Have you been told that you have shoulder impingement, tendonitis or bursitis or simply a reduced range of motion at the shoulder joint? More importantly, have you gone to physical therapy for weeks or months without any significant reduction in pain? Have you had one or more injections that helped for a while, but only resulted in the pain returning. Are you contemplating surgery and wondering if there is another way to improve your situation without surgery.
Before we move on, it is vital to communicate that physical therapy can be and is effective for many individuals suffering from shoulder pain due to bursitis, tendonitis or shoulder impingement. This article is intended to offer information on how massage therapy can assist within an overall treatment plan for individuals suffering from a shoulder impingement syndrome, AC arthrosis, bursitis or tendonitis of the shoulder joint and frozen shoulder. Not everyone is a good candidate for rotator cuff surgery and many that have had rotator cuff surgery are still finding themselves in pain and looking for relief.
Therefore, if you are in pain and looking for relief, please take the time to read through this entire article. Each individual is unique even if there are similarities within pain and or reduced range of motion. Improvement is a combined effort of both your caregivers and yourself. Research studies have shown that injections only have moderate success for a few by relieving pain, allowing for our natural inflammatory response to resolve the issue. For a vast majority it provides temporary relief but does not resolve the pain symptoms or reduced motion.
Surgery has been shown to be a viable option for individuals with a significant tear or tears within the rotator cuff. The rotator cuff is comprised of four muscles that attach to the head of the humerus. They are supraspinatus, infraspinatus, teres minor and subscapularis. An avulsion fracture of the head of the humerus is often involved in rotator cuff injury. An avulsion fracture happens when a tendon or part of a tendon pulls a portion of bone tissue away from the rest of the bone structure. In this case a small section of bone tissue will have pulled away from the head of the humerus allowing for the sharp edges of bone to cause injury and inflammation of the soft tissues (bursa, tendon, or ligament).
Not all rotator cuff injury leads to surgery. Most impingement syndromes are due to irritation of the supraspinatus muscle tendon (tendonitis) and/or inflammation of the bursa (bursitis). If you do not have significant tearing or an avulsion fracture then it is unlikely that surgery will be an advantage to you.
When the head of the humerus the upper arm bone is pulled up tightly against the shoulder blade or acromion process of the scapula inflammation of the bursa and tendons will result (see the above image). What kind of activities are most likely the causes? Repetitive overhead activities such as spending a day painting a room, moving things into or out of storage where placement of items is on a shelf over the head, daily work activities which require one to use their arms over their head. Even sports activities such as swimming, throwing a baseball, basketball, tennis, golf, and any racket sport or activity that requires the shoulder and arm to reach over the head can lead to impingement.
More subtle activities may also be involved such as sleeping on the same shoulder night after night or sleeping with one or both arms over the head. If you drive a car frequently the unconscious act of placing your right arm over the passenger's seat can lead to irritation of the shoulder bursa and supraspinatus tendon. Someone who is responsible for cooking or putting away dishes in a residential kitchen where most of the storage is in overhead cabinets is at risk of developing shoulder impingement. Lifting a heavy object over head on only one occasion can also lead to shoulder impingement, as well as pain and inflammation.
It is important to note that someone who simple lifts moderate to heavy objects on a regular daily basis, placing strain on the shoulder girdle may also experience capsulitis, bursitis, tendonitis and shoulder impingement syndrome. It is often reported that maturing adults tend to experience AC arthrosis which means a condition of the acromial clavicular space. The collar bone (clavicle) is attached to the acromion process of the shoulder blade by strong ligaments. The space between these bones and the head or ball of the upper arm bone known as the humerus is very small (see above image).
When the muscles that move the arm and shoulder blade become stressed due to overloading activity or repetitive activity pain and inflammation of the bursa, tendons and even ligaments can result. So, how can massage therapy help individuals with shoulder impingement pain syndrome? The answer lies within the tissues involved.
Massage Therapy treats the soft tissues of the body. The shoulder girdle is a unique structure within the anatomy of the human form. It is comprised of three bones anchored to the thorax or rib cage. These bones are the collar bone or clavicle, the upper arm bone or humerus and the shoulder blade or scapula. (see the image to the right, the upper arm bone is removed) Looking at the back of the body you see the rib cage, the shoulder blade resting against it and the collar bone passing from the shoulder blade to the front of the rib cage.
