Massage Strategies for Shoulder Pain

AMTA 2019 National Convention

Hands On Healing112 Douglas Blvd.Roseville, CA 95678916-847-9304jmally@abundanthealth.comwww.abundanthealth.comwww.massagelibrary.com

Normal range of motion - Glenohumeral Joint

Flexion 160 - 180o

Extension 50 - 60o

Abduction 180o

Adduction 30 - 45o

Internal Rotation 90 - 100o

External Rotation 80 - 90o

Horizontal Adduction 135o

Horizontal Abduction 30 - 45o

Hard End Feel Joint CapsuleSoft End Feel Muscle

Capsular Pattern for Glenohumeral Joint

slight limitation of medial rotationgreater limitation of abductiongreatest limitation of lateral rotation

Open Pack Position for the Glenohumeral Joint

• 55 - 70o abduction • 30o horizontal adduction • neutral rotation

Open Pack Position

• joint surfaces maximally separated • joint capsule and ligaments most relaxed • most appropriate for evaluation of joint play, traction, and joint mobilization

Closed Pack Position

• maximal contact of articulating surfaces • joint capsule and ligaments tight or tense • no joint play

Glenohumeral Joint

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �3

Client History

If a client in pain comes to see you and you immediately start working with them, you may injure them further, or they may question whether you know what you are doing. It is very important to uncover the cause of their pain before beginning the massage.The first step in this process is to take a thorough client history. In the client history you will ask about any accidents or injuries, disease conditions, any areas of pain, medications they are taking, and about medical care they may be receiving.

When a client reports pain, there are some questions you can ask to help find the cause of the pain. These questions can be remembered by the letters of the alphabet, OPPQRST.

O - Onset

What were you doing when the pain first occurred? Often this question in itself will tell you the cause of the pain. If the onset is gradual you may need to find out what different activities your client was doing around the time the pain started.

P - Provoke, Palliate

What makes the pain better? What makes it worse? This can give clues to the cause of the pain and can also guide you in your treatment.

Q - Quality

What is the quality of the pain? Is it dull, sharp, burning, aching, throbbing, etc.? Different qualities have different meanings. Dull pain tends to be chronic, sharp pain is more acute. Throbbing pain may be vascular, as in a migraine headache. Burning pain may be from muscle tears or nerve irritation.

R - Radiation

Does the pain travel anywhere from where you feel it most? This can indicate pressure on a nerve root, referred pain from an internal organ, or referred pain from a trigger point.

S - Severity

Does the pain stop you from any activities?

T - Time

How long does the pain last when you have it? Are there times of the day when it is worse?

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �4

Assessment

When a client reports pain around a joint the pain may be from the muscle or tendon, or it may be from the joint capsule. There are some simple tests to help determine the cause of the pain.

Joint Injury

With joint injuries, or with inflammation in the joint or joint capsule (arthritis), any movement that takes the joint through a range of motion will cause pain. This includes passive and active range of motion, but doesn’t include resisted (isometric) testing. Resisted testing will not cause pain because there is no movement in the joint.

Muscle or Tendon Injury

Passive range of motion will not cause pain, as the muscle is not being used. An exception is at the end range when the muscle is being stretched during passive range of motion. Active or resisted movement will cause pain because the muscle is being used.

Muscle and Joint Injury

In some traumatic injuries all tissues will be affected, in which case any testing will cause pain.

This is a general guide to testing. There are more specific tests for each area of the body, testing ligaments and individual muscles.

Movement: Active Passive Resisted

Joint Injury Pain Pain No Pain

Muscle Injury Pain No Pain Pain

Both Muscle and Joint Pain Pain Pain

Start first with active testing, then passive, then resisted.

Specific pain with resisted movement implies muscle strain.

General pain with resisted movement is usually referred pain from trigger points.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �5

Inju

ry E

valu

atio

n •

50

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �6

Joint Capsular Pattern

Temporomandibular Opening

Occipitoatlanto Extension & side flexion equally limited

Cervical Spine Extension & side flexion equally limited, extension

Glenohumeral Lateral rotation, abduction, medial rotation

Sternoclavicular Pain at extreme range of movement

Acromioclavicular Pain at extreme range of movement

Humeroulnar Flexion, extension

Radiohumeral Flexion, extension, supination, pronation

Proximal Radioulnar Supination, pronation

Distal Radioulnar Pain at extremes of rotation

Wrist Flexion & extension equally limited

Trapeziometacarpal Abduction, extension

MCP and IP Flexion, extension

Thoracic Spine Side flexion & rotation equally limited, extension

Lumbar Spine Side flexion & rotation equally limited, extension

SI, Symphysis Pubis, & Sacrococcygeal Pain when joints stressed

Hip Flexion, abduction, medial rotation (order varies)

