Each case of shoulder injury should be assessed and treated as a unique dysfunction that is specific to that individual. Certain cases will only involve local structures, while other cases can involve a much larger kinetic chain. Before we get into the various aspects of treatment, let's review a few important contraindications to manual therapy.

CONTRAINDICATIONS TO MANUAL THERAPY

Before implementation of any manual therapy procedures, the practitioner should first make sure that the problem is actually a musculoskeletal (MSK) condition. It is important that practitioners screen patients to ascertain which patients have a high likelihood of a serious pathology.

Some the common contraindications for manual therapy of the shoulder include:

• Active inflammatory or septic arthritis.

• Signs of vascular disease or any serious condition that could masquerade as a musculoskeletal condition (eg. 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.

• Indications of visceral pain referral patterns.

• Fracture or dislocation.

OSSEOUS JOINT MOBILIZATION FOR SHOULDER INJURIES

With any shoulder injury, it is critical to assess, and then treat any restrictions that are found in the joints of the shoulder girdle. Keep in mind that no joint works in isolation. This point not only applies to the five joints of the shoulder, but also to other joints within the larger kinetic chain.

For example, the stability of the shoulder is often affected by the joints of the cervical and thoracic spine, and sometimes even by the upper extremity joints of the elbow. An injury in any of these other joints can cause mechanical compensations to occur in both adjacent and distant joints.

These compensations could then affect the function of the shoulder girdle complex. If you would like to learn more about the shoulder girdle joints click here to read Part 1 of Shoulder Injuries.

So What Exactly Does Joint Mobilization/Manipulation Do?

To answer this question, let's consider two aspects. The first is the physiological consequences of trauma (including receptive motion) or degeneration, and the second is the neurological dysfunctions that joint manipulation can help address.

Physiological Consequences of Trauma or Degeneration

Research has shown us that when joints become immobile (due to injury or osteoarthritis) then they become subject to several physiological changes.

This typically begins with a decrease in fluid content, within the joint, which in turn can cause a decrease in the joint-fiber distance within the capsule surrounding the joint. (1,15)

This leads to the development of increased cross-fiber linkages, which can then results in the formation of adhesion's in the synovial folds of the joints. These adhesion's cause a decrease in the strength of collagenous tissue; which can then cascade into tissue failure, even with diminished tissue loading. (1,15)

The objective of joint mobilization is to reverse these physiological changes by promoting movement between capsular fibers.

• Research has shown that joint mobilization can gradually cause rearrangement of collagen tissue to increase mobility. (1)

• In addition, joint manipulation can break adhesions within the joint capsule and help to increase the length of capsular fibers. (15)

• Though the best evidence to support these claims have focused on the short-term effects of joint mobilization, clinically we have found that it is possible to retain these changes over the long-term, by combining mobility exercises with strengthening routines.

Keep in mind that the joint capsule is not the only structure whose function is positively affected by joint mobilization. Other peri-articular tissues, such as ligaments, tendons, muscles, and fascia, also improve in function when joint mobilization techniques are used. (1,15)

Neurological Effects of Joint Manipulation

Research has shown that mobilization and manipulative techniques result in a number of beneficial neurological effects. One of the most significant effects is a reduction of pain. (7)

Research has shown that after joint manipulation, there is an increase in what is known as pain-pressure threshold (the minimum applied force which induces pain). This means that the patient can tolerate increased levels of physical stress before experiencing pain. (7) This could be due to:

• Changes in b-endorphin and serotonin levels.

• An alteration in alpha motor neuron activity.

• Changes in the autonomic nervous system (ANS) responses. (7)

At this time, there is no definitive consensus between researchers about the exact neurological mechanism involved in joint manipulation. (7) Most research concedes that this is an area requiring more research.

That being said, we do know that the pain experienced by the patient is greatly reduced after joint manipulation. (7) Obtaining a reduction in the patient's pain should not be taken lightly. Pain reduction can give patients an opportunity to:

• Normalize their movement patterns.

• Perform their prescribed exercises.

• Increase their level of functional activities of daily-living.

• Return to work faster.

All of which promote positive functional, physiological, and emotional changes!

The Power of Chiropractic Adjustments

Chiropractic Adjustment are powerful tools. When patients who suffer from chronic pain receive care, at regularly pre-planned intervals, (Chiropractic Maintenance Care), then they do much better as compared to patients who only receive care during episodes of acute back pain. In the video to the right Dr. Abelson demonstrates some common adjustments.