Joints are formed by two or more bones, ligaments and cartilage that allow for a motion to take place thru the movements produced by muscles that cross over that joint while attaching to bones on either side of said joint. The scapula attaches to the thorax through its union with the clavicle at the acromioclavicular joint and by muscles that anchor it to the rib cage. What? Take a moment and touch one of your collar bones. Now move your shoulder up and down, slide your fingers to your breast bone or sternum then back toward the shoulder joint. Hang out at the shoulder joint for a moment and feel the hard bone at the top of your shoulder and then your collar bone. This is the union between the shoulder blade (scapula) and collar bone (clavicle), which can clearly be seen in the image to the right and is called the acromioclavicular joint.
This joint is comprised of two bones, shoulder blade and collar bone held together by ligaments. The shoulder blade is uniquely shaped, ligaments also attach from one part of the shoulder blade to another part of the shoulder blade. This is a bit unusual because ligaments usually anchor bone to bone at a moveable joint. But if you take a closer look at the 1st image at the top of the page you can clearly see the ligament which passes from the acromion process of the scapula to the finger like projection call the coracoid process of the scapula which is the coracoacromial ligament.
The shoulder blade called the scapula is known as an irregular bone due to its unusual shape. The coracoacromial ligament forms an arch with the acromion (the flat part of the shoulder blade at the very top of the shoulder) (see image). This is where the bursa sits and where the supraspinatus tendon space can be severely reduced.
The scapula bone commonly referred to as the shoulder blade is anchored to the rib cage or the thorax by strong musculature. The stability of the shoulder joint greatly depends on this diverse musculature that provides and enormous range of motion within the shoulder complex.
The irregular features of the scapula bone (shoulder blade) include variations in the shape of the acromion process. The process can have a flat undersurface, arched undersurface (causing some narrowing of tendon space) or hooked undersurface (causing further structural narrowing).
The shoulder joint is a ball and socket joint with the head of the humerus as the ball and the very shallow depression on the irregular shoulder blade being the socket. Unlike the deep socket of the hip joint the glenoid fossa of the scapula provides as very shallow socket and little stability to the shoulder joint. The coracoacromial ligament and the acromion of the shoulder blade deepen the socket in which the ball or head of the upper arm bone sits.
Shoulder impingement is either primarily resulting from structural or bone architectural differentiation from individual to individual. These structural changes may also include osteoarthritic changes during the life process. Secondary shoulder impingement occurs without any structural changes to the shoulder complex.
Get Massage Smart thanks Dr. Randale Sechrest and OrthopodTV for their educational video presentation.
Secondary shoulder impingement is predominately a soft tissue inflammatory pain syndrome and orthopedic or medical massage is well suited as a treatment option. The shoulder joint offers the greatest range of motion of any joint in the body. The structural tradeoff for this increased range of motion is that the glenohumeral shoulder joint is the most vulnerable joint to injury. In addition to a highly recommended professional therapeutic massage there are self-care techniques that can lead to shoulder pain relief.
Shoulder injury is the third most frequently experienced musculoskeletal disorder following low back pain syndrome and cervical pain. Common symptoms can include pain that can extend from the top of the shoulder down to the elbow, muscle pain or weakness when attempting to reach for or lift an object, pain reaching for a seat belt or the back of your head with a brush and pain lying on the shoulder at night. Shoulder impingement resulting in bursitis or tendonitis is a challenging problem to treat as the affected tissue lies underneath a bony process.
Orthopedic massage, Medical massage or myofascial release that uses a systemic assessment to determine the functional shorted musculature that opposes the functionally stretched musculature within the shoulder complex to develop a treatment plan, provides an active and effective approach to shoulder impingement syndrome. It is valuable to find a massage therapist that is specifically trained in assessment and some form of integrated structural therapy such as A.I.S. (Active Isolated Stretching), A.R.T. (Active Release Technique), O.M. (Orthopedic Massage), Medical Massage, Myofascial Release or some similar bodywork modality. Today many Physical Therapists and Physiotherapists are trained in these and similar soft tissue techniques.
The more integrated the massage therapist's skill set the higher efficiency, they will have at resolving shoulder impingement pain syndrome. The more effective they will be at providing you a referral to an orthopedic or physical therapist if your particular issue is best resolved with adjunct medical consultations. Many times PT offices and medical offices will refer their patients to clinical massage therapists as a part of their complete treatment protocol.
The most important point to take away from this article is that soft treatment techniques can help many who are suffering from chronic shoulder pain and reduced range of motion within the shoulder complex. The actual shoulder joint itself the glenohumeral joint is capable of flexion to 90 degrees and abduction to just under 90 degrees in most individuals. The massive trunk and scapular musculature control motion of the arm beyond 90 degrees of flexion and abduction. Take action massage therapy does not require a prescription and 1 hour to 1 1/2 hours of treatment can be very affordable.
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