An Exploration of Complicated Shoulder Conditions

Addressing shoulder conditions like “frozen shoulder” may need to begin with assessing and addressing other areas of the body.

The kinetic chain is an engineering concept used to describe human movement.

It was proposed that rigid, overlapping segments were connected via joints and this created a system whereby movement at one joint produced or affected movement at another joint in the kinetic link.

The major kinetic chain checkpoints, from the bottom up (using colors in Figure 1), are the feet and ankles (purple), the knees (yellow), the hip joints (red), the SI joints (green), the thoracolumbar spine (blue) and the cervical spine (white).

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
 Figure 1: The major kinetic chain checkpoints, from the bottom up, are the feet and ankles (purple), the knees (yellow), the hip joints (red), the SI joints (green), thoracolumbar spine (blue) and the cervical spine (white). These are the checkpoints that can contribute to compensations throughout the body, including complicated neck and shoulder pain.
Courtesy of James Waslaski

These are the checkpoints that can contribute to compensations throughout the body, including complicated neck and shoulder pain. 

Open and Closed Kinetic Chains

There are two kinds of kinetic chain movements, or exercises: open and closed.

In open kinetic chain exercises, the segment furthest from the body—known as the distal aspect, usually the hand or foot—is free and not fixed to an object. In closed kinetic chain exercise, it is fixed or stationary.

So, when we treat a client’s ankle while on the massage table (open kinetic chain), the function of the foot can change greatly when the client gets off the table and puts their body weight into the foot and ankle (closed kinetic chain).

In the closed kinetic chain (weight-bearing ankle), joint interplay can ascend throughout the body, causing knee pain, low-back and hip pain, spine pain, shoulder pain and neck pain.

I am certified as a personal trainer with the National Academy of Sports Medicine (NASM). That training taught me how to evaluate the kinetic chain checkpoints using the following assessment to assure my clients are working out without compensation patterns that too often lead to musculoskeletal injuries. 

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 2: The feet should point forward. Through positional release of the articular ligaments, followed by gentle traction, therapists can easily improve joint function in the foot and ankle.
Courtesy of James Waslaski

1. Foot Ankle Complex: The feet should be lined up straight ahead. Check for supination or pronation patterns of the foot and compensatory tibial torsion patterns into the knee. Through positional release of the articular ligaments, followed by gentle traction, therapists can easily improve joint function of tibia, talus and calcaneus to correct significant joint problems in the foot and ankle.

2. Knees: The knees should also point forward. Knock-kneed appearance is where the knees converge toward each other and are not aligned over the middle of the foot. This is common during squats or lunges and causes lateral meniscus compression, fibular nerve compression and medial collateral ligament eccentric load. This condition can be caused from overpronation of the feet. So, by correcting overpronation of the feet we can resolve a lot of knee pain. 

3. Hip/Pelvis/Lower Back: It is very common for individuals to arch their back, even just in normal standing position. The lumbo-pelvic-hip postural distortion is commonly characterized by short, tight hip flexors and erector spinae, and weak, inhibited gluteus maximus and transverse abdominus. This can create an anterior pelvic tilt and, accompanied by an overpronated foot, can lead to an ilio-sacral torsion that can unlevel the sacral base, causing disc-related nerve pain in the low back. 

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 3: The knees should also point forward. Knock-kneed appearance is where the knees converge toward each other and they are not aligned over the middle of the foot.
Courtesy of James Waslaski 

4. Shoulders: The shoulders should be relaxed and even. If the shoulders are rounded, therapists should look at tight pecs and subscapularis and weak rhomboids and posterior rotator cuff muscles. (This is part of Vladimir Janda, MD’s “upper crossed syndrome” theory.)

5. Head/Neck: The head should stay in line with the spine. Often you can see a forward neck posture from a side view of the head and neck. For every inch the head is forward on the neck, it weighs 10 extra pounds. This can produce descending nerve pain into the shoulder and arms. 

If all kinetic chain checkpoints are lined up, clients will have less compensatory joint pain and can properly perform movements and do exercises without resulting in pain or injuries. 

A Case of “Frozen Shoulder”

In October 2019 I was flown to Kuwait, based on a recommendation of a prominent family’s physiotherapist and orthopedic surgeon, to treat a woman who had been diagnosed, more than a decade previously, with a frozen shoulder resulting from a torn supraspinatus and torn bicipital tendon.

The shoulder work alone was not effective until I assessed and treated the right overpronated foot. I then treated the ascending medial rotation of the tibia and femur, and the ascending ilio-sacral torsion patterns. This helped correct the roto-scoliosis of the lumbar spine and compensatory scoliosis of the thoracic spine. That helped level the shoulders and reduced the forward-neck posture and the compensatory O/A/A joint compression.

