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Frozen Shoulder and Massage

The term “Frozen Shoulder” refers to a painful symptom of the shoulder that can severely limit its range of motion and so giving the impression that the shoulder is “frozen”. The condition affects women more than men, and occurs most frequently in women aged from 45-65. Health-care practitioners prefer to use the term “adhesive capsulitis” as while the term “frozen shoulder” is common, it isn’t entirely accurate.

There are several problems in the shoulder that may be painful and limit the range of motion in ways similar to adhesive capsulitis. An important method of distinguishing adhesive capsulitis from other shoulder problems is to evaluate the way in which motion is restricted at the shoulder joint.

Shoulder MassageIn the glenohumeral joint, the capsular pattern for motion to be limited is first in external rotation, then in abduction and finally in medial rotation. Thus if a client has difficulty bringing the arm up in abduction but has no problems externally rotation the shoulder then it is unlikely that the client has adhesive capsulitis.

The glenohumeral joint has the greatest range of motion of any joint in the body. When the shoulder is in a neutral position (with the arm by the side), there is some slackening of the glenohumeral joint capsule on the underside which is necessary to allow full range of motion of the joint. When the arm/shoulder is moved to other positions, the underside of the capsule becomes taut.

Adhesive capsulitis develops when a portion of the joint capsule adheres to itself and prevents full movement of the joint. As the capsule is highly innervated, it is extremely painful when the adhesions pull on the tissues of the capsule.

Adhesive capsulitis is generally categorized into primary and secondary. In primary adhesive capsulitis there is no obvious cause for the condition – clearly frustrating for practitioners. There may be some correlation between a significant emotional trauma and the development of primary adhesive capsulitis.

Secondary adhesive capsulitis will often develop as the result of rotator-cuff tears, arthritis, shoulder trauma, surgery, bicipital tendinosis, etc. With these injuries, there appears to be a process of fibrosis that is initiated by these other conditions. As such, the individual is usually limiting motion in the shoulder at the same time the fibrosis is occurring and the fold on the underside of the joint capsule is never fully elongated. Thus begins a vicious cycle as the adhesion causes limitation to shoulder movement and pain, thus worsening the problem.

Subscapularis trigger points have also been suspected of causing secondary adhesive capsulitis. This may result from irritation of the attachment site of the subscapularis which is close to the capsule. Local inflammation at the attachment may then cause fibrous adhesion in the capsule.

Frozen shoulder is often divided into three stages:
Freezing. Onset is usually between 2 to 6 months and this period is characterized by a gradual decrease in range of motion and an increase in pain.

Frozen.This stage occurs for between 4 and 12 months after initial onset. Motion will remain extremely limited although there may be a gradual decrease in pain levels.

Thawing.In the thawing period, there is a gradual return of range of motion and decreased pain. This stage can vary from a few months to several years.

Treatment and Massage of Frozen Shoulder

Treatment should always be directed by a trained health-care practitioner who is suitably qualified to diagnose adhesive capsulitis. Most treatments begin with a relatively conservative approach aimed at increasing the range of motion of the glenohumeral joint. Simple movements such as letting the shoulder hang like a pendulum may encourage a gradual increase in range of motion. With adhesive capsulitis, if exercise is too vigorous then further damage and inflammation of the joint capsule may occur.

Massage techniques used to treat frozen shoulder should encourage relaxation of the muscles surrounding the shoulder. Simple effleurage and broad cross-fibre sweeping strokes are often used to assist in restoring proper movement to the joint. As discussed above myofascial trigger points in muscles such as subscapularis may also play a role in adhesive capsulitis. These may be treated with static compression or compression with active movement.

  
Another area that massage therapists may wish to consider is to encourage the elongation of the adhered capsular tissues. This is achieved by gentle stretching motions such as a passive stretch in lateral rotation where the client is taken to the point where discomfort begins and then held there. The client is encouraged to breathe deeply and relax the shoulder as much as possible. After holding the stretch for up to 30 seconds, the client is returned to the neutral position before repeating the procedure a few times.

If conservative treatment is not successful, a more aggressive stance may be taken of forced manipulation of the shoulder joint whilst the shoulder is anesthetized. Whilst this can produce dramatic improvements in the range of motion, it is extremely painful.

By Richard Lane

Subscapularis Massage

I recently posed an online question to other therapists about what muscles they believe do not receive sufficient attention from bodyworkers. My suggestions was the SCM (sternocleidomastoid) muscle at the front of the neck. Other suggestions included the gluteal muscles, the pecs and abs which didn’t surprise me too much. However, a few therapists included the subscapularis muscle in their lists which I have to admit, is not a muscle I would normally spend a great deal of time on.

Their comments inspired me to have a look at subscapularis, what it does and why it may be important for some shoulder conditions.

Now the subscapularis muscle is part of the rotator cuff group, along with the teres minor, infraspinatus and supraspinatus muscles. These muscles work together to stabilise the humerus in the glenoid fossa of the shoulder. From a massage therapists terminology it attaches to the anterior surface of the scapula at the subscapular fossa and the lesser tubercle of the humerus. It’s action is to internally rotating and adducting the humerus (along with it’s stabilisation role).

Pain and dysfunction in the subscapularis muscle often manifests as an inability to lift the arm above the shoulder (although it should be mentioned that not being able to lift the arm above the shoulder does not necessarily indicate that there is an injury to the muscle as there are other conditions which have the same impact on lack of shoulder mobility). It is often the case that someone who spends a lot of time in front of a computer may very well have some dysfunction of the subscapularis, such as trigger points (this applies to anyone who works with their arms out in front of them including massage therapists!).

Pain that is due to dysfunction of the subscapularis can manifest in a number of different ways, it can be sharp and located in the shoulder, deeper or at the top of the shoulder. It can refer down the arm. There can be impingement of the brachial nerve which can lead to numblike sensations or tingling down the arm. The pain can gradually appear over time or, in the case of an acute incident, it can happen at an instant (throwing or pitching a ball is commonly cited as a major contributer to subscapularis injuries). Subscapularis therapy is often indicated when a client is recovering from frozen shoulder.

Massage for the Subscapularis
Access to the subscapularis is limited particularly when a client is lying prone and most therapists prefer to do their subscapularis bodywork with the client either supine or in a side-lying position. Examples of supine and sidelying subscapularis massages are shown in the videos below.

Supine Massage

Sidelying Massage

Dr Ben Benjamin advocates using friction treatments to address subscapularis tendon injuries and claims that it can be a remarkably effective treatment for most muscle, tendon and ligament injuries. Friction massage for the subscapularis can be mildly unpleasant and should be performed from 5 to 15 minutes and is demonstrated on the video below.

  


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