jessephysio

I personally have a love hate relationship with the shoulder joint. It’s a mysterious area with much interconnection with the rest of the body, yet there are multiple local factors that can make a good shoulder bad. Obviously there are the 4 muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularus), the deltoid, teres major, trapezius….and then all the other muscles that attach from the ribs and neck to the shoulder blade….all of which can be pain generating sources.

Above all else though, at least over the past few months for me…has been the glenohumeral joint (GHJ) capsule. The GHJ capsule overlaps the joint providing an extra measure of stability to an otherwise very mobile joint. A tight capsule is one difficult entity to treat. Before I go on explaining why the joint capsule can suck to treat, let’s go through a basic arthrokinematic example talking about a tight capsule:

A tight anterior capsule will drive the humeral head POSTERIOR too soon with external rotation

A tight posterior capsule will drive the humeral head ANTERIOR too soon with internal rotation

A tight inferior capsule will drive the humeral head SUPERIOR too soon with abduction

A tight superior capsule will drive the humeral head SUPERIOR too soon with abduction (this one goes against the joint arthokinematics we learned in school)

I have had a recent influx of clients with chronic capsule tightness that borderlines on being diagnosed as frozen shoulder…but isn’t because they can still actively raise the arm up over 40-50 degrees in the scapular plane. A tight and fibrosed capsule is hard to treat because as a manual therapist, if can’t move their shoulder without pain, I can’t do a heck of a lot. One client I saw 2 weeks ago was so sore (for 8 months!!) that I couldn’t do PROM into ER or IR without a huge bout of rebound pain into the superior and anterior shoulder joint. In her case, both the anterior and posterior capsule was tight leading into multidirectional glenohumeral joint restriction. After clearing the cervical spine, I did tons of soft tissue work to the posterior capsule, quadrilateral space, pecs, lats, and traps…this helped with pain but unfortunately didn’t drastically change her AROM…she is possibly in the freezing stage of adhesive capsulitis.

Above all else, I feel one of the hardest parts of treating the shoulder has nothing to do with me at all. It has all to do with the patient. I often get fantastic results using manual therapy for some spinal conditions. However, the shoulder requires a lot of active care…meaning the patient can’t be lazy. Corrective and rehabilitative exercise is a MUST for the vast majority of shoulder problems. For athletes, this is great. But for a mother of 3 who works full time and barley has enough time in the day to eat, doing the required home exercise program is…well…hard. This is what they don’t tell you in school…they show you great exercises that get shoulders better…but they don’t tell you how hard it is to get clients to adhere to a graded home exercises program. Sometimes even giving 1 or 2 exercises is all I can do because giving all that is required to create needed mobility and strength in the shoulder is just too much.

So what’s the best way I have found to convince clients to do their exercises? You need to PROVE to them how important they are. Here is how I go about doing that:

1) Many clients with painful shoulders have a large kyphosis or sit in a hunched forward position (desk workers syndrome). This effectively closes off the subacromial space leading to impingement. Have the patient assume their normal poor posture position and tell them to maximally flex their arm. They will have decreased ROM with sooner onset of pain. Then have the client sit erect with scapula back and down and repeat shoulder flexion. This will produce increased ROM and later onset of pain (which hopefully is diminished in the new position). This teaches the patient how important it is to have good posture and strong scapular retractors….this proves to the client how important the exercises are.

2) I also do assisted scapular upward rotation to help clear the acromion and humeral head during arm elevation. If this diminishes or abolishes the shoulder pain I always tell the client that we have to make the muscles that my hands acting as to keep your shoulder feeling this good. Again, I’m proving to them how great they could feel if they put in the work.

A 2009 article from JOSPT did a great job of summarizing the proposed biomechanical mechanisms of scapular kinematic deviations. They are:

1) Inadequate serratus activation: Lesser scapular upward rotation and posterior tilt

2) Excess upper trap activation: Greater clavicular elevation

3) Posterior GHJ soft tissue tightness: Greater scapular anterior tilt and humeral head anterior translation

 4) Thoracic kyphosis or flexed posture: Greater scapular IR and anterior tilt with less upward rotation

(JOSPT Feb 2009: The Association of Scapular Kinematics and Glenohumeral Joint Pathologies)

So what do I do for painful shoulders? Here are some of the usual steps I take for most shoulders problems:

1) Address Thoracic kyphosis: Retraction and extension exercises, thoracic spine manipulation, soft tissue release, posture arch, spikey ball, posture education

 

2) Address scapular stabilizers: Strengthen serratus anterior (wall slides, push up plus, hugs, punches etc), lower traps (Y’s, Overhead pull aparts, chair dips), and rhomboids (rows and active scap squeezing)

 

3) Address soft tissue tightness (BIG ONE!!): Release levator scapula, scalenes, SCM, upper traps, QL space, subscap, pec minor, pec major, lats

 

4) Rotator cuff strengthening: Side lying ER, Isometric ER/IR, scapular plain abduction progressing to ER at various degrees of shoulder abduction, “W” squeezes ( a favourite of mine)

5) Capsular stretching: Door way ER stretch, horizontal adduction and sleeper stretch with PNF contractions being my favourites

Overall, the shoulder is a tough joint to treat because no one exercise or technique works for everyone. It’s a constant trial and error processes that is made easier by a good assessment that takes into account posture, the cervical spine, contractile and non-contractile tissue along with more distal and inter-systemic issues manifesting as shoulder problems. The one thing we as therapists need to remember is that non-acute shoulder dysfunction doesn’t happen overnight…it takes months of misuse before problems arise. Therefore, we shouldn’t expect shoulder problems to disappear instantly. It takes time, focus, and a considered effort on the clients part to get a shoulder healthy.

Do you have any tips for treating painful shoulders? What kinds of techniques do you use?

Have a great day!