Don't Shoulder the Pain


The shoulder is an interlocking system of bones, joints, cartilage, tendons and fluid that allows us to lift anything from a pen to a child. But unfortunately, this complicated system is also vulnerable to injury, overwork or even just age. “The story of the shoulder can be complicated,” says James Waslaski, LMT, CPT, who developed a 12-step protocol for treating shoulder conditions. However, new research is pointing to ways that massage therapy can help manage shoulder issues.

Shoulder pain is a common complaint in primary care practices, according to a 2011 study published in BMC Musculoskeletal Disorders,with the most commonly reported conditions being rotator cuff disorders and acromioclavicular (AC) joint and glenohumeral (GH) joint disorders. Other conditions include “frozen shoulder” (adhesive capsulitis), thoracic outlet syndrome and muscle-tendon strains.

“In many of these cases, the shoulder bone has rolled up on the edge of the socket,” says George Russell, DC, a bodyworker and chiropractor who practices in New York City. He describes the shoulder as a ball-and-socket structure: the head of the humerus bone, or the upper arm, is the “ball” that fits into the glenoid fossa, the “socket” that is part of the scapula, or shoulder blade. According to Russell, it’s when the ball rolls to the edge of the socket and stays there that problems begin. So, when he works with a client, he helps that ball glide back into the socket where it belongs.

“That’s what joints love,” Russell says. “When cartilage touches cartilage, the joint is happy.”

Causes of Shoulder Issues

The “ball and socket” is formally known as the GH joint and is one of the two joints that comprise the shoulder. The other is the AC joint, located where the collarbone (clavicle) and the top part of the scapula meet. Arthritis in the AC joint is actually more common than arthritis in the GH joint.2 Articular cartilage covers both surfaces to allow them to move smoothly.

The rotator cuff is made of tendons that connect four muscles—the supraspinatus, the infraspinatus, the teres minor and the subscapularis3—to the shoulder bones, keeping the GH joint in place. When one or more of the rotator cuff tendons are injured, the bursa, a fluid-filled sac between the rotator cuff and the acromion that lubricates the joint, can also become inflamed.4 There are two primary kinds of rotator cuff tears: a partial tear that damages the tendon, and a full-thickness tear in which a tendon is fully separated from the bone.

Some shoulder conditions are caused by trauma like an accident or fall, or by lifting something too heavy. Others are related to the vicissitudes of age: a 2012 study in the Clinical Journal of Sports Medicine5 identified age-related degeneration as a factor in rotator cuff disease, with more than half of individuals in their 80s experiencing a rotator cuff tear, while osteoarthritis, or degenerative joint disease, typically occurs in people 50 years and older.6 Smoking, genetics and high cholesterol were also identified as risk factors. Interestingly, a 2014 study published in Muscles Ligaments Tendons Journal7 found a relationship between thyroid disease and non traumatic cuff tears.

Adhesive capsulitis is more common in people older than 40, especially women, and studies have confirmed it as a common problem after breast cancer treatment.8 Immobility after a broken arm, stroke or surgery also increases the risk of developing adhesive capsulitis.9 Waslaski says one of his trademarks has become releasing various stages of adhesions in the joint capsules. “We do a lot of work for that particular condition,” in which myofascial adhesions can form deep in and around the joint capsule.

Shoulder injuries are also common, as might be expected, in athletes. Gisele Guirand-Griffin, LMT, who works with the Oakland Raiders, says “there are a lot of AC joint strains, seen mostly with running backs.” She says upper trapezius deltoid strain is another frequent injury, particularly for quarterbacks.

Standard medical treatment includes physical therapy, medications such as anti-inflammatories and surgery. A 2016 study in Muscles Ligaments Tendons Journal10 found that complete rotator cuff tears can be effectively treated with injections and exercise, and that transition to surgery is likely indicated when a patient demonstrates increased weakness and loss of function not recoverable through physiotherapy. While shoulder replacement surgery is less common than knee or hip replacement surgery,11 people may undergo it for osteoarthritis and post-traumatic arthritis.

Guirand-Griffin tells the story of one client who had a bilateral shoulder replacement. “My job was to relax the surrounding musculature near the scapula to ease her pain before she went into surgery,” she says. After a client has surgery, she follows a post-surgical protocol to make sure muscles “are functioning and stable, and to get their flexibility back.”

While arthritis is a degenerative disease, Russell feels massage therapists can still help. “The perceived wisdom is that cartilage can’t repair itself,” he says. “But it is fed by the synovial fluid in the joint, so if you can move that bone and ‘stir’ that fluid, you feed the cartilage. It is like a sponge—compressing and releasing it allows it to get fresh blood and nutrients.”

What the Research Says

Several recent studies have bolstered the case for the effectiveness of massage therapy for shoulder issues, although, as Waslaski points out, more and larger studies are still needed. “The research is still lacking,” he says. That said, recent results are promising.

A 2015 systematic review12 published in the Journal of Physiotherapy of 26 randomized clinical trials that involved 2,565 participants found that massage as a stand-alone treatment reduces pain and improves function compared to no treatment in some musculoskeletal conditions, including shoulder pain. Two 2017 metaanalyses published in the Journal of Physical Therapy Science13 found that, respectively, massage therapy had a “significant effect” in reducing shoulder pain for short-term and long-term efficacy, and that it is effective in improving shoulder flexion and abduction.