Knee Flexion, extension

Tibiofibular Pain when joint stressed

Talocrural Plantar flexion, dorsiflexion

Subtalar (Talocalcaneal) Limitation of varus range of movement

Midtarsal Dorsiflexion, plantar flexion, adduction, medial rotation

First MTP Extension, Flexion

Second to Fifth MTP Variable

IP Flexion, Extension

Capsular Patterns

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �7

Frozen Shoulder

Incidence

• Affects 2 - 5% of population

• Affects females slightly more than males (60:40)

• Typically between 40 - 60 years of age

• Non-dominant arm most likely involved

• 12 - 15% of people affected bilaterally

• Normal shoulder has 60 - 70 ml of synovial fluid in joint capsule

• Frozen shoulder has as little as 5 ml

Primary or Idiopathic

May be associated with diabetes, COPD, ischemic heart disease, cervical disc disease, thyroid disorders, neurological conditions including Parkinson’s and hemiplegia

Secondary

Rotator cuff tears, tendonitis, injury, surgery, immobilization

Risk Factors

• Aging• Posture• Occupation• Diabetes• Immobilization• Fracture• Surgery

Stages

1. Pre-Adhesive - Pain with active & passive ROM, decreasing ROM 2. Freezing - High level of pain at end range - from 3 - 9 months 3. Frozen - Stiff, minimal pain except in end ranges - from 9 - 15 months

4. Thawing - Movement returns - from 15 - 24 months

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �8

Shoulder Impingement

Painful Arc

Pain on abduction between 60 and 120 degrees

Hawkins - Kennedy Impingement Test

Have your client’s shoulder and elbow flexed to 90 degrees.

Internally rotate your client’s arm as far as it will go comfortably.

Try to internally rotate the arm a little more. If there is pain the test is positive for shoulder impingement.

Modified Hawkins - Kennedy Impingement Test (self test)

Client places hand on opposite shoulder and raises elbow toward ceiling.

If there is pain the test is positive for shoulder impingement.

Neer’s Impingement Test

Use one hand to stabilize your client’s scapula.

With your client’s palm facing down, take your client’s arm into flexion as far as it will go.

If there is pain the test is positive for shoulder impingement.

Crossover Impingement Test

Bring your clients arm horizontally across their chest as far as it will go. Positive sign is pain:

Superior - AC joint pathology Anterior - subscapularis, supraspinatus or biceps long head Posterior - infraspinatus, teres minor, post. capsule

Empty Can Test

90 degrees of shoulder flexion, internal rotation, and 30 degrees of horizontal abduction

Downward pressure is applied

Weakness and pain are assessed bilaterally.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �9

The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis

“the individuals in the posterior mobilization group had a mean improvement of 31.3°”

J Orthop Sports Phys Ther 2007;37(3):88–99. doi:10.2519/jospt.2007.2307

http://www.aptei.ca/library-article/shoulder-mobilizationmulligan-or-kaltenborn-who-is-right/ orhttps://goo.gl/eMK5cM

Patterns of motion loss in subjects with idiopathic loss of shoulder ROM

The internal rotation less than abduction less than external rotation pattern was demonstrated in 14 of 25 (56%) involved shoulders.

Clin Biomech (Bristol, Avon). 2004 Oct;19(8):810-8.https://www.ncbi.nlm.nih.gov/pubmed/15342153 or https://goo.gl/7AFHiQ

High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders

Orthop J Sports Med. 2016 Jan 5;4(1):2325967115623212. doi: 10.1177/2325967115623212. eCollection 2016.

https://www.ncbi.nlm.nih.gov/m/pubmed/26779556/

Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period

R Herzog, DR Elgort, AE Flanders, PJ Moley - The Spine Journal, 2017 - ElsevierThe Spine Journal, April 2017 Volume 17, Issue 4, Pages 554–561DOI: http://dx.doi.org/10.1016/j.spinee.2016.11.009

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �10

Don’t Blame the Rotator Cuff - Erik Dalton

Working with the sternoclavicular joint to relieve impingement at the acromioclavicular joint.

https://erikdalton.com/blog/dont-blame-the-rotator-cuff/

Clickable links to blogs, article, and studies are at massagelibrary.com/shoulder-pain

Surgery or Physiotherapy

For people diagnosed with atraumatic partial thickness tears of the supraspinatus tendon involving less than 75% of the tendon, a graduated physiotherapy exercise program has been found as beneficial as surgery involving acromioplasty, or acromioplasty and rotator cuff repair.

