Article by Gretchen Rieger LMT, B.S.
Posted September 11, 2014 Update November 4, 2016
How can ROM in the massage treatment room benefit the massage client? Massage therapy is well matched to the demands of shoulder impingement syndrome due to chronically tight shoulder musculature. Compression of the shoulder girdle can lead to pain, loss of range of motion, and the inability to perform activities of daily living. The shoulder joint cannot move freely through a normal range of motion because the structures of the joint have been pulled too closely together.
When the rotator cuff muscles become chronically tight the head of the humerus will be pulled up into the shoulder socket compressing the bursa and supraspinatus tendon. As a result of the narrowing of the space between the acromion and the head of the humerus the tendons and bursa can become inflamed leading to bursitis and tendonitis.
When the client raises their arm to shoulder level at 90 degrees of flexion or abduction the space between the acromion and head of the humerus becomes very narrow. It is best to test both active and passive range of motion to determine limitations and pain level prior to performing the treatment. It is important to test for the rotator cuffs, full range of motion, while identifying the muscles that cause pain. In addition, it will be necessary to test the scapular range of motion as the scapular muscles will provide further information and treatment options.
Shoulder impingement is common among both amateur & professional athletes as well as week end warriors. In addition individuals with jobs that involve repetitive motions of the shoulder can be at risk. Massage therapists do not diagnose, yet the ROM assessment of the soft tissues of the body and treatment of the musculature to improve muscular function are well within the scope of practice of the massage therapist.
Many times clients will be referred to massage from physical Therapy, orthopedic, and rehabilitation centers. If the client presents with a non- operable shoulder impingement syndrome perform a ROM test to determine key musculature inflammation. To determine whether the client presents with supraspinatus or biceps brachii pain and inflammation use active range of motion and active assisted testing.
To determine if the supraspinatus is involved here is a series of active and active assisted ROM tests. First have the client take the arm of their painful shoulder and place their hand on their other shoulder. Once in this position have them raise the elbow of the painful shoulder up. When pain is experienced with this motion supraspinatus inflammation is indicated.
Next assist the client as they bring their arm out to the side and up to almost 90 degrees. Bring the forearm in so that the arm is flexed to 90 degrees and move the hand down by rotating the shoulder forward. Now from this position assist the client by bringing the hand & forearm inward toward the midline of the body. Have the client assist in this motion, pain may be immediately felt, make sure the client knows to communicate moderate to severe pain and stop motion at that point.
Always test both shoulders for comparison and record clients' responses within client files by maintaining daily client S.O.A.P. notes. Another active assisted range of motion test is to place one hand on top of the shoulder (to limit motion to 90 degrees) now assist the client as they raise their arm palm down from their side to 90 degrees of flexion. The next active assisted range of motion test has been shown to be accurate for determining shoulder impingement syndrome 97 to 98 percent of the time.
With the client lying on the table in the prone position with forearm palm up, have the client abduct the thumb outward while externally rotating the forearm as far as the can. Next assist the client by holding the elbow straight and moving the arm up above the head at the end range of motion move the arm in toward the clients' ear. Now with the arm next to the ear assist the client by supinating the forearm or medially rotating the forearm palm down. Pain in any of these tests would be felt at the articulation of the head of the humerus and the lateral end of the acromion process confirming supraspinatus tendonitis and shoulder impingement syndrome.
If the client does not present with significant pain or they indicate that these tests did not reproduce their pain, then use ROM to determine inflammation within the long head of the biceps brachii tendon. While the client is sitting or standing have the client turn their forearm palm up, while forming a fist, then have them flex as if doing a biceps curl placing the fist on the shoulder and continuing to bring the elbow up as far as the can. Pain with this motion indicates biceps tendonitis.
An active resisted range of motion test can also be utilized to confirm biceps brachii tendonitis. While the client is sitting or standing have the client flex the elbow to 90 degrees apply a downward force as they try to perform a biceps curl. Pain just below the medial edge of the acromion process would indicate biceps brachii tendonitis.
To treat biceps brachii tendonitis use cross fiber friction. First relax the belly of the biceps with compression. Then follow the belly up toward the long head and cross fiber friction the tendon as it passes up toward the bicipital groove of the humerus to the point of the acromion process. Take a moment at the end of the session to teach the client how to utilize cross fiber friction on this tendon as part of a home care plan.
When impingement syndrome has been indicated by ROM testing, it is often favorable to begin treatment with the larger musculature that produce movement of the shoulder joint and scapula, namely the latissimus dorsi, Trapezius, serratus anterior and pectoralis major. Like peeling the layers of an onion, move from superficial muscles to deep muscles as you warm and improve blood flow to the area. Treat the arm muscles such as biceps brachii, triceps brachii, coracobrachials, deltoid and do not forget the scapula moving chest muscle pectoralis minor. The client may indicate a change in pain threshold. Utilize joint mobilization along with traditional deep tissue technique.
Relaxing the deltoid and upper trapezius is necessary in order to have access to the supraspinatus tendon and belly. The goal is to cross fiber the supraspinatus tendon deep to middle deltoid and the belly of supraspinatus within the supraspinatus fossa and deep to upper trapezius. Once access and treatment of the supraspinatus has been accomplished remember to smooth out the shoulder with effleurage and petrissage paying attention to both shoulders and both sides of the body.
Many clients may be seeing a massage therapist as a part of a comprehensive care plan with other adjunct health care providers. Joint strengthening and mobilization is a vital process in maintaining a pain free lifestyle. As a part of a comprehensive care protocol, it may be beneficial to demonstrate simple strengthening moves to the client.
One effective strengthening mobilization move has been developed by Dr. Fishman. A New York Times article by Jane Brody describes Dr. Fishman's use of yoga in his practice to help his patients recover from shoulder pain. Follow the link to read more about Dr. Fishman's insights and to see an image of this amazing move that increases range of motion while strengthening the subscapularis.
Show your client how to use Dr. Fishman's triangle exercise by demonstrating the move. Clasp hands together and place against a wall with elbows abducted out to about 45 degrees. Place the head from the forehead to the crown on the wall. Take a lunge stance with the leg on the same side as shoulder pain forward and opposite leg back. Now have the client use both their legs and shoulder to push into the wall isometrically and hold for about 30 seconds. The head can be left relaxed or included with the forward isometric contraction, its best to repeat the move 3 to 5 times a day.
The following educational video from orthopod.com provides a detail animated review of the shoulder anatomy. Having a clear picture of anatomy can be useful for both the massage therapist and client. For more active and athletic clients take a look at the next video of a modified yoga headstand performed by Norman Popovsky from YogaNorman.com which can be suggested as a part of an active self-care plan.
Norman Popovsky of YogaNorman.com demonstrates a triangular forearm supported partial head stand to help with rotator cuff pain and increase range of motion within the shoulder joint. Get massage Smart extends their thanks to Norman Popovsky for providing a wonderful educational video. Norman also provides a presentations of Dr. Fishmans' triangular wall exercise on his bog slyoga.com.
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