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The Shoulder By Othon Molina, Ph.d.c, LMT First of all I want to make it clear that this information is not to diagnose nor prescribe, and it should not take the place of the advice of your doctor. This is intended to educate about conventional medicine, not to replace it. Consult with your doctor before starting any kind of nutritional or physical program. The shoulder is one of the areas most difficult to treat. Think of the motion of the shoulder, it has the largest range of motion of any other joint in the body. What that means is that it is a very complex working mechanism. Because the shoulder needs to have such extreme range it does not have many ligaments structures holding it in place. There are mostly muscles tied in from the back of the scapula, the shoulder, and arm, as well as the pectorals the deltoids, need I go on. There are lots of muscles holding that shoulder together and very little ligaments. The bones that make up the shoulder are the Humerus, the clavicle, the scapula, which holds the shoulders ball and socket joint, another big reason why it has such a wide circle of action. This is where most of the injuries to the shoulder happen we call it the rotator cuff. Most pain oddly enough is felt in the middle of the deltoid at the proximal (closer to the body) end of Humerus. If we are to help with any part of the body we must know how it works. Why it works, and what could it possibly be when it doesn t work. Sound confusing? That it is. The shoulder is one of the hardest areas of the body to help with through the use of massage. Lets look at the different ways we get shoulder problems; The most common is Bursitis, or an inflamed bursa in the shoulder. This can result from an injury where you damage the sack that holds the fluids in the shoulder joint to keep it lubricated. Falling on your hand or landing on your shoulder (football) can create a pain and swelling in this joint. It starts to make most wide arm movements painful. It could also come from long slow, improper mechanical action on it as well. The overuse syndrome can happen to any part of the body, when you are not mechanically sound, however it s very common in the shoulder, it s called frozen shoulder . Testing the shoulder is a regular part of the body treatment that I do; mainly because it s a common source of stress. Especially if the shoulders are rounded, and there is some pectoral muscle tension. You can just check the insertion of the pectoral group, as well as the origin of the biceps to find there is a lot of stress on these tendons. Some of shoulder pain can be referred pain, coming from the neck or upper thoracic vertebrae. The other common pain is overuse, as we said but that is tendon tension and tendonitis at the farthest onset. Pain at this area, can be very diffused though the shoulder and upper arm. This is the difficulty as it is on the C-5 dermatome, so we have to be specific in our tests to find out what the problem is. Test the neck to rule out referred pain. If movement of the neck causes the shoulder pain then check the neck further. The test for Bursitis (Inflamed shoulder joint) Testing for bursitis, or limited range of any joint or muscle group, will give us an evaluation of the mechanics working on any joint. Imbalances on any joint causes intense stress on any system. Passive abduction (Raising the arm to the side) may create the worst pain. You will find external rotation is less painful. If you palpate the shoulder you can find scar tissue or knots in the sub-deltoid bursa. The subscapularis tendon A common shoulder injury is tennis, pitchers, or swimmers shoulder. This is when you have injured the subscapularis tendon. The test is to have the patient do a forehand action with the arm and the therapist resists with internal rotation. It s in this action that the pain occurs. The problem is that so many athletes, as well as regular people create little tears every time with small injuries. Then that creates larger scar tissue; this is an area hard to reach with DTF (Deep Transverse Friction Massage). So you play tennis or softball real hard at the company pick-nick and you hurt for a week or two, often times a month is not uncommon, and the wonderful body heals it again. So we start to feel better, that scar tissue is brittle and we create a potential injury site again. RICE will always help any injury. The supraspinatus There is another shoulder injury, if it huts to lift your arm on the top of the shoulder. This muscle helps lift the arm before other muscles come into play. It can be injured with falls, or by trying to lift or push harder than it is built for. Take the arm out (Abduct) at about a 30 or 40% angle and push in towards the groin, as patient tries to push out with a straight arm. The pain will be usually near the tendon and shoulder (insertion of muscle). Infraspinatus The back side of the shoulder is the location for the Infraspinatus, hitting a back hand. Playing baseball or football is a common way to injure this muscle. This pain is usually felt in the back of the shoulder. The muscle, originates in the medial edge of the scapula, and inserts at the posterior aspect of the Humerus. This muscle can be rather weak, mainly because we do more internal rotation of the shoulder than external rotation. In weight training, they do more pectoral work than work on those very specific back muscles. Test Have the person with their arm in a 90% angle out in front of them place your hand on their wrist and resist their external rotation, or backhand. This will hurt the muscle more if it is the problem. Biceps The biceps are actually two muscles that insert at the elbow joint. These muscles don t get inured too often but can also be a pain in the shoulder that we should rule out. It could of course be injured down at the elbow but it is less common. This muscle is hurt by trying to lift something heavy, usually weight training. The test for the biceps is to have the person with their arm bent palm upwards. Put your hand on the wrist and have them try and curl their arm. You resist and notice the area that may have the pain. Go slow always, on all tests, in fact if there is pain without resistance, have them first move, then contract the muscle 50% that you suspect, then if still in doubt up to 75% of a contraction with resistance. Triceps There is another injury to the upper arm and shoulder area, the Triceps. It s even less common than the biceps, it is three origins at the posterior part of the Humerus, and turns into a large tendon at its insertion into the elbow. Pushing yourself up with your arm will cause pain. The triceps test To test the triceps have person supine, or sitting and have elbow and arm at a 90% and have them turn palm up and push inferior to their feet. You resist that action by holding below the wrist, with an open palm. The pain will be felt at the back of the shoulder and somewhat inferior. Treatment for all these tendonitis conditions RICE, and DTF will always help any tendon injury improve, if you can get at it. However the difficulty is doing it correct, so that you don t cause more irritation. The more acute the condition, the softer and more icing needs to be done. The more chronic condition, then you can go without ice and do deeper work to break up the adhesions. Massage is great for these conditions, as you increase the circulation as well as reduce some of the peripheral muscle tension and possible injuries. Any time we can increase circulation to a soft tissue tear you increase the healing time. The shoulder pain that we can t help much with massage, and manipulations can actually make it worse is the Bursitis of the shoulder Acute or Chronic. The shoulder pain most people have that comes on gradually or just appears out of the blue is Bursitis see above. When you have pain sleeping on this shoulder it s often bursitis. Shoulders are tricky have them see a doctor if you have any doubts. Bursitis is the one that definitely needs a doctors help, as one of the best treatments is to inject it with corticosteroid medicine. It will reduce the inflammation in a few days to a week. It s important to rest it and not strain, as you may get a worse injury. The medication can actually weaken that tissue as it softens the tissue and reduces the inflammation . The Ligaments. Where the acromium process and the clavical meet is the Acromioclavicular joint. This injury does not cause pain to run down the arm, it s at a very precise point in the anterior superior part of the shoulder. It is called a separated shoulder and is common in sports. It can also happen falling down hard, or off a bike or horse and landing on your out stretched arm. There are two ways to put stress on the joint to see if it s those ligaments. Palpation is great for finding this injury. Massage does not do much although DTF applied with ice and in the acute time could reduce the recuperation time, as these injuries if left alone will take a few months to heal. They could be re-injured and could last half a year. If you suspect a serious tear refer to a doctor. They will take an x-ray with the patient holding something heavy and see if there is a separation of the shoulder joint. Once again injections are some of the best treatments for this condition, corticosteroid, or a prolifeant as it can help build up the new scar tissue and get you pain free. Othon Molina, Ph.d.c, LMT P.O. Box 1231 Kamuela, HI 96743 Cell: (808) 895-2688 www.molinamassage.com
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