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Background Information of the shoulder joint

The  shoulder joint (glenohumeral joint), has a tremendous range of movement. The shoulder joint is too shallow to offer any bony security for the head of the humerus. As ligaments would severely limit joint movement, muscle tension must be employed to pull the humeral head in to the shallow shoulder (scapular)socket during shoulder movement. Four muscles fulfill this function, called the rotator cuff muscles: supraspinatus, infraspinatus, teres minor and subscapularis  or (S.I.T.S) (Kapit  2002)

Apart from these rotator cuff muscles many other muscles attach to the shoulder blade.  On this note it is important to consider the holistic picture in a shoulder injury.

The shoulder joint is encased in a ligamentous joint capsule that helps provide some stability at the joint. It is often the joint capsule that is the primary factor in limiting the end range of motion for the shoulder in certain directions. (Lowe 1997)

What  is Frozen shoulder (Adhesive Capsulitis)?

Frozen shoulder is when the joint capsule of the shoulder becomes fibrous and adheres to adjacent tissues, which greatly limits mobility in the shoulder. This condition is often very long standing and slow to respond to treatment and occurs more often in women in their forties.

Reasons for developing this injury?

Numerous factors including recent trauma, immobilization or emotional stress.

How to access if it is frozen shoulder?

The signs of frozen shoulder are limited range of motion and often displaying difficulty when:
•   moving their  arm away from the body
•   with the elbow bent at 90 degrees and fixed at the waist while attempting to move the forearm away from the body

When performing these movements the shoulder blades will raise or their will be lateral flexing of the torso. The “Apleys scratch test” is a good test to use to access range of motion in the shoulder. (Please see the photo below).

Treatment

Massage is a very effective approach when used in conjunction with other range of motion techniques, stretching and strengthening activities. Massage is particularly effective because the change in tissue consistency that can be encouraged is slow and the results will tend to stay longer than an abrupt intervention. Deep longitudinal stripping techniques on the front and back of the shoulder girdle muscles are generally successful. In severe cases where the shoulder is not responsive to conservative treatment, a manipulation under anesthesia is often performed. This is done to forcibly elongate and “tear” (ow!) the adhered fibers loose so the capsule can resume its free movement. (Lowe 1997)

As mentioned the glenohumeral joint relies on four main muscles for stability; supraspinatus, infraspinatus, teres minor and subscapularis  (S.I.T.S muscles). Considering the treatment of this injury these muscles may have developed trigger points that need to be deactivated. It is also important to treat the muscles around the scapular. 

Most likely many muscles around the scapular have wasted in protecting the injury and need strengthening. Some strengthening exercises are:

•    Rounding the shoulders by pushing the arms forawrd
•    Retracting the shoulder blades together, imagine trying squeeze an orange with your shoulder blades
•    Moving your shoulder blades towards your ears
•    Depressing your shoulders down, the opposite movement to moving your shoulder blades towards your ears



•    Modified push ups. (Push up performed on ones knees in a modified range of movement).
•    Ball catch:- which is throwing and catching a basketball against a mini-trampoline.
•    As the treatment progresses an exercise that allows the development of the kinetic train, (using other muscles to
      support the movement e.g. lower back muscles) is a modified shoulder press standing on a mini tramp.
      (Brukner 2001)

Clair Davies in The Trigger Point Therapy Workbook found recovery from a frozen shoulder injury was from trigger points in the infraspinatus, (the muscle that covers part of the outside of the shoulder blade) and the subscapularis, (the muscle on the underside of the shoulder blade) plus anterior scalenes, (muscles down the front of the neck).

What are trigger points?

A Trigger point is a small contracted knot in muscle tissue. The place where contractions actually occur is in the muscle fibres which consists of microscopic units called sarcomeres. Trigger points exist when over stimulated sarcomeres become unable to release their contracted state. Which limits oxygen and nutrients to the muscle. This keeps the muscle and then even surrounding muscles weak and tight. Trigger points generally refer pain elsewhere. This means that often other muscles need to be treated rather than the original source of pain. (Davies 2004)

How to treat them?

1.    Use deep stroking massage not static pressure.
2.    Massage with short repeated stroked.
3.    Do the massage stroke in one direction only.
4.    Do the massage stroke slowly.
5.    Aim at the pain level of seven out of ten.
6.    Limit massage from six to twelve strokes per trigger point.
7.    Work a trigger point six to twelve times a day.
       
(Davies 2004)
       
In conclusion, to treat frozen shoulder a variety of massage techniques with stretching and strengthening exercises can be very successful.

Bibliography

•    Brukner & Khan 2005, Clinical Sports Medicine, McGraw Hill, Australia.
•    Davies C 2004, The Trigger Point Therapy Workbook, New Harbinger Publications, USA.
•    Lowe W 1997, Functional Assessment in Massage Therapy, OMERI, USA
•    Kapit & Lawrence 2002, The Anatomy Coloring Book, Benjamin Cummings, USA

Kerrie Baumgartner
Diploma of Remedial Massage
Victoria University
0402 125962
rungirlgo@hotmail.com