Shoulder Injuries Part 4 - Treatment Logic & Recommendations
- Dr. Brian Abelson DC
- Apr 11, 2023
- 12 min read
Updated: Jul 23, 2024
In part four of this series, we will delve into the logic of our treatment recommendations. Each shoulder injury case should be evaluated and treated as a unique dysfunction specific to the individual. Some cases may involve local structures, while others involve a larger kinetic chain. Before delving into treatment aspects, it is crucial to review some key contraindications to manual therapy.
Article Index:
Contraindications
Treatment
Conclusion & References
Contraindications To Manual Therapy
Practitioners must ensure the problem is a musculoskeletal (MSK) condition before applying any manual therapy procedures. Proper patient screening is essential to determine the likelihood of severe pathology.
Common contraindications for shoulder manual therapy include:
Active inflammatory or septic arthritis.
Signs of vascular disease or serious conditions mimicking MSK issues (e.g., aortic aneurysm).
Joint and ligament instability.
Excessive swelling or pain.
Active bone disease or malignancy (cancer).
Non-mechanical causes of pain.
Indications of cervical spine pathology.
Progressive neurological deficit.
Signs of visceral pain referral patterns.
Fracture or dislocation.
Joint Mobilization
When it comes to shoulder injuries, the role of professionals in evaluating and addressing limitations in the shoulder girdle joints cannot be overstated. Their expertise and specialized knowledge allow them to recognize the interconnected nature of our joints. This interconnectedness is not limited to the five joints of the shoulder but extends to the broader kinetic chain, emphasizing the need for their involvement in effective rehabilitation.
For example, the cervical and thoracic spine joints and occasionally the upper elbow joints can influence the shoulder's stability. Any injury in these areas can trigger compensatory reactions in nearby or even far-off joints, which, in turn, can affect the shoulder girdle's functionality.
Understanding Joint Mobilization/Manipulation Effects
To comprehend the impact of joint mobilization/manipulation, we must examine two aspects. The first aspect involves the physiological consequences of trauma (including repetitive motion) or degeneration, while the second aspect focuses on the neurological dysfunctions that joint manipulation can help alleviate.
Physiological Consequences of Trauma or Degeneration
Studies have demonstrated that joints undergo various physiological changes when they lose mobility (due to injury or osteoarthritis).
These changes usually start with a reduction in joint fluid content, leading to a decrease in the joint-fibre distance within the capsule surrounding the joint. (1,15)
Consequently, increased cross-fibre linkages develop, resulting in adhesions forming in the synovial folds of the joints. These adhesions cause a decrease in collagenous tissue strength, potentially leading to tissue failure, even under reduced tissue loading. (1,15,26)
Joint mobilization counteracts these physiological changes by encouraging movement between capsular fibres.
Research has shown that joint mobilization can progressively rearrange collagen tissue to enhance mobility. (1)
Moreover, joint manipulation can break joint capsule adhesions and help increase the length of capsular fibres. (15)
While the existing evidence primarily focuses on the short-term effects of joint mobilization, it's important to note that clinically, the combination of mobility exercises with strengthening routines has been observed to maintain these changes over the long term. This underscores the potential of joint mobilization in promoting sustained joint health.
It's worth noting that joint mobilization benefits the joint capsule and positively impacts other peri-articular tissues, such as ligaments, tendons, muscles, and fascia. (1,15)
Neurological Effects of Joint Manipulation
Studies have demonstrated that mobilization and manipulation techniques lead to various advantageous neurological outcomes. One of the most notable effects is a decrease in pain. (7)
The significance of our research findings is that joint manipulation has been shown to increase patients' pain-pressure threshold, enabling them to tolerate higher levels of physical stress before experiencing pain. This is a crucial improvement that could potentially revolutionize pain management in physical therapy. (7) The underlying mechanisms for this increased tolerance are still being explored.
