SHOULDER TREATMENT PROTOCOL

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" ...shoulders transform from rigid blocks to exquisitely supple joints with unresisting, large radius, fluid like circular movement..." Simon Crittenden, Remedial Massage Therapist

Outline of a Shoulder Treatment I developed for athletes. I came to find results beyond expectation can be achieved applying this shoulder treatment to individuals with severely dysfunctional shoulders; ie, Rotator Cuff issues, Supraspinatus impingement, Thoracic Outlet Syndrome, RSI at the elbow and forearm, Carpal Tunnel at wrist and hand. Technique coming from Remedial Therapy, Osteopathy and Traditional Chinese Medicine (TCM) and some I developed independently.

Pump, Shake and Stretch, Indirect Fascial Release technique using the arm as a lever into the shoulder, and the Muscular Energy Technique manoeuvre are little known and little used by massage practitioners generally. Chinese Cupping and/or Gua Sha are particularly effective where warranted...in fact, amazingly so...the result of the first TCM treatment I received for a back injury nearly four decades ago was like a miracle to me.

 

There are Google and True Local reviews on the treatment of severely crippling shoulder conditions unresponsive to conventional therapy that tell the story of rapid resolution from the application of this Protocol. See Simon Crittenden, Simon Crittenden - Remedial Massage Therapist and Massage Works Dandenong Ranges.

 

DRAPING REQUIREMENT: This protocol entails side lying treatment. Additional draping is required to maintain modesty about the chest of female clients. My practice includes use of standard heavyweight massage towelling (95cm x 190cm, 650gsm) and on moving into sidelying, this is supplemented with a bath towel across the body and under the exposed upper arm. Pulled up under the arm and chin, 150cm length provides generous draping across chest and back of the client and eliminates awkwardness and embarrassment the client might otherwise feel undergoing this physical treatment. Furthermore, to aid grip and technique when using the exposed upper arm as a lever working into the torso, I employ a hand towel along its length from wrist to shoulder. Apart from benefit to technique, reducing skin on skin contact in this procedure is preferable on several levels. This is not a massage technique. On completion of the Indirect Fascial Release and subsequent Muscle Energy Technique Manoeuvre described below, I typically leave the extra bath towel in place across the chest when moving back into supine on the table. Clients do take comfort in the additional weight and coverage.

ASSESSMENT: Palpation, ROM, determine restrictions, recreate pain under static load identifying possible injury. Where no injury or pain, determine regions of tightness restricting range of motion; anterior (pectorals), posterior (infraspinatus, rhomboids, middle trapezius), superior (upper trapezius, levator scapula), inferior (teres minor/major, latisimus dorsi), lateral abduction(deltoids and supraspinatus), somatic (torso, spine, intercostals).

 

PUMP: Patient supine, pump shoulder to warm & soften shoulder with compression and movement of the joint. Intersperse series of pumps with gentle rocking stretches. Opens upper chest, improves posture and releases tightness.

Practitioner standing at the side and facing head of table, pump patient’s right shoulder by grasping arm at the wrist with your left hand and pull upwards until shoulder lifts slightly off the table. Then using palm and heel of your right hand, press downwards into the upper chest beneath the clavicle working across Pec Major finishing on Pec Minor. As downward pressure is applied, simultaneously lower the patient's arm until the humerus drops to horizontal position. Lateral movement working across pecs is more body English through the palm of the hand rather than actual movement. Avoid rolling over the head of humerus. Lean firmly into Pec Minor and the shoulder.

Care must be taken when grasping and pulling arm at the wrist. A fully encompassing grip predominantly on the end of the radius and ulna is preferable to pulling on the hand. Discomfort or injury at the wrist should be avoided.

Question patient on pressure levels, discomfort or pain being experienced. In some instances, pain in chest musculature prevents this procedure being applied until tightness and stagnation is cleared with light effleurage & stretching. Ultimately, with a strong athletic subject, I will progress to leaning with full body weight behind the compression. This is not necessary for more fragile subjects.

