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Thomas Gordy, Rolf Practitioner, LMT
Acknowledgements and Disclaimers
Many thanks to past teachers, assistants, colleagues, and participants for their assistance in the development of this work and this manual. Teachers who have influenced these materials include Liz Gaggini, Neal Powers, Emmett Hutchins, , Til Luchau, Nilce Silvera, Andy Goodwin, Michael Salveson, Art Riggs, and Jan Sultan, to name a few. Of course, also to be mentioned is the groundbreaking pioneer in this field, Dr. Ida P. Rolf, without whom, none of this would have been possible. And of course, many thanks to Eric Asay, the photographer and web site designer making this presentation happen.
Disclaimer: This course teaches soft-tissue techniques for students and practitioners of manual therapy/massage therapy/bodywork. This is not a course in Rolf Structural Integration.
These methods do not constitute medical treatment and a physician should be consulted in advance about any conditions that are questionable or might contraindicate this work. While every attempt is made to insure the safety of the techniques taught, participants assume all risk for participation and subsequent application of the techniques learned.
It is recommended that students review anatomy before the class begins and use anatomical charts or books to aid in the understanding of this material.
Preface
The shoulders, or “shoulder girdle” are, like the pelvis, a point of reference for the body. We look to both the pelvic girdle and the shoulder girdle for balance, as balance within these two girdles and balance relative to each other largely determines the health and well-being of our fascial and musculo-skeletal system as a whole, how well we are aligned, and whether or not our bodies move with ease and grace. To begin with, function or dysfunction that occurs in the shoulder girdle can often be attributable to the function or dysfunction in the pelvis. Simply put, the pelvis inhabits a space below the shoulders. This means that within our context of gravity, the pelvic girdle is a foundation for the shoulder girdle, thus dysfunction below will often become dysfunction above.
With that we are reminded how important it is to strive to see the body as a whole rather than a sum of disjointed parts. Indeed no body part exists in isolation. That being said, shoulder dysfunction may well exist independently of a perfectly normal pelvis. But the point is that in learning to identify and treat dysfunction, we strive always to look beyond the immediately affected area.
This imperative remains for treatment of shoulder pain. Rather than simply working the symptomatic area, we are looking for other relationships that are contributing to the symptoms, and in working with the shoulder girdle there is some necessity in examining all of the structures below as well as those that primarily make up the “shoulder girdle” in its entirety. Treatment of the structures below the shoulder girdle, including the pelvis, is not of course the point of this manual. But is important to note how important an effect structures such as the ribcage and the pelvis have on the shoulder girdle. In regards to the pelvis, the shoulder girdle will most often have a structural pattern that is the mirror opposite of what is occurring in the pelvis. For example, if the pelvis is rotated to the right, the shoulder girdle will tend to rotate to the left. This is the basic effect of gravity and the body’s reaction to it: a rotation will cause a counter rotation. If the rotation in the pelvis is something that is fairly recent, such as the result from a traumatic injury, the shoulder girdle will eventually, over time, adapt to the structural pattern in the pelvis…and will do the mirror opposite.
With the ribcage, a sagging ribcage will drag the shoulders with it. Thus we often must find ways to correct the ribcage before we can really correct the shoulder girdle. In any case, the point is, to make long lasting changes in the shoulder girdle, it is a more than likely a necessity that we address the rest of the body.
We’ve already pointed to a possible cause or contributing factor in shoulder dysfunction – i.e. all of the structures/foundations below it. Other shoulder issues may be due to overuse, trauma, or a myriad of other possibilities. Regardless of cause, our job, through manipulation, is balance. But what is balance?
Balance with the shoulders essentially means balance of the scapulae. They are your guides. Scapulae that are well balanced on the back are indicative of a strain-free structure that has easy mobility and gracious space at the shoulder joints (glenoid fossa). Thus our job is to balance the scapulae by working through the muscles and fascia that dictate scapular position. This also requires that we adequately determine the position(s) of the scapula through visual assessment.
Setup Considerations
A. Draping – underwear vs. bare
Having the client in underwear allows for easier positioning and draping. At times, less draping will be necessary making underwear essential. Underwear also gives the client a greater sense of safety. Clients are often “used” to being naked and often expect this, however, in a clinical setting where you may need the client to be in multiple positions; underwear makes the whole time-consuming issue of draping one that is less pressing and certainly less stressful. Where underwear becomes a modesty issue for the client, a pair of shorts and a loose top is preferable.
To work most effectively, one must be able to accurately “see”, whether that is while working with a client during a session, or before the session even begins, assessing where tissue is held or shortened. It also useful to assess in between our work -- to have the client’s stand and move around so that we, as practitioners, can see the work in progress, and the client better feel the changes as they happen in the field of gravity.
B. Table Height
Clinical and deeper work often requires the table height to be lower than for other modalities, such as Swedish. The table height should be such that the practitioner can bring his/her weight to bear with arms in a fairly straight position. Also of use here is a small stool from which the practitioner can stand in order to bring more weight to bear. The important thing here is to be able to work comfortably, and if you cannot use your weight to do the work and are instead relying on muscle power, you are straining yourself.
C. Lubrication
For deep work, clinical work, and myofascial release, less rather than more lubrication is necessary. You can’t use your weight if you are sliding off of your clients. The key here is to engage tissue, not slide over it. Less lubrication allows for slower work, allowing you to feel what is happening.
For clinical work, it is recommended that you use a lotion rather than oil. Often, you may only want to use a small amount of over the counter skin moisturizer – enough to ensure that the client will be comfortable as you engage the tissue, but not too much that you unintentionally slide. Over-lubrication actually makes it harder to work and causes you to strain.
D. Speed
Most deep, clinical, or myofascial work should be done at a much slower pace. This allows tissue to respond and minimizes any bruising. Further, working slow allows us to feel what is happening...and that allows us to learn. Go in slow, work slow, and come out slow. For lighter or more vigorous massage such as a pre-event sports massage, speed may be required, but most of the time, slowing down is both beneficial for us as practitioners, and for our clients who feel a more relaxed, easy, and sensitive touch.
E. Unilateral vs. Bilateral work.
Your approach to a session is extremely important. My typical advice to all students and practitioners that it is very important to work both sides of the body symmetrically. This class however presents situations in which we will often be working asymmetrically (unilaterally) through the body in order to bring about structural change, balance and pain cessation. While such goals can somewhat be reached by working symmetrically, we can work smarter, faster, better, and easier by working asymmetrically. There is one simple reason why we can work asymmetrically easily with the shoulder girdle – and that is the ease of assessment in this particular region.
Assessment