I used Myoskeletal Alignment techniques that I had learned over the past 12 years from Erik Dalton, PhD, to correct the closed kinetic chain ascending syndrome problems prior to treating her chief complaint—frozen shoulder.

Fortunately, I had just read a paper written by anatomist John Sharkey, MSc, from Dublin, Ireland, claiming that most frozen shoulders were actually problems with scars and secondary muscle guarding. (Meaning that many of these clients had been misdiagnosed by their physicians.)

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 4: For every inch the head is forward on the neck, it weighs 10 extra pounds. This can produce descending nerve pain into the shoulder and arms.
Courtesy of Erik Dalton, PhD

Frozen shoulder is the term for the painful condition referred to as adhesive capsulitis. Pain is often reported to be worse at night and is aggravated by sleeping on the affected shoulder, often leading to the person waking up several times during the night. The so-called adhesive capsulitis tends to afflict individuals aged 40 and over and is more predominant in diabetics and people who have suffered a stroke, thyroid disease, recent surgery or Parkinson’s disease. 

Adhesive capsulitis infers that the joint capsule of the shoulder has adhesions and inflammation, thereby limiting the motion available at the shoulder or glenohumeral joint. While this condition is common, its underlying origin is not well understood. This condition is more common in females than in males. The nondominant shoulder is more affected than the dominant shoulder. 

Some characteristics of this condition, according to Sharkey, include:

• Frozen shoulder is the lay term for the painful condition referred to as adhesive capsulitis.

• The results of frozen shoulder diagnosis call for a larger investigation. 

• As a clinical anatomist, Sharkey has had a special interest in the topic of frozen shoulder for over three decades. 

• Underlying origin is not well understood. 

• Sharkey rarely found a truly adhered capsulitis on cadavers that were identified as having adhesive capsulitis when they were alive. So, many people are diagnosed with a specific pathology that they simply don’t have.

• Motion restriction is usually a result of neuromuscular “splinting” resulting in hypersensitivity (i.e., central sensitization) in pain on attempted movement. 

• According to researchers Alban Latremoliere and Clifford J. Woolf, “Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by an increase in membrane excitability and synaptic efficacy as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury.”

• So, a treatment plan must take into account that the true source of pain and limited range of motion is so often due to a protective or guarding increase in contractile tone along with visible or non-visible scars.

A Misdiagnosis Epidemic?

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
 Figure 5: When one area of the body is tight it can affect other areas, causing misalignment and pronation, as examples.
Courtesy of Erik Dalton, PhD

I do not think we should use the generic term frozen shoulder as a diagnosis. There is no thermodynamic aspect in this condition. Also, in my over 30 years in clinical practice, my specialty has been successfully treating complicated shoulder conditions.

Many of those clients were diagnosed by their physician as having a frozen shoulder, but as stated by Sharkey, many of those clients may have been misdiagnosed. 

My success in treating those clients involved a lot of techniques including positional release, strain-counterstrain, gentle rocking to reduce secondary muscle guarding, and precise capsule work. This was ongoing while releasing and stretching tight facilitated muscle groups, and relaxing, activating and strengthening weak, inhibited muscle groups around the shoulder.

I have also had great success with clavicular and rib work to decompress nerves, and by using the Dolphin MPS (micro-current) to address associated scar tissue.

Personally, I have found that if a client strains muscle groups in the shoulder area, the clinical assessment often mimics those with adhesive capsulitis, including hard or “bone-on-bone” end feels. So, a lot of detailed assessment and clinical reasoning is needed to sort out the multiple causes of shoulder pain and restricted shoulder movement. 

Postural Awareness

According to an article by my friend and colleague, Erik Dalton, “Ideal shoulder girdle balance requires that some muscles act as stabilizers and others as mobilizers, depending on joint position and movement required for the particular task. A perfect balance of mobilizers and stabilizers results in optimal alignment, or joint centration. Think of joint centration like the wheel on a car.

“If the center of rotation is aligned with the center of the hub, it will deliver the most efficient performance,” Dalton added. “Conversely, when this neutral position becomes misaligned, the wheel spins incorrectly and can result in future mechanical problems. We commonly see this in upper crossed syndrome postures where slumped shoulders and a head-forward carriage lead to scapular winging and decentration of the glenohumeral joint.

“Although researchers have not been able to correlate rotator cuff impingement with suboptimal postures such as upper crossed syndrome, my experience is it plays a major role in many rotator cuff tendinopathies—particularly in those who perform overhead activities.”