Changes in b-endorphin and serotonin levels: These are chemicals in the brain that help regulate pain and mood.
Alterations in alpha motor neuron activity: Alpha motor neurons are nerve cells that control muscle contractions.
Shifts in autonomic nervous system (ANS) responses: The ANS controls involuntary bodily functions, such as heart rate and digestion. (7)
Researchers have yet to agree on the exact neurological mechanisms involved in joint manipulation. (7) Most research admits that more studies are needed in this area.
Despite the lack of clarity, we know patients experience significantly less pain after joint manipulation. (7) Reducing pain is a crucial outcome, as it allows patients to:
Normalize their movement patterns.
Perform their prescribed exercises.
Increase their ability to perform daily activities.
Return to work faster.
Joint Treatment Demonstrations
MSR 5 Point Shoulder Joint Mobilization
In this video, Dr. Abelson (the developer of MSR) demonstrates highly effective procedures for mobilizing the shoulder joint using the MSR technique. (26)
Chiropractic Adjustment
Chiropractic adjustments are effective techniques that can be employed to address the broader range of interconnected body structures involved in rotator cuff injuries. (26)
Cervical Joint Mobilization
In this video, Dr. Abelson demonstrates examples of cervical joint mobilization techniques. These methods can also be applied to address the more extensive kinetic chain involved in rotator cuff injuries. The choice between manipulation and mobilization depends on factors such as the individual case and patient preference. (26)
Myofascial Treatment
Addressing myofascial restrictions is just as crucial as addressing joint restrictions. The term "myofascial" refers to the muscle (the prefix "myo") and the connective tissue surrounding and infusing every structure in the body (fascia).
The Fascia Research Journal succinctly describes the fascial system:
"The fascial system forms a three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissue that permeates the body, allowing all body systems to function in an integrated manner." (8,26)
Fascia plays a crucial role in communication, holding a record of our body's history and acting as a tensional network (8,26). Any techniques used to address the myofascial system must consider local issues and the multiple interconnected aspects of our fascial system.
To better understand its importance, let's explore certain critical aspects of the fascial system:
Communication: The nervous system is the primary communication system in our body. However, research shows that the fascial network contains ten times the number of sensory nerve receptors as those that innervate muscles (11,14,17,26).
Our Fascia Contains Our History: Our fascial network is like a living record of our lives! Every injury or physical force we experience transmits mechanical forces throughout the body. Over time, these forces cause transcriptional (RNA) changes in the body, altering our fascial architecture. These changes can lead to imbalances, adhesion formation, thickening, or decreased mobility (4,26).
The Tensional Network: Fascia is often described as "one interconnected tensional network that adapts its fibre arrangement and density according to local tensional demands" (8,26). Balanced fascial tension distributes force throughout the body and allows us to store and release energy for propulsion. However, when fascial tension is imbalanced, hypertensive, or restricted, it can become the source of various dysfunctions (14,26).
Addressing Myofascial Restrictions
Numerous MSR procedures can be used to address myofascial restrictions in the shoulder. Which methods you use will depend on the specific case. Below is a demonstration of a few procedures for the myofascial restrictions associated with a rotator cuff injury.
Stop Rotator Cuff Pain Now
In this video, Dr. Abelson, the creator of Motion Specific Release, demonstrates the comprehensive 6-Point Rotator Cuff protocol designed to address rotator cuff injuries. (26)
MSR Fascial Expansion:
Shoulder Pain - Utilizing fascial expansions in shoulder pain management presents an effective strategy that merges contemporary insights in fascia, kinetic chain relationships, and core principles of acupuncture or traditional Chinese medicine.
Treatment Phase Considerations
Conservative therapy and exercises for shoulder injuries can generally be divided into three phases. It is crucial for patients to demonstrate functional progress before transitioning to the next treatment phase:
Phase 1: Acute Phase
Phase 2: Intermediate Phase
Phase 3: Athletic Training
Phase 1 - The Acute Phase
During the Acute Phase, our objectives are to:
Decrease pain and inflammation.