This is the crucial part of the process. Assessment allows you to accurately judge where to work, and when we are working with a painful shoulder, knowing where to work is fairly essential. Working globally throughout the muscles and fascia of the shoulders will bring some balance and relief…but by being more specific, you can generate better results easier and faster.
Our guide(s) will be the scapulae. The scapulae are capable of various positions on the back but we will be chiefly concerned with tilt and shift of the scapulae. Tilting and shifting of the scapulae can occur both anteriorly and posteriorly. We look at tilt separately from shift.
Starting with assessing tilt, a scapula will typically be in an anterior tilt or a posterior tilt. Both scapulae may be anteriorly tilted…or both may be posteriorly tilted…, but more often than not, one scapula will have an anterior tilt relative to a posterior tilt in the other scapula.
Certain muscles and fascia will be directly responsible for the anterior tilt. Just as other distinct muscles and fascia are responsible for a posterior tilt. Thus our jobs will often be to work with a particular set of muscle groups on one shoulder and then work with a completely different set of muscle groups on the other to correct the tilt patterns.
Shift of the scapulae works the same way, with a separate group of muscles and fascia responsible for anterior shift and a different set of muscles and fascia responsible for posterior shift.
Our abbreviations will be:
AT = Anterior Tilt
PT = Posterior Tilt
AS = Anterior Shift
PS = Posterior Shift
Bear in mind that it is possible that both scapulae have a similar pattern – for example, both scapulae may appear to be in a slight anterior tilt and posterior shift. Such may be the natural pattern of that person’s body. We are not really looking to upset that pattern unless it appears to be dysfunctional. What we are really looking at is the pattern in one scapula relative to the other scapula – i.e.: one scapula as compared to the other. Most often, one scapula will have a pattern very distinct from the other scapula.
We can thus have the following patterns in the scapulae:
Right scapula: AT/PS
Left scapula: PT/AS
Or (left and right interchanged)
Right scapula: PT/AS
Left scapula: AT/PS
This is the most common tilt/shift pattern.
A less common and more dysfunctional pattern is:
Right scapula: AT/AS
Left scapula: PT/PS
Or
Right scapula: PT/PS
Left scapula: AT/AS
Thus, for the above first example pattern (Right AT/PS, Left PT/AS) we would be working with particular muscles of the right scapula to lessen the anterior tilt and posterior shift…and then working with particular muscles associated with the left scapula to lessen the posterior tilt and anterior shift…thus bringing balance between the two scapulae.
Now…how do we tell what is an AT or a PS…and so on? The easiest way to do this is to look closely at your client’s scapulae while they are standing:
Anterior tilt: the scapula will appear higher than the other with a defined posterior border. The same-side humerus will rotate medially.
Posterior tilt: the scapula will appear lower than the other and appear to be very flat on the back with little definition. The humerus will rotate laterally.
Anterior shift: the scapula will be further away from the spine and will have the look of “winging” – or a very defined medial border.
Posterior shift: the scapula will be closer to the spine with little definition to the medial border.
With some clients, they will be uncomfortable being examined without a shirt or covering. If this is the case, you can assess with their clothes on by having the client stand and placing your hands on their scapulae. Now utilize the same visual assessment except do so by examining the placement of your hands.
When we are in doubt of our assessment, we can of course work globally through all the tissue. This will provide a measure of relief and balance for the client, and we can refine our work at another time. There are times as well where global work will be a necessity – shoulders that are limited and restricted in every sense. Again, specific balancing work can be done after general work is initiated to just open up the structure. When in doubt, work globally throughout all of the tissue. Keep looking however, and you will begin to see the patterns.
Techniques: Working with the tissue
There is a vast difference between working “on” a body and working “with” a body. Our goal is obviously to work “with” the body so that we cause the client very little discomfort and maximize our results. In working with the tissue we will be working fairly slowly. This allows time for the tissue to respond while the client remains much more receptive to the work. It also allows us to really feel what is happening under our fingers. This is pure, honest myofascial technique. When done correctly, there will be very little need to repeat these techniques. Three times over an area will typically give all the desired effects, or at least all the effect that you are going to get in that session. Take the time to re-assess and let your eyes, fingers and intuition be your judge on whether or not a particular area needs extra work. When the tissue has given as much as it is going to give, move on, and revisit that area during the next session.
Our goal in working the tissue is to lengthen it. This is best accomplished by working in the same direction as the fibers run. With a client’s movement involved, it often helps to take the tissue the same direction that the tissue is being stretched. This is called a “facilitated stretch”. Taking the tissue in the opposite direction is closer to what is called a “pin and stretch”. Either technique will give you length to the tissue provided you are working in the same direction as the fibers.
A general guideline to follow: Utilize three strokes per area.
1. A superficial stroke
2. A stroke at medium depth
3. A deep stroke.
By this method we will be engaging the superficial fascia as well the entirety of the muscle, including all of the fascia that runs through it. Of course, with a big muscle such as lats or even pec major, you may need to do several strokes on each level just to cover the entire muscle. The idea is to make sure we work all of the fibers of the muscle.
We will be using the names of muscle to denote the tissue that we are working with. By simply using muscular terms, we are of course oversimplifying a bit given that along with muscle tissue we will also be working with fascia, both superficial and deep. We can also work with tendons, and a tendon is deep muscle fascia as it joins together at the ends of the muscle. Stubborn tissue may respond well to working on a tendon first, and then addressing the rest of the tissue.
As per our guidelines above, superficial fascia should be addressed first as we work through an area. Superficial fascia is the fascia directly below the skin and we will release this fascia in areas where it feels “stuck” to bone or the deep fascia below it. We are interested in the superficial fascia directly above and near the muscle groups we are targeting. This includes any superficial fascia that is nearby or on top of bone.
The principle muscle and fascia that contributes to the positions of tilt and shift are listed below. These are the primary tissues that are shortened and causing the particular scapular position. Hence these are the tissues that need to be lengthened in order to ease or correct the scapular position.
Anterior Tilt
Latissimus Dorsi
Triceps Brachii
Supraspinatus
Teres Major
Levator scapula
Trapezius
Pectoralis Minor
Posterior Tilt
Infraspinatus
Teres Minor
Biceps Brachii
Coracobrachialis
Anterior Shift
Subscapularis
Posterior Deltoid
Serratus Anterior
Posterior Shift
Pectoralis Major
Anterior Deltoid
I. Anterior Tilt
1. Latissimus Dorsi
Lats are strong muscles which, when over-taught, have the effect of causing anterior tilt of the scapula – pulling the shoulder forward and down. Be aware of where both lats and teres major attach. When overly tight, not only do they cause anterior tilt of the scapula, but they tend to pull the humerus posteriorly.
Best accessed in sidelying with the client’s arm above the head. Starting at the lower aspect of latissimus (near the iliac crest), engage the tissue of latissimuss and slowly take the tissue headwards as the client reaches with her arm above her head.
 
