The good news, from the results in treating hundreds of patients in various stages of adhesive capsulitis and com- plicated frozen shoulder conditions, is there is a protocol to specifically address each specific clinical condition. The inner fascial and capsular work must be performed pain-free, in conjunction with balancing out the muscle groups of the shoulder while systematically treating associated sprains or strains. The deep fascial adhesions inside the joint capsule can be softened and mobilized with precise joint capsule tech- niques. Pain-free movements, using the head of the humerus to create pressure, movement, and slow velocity stretch to the deepest investing fascia inside the joint capsule, can facili- tate myofascial release within the shoulder joint. The head of the humerus can be used as a massage tool to release and reposition the fascia or adhesions in the joint capsule. This is achieved by performing very gentle pain-free movements using the articulating cartilage of the humerus to massage the articulating cartilage, fascia, and osseous membrane of the shoulder within the joint capsule at the exact areas that you find a bone-on-bone-like end feel in the shoulder.
An added plunging technique, by gently compressing and decompressing the scapula with the head of the humerus, seems to even organize the disorganized collagen in the joint capsule itself. The author’s hypothesis is that when you gen- tly, but deeply compress the humerus into the scapula, it is a form of strain–counterstrain allowing the fibrin formation in the joint capsule to relax. When you gently traction or decompress the capsule with the humerus, the adhesions or fibrin formations create an eccentric force through resistance to your decompression. Thus, he believes that is what may better organize or realign the fibrin formation or disorganized collagen. The goal is to align with research experts to do clin- ical studies that will validate this result-driven hypothesis.
This can often release the frozen shoulder in literally one session, especially in early onset adhesive capsulitis. This is a unique technique that is one of the author’s trademarks. Although some people in the health care industry are skeptical about the feasibility of releasing long-term frozen shoulders, orthopedic massage practitioners using this technique have witnessed the release of frozen shoulders in many cases where the participants had previously been diagnosed with adhe- sive capsulitis and true forzen shoulders, by their physicians. (Watch the shoulder joint capsule release video clip at www .myhealthprofessionskit.com). This shoulder capsule work
is one of the most revolutionary techniques you will learn in this book.
what makes it better or worse. This will give you a starting point from which to assess the client’s active range of motion.
Step 2: Assess Active Range of Motion (AROM)
Goal: to assess range of motion of single-plane move- ments, performed solely by the client, to identify tight or restricted shoulder muscle groups.
Assess the client’s active ROM for the primary single- plane shoulder movements—flexion, extension, abduc- tion, adduction, medial rotation, lateral rotation, horizontal abduction, and horizontal adduction—with zero discom- fort. Determine if the range of motion is normal. Please understand that the normal degrees for each shoulder range of motion will vary with different references. The degrees listed in this text are accurate estimates for clients with healthy shoulders. (see the single-plane movement Fig- ures 5-1 ■ through 5-8 ■). If the range of motion is less than average, identify which muscle groups are restricted and therefore preventing normal movement. Focus on releasing these restricted, antagonist muscle groups:
If flexion is less than 160 to 180 degrees, work on releasing the extensors (antagonists)—latissimus dorsi, pectoralis major (lower fibers), posterior deltoid, teres major, and triceps (long head)—to restore normal muscle resting lengths.
If extension is less than 50 to 60 degrees, work on releasing the flexors (antagonists)—anterior deltoid, biceps brachii, coracobrachialis, and pectoralis major (clavicular portion)—to restore normal muscle resting lengths.
If abduction is less than 180 degrees, work on releas- ing the adductors (antagonists)—latissimus dorsi, pectoralis major, and teres major—to restore normal muscle resting lengths.
If adduction is less than 30 to 45 degrees, work on releasing the abductors (antagonists)—deltoid (middle), and supraspinatus—to restore normal muscle resting lengths.
If medial/internal is less than 90 degrees, work on releasing the lateral rotators (antagonists)— infraspinatus, posterior deltoid, and teres minor—to restore normal muscle resting lengths.
