jw complicated shoulder

Integrated Manual Therapy & Orthopedic Massage

For Complicated Shoulder Conditions

Assessment Protocols Treatment Protocols

Treatment Protocols Corrective Exercises

Artwork and slides taken from the book Clinical Massage Therapy: A Structural

Approach to Pain Management Published by Pearson Education

By

Author & International Lecturer

James Waslaski LMT, CPT

Integrated Manual Therapy & Orthopedic Massage

For Complicated Shoulder Conditions Today’s manual therapist needs to have multiple skills in order to address a wide variety

of complicated musculoskeletal pain conditions. Specialization in just one modality is

becoming a thing of the past because of limited patient outcomes. This unique total

system consists of orthopedic assessment, clinical reasoning, multidisciplinary and multi-

modality therapies, and precise corrective stretching and strengthening exercises.

Participants will learn to integrate the skills of leading practitioners from the fields of

massage therapy, physical therapy, athletic training, personal training, osteopathic and

chiropractic to restore balance, posture, function and pain free living. Recent clinical

studies will forever change the way manual therapists look at musculoskeletal pain,

muscle-tendon strain pain, and adhesive capsulitis of the shoulder. Manual therapists will

learn techniques to help eliminate pain from shoulder capsule adhesions, shoulder

impingement, rotator cuff injuries, thoracic outlet, including multiple nerve crush

phenomenon, and complicated frozen shoulders. Corrective stretching and strengthening

techniques will be also taught to keep the muscles balanced, and joints aligned for pain

free living. Our Unique 12 Step Protocol will be used throughout this presentation.

Twelve Steps: 1. Client History 2. Assess Active Range of Motion 3. Assess Passive Range of Motion 4. Assess Resisted Range of Motion 5. Area Preparation 6. Myofascial Release/ Compression Broadening 7. Cross Fiber Gliding/Trigger Point Therapy 8. Multidirectional Friction 9. Pain Free Movement 10. Eccentric Scar Tissue Alignment 11. Stretching 12. Strengthening James Waslaski is an Author & International Lecturer who teaches approximately

40 seminars per year around the globe. He’s served as AMTA Sports massage Chair

and FSMTA Professional Relations Chair. He’s developed 8 Orthopedic Massage and

Sports Injury DVDs, and authored manuals on Advanced Orthopedic Massage and

Client Self Care. His new book, Clinical Massage Therapy: A Structural Approach to

Pain Management was published by Pearson Education in 2011. James presents at

state, national and international massage, chiropractic, and osteopathic

conventions including keynote addresses at the FSMTA, World of Wellness, New

England Regional Conference, the World Massage Festival, and Australian National

Massage Conventions. His audience includes massage and physical therapists as

well as athletic trainers, chiropractors, osteopaths, nurses and physicians. He is a

certified personal trainer with NASM. James received the 1999 FSMTA International

Achievement Award and was inducted into the 2008 Massage Therapy Hall of

Fame. www.orthomassage.net

http://www.orthomassage.net/

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CLINICAL MASSAGE THERAPYA Structural Approach to Pain Management

CHAPTER

Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski

Shoulder Conditions

5


Chapter Outline

• Twelve-Step Approach to Shoulder Conditions

• Specific Muscle Resistance Tests• General Shoulder Protocol• Pectoralis Major• Pectoralis Minor• Subclavius• Biceps and Coracobrachialis


Chapter Outline

• Upper Trapezius and Middle Deltoid• Subscapularis• Rhomboids• Triceps and Posterior Deltoid• Scapula Reposition• Supraspinatus and Upper Trapezius• Infraspinatus and Teres Minor• Common Conditions


Learning Objectives

• Choose the appropriate massage modality or treatment protocol for each specific clinical condition of the shoulder


Learning Objectives

• Work on the short, contracted muscle groups such as pectoralis major, pectoralis minor, subclavius, biceps,upper trapezius and subscapularis before working on the weak, inhibited antagonists such as triceps,rhomboids, middle trapezius, lower trapezius infraspinatus, and teres minor


Learning Objectives

• This will ensure:– structural integration—balance of the

muscle groups– that the therapist eliminates the

underlying cause of the shoulder problems before addressing the clinical symptoms