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 6: Flexibility can usually be restored to the anterior and middle scalene muscles by using the first and second rib to apply a stretch. Courtesy of James Waslaski

Like Dalton, I often teach this postural awareness exercise in my classes to demonstrate how many of the painful shoulder conditions seen in clinic result from rounded shoulders and a forward head posture.

You can experiment with this theory by standing in your best upright posture with shoulders back and chin tucked. Then bilaterally abduct both arms at the same time towards your head keeping your chin tucked. The range of motion should be between 160 and 180 degrees, with a soft end feel. Now bring your head forward and round your shoulders.

As you again abduct the arms out to your side, you will find you lose as much as 50% of available range of motion due to the head-forward posture position. This, of course, creates abnormal balance and function of the glenohumeral joint and can be a contributing factor to conditions like supraspinatus impingement, thoracic outlet syndrome, and bicipital tendinosis.

Even if we treat the resulting supraspinatus tendinosis and bicipital tendinosis, the postural patterns will make those conditions chronic if we fail to address the forward-head and rounded-shoulder pattern.

So now, let’s talk a little more in depth about some of these conditions that may arise from suboptimal posture conditions.

Thoracic Outlet Syndrome (TOS)

Thoracic outlet syndrome typically begins as a nerve entrapment problem resulting from weak posture that allows spinal nerves (radial, median and ulnar) to become compressed under several structures as they make their way through the chest wall and down into the arms.

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 7: The therapist can release any hypertonicity in the client’s upper trapezius and middle deltoid muscles to help decompress the humeral head from the acromion. This will help reduce compression of the supraspinatus and sub-acromial bursa.
Courtesy of James Waslaski

One of the first places that clients typically experience nerve entrapment is between fibrotic fibers of the anterior and middle scalene muscles. Fortunately, flexibility can usually be restored to these short-lever cervical muscles by using the first and second rib to apply as stretch.

As the client deeply exhales, the therapist slowly side-bends the client’s head to the contralateral side while his fingers pin the ribs. Simply moving the head without anchoring the ribs will not adequately stretch the anterior and middle scalene muscles and free the underlying nerves.

Once that entrapment site has been addressed, the therapist then needs to release any hypertonicity in the client’s upper trapezius and middle deltoid muscles to help decompress the humeral head from the acromion. This will help reduce compression of the supraspinatus and sub-acromial bursa.

Relieving compression of the humeral head in the glenoid fossa can prevent and help rehabilitate conditions like subacromial bursitis, supraspinatus tendinosis and bicipital tendinosis. Additionally, it may make it easier to stretch the pectoralis minor muscle without impinging the supraspinatus tendon in the process. The goal of this routine is to try and increase subacromial space and aid in treating possible strain patterns in the supraspinatus tendon.

Figure 8 shows some of the places where the brachial plexus can become entrapped in cases of thoracic outlet syndrome. Notice how the anterior and middle scalene muscles wrap around the brachial plexus of spinal nerves. You can see how techniques designed to help decompress the glenohumeral joint can reduce compression on all structures located between the acromion and the humeral head, and how a drooping clavicle may also contribute to thoracic outlet problems.

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 8: Some of the places where the brachial plexus can become entrapped in cases of thoracic outlet syndrome. Courtesy of James Waslaski

Of course, most therapists are aware of how tight pectoralis minor muscles can also contribute to thoracic outlet syndrome and possible rotator cuff problems. Therapists should always evaluate for strain in all four rotator cuff muscles as well as pectorals minor to facilitate better balance of the shoulder girdle mobilizers and stabilizers. 

As stated above, shoulder-girdle balance requires that some shoulder muscles act as stabilizers and others as mobilizers, depending on joint position and the movement required for that particular task. Releasing and stretching tight shoulder girdle soft tissues, and activating and strengthening weak shoulder stabilizers can often restore optimal shoulder function.

According to Vladimir Janda, MD’s Upper Crossed Syndrome theory, this muscle imbalance condition is often seen: Tight upper trapezius, levator scapula, pectoralis major, and pectoralis minor, accompanied by weak middle and lower trapezius and weak infraspinatus and teres minor. 

Earlier in this article, we talked about a paper written by anatomist John Sharkey, MSC, from Dublin, Ireland, claiming that most frozen shoulders were actually problems with scars and secondary muscle guarding. (Meaning that many of these clients had been misdiagnosed by their physicians.)

This study stated that frozen shoulder is the term for the painful condition referred to as adhesive capsulitis. Pain is often reported to be worse at night, and is aggravated by sleeping on the affected shoulder often leading to the person waking up several times at night.

The so-called adhesive capsulitis tends to afflict individuals who are aged 40 and over and is more predominant in diabetics and people who have suffered a stroke, thyroid disease, recent surgery or Parkinson’s disease.