Kuhn, J. Exercise in the treatment of rotator cuff impingement. A systematic review and synthesized evidence based rehabilitation protocol. 2009, J shoulder Elbow Surg, Jan. - Feb.http://www.jshoulderelbow.org/article/S1058-2746(08)00476-X/abstract or https://goo.gl/gPaZ8w

Tennis Serve

54% of the power comes from the legs and trunk

Kibler, W.B. 1995. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med, 14:79-85http://europepmc.org/abstract/med/7712559 or https://goo.gl/rOOlKE

Baseball Pitching

24% energy decrease from hip and trunk requires 34% increase at the shoulder to deliver the same amount of force

WB Kibler - The role of the scapula in athletic shoulder functionThe American journal of sports medicine, 1998 - ajs.sagepub.comhttp://journals.sagepub.com/doi/abs/10.1177/03635465980260022801 or https://goo.gl/2Jxdfz

MRI study of 31 asymptomatic subjects

Age 50+ 72% had rotator cuff disorderAge 40 - 49 48%Age 30 -39 43%

Frost, P. Anderson, J.H and Lundorf, E. 1999. Is supraspinatus pathology as defined by MRI associated with clinical sign of shoulder impingement?http://www.jshoulderelbow.org/article/S1058-2746(99)90090-3/abstract?cc=y= or https://goo.gl/om7gT4

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �11

Symptoms of Pain Do Not Correlate with Rotator Cuff Tear Severity

J Bone Joint Surg Am. 2014 May 21; 96(10): 793–800.Published online 2014 May 21. doi: 10.2106/JBJS.L.01304

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018774/

Ultrasound study on 51 men, aged 40 - 70, asymptomatic for shoulder pain.

96% had some degree of moderate to severe shoulder pathology.

Sub acromial bursa thickening 78%Acromio-clavicular joint degeneration 65%Supraspinatus tendinosis 39%Subscapularis tendinosis 25%Partial thickness tear supraspinatus 22%Posterior glenoid labral anomaly 14%

Girish, G., Lobo, L.G., Jacobson, J., Morag, Y, Miller, B. and Jamadar, D. Ultrasound of the shoulder: Asymptomatic findings in men. American Journal of Roentgenology, 2011;97, 713-9.http://www.ajronline.org/doi/abs/10.2214/AJR.11.6971 or https://goo.gl/s6yJIW

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �12

Headstand for Rotator Cuff Tear: Shîrshâsana or SurgeryInternational Journal of Yoga Therapy: 2006, Vol. 16, No. 1, pp. 39-47.

http://iaytjournals.org/doi/abs/10.17761/ijyt.16.1.l3p3u261u8522451?code=iayt-site or https://goo.gl/obhmyW

Yoga-Based Maneuver Effectively Treats Rotator Cuff SyndromeTopics in Geriatric Rehabilitation April/June 2011 - Volume 27 - Issue 2 - p 151–161

http://journals.lww.com/topicsingeriatricrehabilitation/Abstract/2011/04000/Yoga_Based_Maneuver_Effectively_Treats_Rotator.10.aspx or https://goo.gl/QV5bpU

Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects

87.6% of subjects presented with disc bulging

Spine: 15 March 2015 - Volume 40 - Issue 6 - p 392–398

http://journals.lww.com/spinejournal/Abstract/2015/03150/Abnormal_Findings_on_Magnetic_Resonance_Images_of.11.aspx or https://goo.gl/rsr9TX

Shoulder Health: an Overview of Anatomy and Injury

http://www.otpbooks.com/shoulder-health/

Can you have a Rotator Cuff Tear and No Symptoms?

https://mikereinold.com/can-you-have-a-rotator-cuff-tear-and-no-symptoms/

Gentle Thawing of the Frozen Shoulder a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years.