If lateral/external is less than 80 to 90 degrees, work on releasing the medial rotators (antagonists)—anterior deltoid, latissimus dorsi, pectoralis major, subscapularis, and teres major—to restore normal muscle resting lengths.
If horizontal adduction is less than 135 degrees, work on releasing the horizontal abductors (antagonists)— infraspinatus, posterior deltoid, teres major, and teres minor—to restore normal muscle resting lengths.
If horizontal abduction is less than 30 to 45 degrees, work on releasing the horizontal adductors (antago- nists)—anterior deltoid and pectoralis major—to restore normal muscle resting lengths.
The shoulder protocol involves moving between
Soft-tissue restrictions: muscle–tendon, fascia, scar tissue
Bone-on-bone-like end feel: joint capsule
Client emotions: guarding, fear of pain
This is called “the dance,” as the protocol may be different for each client. You will learn how to assess restrictions creating an individualized treatment for each client. The fol- lowing conditions are covered in this chapter:
Thoracic outlet syndrome
Adhesive capsulitis and frozen shoulder
Rotator cuff tear
Supraspinatus tendinosis and supraspinatus impingement
Infraspinatus tendinosis and teres minor tendinosis
Subscapularis tendinosis versus bicipital and coraco- brachialis tendinosis
Subacromial bursitis
Upper crossed syndrome
CORE PRINCIPLE
Imbalances in the hips can create distortions that affect the shoulders. It is highly recommended to perform pel- vic stabilization before working on the shoulder.
PRECAUTIONARY NOTE
Do not work on a client with a recent injury (acute condi- tion), exhibiting inflammation, heat, redness, or swelling. RICE therapy (rest, ice, compression, elevation) would be the appropriate treatment in this situation. This work cannot be performed on clients with severe shoulder con- ditions like a complete rupture of a muscle, complicated labrum tears, and fractures.Step 1: Client History
Goal: to obtain a thorough medical history including pre- cautions and contraindications for treatment of the cli- ent’s shoulder condition.
As mentioned in Chapter 1, taking a thorough client history will offer you valuable insights into a client’s condition. In addition to the basic information completed on the client his- tory form, ask the client when, where, and how the problem began. Also ask the client to describe the area of pain and
SHOULDER JOINT SINGLE-PLANE MOVEMENTS—PRIMARY MUSCLES
FIGURE 5-3
Shoulder Abduction, 180 degrees.
FIGURE 5-4
Shoulder Adduction, 30–45 degrees. FIGURE 5-2
Shoulder Extension, 50–60 degrees. FIGURE 5-1
Shoulder Flexion, 160–180 degrees.
Flexion, 160 to 180 Degrees
Abduction, 180 Degrees
Deltoid (middle portion)
Supraspinatus
Anterior deltoid
Biceps brachii
Extension, 50 to 60 Degrees
Latissimus dorsi
Pectoralis major (lower fibers)
Posterior deltoid
Adduction, 30 to 45 Degrees
Latissimus dorsi
Pectoralis major
Teres major
Teres minor coracobrachialis
Coracobrachialis
Pectoralis major (clavicular portion)
Teres major
Teres minor
Lateral/External Rotation, 80 to 90 Degrees
Infraspinatus
Posterior deltoid
Teres minor
FIGURE 5-5
Shoulder Medial/Internal Rotation, 90–100 degrees.
FIGURE 5-6
Shoulder Lateral/External Rotation, 80–90 degrees.
FIGURE 5-7
Shoulder Horizontal Adduction, 135 degrees.
FIGURE 5-8
Shoulder Horizontal Abduction, 30–45 degrees.
Horizontal Adduction, 135 Degrees
Anterior deltoid
Pectoralis major Medial/Internal Rotation, 90 to 100 Degrees
Anterior deltoid
Latissimus dorsi
Pectoralis major
Subscapularis
Teres major
Horizontal Abduction, 30 to 45 Degrees
Infraspinatus
Posterior deltoid
Teres major