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's crucial to review some key contraindications to manual therapy.
Article Index:
Contraindications
Treatment
Conclusion & References
Contraindications To Manual Therapy
Before applying any manual therapy procedures, practitioners must first ensure the problem is a musculoskeletal (MSK) condition. Proper patient screening is essential to determine the likelihood of serious 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
In the realm of shoulder injuries, evaluating and addressing limitations in the shoulder girdle joints is imperative. It's essential to recognize the interconnected nature of our joints. This interconnectedness extends beyond the shoulder's five joints, encompassing the broader kinetic chain.
For example, the stability of the shoulder can be influenced by the cervical and thoracic spine joints and occasionally by the upper joints of the elbow. Any injury in these areas can trigger compensatory reactions in nearby or even far-off joints, which, in turn, can affect the functionality of the shoulder girdle."
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 when joints lose mobility (due to injury or osteoarthritis), they undergo various physiological changes.
This usually starts with a reduction in joint fluid content, leading to a decrease in the joint-fiber distance within the capsule surrounding the joint. (1,15)
Consequently, increased cross-fiber 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 aims to counteract these physiological changes by encouraging movement between capsular fibers.
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 fibers. (15)
Although the strongest evidence supporting these claims focuses on the short-term effects of joint mobilization, clinically, it has been observed that combining mobility exercises with strengthening routines can maintain these changes long-term.
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)
Research has shown that after joint manipulation, patients can tolerate higher levels of physical stress before experiencing pain. This increased tolerance is known as pain-pressure threshold. (7) This improvement may be due to:
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)
At this time, researchers haven't reached a consensus 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 do know that 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.
All of these factors promote positive functional, physiological, and emotional changes!
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 important 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 key 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 fiber 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 techniques can be used to address myofascial restrictions in the shoulder. Which procedures you use will depend on the specific case. Below is a demonstration of a few procedures we use 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)
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Functional Atlas of the Human Fascial System - Carla Stecco https://amzn.to/3TE1EqP
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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).
Enhance the non-painful range of motion for both active and passive movements, which 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:
Increase strength and muscle control by introducing isotonic exercises, which are exercises where the muscle changes length against a constant weight, like lifting a dumbbell.
Improve body awareness (proprioception) and muscle control through special exercises that focus 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.
Apply manual therapy techniques to reduce muscle tightness and spasms, improve blood flow, and support better shoulder joint stability.
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.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
Revolutionize Your Practice with Motion Specific Release (MSR)!
MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.
Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.
Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.
With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!
References - Part 4
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