Diercks RL, Stevens M., J Shoulder Elbow Surg. 2004 Sep-Oct;13(5):499-502.http://www.jshoulderelbow.org/article/S1058-2746(04)00082-5/abstract or https://goo.gl/8aBww8

Manipulation Under Anaesthesiahttp://www.aptei.ca/library-article/frozen-shoulder-is-manipulation-under-anaesthesia-a-good-option/ or https://goo.gl/88Ck8y

Isometric Shoulder Exerciseshttp://www.aptei.ca/library-article/novel-isometric-shoulder-exercises/ or https://goo.gl/JblwDX

Massage for Shoulder DysfunctionMassage Therapy Journal - Nov. 2016https://www.amtamassage.org/articles/3/MTJ/detail/3592 or https://goo.gl/HYZ91a

New Paradigms in Rotator Cuff Retraining

Bahram Jam, MPhty, BScPT, FCAMThttp://www.aptei.ca/wp-content/uploads/New-Concept-in-Rotator-Cuff-Retraining-Final-Sep-04-3-column.pdf or https://goo.gl/J5YsrK

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �13

Rotator Cuff Pain and Sleepless NightsHere is a very simple technique to help your shoulder pain clients get a good nights sleep.

https://goo.gl/i6L7pF

Pain Medial to the ScapulaThis may be from the Dorsal Scapular Nerve

http://massageofferings.com/index.php/2017/08/04/shoulder-blade-pain-everyones-bane/

https://goo.gl/174hPx

Muscle Energy for Sterno-Clavicular JointTom Ockler, PThttps://www.youtube.com/watch?v=o7NQsO8nry0&t=11s or search YouTube for Tom Ockler Sternoclavicular Joint

Previous Article Next Article

Peer-Reviewed ExerciseCures Rotator Cuff Painand DisabilityReleased: 2-May-2011 2:45 PM EDT Embargo expired: 15-May-2011 12:00 AM EDT Source Newsroom: Manhattan Physical Medicineand RehabilitationAdd to Favorites

Contact Information

Available for logged-in reporters only

CitationsTopics in Geriatric Rehabilitation (May 15, 2011)

Newswise — New York -- Gary, a 40-year-old magazine photographer, fell and tore his rotator cuff whileon assignment in the mountains. He felt intense pain in his shoulder; he could not lift his arm to shakehands.

Like many with this common injury, Gary faced an expensive surgery-- costs can total more than$12,000 -- and up to 18 weeks of physical therapy, often with disappointing results. Fortunately Garyneeded none of it. Dr. Loren Fishman, a specialist in physical medicine and rehabilitation who teachesat Columbia Medical School, came to his rescue.

Dr. Fishman has developed a yoga-based maneuver, reported in the peer-reviewed Topics in GeriatricRehabilitation, that relieves the pain of rotator cuff tear and restores range of motion during one shortoffice visit. His method trains the subscapularis muscle to take over for the injured supraspinatusmuscle in the rotator cuff. Though the rotator cuff has not healed, symptoms usually almost completelydisappear.

The method, called the Triangular Forearm Support, is an exercise that can be done against a wall, in achair or in a yoga headstand. Dr.Fishman studied 49 patients for an average of 30 months to confirm itsefficacy.

Immediately after completing the exercise, the average improvement for 46 patients was 150% ; inother words, patients more than doubled their range of motion and could lift their arms normally. Muchof their pain disappeared. Patients reported their pain reduction on a questionnaire. Their pain reliefaveraged 82%. Many said that they were pain-free. Three patients did not improve at all.

All 46 patients were satisfied with their outcomes in Dr. Fishman’s longitudinal before-and-after study,and they sustained the initial cure for 30 months or longer. Most patients also received a little physicaltherapy to solidify their gains -- an average of 5 sessions over a period of a week to ten days.

Those who improved in Dr. Fishman’s clinical trial of the new conservative treatment had results equal

Channels:

Pain, Surgery, Seniors

Keywords:

Rotator Cuff, Rotator Cuff Tears, yoga, PainRelief, range of motion increase, exercise androtator cuff tear, non-surgical cure, ConservativeManagement , increased range of motion,Shoulder, Shoulder Injuries, Shoulder Pain,Shoulder Problems, Sports Injuries, SportsInjury, Elderly

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �14

to or far exceeding outcomes for participants in published international surgical, arthroscopicand\conservative treatment outcome studies. One study of comparable tears in the Journal of Shoulderand Elbow Surgery, for example, found a 22% gain in range of motion for arthroscopic procedures and did not specify pain relief. A paper in Joint, Boneand Spine reported 55% pain reduction and 25% increase in range of motion. Another trial inOrthopedics that measured results of conservative therapy showed only a 19% improvement in rangeof motion after six months.

