Sore Shoulders – Treatment Guide
Treating Sore, Stiff and Frozen Shoulders
By Curt Redd, LMT, JFB Myofascial Release Specialist
I had a client a few years back, when I was still fairly new in the business, who would come in every week for a 90 minute massage. We would always spend some time on her chronically sore shoulder. But, being the lover of a challenge that I am, that shoulder became my favorite target. I believed that I should be able to “fix” it once and for all if I just did it right.
The problem was that it would change from week to week. One time it would be the rotators, the next time it was the teres, or scapula mobility. It didn’t take long to figure out that they were all the same thing, or at least parts of the same problem. Luckily, she was slender and flexible enough that I could easily find and access nearly all the parts of the shoulder girdle, including the subscapularis, and the first rib. Eventually I tried working all areas of the shoulder girdle in the same session, whether I thought they needed it or not. And, it worked!
Patience is Essential
Since that discovery, I have routinely had good success getting sore, tight and even frozen shoulders to release and remain virtually pain free. The key is to spend all the time it takes (which is often all the time available in any one 60 to 90 minute session) on that one shoulder until it is completely released.
Obviously, for one shoulder to take a whole therapy session, we are talking about more than traditional massage techniques. It is not enough to just run a few passes of the elbow or forearm over the sore muscles. Deep tissue or trigger point work is designed to release muscle knots. The problem is that this type of work doesn’t last. In my own experience when I did traditional deep tissue work, it might last about as long as it takes to walk out to the parking lot, if you are lucky.
The modality I am talking about is Myofascial Release (MFR). When I say that I treat with MFR, and I get the comment back, “Isn’t that really painful?”, then I know that we are not talking about the same thing. I don’t mean the old style MFR, nor do I mean Rolfing. Myofascial Release, as taught by John Barnes P.T., utilizes stretches and compressions applied with gentle pressure, which are held until the restriction releases. In the case of chronically frozen shoulders, MFR can be used to release scar tissue that has built up around the joint.
Start with the Trapezius
I like to start with the upper trapezius muscles and follow it up the neck to the mastoid process, doing a combination of compression (squeezing) and gentle stretch. Sometimes it helps to compress the shoulder up towards the head to shorten the trapezius before elongating them again into a stretch position. The idea with Myofascial Release is to come up against the barrier, or the edge of resistance, and then just wait for the release to begin, never forcing, but following three dimensionally as it begins to let go.
In that same area are some key muscles that might easily be overlooked; the subclavius, the coracobrachialis, and trapezius where it connects near the coracoid process and posterior to the clavicle. You need to get rather deep into that groove formed by the clavicle and the spine of the scapula at the top of the shoulder to release the trapezius. The coracobrachialis originates at the coracoid process and descends to attach at the medial humerus. The subclavius is inferior to the clavicle.
One common theory suggests that frozen shoulders are a result of pinched nerves at the occipital area, which limits the mobility of the scapula. It is always a good practice to release the neck muscles, particularly those connected to the occiput. This can be accomplished by supporting the head at the occiput with the fingers of both hands fully extended towards the ceiling. Once those muscles have released, it is possible to perform an occipital condyle release by lifting the 2nd and 3rd vertebrae with the ring fingers of both hands, while pulling down on the occipital ridge with the first two fingers.
Axilla (Underarm Area)
Have the client lie supine while holding the arm by the elbow. With the free hand, place the fingertips on the pectoralis minor, and span the thumb down to the subscapular muscle. Pull down on the arm while pressing up into these muscles and applying pressure through a grasping action with the fingers. Wait for the fascial release process to complete. Raise the arm up toward the head to test for the extent of the releases.
It may be helpful to extend the arm out at a 90 degree angle and apply traction while pressing down on the anterior surface of the shoulder joint with the base of the palm putting pressure on the pectoralis to release more of the deep joint fascial restrictions. This is also a good time to check for tension in the coracobrachialis, and the short head of the biceps.
Usually it will be necessary to free up and mobilize the scapula before the muscles in the lower axilla (parascapula) area can be easily accessed. This can be accomplished by elevating and tractioning the arm to create a stretch on the rhomboids, while slipping the free hand under the scapula such that the fingers go just beyond the medial border to apply pressure to the restricted fascial adhesions typically found there. A little higher towards the superior border will be the levator scapula, which are often very tense and tender.