There may be areas where you feel that latissimus is “stuck” to the ribs. This is a place where you may want to focus your work until the tissue feels supple and free.
Often it helps as well to take the latissimus tissue a bit posteriorly – towards the spine. Lats have a tendency to creep forward around the sides of the body.
2. Teres Major
Working in conjunction with latissimus is teres major. Teres major is the “bad boy” of the neighborhood – a very strong, short muscle that has the tendency to pull the shoulder down and forward (anterior tilt) even more so than lats. You’ll find teres major at the lateral border of the scapula, and it can be quite ropey and tough.
You can work with teres major in the same way as you worked with lats (above), except that you are instead engaging teres major and taking the tissue headwards while the client reaches over his head.
A second way to work with teres major is in supine with the client’s arm abducted and flexed. Again slowly take the tissue headwards while the client reaches above her in a “snow angel” type of motion.
 
3. Triceps Brachii
Not given as much credit as it is due, triceps can be a strong contributor to anterior tilt. Keep in mind that one aspect of triceps attaches to the scapula…and when overly tight, will tend to both bend the arm at the elbow while causing the humerus to stray posteriorly. As this occurs, the scapula tends to tilt anteriorly.
Have the client in supine and the arm overhead. Dependent on the client’s range of motion, you may need to bolster under the arm with a pillow or your leg. You now have excellent access to triceps and, dependent on your position, you can work the tissue either up or down. To fully engage the tissue, have the client slowly flex and extend at the elbow while you work. You will often find hard, tight triceps tissue near the medial aspect of the elbow. Often after working this tissue the client will have a much fuller extension over the head.
 
