Hit a Wall with Shoulder Capsule Orthopedic Massage

[Candice]

I have been working with a female client (61 yrs old). She suffers from pain all over. May have fibromyalgia (though she's skeptical about that), may have Lymes disease (repeatedly tested negative, but just last week started antibiotics from her doctor anyway ... seems awfully late to be starting on that, but whatever).

She was in great physical shape and very active until two years ago and is still slim today. While on vacation (in Greece?) she suddenly started having strange symptoms, intense pain that inexplicably traveled back and forth between her arms, shoulders and wrists. It seemed the pain moved every few days or couple of weeks back and forth from point to point. At one point it occurred to her to stop taking the cranberry supplements she was on and the pain dissipated. Physical therapy also helped, but she still suffers from "frozen shoulder" type symptoms, noticeably restricted ROM.

1.5 years ago she took a misstep and twisted her knees. An MRI showed osteoarthritis in her right knee and right shoulder. The left knee is similarly achy and stiff. She has had physical therapy on her knees but still suffers some.

Her sternum aches, as does the front of her neck and the back of her legs. She believes she suffers from hypothyroidism (is just starting to see an endocrinologist). She feels like when she is moving she is "ripping" muscle fibers. She's also started suffering from a sleep disorder where she wakes up after two hours and can't go back to sleep.

Naturally, I decided to start tackling her structural issues with pelvic stabilization. We did the battery of hip, ankle/knee, shoulder and cervical spine assessments. She made a lot of progress with the pelvic stabilization over two sessions, so last time she came in we started on the shoulder protocol. That's where I got stuck.

When I did the assessment, the discomfort she described with either pain at the deltoids or deep within the shoulder capsule. She complained of no other discomfort as we assessed. Her abnormal shoulder numbers were:

Flexion (ideally 180˚)
R- 150˚
L- 155˚

Abduction (ideally 180˚)
R- 140˚
L- 45˚

Lateral/External Rotation
R- 70˚
L- 70˚
(close to 80˚ normal)

Horizontal Adduction
R- 130˚
L- 130˚
(close to 140˚ normal)

The following were normal:
Extension
Adduction
Medial/Internal Rotation
Horzontal Abduction

There was bone-on-bone like end feel to her shoulders (as much as I could tell at the low ROM; it was definitely not a normal end-feel).

So anyway, I proceeded to the shoulder protocol, but as soon as I got into the joint capsule work I couldn't abduct her arms beyond about 140˚ without her having pain deep in the shoulder capsule. I did the lateral and medial plunge-rotate-decompress (lateral at the maximum abduction caused a "pinching" sensation, so I would back off), but I could never get past the less-than-ideal abduction.

We did try moving forward to the next step, but that was only painful for her so I abandoned that idea right away.

In frustration I finally told her I couldn't proceed and was sending her home. She knows I am still studying this work and is a really nice woman, willing to work with me. I've done this exact same work on several other clients with good results, so I suspect something else is going on (perhaps the osteoarthritis? Lyme disease?). I told the client I was going to do some more research and see if could determine a way to proceed with the shoulders.

So at this point I'm stymied and am seeking feedback or suggestions. Your thoughts would be appreciated!

 

[GopBLissIgnorance]

Hit a Wall with Shoulder Capsule Orthopedic Massage

Thanks for such a well thought out post. Would you mind describing the "shoulder protocol"?

 

[Pompal 09.]

Hit a Wall with Shoulder Capsule Orthopedic Massage

Not sure if I can post legally, it's from Waslaski's Advanced Orthopedic Massage Manual. But here is the beginning as I've transcribed/abbreviated it. As you can see, I barely got into the protocol (three steps), which goes on for pages.

GENERAL SHOULDER PROTOCOL
Assess active, passive and resisted ROM. Bone-on-bone end-feel indicates joint capsule work is needed. (Otherwise, skip SJC work.)

“VELVET GLOVE” TECHNIQUE
• Sit at head of table. Client supine. “As I do these neck strokes, SLOWLY rotate your head only as far as is comfortable, away from my hand.” Hand on forehead controls speed of rotation.
• Soft fist superior to clavicle, MFR down over upper traps several times.
• Soft fist over curve of neck at base, anterior to spine several times.
• Hook scalenes, soft fist MFR to spine. (Client still turning head.)
• Fingertips stroke occipitals lateral to medial several times.

PECTORALIS MAJOR
• Supine. SHE may need to move breast tissue down/medially.
• Stand side of table. Take hand, bend elbow, abduct arm comfortably. While rocking arm, palm MFR pec major sternum to shoulder several times. Bone-on-bone end feel? = SJC work.* (Otherwise continue without.)
• Palm MFR sternum to armpit several times deeper while rocking arm.