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions
Figure 9: Frozen shoulder is the common term for the painful condition of adhesive capsulitis. Courtesy of James Waslaski

Adhesive capsulitis infers that the joint capsule of the shoulder has adhesions and inflammation thereby limiting the motion available at the shoulder at the glenohumeral joint. While this condition is common, it’s underlying origin is not well understood.

This condition is more common in in females than in males. The non-dominant shoulder is more affected than the dominant shoulder. Please review part one of this article to review his findings.

The most important part of his research is that Sharkey rarely found a truly adhered joint capsule on his cadaver studies that were identified as having adhesive capsulitis while they were alive. So, that leads us to believe that many clients and patients are diagnosed with a specific pathology they simply don’t have.

Motion restriction is usually a result of neuromuscular splinting, resulting in hypersensitivity (i.e. central sensitization) in pain on attempted movement.

So a treatment plan must take into account that the true source of pain and limited range of motion is so often due to a protective or guarding increase in contractile tone along with visible or non-visible scars.

As a result of these findings, I think we should abandon the generic term of frozen shoulder as a diagnosis.  There is no thermo-dynamic aspect in this condition. Also, in over 30 years in clinical practice, my specialty has been successfully treating complicated shoulder conditions and many of those clients had been diagnosed as having a frozen shoulder. But, but as stated in Sharkey’s paper, many of those clients may have been misdiagnosed.

The success in treating clients suffering painful or restricted glenohumeral joints is dependent on performing a detailed orthopedic assessment and by using good clinical reasoning skills. 

Often the underlying source of motion restrictions can result from conditions like a supraspinatus strain accompanied by bicipital tendinosis. Then when you add in motion restriction resulting from neuromuscular “splinting” and central sensitization you find that a lot of secondary muscle guarding arises from an unconscious fear of more pain.

What we experience when assessing these people is often a bone-on-bone-like end-feel, which is very similar to the hard end-feel found in true adhesive capsulitis conditions.

Effective Treatment

Treatment must include techniques such as positional release, strain-counter-strain, gentle rocking maneuvers to reduce secondary muscle guarding, and precise capsular work. And we must also address the scar tissue and inflammation that is commonly present. Of course, treatment should always stay pain-free, to avoid up-regulating sympathetic stress and triggering additional secondary muscle guarding.

I have also had great success with clavicular and rib work to decompress nerves, using the Dolphin MPS (micro-current) to treat any associated scar tissue, and CryoDerm occlusion strapping to reduce inflammation and block the gatekeeper of pain. The addition of these adjunctive therapies greatly enhances client outcomes.

Every single technique throughout the treatment must start and finish with assessment to assure you are using the correct next techniques. The evaluation process is ongoing while releasing and stretching tight facilitated muscle groups, and relaxing, activating, and strengthening weak, inhibited muscle groups around the shoulder.

About the Author

Complicated, Conditions, Exploration, Shoulder ⋆ An Exploration of Complicated Shoulder Conditions

James Waslaski integrates 30-plus years of expertise in manual therapy to teach over 45 live seminars per year all over the world. He is a published author and lecturer, teaching health care professionals how to integrate their techniques to increase client outcomes. Waslaski received the FSMTA International Achievement Award in 1997 and was inducted into the Massage Therapy Hall of Fame in 2008. He is also a MASSAGE Magazine All-Star (massagemag.com/all-stars). Based on the complicated frozen shoulder case study in Dubai, and the information in this two-part article, in December 2019 he produced a new DVD, seminar and Zoom Class on Kinetic Chain Patterns and MPS Scar Release Therapy for Complicated Shoulder  Conditions.

References

• Kinetic Chain definition: Physiopedia.

• Fascia & Fitness Article: Response from Clinical Anatomist (BACA) John Sharkey; article on frozen shoulder following Anesthesia (September 2, 2018).

• National Academy of Sports Medicine, Optimum Performance Training for The Fitness Professional, copyright 2002.

• Images purchased for commercial use from Shutterstock.

• Images: Erik Dalton Myoskeletal Alignment.

“Kinetic Chain Patterns and MPS Scar Release Therapy For Complicated Shoulder Conditions” DVD; Orthopedic Assessment for Massage Therapists, Whitney Lowe.

Myoskeletal Alignment Techniques, Erik Dalton.

“Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity,” Latremoliere, Alban; Woolf, Clifford J., Journal of Pain, 2009.

“Integrated Manual Therapy & Orthopedic Massage for Complicated Shoulder Conditions” DVD, James Waslaski.

“Assessment, Treatment & Home Retraining Exercises for Multiple Nerve Compression Patterns” DVD, (upper body), James Waslaski.


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