Once the scapula is able to slide side to side freely, it is easier to work on the muscles that attach at the posterior portion of the shoulder girdle that are accessible only from underarm area, specifically, the subscapularis, teres minor, and the latisimus dorsi. Once again, the arm is tractioned out perpendicular to the body to expose the underside of the scapula. The fingers of the free hand can be used to apply pressure to all the adhesions from the acromium process down across the anterior surface of the scapulae to the serratus anterior. Take this opportunity to further mobilize the scapula by working the fingers under the medial and lateral lower edges with one hand, and the upper medial border with the other hand. Then gently pull it away from the rib cage and hold until the fascial restrictions are released.
The Rotator Cuff Muscles
The teres minor is an extremely important muscle to get to release as it is often tight and painful. By positioning their arm across the chest, the teres minor and the triceps can be released using either stretching or pressure.
From there, the remaining muscles along the rotator cuff are a natural progression. It is possible to grasp the anterior and posterior aspects of the humerus simultaneously applying pressure and waiting for the releases. As each fascial restriction softens, move along toward the top of the shoulder, applying firm but gentle pressure at each muscle in turn. If there is intense pain at any of these, it may be necessary to apply extra pressure to reset a herniated trigger point. This can be extremely painful, but seems to be a requirement at times to achieve lasting results. In such cases, it is also common that the muscle cords (strands of knotted muscles) or trigger point bands will trail down the arm from the head of the humerus . It all has to be released in order for it to last for any length of time.
It is also expedient to check for muscle cords or trigger point bands, running down the deltoids, triceps and biceps. Follow them as far as they go, even down to the elbow and beyond. They can be released with either MFR stretching or direct pressure.
As long as you are able to complete the release of the entire shoulder girdle complex as described above, you can expect the client/patient to have 90-100 % range of motion, with very minimal pain, immediately. Because the scapula is now mobilized and the restrictions are eliminated, the position of the shoulder and subsequent posture will be greatly improved. It is important to make the client aware of this new postural improvement so as to encourage them to maintain it, and not slip back into what will have become a (bad) habit. The really good news is that there is about an 80% chance that the problem will not reoccur any time soon. And if it does, it will be much easier and quicker to resolve in a follow up session.
Of course there is the very real possibility that you have just worked on what can only be considered a symptom of the real problem. Meaning, if you have not previously done work to align and level the hips, the potential root cause of the sore shoulder, then the condition will likely return. Look for a discussion on the hips in a future post. It is an integral part of the John F. Barnes, Myofascial Release Approach.
Fascial Research Congress
Recent findings by the First International Fascial Research Congress, held at Harvard Medical School in 2007, verifies what has been taught in John Barnes’ seminars for the last forty years:
The Piezoelectric Effect: It generally takes about four minutes of sustained moderate direct pressure, or stretching until the fascial tissues begin to loosen up. As the fascia ground substance “melts”, through phase change with heat and pressure due to the piezoelectric effect, the fascia elongates and opens up to allow reduced pressure on pain sensitive tissue.
Anti-Inflammatory benefits: Sustaining pressure at the fascial restriction for 3 minutes starts to stimulate interleukin production, a crystalline communication protein essential for healing. At 5 minutes of sustained pressure, interleukin levels double. The result? Free radicals associated with the inflammatory process are neutralized and blood cell production is stimulated. Until now, the only previously known non-chemical anti-inflammatory was soft laser treatment. Through science, we now know that we can elicit anti-inflammatory capabilities from within.
Water is Essential to Healthy Fascia. There is a lot of water surrounding the fascial fibers. This moisture is a vital lubricant in our body, maintaining smooth functioning. Within each muscle, every strand of muscle is encased in fascial tissue. The moist lubricant allows the muscle packets to glide smoothly past each other, as we move.
By Curt Redd, LMT, TheReleaseConnection.com, Pleasant Grove, UT, 480-540-2835
Shoulder Pain Treatment & Prevention: Rotator Cuff & Frozen Shoulder – Sock Doc
Fascial Research (Geheimnisvolle Faszien – German)
Fascia Video magnified 25 times
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Rotator Cuff Muscles