4. Pectoralis Minor
Often thought as the main culprit in an anterior tilt of the scapula, pec minor remains a worthy contributor. Pec minor attaches at the coracoid process on the anterior aspect of the scapula and attaches (typically) on ribs 3,4,5. A shortened pec minor has an obvious effect of pulling the scapula forward and down.
In supine, with the arm abducted, engage pec minor, working the tissue either up or down as the client move’s their arm in the “snow angel” movement. Be sure to work with the tissue directly off of the coracoid process.
 
5. Supraspinatus
A minor contributor to anterior tilt, supraspinatus can be accessed in sidelying, seated, prone, or even supine. Here we will access it in sidelying with the client’s arm resting on their side. Taking the tissue down towards the table with a knuckle, soft fist, or fingers, have the client reach with the same side arm towards his feet. Reach for a second or two while working, then relax. Repeat.
6. Trapezius
A big burly muscle trapezius is a favorite for any client who suffers from shoulder or upper back pain. Here we are most concerned with the upper trap fibers. As with supraspinatus, we can access traps easily from sidelying. Utilizing the same client movement as with supraspinatus, engage and work the trap tissue down towards the table as the client is reaching towards their feet with their arm.
 
7. Levator Scapula
Levator attaches at the medial/superior border of the scapula, inserting on the transverse processes of the cervical (often C5,C4,C3). Often a place of pain, levator is routinely victimized by scapula that are pulled out of position, causing strain to levator. Levator also has trap, rhomboid, supraspinatus, and erector fascia cris-crossing it and often gumming it up. It is an area that can be a fascial trainwreck.
While a minor contributor to an anterior tilt to the scapula, releasing levator will often be much appreciated by the client. Levator can be accessed and worked in the same way as both supraspinatus and trapezius above. Another method is in the seated position. Here, you can engage levator as the client rotates their head to the opposite side. Again, work slowly here and either take the tissue towards the scapula or the opposite way towards the cervical.
 
