after just a couple minutes of rubbing Spot 14 on the back of his shoulder, he was completely fixed … in less time than it takes me to make coffee. He spent that weekend swinging his arm around, chuckling, and saying, “Well, damn, ain’t that something!” He never had that problem again.

For most people, Spot 14 is a just pleasant surprise: a “secret” way to ease shoulder tension that almost no one has a clue about until they feel it, but after that it seems obvious. Learning about Spot 14 is a great way to get a reputation for magic hands.

How do you find Perfect Spot No. 14?

To qualify for “perfection,” a satisfying spot for massage should be both easy to get to and worthwhile. It is easy to get to the neighbourhood where Spot 14 lives. It’s just hard to find the exact address, which is the most worthwhile.

The neighbourhood is the triangular shoulder blade. Finding the infraspinatus muscle is basically as easy as touching the shoulder blade. That bone is mostly covered by the infraspinatus muscle, which is under (infra) the ridge (spine) of bone. The shoulder blade’s ridge of bone is roughly horizontal and spans the full width — it’s an easy bony feature to find. (There is a supra-spinatus muscle above it, but it’s much smaller and hidden under a thick layer of trapezius.) The infraspinatus is large, flat and mostly just below the skin (or a paper thin part of the trapezius).

This schematic shows how the fibres of the infraspinatus fill the space below the spine of the scapula & converge on a point on the upper arm. When they contract, they spin the arm in its socket (arrow).

The entire muscle really is worth massaging, more satisfying than many other muscles, “good” for massage. But the top edge is “better” for massage. And “best”? Perfect even? Spot 14 tends to be quite a small, specific patch of muscle at one end of that strip, closest to the middle of the back: the upper, inner “corner” of the shoulder blade, just under the ridge. There really is one spot here that is particularly, profoundly sensitive in many people, but you can be right beside it and no one is the wiser — it usually takes some fairly detailed fingertip and thumbtip exploration to “nail it.” On the bright side, I think it’s a noteworthy spot in easily 90% of the population, so the search probably won’t be in vain.

And if you miss it? Luckily, the rest of the muscle rarely disappoints. See below for “closely related spots.”

What does Perfect Spot No. 14 feel like?

More than any other perfect spot in this series, Spot 14 is obscure until you feel it. Spot 14 itself rarely aches or feels stiff, in my experience. Instead, people feel pain and tightness well lateral to Spot 14. Spot 14 lurks so far towards the inner edge of the shoulder blade that it almost doesn’t seem like a shoulder spot, but that’s its secret: rub it firmly, and almost anyone will feel the sensation spread laterally and penetrate through and around the rest of the shoulder.

Like most trigger points, Spot 14 will feel raw and burning if you are too hard on it, but it usually produces a sickly ache. Penetrating referral to the front of the shoulder can be surprisingly specific and isolated — almost as if the shoulder is being touched in two different places at once.

How do you treat Perfect Spot No. 14?

A small rubber ball can be the perfect self-massage tool for the infraspinatus muscle.

Not only is this spot a bit tricky to find, it’s also hard to reach. If you’re doing self-massage, this significantly increases the difficulty level. It virtually requires a couple tips and tricks. Specifically, you really need just the right kind of ball — fairly firm and small for accuracy, and a bit grippy so that you can easily trap it between your shoulder blade and a wall without it slipping. Most toy/dollar stores have small bouncy rubber balls. It should be about 2–3 centimetres in diameter (small enough to be accurate, large enough that it doesn’t get “lost” in the tissue). These are just about ideal, although they can be a little bit too hard for some people. A squash ball is a perfect way to start off more gently, but it’s also a little too soft to finish the job. So you really want both: a squash ball to start, a harder rubber ball once the tissue is warmed up.

Squash balls are good & grippy & soft enough to be a gentle way to start massaging a thin, sensitive muscle like the infraspinatus.

And then you need some practice. It’s not rocket science, but it won’t go smoothly the first time you do it either. It’s almost impossible for the average person (who has never really even thought about anatomy before, let alone studied it) to accurately explore muscle this way. I’ve watched people try. They drop the ball. It ends up on the other side of their back. Even if they get in into the right area, it quickly moves — control comes only with more practice.

But with that practice, it’s no big deal. It just takes a few tries to start to get the hang of it.

The infraspinatus is not a thick muscle. You’re pinching a thin layer of muscle between skin and bone. Gentleness is strongly advised, especially at first.

Closely related spots

The approximate location of Spot 14 & friends in the infraspinatus triangle. The pale blue band across the top indicates the most worthwhile area.