*SHOULDER JOINT CAPSULE WORK
• Supine, abduct arm to first restriction. SUPPORT AND STABILIZE SCAPULA (on top of or under shoulder w/even pressure). Other hand holds arm above elbow.
• “Visualize joint softening.”
• “This work must be done completely pain-free.”
• Plunge, rotate towards head, decompress several times with varied rhythm. “Any discomfort?”
• Then contact, rotate to restriction, deep capsular stretch; return to neutral, decompress. “Popping” in fascia is okay.
• WATCH CLIENT’S face, breathing, “helping.”
• Repeat plunges towards feet. MUST BE TOTALLY PAIN FREE.

The goal at that point is to gradually be able to completely abduct the arm as I move through the joint capsule work, increasing the abduction to the next restriction and plunge, rotate and decompress, then moving to the next restriction point and repeating ... all pain free. This I could not do beyond 140˚ abduction.

 

[Aly B]

Hit a Wall with Shoulder Capsule Orthopedic Massage

when doing joint capsule work I start at a comfortable position - usually not even 90 degrees - usually only at 45 degrees - and gradually work up. I am looking to free up any restrictive tissue not just where end ROM is. If you've cleared out the joint capsule and can't get any farther then go back and do more myofascial work in the back.
If you are not getting any improvement at all you might want to change your focus.

I am happy with ANY improvement, there is no need to rush anything. As I tell my clients, I don't always get a "miracle" but you never know...

Pain referral into deltoid is often from supraspinatus. Just verify that if she had imaging on that shoulder that she does not have a bone spur irritating the supraspinatus tendon. And of course an inflamed bursa would preclude any joint capsule work. I have found that when there is irritation of the supraspinatus from a bone spur the "twisting" from treatment can actually aggravate the condition. Anyway, I would suggest backing off and not being so aggressive with the joint capsule work and just see where it takes you.

I don't understand the cranberry supplement connection at all.

Her symptoms would have led me to suggest that she get an evaluation from a chiropractor. Medical doctors will never refer to chiros because they treat most problems with medications only and do not seem to treat the physical body directly. I would guess that she has osteoarthritis in the cervical spine and some disc degeneration that is affectiing the cervical nerves.

My clients have had mixed results with physical therapy. In my experience they just go because their insurance covers it. They often do better from seeing me and of course I have a few clients that are PT's.... :grin:

 

[2cold scorpio]

Hit a Wall with Shoulder Capsule Orthopedic Massage

ALMT,

Thanks for the additional info. I have c&p'd it into a PM to myself, in case you have to take it down.

I'll get back to you in a few days or so. Just have a whole lot going on right now with company coming in from out of the country.

But, don't think I am not replying because of the extra info. Just need to look through it to know exactly how I want to respond.

 

[Julian]

Hit a Wall with Shoulder Capsule Orthopedic Massage

She may have even experienced a labrum tear depending on how she fell on her arms and maybe she's experiencing non-functional scar tissue pain from it? Here's some ortho tests for labrum tears and SLAP lesions, although she would have done it a while back from falling, maybe the scarring from it is catching up to her?

http://www.wellsphere.com/endurance-training-article/clinical-examination-of-superior-labral-tears-what-is-the-best-test-for-a-slap-tear-part-1-of-2/543185


Okay, ignore all that.....

'Course the saying is that the simplest explanation is usually the right one (Occam's Razor), sometimes I tend to go for the most difficult explanations! The pain upon abduction her arm can signify impingement, but while she stands have her abduct both arms out to the side as high as she can go. If she hits about 90 degrees and feels pain anywhere from there to 180 that is a sign of impingement which also is felt deep in the joint. This is called a painful arc. Usually the pain is the supra being impinged and this can occur when the infra/teres/subscap aren't strong enough to depress the humerus so the deltoid pulls the humerus into the lateral edge of the clavicle. Also, as mentioned by an earlier poster, there could be a bone spur there.

A note about Waslaski's joint capsule work-- it is taught by him to be done first before any other work to the shoulder. Also, the therapist is to start at the minimal amount of abduction to start with the work, not take the arm out to where the client feels pain and then slowly use the plunging system he developed. But in case there is a bone spur, I wouldn't recommend it and that's why it's probably better to refer her out for a diagnosis or at least check for bone spurs.

If you haven't already you might want to look into taking some of Whitney Lowe's courses. They are an excellent addition to the Waslaski work, Waslaski has some great technique but doesn't really delve into the actual conditions themselves or learning to really assess the client, besides using ROM which sometimes you need more! Anyway, both of those really compliment each other and from the work you do (reading your website) you would probably really enjoy it!

 

[The Man with No Name]

Hit a Wall with Shoulder Capsule Orthopedic Massage

Great replies already - have nothing to add but kudos to the prior posters.

 

[Life In Technicolor]

Hit a Wall with Shoulder Capsule Orthopedic Massage

I really haven't forgotten to post here... just haven't had enough time to really sit down and write something that might be useful.

Please be patient.

Of course, I might not be useful anyway.............