Dr. Fishman’s exciting treatment for rotator cuff tear is particularly well-suited to elderly patients who arepoor candidates for surgery. However, rotator cuff tear is one of the most common upper extremityinjuries. It is widespread among people over forty, gym-goers, field athletes, those who have accidents, anyone whomakes repeated overhead motions, like taking a suitcase from an airplane storage bin, or forcefulpulling or lifting motions. While there are no definitive statistics, because not all are painful, estimates are that rotator cuff tearaffects as many as 30% of all adults.

After suffering a painful injury to his own shoulder that also restricted his ability to lift his arm, Dr.Fishman invented the non-surgical rotator cuff treatment serendipitously.

“Though this paper follows 49 patients for 30 months, I have used this technique on 723 patients overthe past ten years,”says Dr. Fishman.

“Of those patients, 680 have reported nearly complete pain relief and essentially full recovery of rangeof motion.”

Several of Dr. Fishman’s patients who have success with his method would be happy to be interviewed.

Related Experts

Author Available: Tracing the Scent of FearNRAO Scientist Available for Comment on Fast Radio Burst DiscoveryCrafting a Better T Cell for Immunotherapy: New Technology, Not Yet Tested In Humans, Aims ToReduce Patients’ Waiting Time, Increase Potency Of T-Cell TherapyExperts Available for the MediaAllergy Expert Available to Address Adverse Reactions to Marijuana. Allergists Can Treat Symptoms@TheNASEM to Issue Recommendations on 3-Parent Mitochondrial Gene Therapy: Ethicist JeffreyBotkin @UofUHealthCare Available#HPV Vaccine Expert From @FredHutch Available to Discuss HPV Consensus Statement onVaccinationNew Study Links Cancer's Financial Burden To Mortality Rates: Author Available

Promote your organization’s experts with Expert Pitch.

Reporters: follow @Expert_Pitch to receive instant updates via Twitter       Looking for a different expert? Reporters can submit an

Expert Query.

©2016 Newswise, Inc. 215 5th St. SW, Suite 100, Charlottesville VA 22903

434-296-9417 Privacy Notice Terms of Service Contact Us

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �15

Trigger Points

Finding Trigger Points

• Rub - don’t poke • Common in overstretched, inhibited muscles • Consider referred pain patterns • Consider synergists - anatomy trains • Consider movements that cause pain • Have muscle in neutral position

Treating Trigger Points

• Release tight facilitated muscles before weak inhibited • Release flexors before extensors • Release superficial muscles before deep • Release proximal muscles before distal • Use static pressure - don’t rub

Trigger Point and Counterstain Principles

1. Find trigger point 2. Position client so there is no pain - Add compression if appropriate 3. Hold 30 - 90 seconds - Have client breathe into point 4. Return client to neutral position while still holding point 5. Inquire about pain

This may be followed with soft tissue release to the muscle.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �16

Trigger Point Definition “a hyperirritable spot in skeletal muscle that is associated with a

hypersensitive palpable nodule in a taut band. The spot is tender when

pressed and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena.”

Dr. Janet Travell

“After an injury, tissues heal, but muscles learn. They readily develop habits of guarding that outlast the injury.”

Dr. Janet Travell

Techniques

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �17

Muscle Strain Treatment

Find site of muscle strain using manual muscle testingHave the muscle in a relaxed positionMultidirectional friction for 20 secondsEccentric muscle contraction with increasing resistance

Rounded Shoulder Technique

Have your client sitting, then stand behind them. Place your thumbs underneath the spine of each scapula and your fingers around the front of the shoulder. Have your client try to bring their shoulders together in front. Offer resistance, but slowly allow them to bring their shoulders forward. Then ask your client to relax and bring their shoulders back.

When the muscles are fatigued the shoulders should go back further. Repeat this from the new position, and continue to repeat until you see no further gains.

Dowager’s Hump

This technique is my adaptation of work shown by Erik Dalton. I highly recommend his DVDs and home study courses which can be found at www.erikdalton.com.

Have your client prone with their head hanging off the end of the table. Place your “second knuckles” (middle phalanges) underneath the top edge of the trapezius. Work down to around T4 with your knuckles as your client slowly lifts their head.