Cervical Manipulation or Mobilization

The cervical region (neck) is an important aspect of the shoulders kinetic chain. Often restrictions in the cervical region will affect both shoulder and neck function. Research has shown that spinal manipulation and mobilization are both viable options for addressing these restrictions. (19)

That being said, there are situations where as a practitioner (or patient) you may prefer to use cervical mobilization over cervical manipulation procedures. For example patients with osteoporosis, vascular issues, severe arthritis, patients who have suffered recent trauma, or even patients who have a psychological aversion to cervical adjustments, may want to consider cervical mobilization.

Cervical Joint Mobilization - MSR: In this video Dr. Abelson shows you examples of Cervical Joint Mobilization. These are examples of some of the procedures that we teach in our Motion Specific Release (MSR) courses. Please note MSR procedures are to be performed only by certified MSR Practitioners!

THE MSR -5 POINT SHOULDER JOINT MOBILIZATION PROTOCOL

In this video Dr. Abelson demonstrates the Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol Part One. When we think of the shoulder, we often think of it as being just one joint. In reality, we must consider five different joints. Understanding the inter‐relationships between the structures in these five joints will play a critical role in successfully resolving shoulder injuries.

Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol Part Two.

RECOMMENDED REFERENCE BOOKS

Netter Atlas of Human Anatomy https://amzn.to/3SQYWgx

Functional Atlas of the Human Fascial System - Carla Stecco https://amzn.to/3TE1EqP Functional Anatomy: Anatomy, Kinesiology, and Palpation https://amzn.to/3f49Xgn

The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns and Stretching Joseph E. Muscolino – https://amzn.to/3SAh5Pl

Anatomy Trains: Myofascial Meridians for Manual Therapists https://amzn.to/3SCkhtZ

Neuro Anatomy Publications https://amzn.to/3fj1RRe

Joint mobilization/manipulation extremity and spinal techniques https://amzn.to/3DxqCCs

The Trigger Point Manual - https://amzn.to/3gFDDRu

Chinese Acupuncture and Moxibustion (4th Edition) - https://amzn.to/3TRDs3M

MOBILIZING THE MYOFASCIAL SYSTEM

Just as we have emphasized the importance of addressing joint restrictions we must also take a comprehensive approach to treating myofascial restrictions. (The prefix "myo" refers to muscle or related to muscle, while fascia refers to the connective tissue that infuses and surrounds every structure in the body.

The Fascia Research Journal describes the fascia system in a very concise way.

"The fascial system builds a three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissue that permeates the body and enables all body systems to operate in an integrated manner." (8)

Fascia plays a critical role in communication, and in maintaining a memory of our body’s history, while also acting as a tensional network. (8)

Any techniques we use to address this myofascial system must be able to address not only local problems, but also the multiple inter-connections of our fascial system.

Just so you understand how important this is, let me elaborate on certain key aspects of the fascial system.

1. Communication: We all know that the nervous system is our body’s primary communication system. However, there is more to it than we previously realized. Research has shown that the body’s fascial network contains ten times the number of sensory nerve receptors as those that actually innervate muscles. (11,14,17)

2. Our Fascia Contains Our History: Our fascial network is like a written history of our life! Every injury or physical force that we experience transmits mechanical forces throughout the body. Over time, these forces eventually produce transcriptional (RNA) changes in the body, which in turn produce changes in our fascial architecture. These changes can cause imbalances, adhesion formation, thickening, or decreases in mobility. (4)

This is amazing, since we are literally talking about how mechanical forces initiate transcription – the process of making an RNA copy of a gene sequence,(4) and producing corresponding proteins – based on the physical history of the body.

3. The Tensional Network: Fascia is often defined as “one interconnected tensional network that adapts its fiber arrangement and density according to local tensional demands.”(8) When fascial tension is in good balance, fascia acts to distribute force throughout the body, and allows us to store and release energy for propulsion. When fascial tension is out-of-balance, hypertensive, or restricted, fascia can become the source of various dysfunctions. (14)

ADDRESSING MYOFASCIAL RESTRICTIONS

There are numerous techniques that can be used to address myofascial restrictions in the shoulder. Which techniques you use will depend on the specific case.

My recommendation for practitioners is to become familiar with a wide range of techniques. Then combine those procedures to achieve optimum results with each individual case. NO one technique addresses the needs of all individuals.