Minimize hypertonicity and muscular spasticity through heat, manual therapy, and potentially pharmaceutical intervention (based on their healthcare provider's recommendations).
Enhancing the non-painful range of motion for both active and passive movements can often be accomplished with soft-tissue therapy, joint manipulation, and exercise.
Introduce exercises to prevent muscular atrophy by utilizing appropriate isometric exercises. Isometric exercises involve static muscle contractions without visible joint angle movement.
Incorporate exercises to improve proprioception.
Phase 2- The Intermediate Phase
Before moving to the Intermediate Phase of rehabilitation, the patient should be able to show:
Improved range of motion with minimal pain.
Better static stability.
Enhanced control over muscles and nerves.
During the Intermediate Phase, our treatment goals are to:
Introduce isotonic exercises, such as lifting a dumbbell, to increase strength and muscle control. In these exercises, the muscle changes length against a constant weight.
Improve body awareness (proprioception) and muscle control through unique exercises focusing on balance and coordination.
Boost dynamic stabilization (control during movement) with exercise.
Ensure the normal movement of shoulder joint surfaces through hands-on therapy and exercise.
As part of our comprehensive approach, we apply specific manual therapy techniques. These include: Reducing muscle tightness and spasms, which can improve the patient's comfort and mobility; Improving blood flow, which aids in the healing process; and Supporting better shoulder joint stability, a key factor in the patient's overall rehabilitation.y.
Phase 3 - The Advanced Phase (Athletic Training)
Before moving to the Advanced Phase of rehabilitation, the patient should be able to show:
Normal range of motion with little or no pain.
Good flexibility and movement in the shoulder area.
Strong muscles that help move the shoulder blade (scapula).
During the Advanced Phase, our treatment goals are to:
Continue building strength with exercises that involve changing muscle length while lifting weights.
Practice advanced exercises that focus on muscle control and coordination.
Work on exercises specific to the patient's sport or activity, targeting strength, endurance, and power.
Increase the time, weight, and number of repetitions for exercises.
Introduce exercises that involve quick, powerful movements (plyometrics).
Keep using manual therapy techniques to improve how the body moves and performs.
Conclusion
In conclusion, treating shoulder injuries requires a comprehensive and individualized approach that addresses joint restrictions, myofascial restrictions, and the larger kinetic chain. By incorporating various phases of treatment and rehabilitation, patients can progress from acute pain management to intermediate strengthening and, ultimately, advanced athletic training. By understanding the intricate relationships between the shoulder and body structures, healthcare practitioners can create effective treatment plans that help patients regain their full range of motion, strength, and function.
It is essential for both patients and practitioners to recognize the importance of a tailored treatment plan that considers the individual's unique needs and circumstances. By combining manual therapy, joint mobilization, and targeted exercises, patients can experience significant improvements in their shoulder health and overall well-being. Through proper communication, diligence, and a commitment to the healing process, patients can overcome their shoulder injuries and return to the activities they love.
References - Part 4
Akeson WH, Amiel D, Abel JF, et al. (1987). Effects of immobilization on joints. , 219, pp. 28-37.
Akima H, Takahashi H, Kuno S, et al: Coactivation pattern in human quadriceps during isokinetic knee-extension by muscle functional MRI. Eur J Appl Physiol 91:7, 2004.
Bhowmick S, Singh A, Flavell RA, et al. (2009). The sympathetic nervous system modulates CD4(+) FoxP3(+) regulatory T cells via a TGF-beta-dependent mechanism. J Leukoc Biol, 86, pp. 1275-1283.
Chen C, and Ingber D. (2007). Tensegrity and mechanoregulation: from skeleton to cytoskeleton. In: Findley T, and Schleip R, eds. Fascia research. Oxford: Elsevier, pp. 20-32.