It is important also to work on the front of the body, working pectoralis major, pectoralis minor and other muscles that are pulling the shoulders forward and contributing to the dowager's hump. Front line work from the work of Tom Myers (www.anatomytrains.com) is excellent for this.

A variation is to have your client tuck their chin, then lift their head their head up while keeping the chin tucked. This isolates the extension to the lower cervical vertebrae and upper thoracics rather than the upper cervicals.

Clickable links to these techniques are at massagelibrary.com/shoulder-pain-techniques

TechniquesPottenger’s Saucer

If your client has a flattening of the normal kyphotic curve or even a slight lordotic curve in the thoracic area it is important to not press the vertebrae further anterior. Place a rolled up towel under your client’s sternum when they are lying prone before doing any deep work in the upper thoracic area.

Rhomboserratus Rock

Have your client in a side lying position with their arm overhead draped over your forearm. Work on the serratus anterior muscle by pressing on it with your palm while pushing the scapula medially towards the spine. You can then work on the rhomboids by placing your fingertips next to the spine then pulling laterally, pressing into the rhomboids until you get to the

medial border of the scapula then pulling the scapula away from the spine to stretch the rhomboids.

Alternate these two techniques so that you are pushing the scapula toward the spine while working the serratus anterior, then pulling the scapula away from the spine while working the rhomboids. When you alternate these two techniques you can get into a nice rocking motion that is soothing to your client and facilitates release of muscle tension.

You can also do this with your clients breath. Have your client inhale as you are pressing into the serratus and pushing the scapula towards the spine, then exhale as you are pressing into the rhomboids and pulling the scapula forwards. Be sure to go slowly so that you don't get your client to hyperventilate, and check in with your client to see how this feels for them.

Scalenes - Supine

You need short fingernails for this technique. Face your client’s head then traction your client’s arm with your inside hand. With your client’s head turned toward you press the fingertips of your outside hand around the superior part of the clavicle near the sterno-clavicular joint, pressing your fingertips in towards the first rib.

Slide your fingers laterally toward the acromioclavicular joint while your client slowly turns their head away from you.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �18

Techniques

Pectoralis Minor - Supine

Place the pads of your fingers onto your client’s rib cage sliding up under the pectoralis major towards the coracoid process of the scapula.

Move your fingers superiorly along the pectoralis minor while at the same time abducting your client’s arm overhead.

Subscapularis - Supine

Place the pads of your fingers onto the anterior aspect of your client’s scapula. While pressing into the subscapularis, move your fingers superiorly while abducting your client’s arm overhead.

You can get an even better stretch by externally rotating your client's arm as you bring it overhead. This stretches out the subscapularis underneath your fingers.

First Rib Release - Supine

For clients with Thoracic Outlet Syndrome, there may be compression of nerves between the clavicle and the first rib. This release helps to create more space for the nerves by allowing the first rib to move inferiorly. I use this in conjunction with other techniques including work on the scalenes and pectoralis minor.

With your outside hand bring your client’s shoulder toward their ear. Press the finger pads of your inside hand into the first rib under the clavicle, pulling inferiorly. Have your client breathe deep then exhale. On the exhale traction their arm inferiorly while pulling inferiorly on the first rib. Hold the first rib in place as your client takes a deep inhale. Have your client exhale again then try to bring their shoulder toward their ear while you are still pulling the rib inferiorly. This brings the clavicle up off of the first rib.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �19

Techniques

Scalenes - Side Lying

Have your client lying on their side and sit behind them so that your thigh supports their back. Remove any pillow under your clients head, if they are comfortable with their head resting on the table.

Sit behind your client so that your thigh is supporting their back. Bring your client’s shoulder

forward and also upwards (anterior and superior) toward their ear, then hook your fingers into the space superior to the medial end of the clavicle right next to the sternum. Press inferiorly with your fingertips then pull your fingers laterally out toward the notch at the acromioclavicular joint while you pull your clients shoulder in an inferior and posterior direction with your other hand. You can lean back with your upper body to get traction to your client’s shoulder as you slide your fingers out toward the acromioclavicular joint.

Have your client face different directions as you are working to stretch the three scalene muscles. Looking toward the floor will stretch scalenus posterior. Looking straight ahead will stretch scalenus medius, and looking toward the ceiling will stretch scalenus anterior.