Unconscious holding patterns in the shoulder will often resist lowering the arm...first attempt a gentle shake of the limb to overcome the resistance. If this fails, a verbal request to relax the arm and let it drop will usually do the trick. In some instances this fails too, in which case, attempt several cycles of Pumping followed by the Shake and Stretch. Where that also fails, embedded holding patterns are too entrenched. Go to the Indirect Fascial Release procedure for shoulder and torso.

SHAKE & STRETCH: After several pumping cycles, move down the table, lower arm to horizontal and abduct roughly 30 degrees from the torso. Gently shake the arm in a wave like motion, focusing the node of the wave at the shoulder. Then lightly pull on the limb from the wrist, stretching through the shoulder as the gentle rocking motion subsides. Emphasis is on the gentleness and lightness of this procedure. Again unconscious holding and resistance to soften and relax can be overcome by a direct request to relax the shoulder and repeated Pump, Shake and Stretch cycles.

While I emphasise gentleness here, it is sometimes necessary to apply greater force and amplitude on occasion to overcome holding patterns in stronger individuals. In fact, some shoulder treatments consist solely of the Pump, Shake and Stretch components only and can prove effective used for as long as it takes on tight tight shoulders.

Intersperse a few effleurage strokes along the full arm between Pump, Shake and Stretch cycles.

Place subject's elbow on the table, forearm vertical and grasp it at the wrist between thumb and fingers, thumb pressing into the flexor muscles and push down the length of the forearm, repeatedly alternating your left and right hands. Finish with two or three strokes with both hands simultaniously squeezing the forearm and pushing firmly and slowly toward the elbow.

Repeat Pump, Shake and Stretch using mirror image of this procedure for the subject's left shoulder.

BACK & NECK TREATMENT: Subject prone, do your thing to warm and loosen vertebral extensors, QL, Glutes, Trapezius, Rotator Cuff, Neck, Head and Occipitals. Work through Rotator Cuff in both relaxed (arm down/by the side) and extended positions (arm up overhead, if possible). Commence work on arm extended overhead by interlocking fingers with the patient and pulling to stretch finger, hand, arm and shoulder joints...patient’s hand is to be relaxed, not grasping. Stretch rhomboids, mobilize scapula, lift/pull medial border off the back, PNF stretch for middle traps and rhomboids. Scapula mobilization and rhomboid/middle trapezius stretches can be done prone or side lying. Should the Rhomboids be unresponsive and in chronic spasm, this is not uncommon. If so, with client in supine, trigger point and cross fibre Subscapularis...the two are physically and energetically linked.

Refer to the Sports Massage procedure (aka Mr Australia Rubdown) for instruction on full arm massage technique in the prone position. A wide traditional table shape, as opposed to a body contour table, is better suited.

INDIRECT FASCIAL RELEASE (IFR): Also known as or similar to Ortho Bionomy, Strain/Counter Strain and Positional Release. Subject side lying, head supported on bolster. A complex series of gentle sustained compressions of the arm into the shoulder, with and without torque applied to arm, to elicit a neural response and somatic release. Note additional draping requirements described at the commencement of this article for the treatment of female clients in side lying.

 

Before commencing IFR, open chest and mobilise torso in the side lying position by pushing the upper shoulder back, arm abducted and extending back, while pushing down on the distal part of the thigh with hip flexed between 60 and 90 degrees; twisting the torso, stretching the pectoral muscles and opening the chest. To aid release, have subject take several slow deep breaths. 

Commencing IFR compressions, hold bent elbow and work through the shoulder joint only. Then progress to working through two joints together, both the elbow and shoulder holding at the wrist, arm straight and elbow lightly locked. These compressions are carried out with the arm in a variety of positions. Tightness around the shoulder is regularly monitored by holding arm vertically at the wrist with one hand and rotating shoulder with the other; assists loosening joint and provides feedback to patient and practitioner of progress. Conventional massage through the rotator cuff, direct fascial release techniques and stretching is employed to aid the process.

There is a limit to how far the body will release in a single session. Results achieved with IFR are cumulative and more progress will be made each session. That said, IFR achieves a degree of release beyond expectation. Frequently shoulders transform from rigid blocks to exquisitely supple joints with unresisting, large radius, fluid like circular movement. The large degree of fascial release causes profound relaxation in the patient.