6 ‐ Point MSR Rotator Cuff Protocol: The rotator cuff is made up of four major muscles and their associated tendons: supraspinatus, infraspinatus, teres minor, and the subscapularis. This group of muscles is also referred to as the SITS muscles (the first letter of their names). The SITS muscles are involved in almost every type of shoulder movement. It is extremely important to have strong, flexible, and balanced SITS muscles in order to maintain optimal shoulder function.

RECOMMENDED FASCIAL BOOKS

Functional Atlas of the Human Fascial System - Carla Stecco https://amzn.to/3TE1EqP

Fascia: The Tensional Network of the Human Body https://amzn.to/3gQlUXB

Anatomy Trains - Thomas Myers Publications https://amzn.to/3Njsj9L

Fascia Stecco Publications - https://amzn.to/3FrWI3P

Fascia: The Tensional Network of the Human Body: The science and clinical applications in manual and movement therapy, 1e https://amzn.to/3SV2WN2

TREATMENT PHASE CONSIDERATIONS

Conservative Therapy and exercises for shoulder injuries can usually be divided into three phases. Keep in mind that it is important for the patient to show a functional progression before moving them onto the next phase of treatment.

• Phase 1: Acute Phase

• Phase 2: Intermediate Phase

• Phase 3: Athletic Training

Phase 1- The Acute Phase

Our goals during the Acute Phase are to:

• Decrease pain and inflammation.

• Reduce hypertonicity and muscular spasticity by using heat, manual therapy, and possibly pharmaceutical intervention (depending on the recommendations of their physical).

• Increase the non-painful range-of-motion for both active and passive motion. This can often be achieved through soft-tissue therapy, joint manipulation, and exercise.

• Add exercises to prevent muscular atrophy. This is achieved through the use of appropriate isometric exercises. An isometric exercise involves the static contraction of a muscle without any visible movement in the angle of the joint.

• Add exercises to improve proprioception.

Phase 2- The Intermediate Phase

Before proceeding to the Intermediate Phase of rehabilitation, the patient should first be able to demonstrate:

• Increased range-of-motion, with only minimal pain.

• Increased static stability.

• Increased neuromuscular control.

Our treatment goals during the Intermediate Phase are to:

• Increase strength and neuromuscular control through the introduction and use of isotonic exercises. An isotonic exercise is a type of exercise where the contracting muscle shortens against a constant load, as when lifting a weight.

• Enhance proprioception and neuromuscular control through the use of proprioceptive and rhythmic stabilization exercises.

• Enhance dynamic stabilization through exercise.

• Normalize arthrokinematics (movement of joint surfaces) of the shoulder joints. This is achieved by hands on therapy and exercise.

• Use appropriate manual therapy to reduce hypertonicity and muscle spasticity, increase circulation, and promote increased stability of the shoulder joints.

Phase 3- The Advanced Phase (Athletic Training)

Before proceeding to the Advanced Phase of rehabilitation, the patient should be able to demonstrate:

• A normal range-of-motion, with little to no pain.

• Good joint mobility of the shoulder girdle (including good capsular mobility).

• Increased strength of all structures involved in scapulothoracic mobility. Remember, 17 different muscles attach to just the the scapulae!

Our treatment goals in the Advanced Phase are to:

• Achieve progressive strengthening through the use of isotonic exercises.

• Practice advanced neuromuscular control drills.

• Apply sport-specific strengthening, endurance and power drills.

• Increase the duration, weight and repetition of exercises.

• Introduce plyometric training.

• Continue with manual therapy with a focus on increased bio-mechanical performance.

EXERCISE EXAMPLES

The following section provides links to exercise videos that we have produced.

Which exercises we prescribe for each patient always varies pending on the needs of each specific case.

Note: This is a small subset of the exercises we prescribe to our patients and should not be considered as a recommendation for your specific case. I have also included a series of exercises that we often prescribe for Frozen Shoulder, so that you can see the type of exercise we prescribe for patients with a very limited range of motion within the shoulder.

Flexibility and Mobility Exercises

• 5 Daily Shoulder Mobilization Exercises

Myofascial Release Exercises

• Myofascial Release of the Pectoral Muscles

• Myofascial Release of the Posterior Shoulder

• Myofascial Release of the Rhomboids

Strengthening Exercises

• Strengthening Internal & External Shoulder Rotation

• Single Arm Theraband Row

• Rear Deltoid Fly - Theraband

• L's Shoulder & Upper Back Strengthening

• T's - Shoulder & Upper Back Strengthening

• Y's - Shoulder & Upper Back Strengthening

Frozen Shoulder Routine - MSR: We have found the following exercises to be an important component of the over all strategy in treating Frozen Shoulder. This is a sample of some of the exercises that we prescribe to our patients.