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Learning Objectives

• Restore pain-free shoulder normal joint range of motion

• Restore normal muscle resting lengths in the muscle groups of the shoulder


Learning Objectives

• Create shoulder stability• Differentiate between soft-tissue

problems caused byMyofascial restrictionsMuscle–tendon tensionMyoskeletal alignment problems


Learning Objectives

• Differentiate between soft-tissue problems caused by trigger point tension joint capsule adhesions strained muscle fibers scar tissue


Learning Objectives

• Teach the client self-care stretches and strengthening exercises to perform at home to maintain shoulder structural balance and pain-free movement following therapy


Precautionary Note

• Do not work on a client with a recent injury (acute condition) exhibiting inflammation, heat, redness, or swelling. RICE therapy (rest, ice, compression, elevation) may be the appropriate treatment in this situation.


Precautionary Note

• This work cannot be performed on clients with severe shoulder conditions like a complete rupture of a muscle, complicated labrum tears, and fractures.

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Figure 5-1 Shoulder Flexion, 160–180 Degrees.


Figure 5-2 Shoulder Extension, 50–60 Degrees.


Figure 5-3 Shoulder Abduction, 180 Degrees.


Figure 5-4 Shoulder Adduction, 30–45 Degrees.


Figure 5-6 Shoulder Lateral/External Rotation,80–90 Degrees.


Figure 5-5 Shoulder Medial/Internal Rotation,90–100 Degrees.

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Core Principle

• When performing PROM, you should always be sensitive to the client’s breathing and patterns of guarding. Your overall confidence, combined with a calming voice, can help the client relax.


Core Principle

• If there is a torn muscle or tendon, it will be treated last, after you have balanced out opposing muscle groups and addressed the problems in the muscle belly leading to the muscle tear.


Core Principle

• Integrated Manual Therapy will stress this statement continually: Never treat a muscle–tendon strain, or a ligament sprain, unless the injured muscle–tendon unit, or injured ligament, is brought back to its normal resting position.


Core Principle

• If the client reports pain after you finish the resisted test, this is not a positive test and the problem may be in the surrounding or stabilizing muscles. The pain must be in the muscle you are testing during the test.


Figure 5-10 Muscle Resistance Test, Subscapularis.


Figure 5-11 Muscle Resistance Test, Pectoralis Minor.

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Figure 5-13 Muscle Resistance Test, Supraspinatus.


Figure 5-15 Muscle Resistance Test, Middle Deltoid.


Figure 5-14 Muscle Resistance Test, Infraspinatus and Teres Minor.


Core Principle

• Thoracic outlet syndrome can create symptoms similar to carpal tunnel syndrome. Always look for the source of the pain, don’t just rely on the symptoms.


Figure 5-55 Thoracic Outlet Syndrome.


Figure 5-59 Joint Capsule Adhesions.

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Precautionary Note

• If the client tested positive for a muscle–tendon strain, it is highly recommended that you bring that muscle back to resting length, and treat the strain prior to attempting joint capsule work. If the client is guarded due to shoulder discomfort during the capsule work, you will not be able to access and release the deep fascial adhesions inside the shoulder capsule.


Core Principle

• You must change the protocol and perform the joint capsule work anytime during the session if you find a bone-on-bone-like end feel.


Figure 5-17A Positional Release, Joint Capsule.


Figure 5-17B Joint Capsule Release, External Rotation.


Figure 5-17C Joint Capsule Release, Internal Rotation.


Figure 5-17D Joint Capsule Release, Decompression.

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Core Principle

• Always perform myofascial release before proceeding to deeper, more specific work.


Figure 5-20A Myofascial Release, Inferior Fibers Pectoralis Major.


Figure 5-20B Myofacial Release, Superior Fibers Pectoralis Major.


Figure 5-21 Cross-Fiber Gliding Strokes and Compressive Stretch, Pectoralis Minor.


Figure 5-28 Subclavius Myofascial Release.


Figure 5-30A Biceps Myofascial Release.

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Figure 5-30B Compression Stretch, Biceps.