Tightness in the scalene muscles may compress nerves of the brachial plexus, causing referred pain, tingling, and numbness into the arm and hand. This technique along with work into the pectoralis minor can help to relieve that.

Scalenes - Side Lying Variation

Do this same technique, but starting with your client's head turned toward the ceiling. Have your client slowly turn their head toward the floor while you lean back pulling their shoulder inferiorly while sliding your fingers out toward the acromioclavicular joint. Time it so you reach the AC joint when your client's head is turned toward the floor.

This technique works into the scalene attachments while the scalenes are being stretched.

Pectoralis Major - Side Lying

Sit on the table behind your client’s back so that you are sitting on your foot with your thigh supporting your client's back. Extend your client's arm behind their back while stroking the upper fibers of the pectoralis major with your fingers, going from the sternum out to the humerus. You can also do kneading with the heel of your hand to the distal fibers of the pecs.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �20

TechniquesPectoralis Minor - Side Lying

Sit on the table behind your client so that their back is supported by your knee and thigh. Hold your client’s arm by the elbow then slide your fingers on the chest wall underneath the front wall of the axilla (pectoralis major) until you contact the fibers of the pectoralis minor. Try to have as much of your finger pads contacting your client as possible. If you are pressing with just fingertips it will feel pokey. Slide your fingers up the fibers of the pectoralis minor while at the

same time bringing your client’s arm overhead. Go gently as this can be tender.

If your client is ticklish, you can have them hold your wrist and then guide your hand into the axilla. If the client has a sense of control they often will not feel ticklish, as it is difficult to tickle yourself.

Subscapularis - Side Lying

Sit on the table behind your client so that their back is supported by your knee and thigh. Hold your client’s arm by the elbow then wrap your fingers around the back wall of the axilla and the scapula, so that they are on the subscapularis. Press into the subscapularis while bringing the arm overhead and into external rotation. Go gently as this can be tender.

This is a good technique for clients that have limited external rotation of the humerus, or who have frozen shoulder.

First Rib Release - Side Lying

Sit on the table behind your client so that their back is supported by your knee and thigh. Raise your client’s shoulder toward their ear. Press the pads of your fingers of your inside hand up under the clavicle onto the first rib. Find the posterior aspect of the first rib with your outside hand and pull inferiorly on it with your finger pads. Have your client take a deep inhale, then pull the rib inferiorly with both hands as they exhale. Have then inhale again as you hold the rib in place.

Impingement Test

Have your client place their hand on their opposite shoulder, then bring their elbow toward the forehead. Pain in the shoulder is positive for impingement.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �21

TechniquesImpingement Treatment

This treatment uses a stretching handle and a stretching strap, which can be purchased at www.simplefitnesssolutions.com. Place the stretching handle in the hinge side of a door at a height that is comfortable. Wrap the stretching strap over your proximal humerus. Grasp the stretching handle then pull down on the stretching strap. The intention is to have a downward pull on the head of the humerus as you abduct your arm. Continue to pull on the stretching strap and bend your knees to further abduct your shoulder. Stretch only as far as is comfortable. All stretching should be pain free.

Yergason Test

Have your client sitting or standing with their arm by their side with their elbow flexed 90 degrees and their forearm pronated. Have them try to bring their hand toward the opposite shoulder and supinate their forearm against your resistance. Pain in the anterior shoulder may indicate a slipped bicipital tendon.

Bicipital Tendon Treatment

Have your client seated with their arm abducted ninety degrees to their body, and their forearm pointed up.

Grasp your clients deltoid firmly with both hands hooking your fingers around the anterior edge of deltoid. Have your client slowly rotate their arm internally, i.e. bringing their forearm so that it is parallel to the floor, and eventually pointing toward the floor.

Your fingers will catch the tendon of the long head of the biceps, then the bicipital groove rotates toward the tendon, so the tendon can go back into the groove.

This technique only needs to be done once or twice.

Glenohumeral Joint - Joint Capsule Release

Do this technique only after working all the muscles around the joint and treating any muscle strains. With your client supine have one hand brace your clients scapula around the acromion and your other hand on the distal humerus. Gently compress the joint capsule for about 30 seconds, then alternate compression and traction to the glenohumeral joint. Abduct the humerus and glide the humeral head anterior, posterior, and inferior while compressing and tractioning the glenohumeral joint. Gently work into the directions where there is a hard end feel. Gently rotate and abduct your client’s humerus while maintaining gentle pressure into the joint socket. All movement needs to be pain free.