II. Posterior Tilt
1. Infraspinatus and Teres Minor
Infraspinatus, along with teres minor, in my experience, are the leading muscular causes of shoulder pain. When taught, these muscles tend to severely decrease joint space in the glenoid fossa, pulling the humerus into lateral rotation and causing a “gapping” effect on the front of the shoulder. In fact, infraspinatus and teres minor are the usual culprits for shoulder pain that occurs on the front of the shoulder. These muscles will also cause a limited range of motion, joint crepitus, and sometimes numbness in the arm. They are very difficult muscles to stretch while being muscles that are very easy to overuse and shorten.
I am grouping these muscles together because, although distinguishable, they cause much the same effect and can be accessed and worked in the same manner. These muscles reside on the back-side of the scapula, below the spine of the scapula, stretching from the medial border of the scapula to the humerus. Teres minor is directly below infraspinatus.
In sidelying, have your client slightly flex at the shoulder, hand on table. Using fingers, a knuckle, or even an elbow, engage infraspinatus/teres minor at the medial edge of the scapula. Work the tissue towards the humerus as your client continues to forward flex at the shoulder.
 
2. Biceps Brachii
Apart from its showy potential on a thong-clad narcissist, biceps brachii can be a real pain in the shoulder, especially by virtue of its connection to the scapula. An overly tight biceps (as well as coracobrachialis) contributes to the lateral rotation of the humerus, often causing pain in the front of the shoulder.
Working with biceps brachii can be a slippery affair, but in general, engage the tissue and work it in the same direction as the fibers run as you passively flex and extend your client’s arm. You can also have the client actively flex and extend although with biceps, flexing will often cause you to slip out of contact with the muscle.
 
3. Coracobrachialis
Located next to biceps brachii on the inside of the arm and running from the coracoid process to the humerus, coracobrachialis is probably better worked without movement from the client (either active or passive). This is a delicate area, with nerves running in close proximity. Here, use firm but gentle pressure on the tissue in the same direction as the fibers run.
III. Anterior Shift
1. Serratus Anterior
Overly tight serratus will be reflected in the scapula, in which the medial edge will be very distinct or “winging”. Serratus anterior attaches on the ribs and the underside of the scapula.
To lengthen here, we will work the tissue from the rib attachments back toward the scapula as the client retracts his scapula by engaging rhomboids. In other words, have the client pull his shoulders back as you work, lengthening serratus as you push the fibers in the same direction.
2. Subscapularis
Subscap is easily the hardest muscle to access out of the many that are listed here. Subscap, as its name indicates, is basically under the scapula, or anatomically speaking, on the anterior side of the scapula. The only access to it is through our armpit – not commonly thought of as a pleasure-zone.
With the client in supine and the arm flexed at the elbow, passively rotate the humerus as you engage the tissue of subscapularis through the armpit. You will need to use fingers here and you will only be able to access the lateral aspects of subscap including its tendon that attaches to the humerus. If finding the muscle proves difficult, you should note the bony surface of the anterior side of the scapula as you press into the tissue. You can also have the client tense the muscle by medially rotating the humerus, causing the tissue to “jump” into your fingers. Have your client relax again to work with the tissue.
 
3. Posterior Deltoid
Best accessed in either prone or sidelying. Client movement here becomes more difficult to direct while you’re working. One option in sidelying is to have your client reach across (adduct) the arm towards the table as you work the tissue.
IV. Posterior Shift
1. Pectoralis Major
Pec major is often a culprit especially for males given our society’s appreciation for a big, meaty chest. Pec major can cause an awful lot of restriction in all areas of the shoulder but more than anything, it tends to pull the entire shoulder toward the midline – thus pulling the scapula towards the spine.
Most easily addressed in supine, with the client’s arm abducted and flexed at the elbow, work all of the fibers of pec major toward the attachment at the humerus as the client continues to abduct the arm in a “snow angel” movement.
 
2. Anterior Deltoid
Easily addressed in supine. Generally, movement by the client is difficult here so you may just want to work with the tissue without movement. Often there is a thickened border on the anterior deltoid. Focus your work there.
Conclusion
This manual is certainly not an end-all, be-all magic guide to the shoulders, but presents fairly easy methods to bring balance to the structure. There is assuredly more to learn, and it is your eyes, ears, and fingers that will serve as your best teacher as you continue in this journey; this limitless exploration of human structure and function.
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