Teres minor: I explained above that it’s worthwhile to massage anywhere under the ridge of bone on the shoulder blade. In fact, you can keep right on going towards the outside edge until you fall off it … and then you’re massaging the teres minor muscle, a close cousin of infraspinatus in the “crotch” where the arm meets the back. In terms of sensation, these two muscles are nearly indistinguishable — both often produce deeply, sickly aches throughout the shoulder. This is true of all four of the deep shoulder muscles, the infamous “rotator cuff,” but the infraspinatus and the teres minor are the two that are reasonably easy to get to.2

Lateral edge of infraspinatus: another noteworthy spot to massage is the lateral edge of the infraspinatus muscle. The muscle fibres are parallel to the edge of the bone, and are fairly thick and easy to feel. Push on them perpendicularly, like you’re trying to push them across the shoulder blade, towards the middle of the back. The sensation comes not just from the point of contact, but from the stretch.

Tip of the shoulder blade: the very bottom of the scapula is an easy spot to find. The shape of the bone there is prominent. As mentioned above, you can make it pop out clearly by putting the hand behind the back. The infraspinatus muscle covers the entire shoulder blade, right down to this tip. The fibres are thin where they anchor to the bone, and they don’t seem like much, but don’t let that fool you: even gentle pressure can feel quite potent here.

The role of Spot 14 in “frozen” shoulder

A true case of frozen shoulder (adhesive capsulitis) involves a mysterious pathological process, and cannot be reliably treated by any means, massage or otherwise, and many attempts to treat it will simply make things worse.3 That said, some of its symptoms may be effectively treatable. Much of the pain and stiffness patients experience can be temporarily, partially relieved by shoulder massage in general and Spot 14 in particular. Although that falls short of a miracle cure, many frozen shoulder victims are grateful for any relief. It probably beats pain killers (but I’m guessing — no one has studied it).

Many people have claimed therapeutic victory over frozen shoulder with massage and manual manipulation alone. I just don’t believe it. What I do believe is that some cases of severe shoulder pain are simply mistaken for frozen shoulder — somewhat like “migraine” is incorrectly used as a synonym for any bad headache. This leads to some great cures for surprisingly yielding cases of supposedly “frozen” shoulder. The anecdote I gave at the top of the article is a good example of a case that could easily have been misdiagnosed as adhesive capsulitis.

The role of Spot 14 in rotator cuff injuries

The infraspinatus is part of the infamous rotator cuff — a group of four muscles that surrounds the ball part of the ball-and-socket shoulder joint. It’s a complicated muscle group that stabilizes and manages fine control of shoulder movements, and it often gets hurt: rotator cuff tears (muscle strains) and other problems are common here.

Trigger points often go along with these problems, sometimes complicating or even replacing them. (This is likely what had happened to my wife’s uncle, from the story at the beginning of this article.)

People may start out with a straightforward rotator cuff tear, but as that heals symptoms may still be produced by trigger points that cropped up after the injury: out of the frying pan of injury into the fire of trigger points. This may be the explanation for unusually persistent pain after an injury. It’s not that the injury isn’t healing, but that it’s gradually been replaced by trigger point pain, or greatly exacerbated by it. And so massage of the rotator cuff — and the infraspinatus in particular — may provide surprisingly easy relief from stubborn shoulder “injuries.” Certainly it’s worth a try.

Did you find this article useful? Interesting? Maybe notice how there’s not much content like this on the internet? That’s because it’s crazy hard to make it pay. Please support (very) independent science journalism with a donation. See the donation page for more information & options.

About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

SUBSCRIBE

Get PainSci updates in your inbox, mostly small, 0–3/week depending on coffee dosage. More info.

Notes

1. Ironically, the other article is an article about doubting the existence of trigger points. It’s interesting. Complicated. But interesting. See: Trigger Point Doubts.
2. The other two, the supraspinatus and subscapularis, are both buried deep under other muscles. A subscapularis massage is literally an armpit massage: a therapist must press straight into the armpit, and there’s a maze of difficult anatomy there. You could easily annoy the brachial nerve if you’re not careful, for instance.
3. Bahr R, Mæhlum S. Clinical guide to sports injuries. Human Kinetics; 2004. “The fact that both surgical and conservative treatment will worsen the course must not be overlooked. The reason why treatment is ineffective is not known. … The natural history of the condition is typically benign, and attempted interventions are generally ineffective and may worsen the condition” (p7).

Appendix A: Is trigger point therapy too good to be true?

Trigger point therapy isn’t too good to be true: it’s just ordinary good. It can probably relieve some pain cheaply and safely in many cases. Good bang for buck, and little risk. In the world of pain treatments, that’s a good mix.

But pain is difficult and complex, no treatment is perfect, and there is legitimate controversy about the science of trigger points. Their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle tissue may well be wrong. What we do know is that people hurt, and it can often be helped.

The Perfect Spots are based on a decade of my own clinical experience as a massage therapist, and years of extensive science journalism on the topic. Want to know more? This is the tip of the iceberg. I’ve written a whole book about it …

Not too good to be true.

Just ordinary good. Trigger point therapy isn’t a miracle cure, but it is a valuable life skill. Practically anyone can benefit at least a little & many will experience significant relief from stubborn aches & pains. The first few sections are free.

Appendix B: Quick Reference Guide to the Perfect Spots

This index is also available on its own page.