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �22

TechniquesGlenohumeral Joint - Posterior Glide

Clients with a limited external rotation of the humerus can be helped by increasing the posterior glide of the humerus in the glenohumeral joint. Assess your client’s ROM before and after this technique.

Have your client supine with their GH joint in open pack position - approximately 60o abduction and 30o flexion. Your client’s elbow is flexed so that their hand is pointing toward the ceiling. Have one hand supporting their elbow and your other hand pressing on the proximal humerus.

Ask your client to reach toward the ceiling. Maintain pressure on the proximal humerus, but let your client win. Do this with only minimal resistance at first, then gradually increase the resistance with each repetition. The aim is to create leverage so that the humeral head glides posteriorly in the socket.

Glenohumeral Joint - Inferior Glide

Clients with a limited abduction of the humerus can be helped by increasing the inferior glide of the humerus in the glenohumeral joint. Assess your client’s ROM before and after this technique.

1. Have your client in side lying position. with open palms work down the upper trapezius, over the acromion and down the deltoid, tractioning the arm distally.

2. With your client supine have one hand around the proximal humerus and the other hand at their elbow. Traction their arm distally, then ask your client to gently abduct their arm as far as they can comfortably. Offer gentle resistance to abduction with your hand at the proximal humerus, but let your client win. Have your client repeat this motion with increasing force as you offer increasing resistance, always letting them win.

Self Care Exercises

Videos and pdf handouts of self care exercises for the shoulder are available at massagelibrary.com/category/self-care/

Pectoralis Doorway Stretch

Rotator Cuff Exercise

Pendulum Exercise

Rounded Shoulder Exercise

Shoulder Impingement Stretch

Scalene Stretch

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �23

Orthopedic Massage

Clinical Massage Therapy - A Structural Approach to Pain Management - James Waslaski - Pearson Education, Inc. - ISBN 0-13-706362-8 www.orthomassage.net

Trigger Point

Myofascial Pain and Dysfunction,The Trigger Point Manual (Vol. 1 & 2) - Janet Travell, M.D. and David Simons, M.D. - Williams & Wilkins, Baltimore, MD - ISBN 0-683-08366-X (v. 1) and 0-683-08367-8 (v. 2)

The Trigger Point Therapy Workbook - Clair Davies - New Harbinger Publications, Inc. Oakland, CA ISBN 1-57224-250-7

The Frozen Shoulder Workbook - Clair Davies - New Harbinger Publications, Inc. Oakland, CA ISBN 1-57224-447X

Neil Asher Trigger Point Courses https://www.nielasher.com/collections/nat-professional-courses/frozen-shoulderhttps://www.nielasher.com/collections/nat-professional-courses/rotator-cuff

Counterstrain

Jones Strain-Counterstrain - Lawrence H. Jones, D.O. with Randall Kusonose, P.T. and Ed Goering, D.O. - Jones Strain-Counterstrain, Inc., 1501 Tyrell Lane, Boise, ID 83706 - 208-343-4080 - ISBN 0-9645135-4-4

Muscle Pain Relief in 90 Seconds - Dale L. Anderson, M.D. - Chronimed Publishing, P.O. Box 59032, Minneapolis,MN 55459-9686 - ISBN 1-56561-058-X

Ortho-Bionomy®:A Manual of Practice - Kathy L. Kain with Jim Berns - North Atlantic Books, Berkeley, CA - ISBN 1-55643-250-X

Injury Evaluation

Illustrated Manual of Orthopaedic Medicine - James & Patricia Cyriax - OM Publications, 206 Albany St, London NW1 - ISBN 0-407-00262-6

Textbook of Orthopaedic Medicine - Vol. 1 - Diagnosis of Soft Tissue Lesions - James Cyriax - Bailliere Tindall, W .B. Saunders - ISBN 0-7020-0935-0

Functional Assessment in Massage Therapy - Whitney Lowe, LMT- Orthopedic Massage Education & Research Institute (OMERI), Bend, OR - (541) 317-9855 - www.omeri.com- ISBN 0-9661196-0-6

Assessment and Treatment of Muscle Imbalance - The Janda Approach - Phil Page, Clare C. Frank, Robert Lardner Human Kinetics, 2010 ISBN 0736074007

Bibliography

Assessment and Treatment of Shoulder Pain - Dr. James Mally Page �24