Cleland JA, Selleck B, Stowell T, et al. (2004). Short-term effects of thoracic manipulation on lower trapezius muscle strength. , 12, pp. 82-90.
Coronado RA, Gay CW, Bialosky JE, et al. (2012). Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. , 22(5), pp. 752-767.
Degenhardt BF, Darmani NA, Johnson JC, et al. (2007). Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study. , 107(9), pp. 387-400.
Findley T, and Schleip R. (2009). Introduction. In: Huijing PA, Hollander P, Findley TW, and Schleip R, eds. Fascia research II. Basic science and implications for conventional and complementary health care. München: Urban and Fischer.
Langevin HM. Fibroblast cytoskeletal remodeling contributes to viscoelastic response of arealoar connective tissue under uniaxial tension. [DVD Recording] Boston MA: Second International Fascia Research Congress; 2009.
Linnamo V, Moritani T, Nicol C, et al: Motor unit activation patterns during isometric, concentric and eccentric actions at different force levels. J Electromyogr Kinesiol 13:93, 2003.
Mitchell JH, and Schmidt RF. (1977). Cardiovascular reflex control by afferent fibers from skeletal muscle receptors. In: Shepherd JT, et al, eds, Handbook of physiology, Section 2, Vol. III, Part 2. Bethesda: American Physiological Society, pp. 623-658.
Perry J, and Green A. (2008). An investigation into the effects of a unilaterally applied lumbar mobilisation technique on peripheral sympathetic nervous system activity in the lower limbs. , 13(6), pp. 492-499.
Sahara W, Sugamoto K, Murai M, et al: Three-dimensional clavicular and acromioclavicular rotations during arm abduction using vertically open MRI. J Orthop Res 25:1243, 2007.
Schleip R, Findley TW, Leon Chaitow L, and Huijing PA. (2012). Fascia: The Tensional Network of the Human Body - E-Book: The science and clinical applications in manual and movement therapy. Canada: Elsevier
Snodgrass SJ, Haskins R, Rivett DA. A structured review of spinal stiffness as a kinesiological outcome of manipulation: its measurement and utility in diagnosis, prognosis and treatment decision-making. J Electromyogr Kinesiol. 2012;22: 708– 723.
Stecco, Carla; Stecco, Carla. Functional Atlas of the Human Fasical System. Elsevier Health Sciences.
Van der Wal J. (2009). The architecture of the connective tissue in the musculoskeletal system: An often-overlooked functional parameter as to proprioception in the locomotor apparatus. In: Huijing PA, et al, eds. Fascia research II: Basic science and implications for conventional and complementary health care. Munich: Elsevier GmbH.
Lin I, Wiles L, Waller R, et al What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review British Journal of Sports Medicine Published Online First: 02 March 2019. doi: 10.1136/bjsports-2018-099878
Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis. Spine J 2004; 4:335-356.
Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, tolerability, and dose- dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176:958.
Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013;154:S94–100.
Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), 531-538.
Page, P., Labbe, A., & Topp, R. (2012). Clinical assessment of scapulohumeral rhythm for scapular dysfunction. International Journal of Sports Physical Therapy, 7(5), 617-623.
Schmitt, L., & Snyder-Mackler, L. (2012). Role of scapular stabilizers in etiology and treatment of impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 42(1), 22-29.
Vermeulen, H. M., Rozing, P. M., Obermann, W. R., Cessie, S. L., & Vlieland, T. P. V. (2006). Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Physical Therapy, 86(3), 355-368.
Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.
Wilk, K. E., Reinold, M. M., & Andrews, J. R. (2009). The Athlete's Shoulder. Elsevier Health Sciences.
Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. British Journal of Sports Medicine, 44(5), 319-327.
Kuhn, J. E. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery, 18(1), 138-160.
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DR. BRIAN ABELSON DCDR. BRIAN ABELSON DC. - The Author
Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.
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