Note: IFR techniques originate in the field of Osteopathy. Owing to the complexity of the IFR procedure, it will be the subject of future, more detailed description or video footage.

MUSCULAR ENERGY TECHNIQUE (MET) MANOEUVRE: Once the limit of release has been achieved with IFR, subject still in the side lying position, lay the arm being manipulated down across the patient’s chest, hand hanging off the table and with instruction to let it flop...do not allow them to place it palm down on the table as they will unconsciously tense supporting through that hand and arm. Practitioner placing one hand on the corner of the subject’s shoulder and the other firmly on the hip, instruct the subject to take a deep breath and warn you are about to squash them. When their lungs are full, instruct them to breath out freely and lean bodily onto the side lying patient with your chest. The direction the shoulder takes in this manoeuvre is from a slightly elevated position at full expansion of the chest toward the floor (remembering they are side lying) in an inferior direction diagonally through the Frontal plane toward the opposite hip until all breath is expelled. On this or subsequent compressions once sufficient movement through the shoulder and torso is achieved, while still in the fully compressed position with your chest pressing into their shoulder and side, use your body to move superiorly towards the subject's head up along the centreline. Doing so you frequently encounter crepitus as musculature through shoulder and torso are moved through a range of motion they have not encountered for a long, long time. Repeat the movement up and down the centreline under compression as necessary. No more than three successive compressions should be required in one session.

I am hyper-vigilent carrying out this procedure and would not do so to an individual with an unstable or injured shoulder or history of "popped" ribs...perhaps restricting the compression to a more gentle version using hands only. Generally, two or three repetitions of the the entire cycle of breathing in, compressing, etc., are sufficient.

Do not break the patient...meaning, if you are a big heavy oaf with no sensitivity and little experience do not do this.

The MET manoeuvre primes the torso and shoulder for further release through IFR. On completing the MET manoeuvre, repeat the IFR process above commencing with the stretch to open chest and rotate torso. You will commonly note rotation through the torso and range of motion of the shoulder girdle greatly increased after this manoeuvre.

UPPER BACK & SHOULDER CUPPING: Subject prone, Chinese cups placed on the spinous process of C7, Levator Scapula & Rhomboids at insertion to the scapula, meridian point Small Intestine 21, Rotator Cuff (Infraspinatus, Teres Major & Minor), Latissimus Dorsi, Lateral Deltoids at shoulder's corner & insertion point of Deltoids & Supraspinatus on the tuberosity distal to the head of the Humerus and, most importantly, directly over the Acromion treating the shoulder's synovial joint. I have found the Acromion is one of the most powerful treatment positions for the shoulder...frequently results in black cup markings; indicating they really needed that. Note, however, if it is suspected there is ligamental damage to the shoulder, placement of strong vacuum cupping on the Acromion is not recommended. Some boney shoulders defy my ability to apply a cup on the Acromion.

Subject supine, cups place on anterior deltoids/longhead biceps insertion and any aspect of the anterior and lateral deltoids not covered by cupping treatment in prone position.

Cupping treatment might be alternated with Gua Sha in another session if fascial/muscle tone indicates this is warranted. There are instances where full shoulder and back cupping is carried out and Gua Sha also applied to the Cx extensors and Upper Trapezius. Apply Cupping and Gua Sha to the same area of skin is not recommended. See further description of Cupping treatment elsewhere on this site.

NECK TREATMENT: I will usually do some of this at the beginning of a treatment largely as a relaxation and diagnostic opportunity and follow up with finishing touches at the end. Patient supine, neck treatment including release of Scalenes, Pec Minor, TMJ and clear Tai Yang through temple and side of head.

Other techniques that might be applied while the subject is in a supine position: myofascial stretch through Upper Trapezius; extend arm over head or to the side, cross fibre and trigger point Subscapularis; and, myofascial stretch through Tx and Lx extensors (patient sitting, slumped forward, legs straight), fascial release of Cranium, Diaphragm and/or Sacrum with Craniosacral Therapy.