Figure 5-30C Cross-Fiber Gliding Strokes.


Core Principle

• Contracting the muscle against resistance to fatigue the muscle prior to the stretch becomes a muscle resistance test, and the client may report pain in a specific area, which is a muscle strain. If so, proceed to multidirectional friction (step 8), pain-free movement (step 9), and eccentric scar tissue alignment (step 10) until the client is pain-free.


Figure 5-25 Muscle Resistance Test For Pectoralis Minor Strain.


Figure 5-26 Pectoralis Minor Multidirectional Friction.


Figure 5-27 Eccentric Muscle Contraction for Scar Tissue Alignment.

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Figure 5-35 Upper Trapezius Myofascial Release.


Figure 5-36 Middle Deltoid Myofascial Release.


Figure 5-40A Subscapularis Myofascial Release.


Figure 5-40B Downward Scapular Rotation.


Figure 5-41 Subscapularis Stretch.


Core Principle

• Ischemic muscle pain and trigger points in the middle traps and rhomboids will usually disappear by working and releasing the pectoral muscles, subscapularis, and upper trapezius. This creates balance around the scapula by relaxing the painful, weak, inhibited rhomboids and middle and lower trapezius.

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Core Principle

• There are no stretching exercises for these muscles as they are weak and inhibited. They need to be strengthened. See the Client Self-Care Manual or Corrective Stretching and Strengthening DVDs at www.orthomassage.net.


Figure 5-44A Myofascial Release, Triceps.


Figure 5-44B Myofascial Release, Triceps and Posterior Deltoid.


Figure 5-44C Myofascial Release of Posterior Deltoid, Middle Trapezius, and Push Erector Spinae onto Spine.


Figure 5-45A Downward Scapular Rotation.


Figure 5-45B Decompress Acromion.

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Core Principle

• For effective treatment of supraspinatus impingement and resultant supraspinatus tendinosis, it is imperative to release the pectoralis minor, upper trapezius, and tight subscapularis muscles before working the supraspinatus.


Figure 5-46 Cross-Fiber Gliding Strokes and Trigger Point Work, Supraspinatus.


Figure 5-48 Supraspinatus Muscle Resistance Test.


Core Principle

• If there is not a muscle–tendon strain or ligament sprain, multidirectional friction would not be part of the treatment.


Figure 5-49 Supraspinatus Multidirectional Friction.


Core Principle

• The greatest error during the eccentric alignment procedure is being too aggressive and not keeping the technique pain-free each time. Too much force in opposing directions can cause a new injury or reinjure the site.

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Figure 5-50 Supraspinatus Eccentric Muscle Contraction.


Figure 5-51 Infraspinatus and Teres Minor Myofascial Release, Cross-Fiber Gliding Strokes and Trigger Point Work.


Core Principle

• Remember, it is not suggested that you stretch the rhomboids, infraspinatus, and teres minor muscles, as they are weak, inhibited, and eccentrically contracted and do not need to be stretched any further. There are exercises to strengthen these muscles in the client self-care section at the end of the chapter.


Figure 5-52 Infraspinatus/Teres Minor Muscle Resistance Test.


Figure 5-53 Infraspinatus Multidirectional Friction.


Figure 5-54 Eccentric Muscle Contraction,Infraspinatus and Teres Minor.

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Figure 5-42 Myofascial Release, Rhomboids.


Figure 5-43 Reduce Forward Thoracic Curves.


Stretching (Client Self-Care)

• Goal: for the client to perform stretches suggested and demonstrated by you to create normal muscle resting lengths in shortened or contracted muscle groups.


Figure 5-62 Pectoralis Major Stretch.


Figure 5-63 Pectoralis Minor Stretch.


Figure 5-64 Properly Stretch Pectoralis Minor into Doorway.

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Figure 5-65 Subscapularis Stretch.


Strengthening (Client Self-Care)

• Goal: to strengthen weak, inhibited muscle groups around a joint creating muscle balance throughout the —structural integration.


Core Principle

• The client must stretch the tight, contracted muscles before strengthening the opposing weak, inhibited, or overstretched muscles.


Figure 5-66 Rhomboid Strengthening.

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