INTERDISCIPLINARY COLLABORATION

The majority of our patients respond extremely well to a combination of manual therapy and exercise. That being said, in some cases, conservative therapy may not address all aspects of a shoulder injury.

Some shoulder injuries require a combination of approaches, or specific interventions, that do not fit into the scope of practice of manual practitioners.

In such cases, we commonly make referrals to family physicians, orthopedic surgeons, chronic pain specialists, neurologists and other disciplines.

Some of the common reasons that we would tap into the resources of a interdisciplinary collaborative team are:

• Pain & Inflammation - In certain cases the level of shoulder pain is so severe that the patient is not able to tolerate treatment, cannot perform their prescribed exercises, or is not able to sleep at night. In such cases, an appropriate prescription (or series of injections) can make the difference between success and failure.

• Partial & Full Thickness Rotator Cuff Tears - Nonsurgical treatment combined with exercise is usually successful in treating rotator cuff tears. The problem is that partial or full thickness tears can be associated with chronic inflammation and the development of spurs. In these cases surgery may be needed to remove the spurs to address the shoulder problem. In most cases, this would only be after conservative care is not able to achieve the desired results.

• Hyper Mobility - Cases that involve hyper-mobility of the shoulder may require injections (Prolotherapy, Platelet-Rich Plasma (PRP) ) or even surgical repair to prevent instability. Younger patients with heavy physical demands (high risk of recurrent injuries) may require immediate surgical intervention so they can return to a desired activity (sport).

• Severe Osteoarthritis - Osteoarthritis can destroy the shoulder joint and surrounding soft tissue. In cases of severe osteoarthritis where conservative therapy has been tried, but with limited or no results, then a shoulder joint replacement may be the best option. Depending on the case, the orthopedic surgeon may recommend either replacement of just the head of the humerus or replacement of the entire socket. Research has shown that most modern shoulder replacements will last for at least 15 to 20 years. If you can get 20 years of increased function with minimal or no pain, then a shoulder joint replacement is well worth it.

CONCLUSION

We have covered a great deal of information in this 4-part blog. The good new is that the majority of shoulder injuries can be addressed with a combination of therapy and exercise. In conclusion:

1. With any shoulder injury a complete physical examination is essential. This examination must include a complete orthopedic and neurological workup and the proper imaging.

2. Shoulder injuries are complex; in order to resolve them it often requires addressing both osseous and soft-tissue dysfunction.

3. Exercise is a key component to reach a full resolution of any musculoskeletal condition. Exercise programs must meet the needs of each individual. Generic exercise recommendations often fail short of achieving optimum results.

4. The majority of our patients respond extremely well to a combination of manual therapy and exercise. That being said, in some cases, conservative therapy may not address all aspects of a shoulder injury. Some shoulder injuries require a combination of approaches, or specific interventions, that do not fit into the scope of practice of a manual practitioner

Shoulder Injuries Part 1 - Five Joints to Consider

Shoulder Injuries Part 2 - Seventeen Muscles

Shoulder Injuries Part 3 - Rotator Cuff & Diagnosis

Shoulder Injuries Part 4 - Treatment Logic & Recommendations

DR. BRIAN ABELSON DC.

Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.

Dr. Abelson believes in running an Evidence-based, Patient-centered, Inter-professional and Collaborative clinical practice.

Make Your Appointment Today!

Make an appointment with our incredible team at Kinetic Health in NW Calgary, Alberta. Call Kinetic Health at 403-241-3772 to make an appointment today, or just click the MSR logo to right. We look forward to seeing you!

Discover more useful information about shoulder and upper body injuries in Dr. Abelson’s book “Exercises for the Shoulder to Hand”.

This book guides you through the exercises you need to rehabilitate your shoulder, elbow, wrist, and hand injuries.

These exercises help you progress in a logical fashion through through Beginner, Intermediate, and Advanced routines, and aid in effectively building flexibility, strength and power throughout the upper body!

REFERENCES PART 4

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2. 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.

3. 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.

4. 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.

5. Cleland JA, Selleck B, Stowell T, et al. (2004). Short-term effects of thoracic manipulation on lower trapezius muscle strength. , 12, pp. 82-90.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. Stecco, Carla; Stecco, Carla. Functional Atlas of the Human Fasical System. Elsevier Health Sciences.

17. 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.

18. 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

19. 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.

20. 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.

21. Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013;154:S94–100.

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