Even more recent studies have provided evidence on the effectiveness of specific techniques. A 2019 study in Physiotherapy Research International14 compared specific interventions in 60 patients (20 per group) as follows: 1) passive mobilization for the upper thoracic spine; 2) massage, passive mobilization and stretching for the posterior shoulder; and 3) active control intervention in a homogeneous group with extrinsic subacromial shoulder impingement (SSI). The researchers concluded that “manual therapy treatment that addresses these extrinsic factors, of thoracic spine or posterior tightness, decreases the signs and symptoms of SSI.”

A 2018 study in International Journal of Therapeutic Massage & Bodywork15 found that myofascial massage for chronic pain and decreased upper-extremity mobility after breast cancer surgery was a promising treatment, with all 21 participants reporting receiving massage treatments as a “positive experience.”

Where to Begin

Three of the first four steps of Waslaski’s 12-step protocol for treating shoulder injuries include an assessment of active range of motion, passive range of motion and resisted range of motion. “By evaluating the shoulder, you can develop a game plan,” he says. “You can do certain tests to assess for nerve entrapment, ligament pain or muscle strain. If you start to stretch muscles without assessment, you can compromise injured muscles.”

When a client comes in with a painful injury, Waslaski explains, their muscles will actually “guard” the area. “The body compensates to protect against additional injuries,” he explains. So it’s important to “find the position of comfort, through positional release and rocking, to reduce the unconscious fear of more pain” for the client. “I wait for the client to take a deep breath and to relax.”

Waslaski uses a cryodermic pain reliever before he begins work. “It shuts down the pain associated with nerve entrapments or injuries associated with particular muscles,” he says. He also uses a myofascial ointment that “hooks” tissue, as too much glide doesn’t allow him to grip connective tissue effectively.

“You have to be consciously aware of a client’s pain level and what you are doing,” says Guirand-Griffin, who will switch up techniques depending on her client’s comfort level. “If they say, ‘I can tolerate it,’ that’s not what you want to do. You may have to switch from trigger point to myofascial release or passive movement stretches to alleviate whatever is causing the pain.”

“If my clients are not getting better in a couple of sessions, I refer out to see what I’m missing,” Wasklaski says. Referrals may include an orthopedic specialist for an MRI. “If an orthopedist repairs a labrum tear, then I can do the rehab.” He also recommends that when possible, massage therapists get their license as a personal trainer, as exercise is essential to rehab. “All the bodywork in the world may not help clients if they won’t do their exercises,” he says.

Moving Quickly

When it comes to soft-tissue injuries, massage therapists stress that speed is of the essence. “When soft tissue tears,” says Waslaski, “the sooner we can mobilize it without creating more pain, the more functional the scar tissue will be.” He points to the research of Susan L. Chapelle, who has co-authored studies in PLoS One16 and the Journal of Bodywork and Movement Therapies17 on treating adhesions with massage therapy. “Scar formation follows movement,” he says, “so early intervention with early movement can be advantageous.”

Guirand-Griffin emphasizes the importance of quick treatment to all of her clients. “If you leave the injury stagnant, you will get more soft-tissue adherence. You need to get to it while it’s still pliable, especially the shoulder, because that can really inhibit the range of movement.” She says her clients who are pro athletes get treated ASAP, but her regular clients need to recognize the benefits of timely treatment as well. “The longer they wait, the longer it will take to rehab. Speed is extremely important not only for athletes but everyday clients, as well. You need your arms for everything.”


When the Therapist Needs Therapy

James Waslaski recalls the time he tore his supraspinatus tendon in a major crash on his mountain bike. “The next morning, I couldn’t raise my arm—I couldn’t brush my teeth,” he recalls. “I knew immobilizing and icing my shoulder would worsen my early onset adhesive capsulitis.” So, he had his teaching assistant apply CryoDerm Occlusion Strapping to block the pain and do positional release of his shoulder to break the pain spasm cycle in the acute stage of the injury. Thanks to this quick action, “I was able to have a therapist move the acromion process off the tear by stretching the pectoralis minor, relaxing the middle deltoid and decompressing the humoral head," he says. That way, scar tissue could be realigned by gently abducting my shoulder only 48 hours later standing in a pool.”

Deborah Rininger, LMT, who practices in Mishiwaka, Indiana, injured her shoulder in a vehicle accident. “After nine months of tests, physical therapy and diagnoses, it still hurt,” she remembers. “They finally diagnosed a labral tear in my right shoulder.” She had surgery almost a year after the accident. “I was out of work for five months—I couldn’t do anything at all.” But the right massage therapist, using myofascial release and cross-fiber friction on scar tissue to realign it, helped her recover. “If not for him, I would not have gotten my range of motion back. I would have remained stuck.” Due to injuries sustained in the accident, she also developed thoracic outlet syndrome on the right side, for which she went to a myofascial release therapist. “My goal was to get full function of my right hand again,” she says. “I couldn’t have done that if I had just taken my painkillers and rested.”


References

1. Cadogan A, Laslett M, Hing WA, McNair PJ, and Coates MH. "A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks." BMC Musculoskelet Disord, 2011; 12: 119. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127806

2. C. Benjamin Ma, MD. “What is acromioclavicular arthritis (AC Joint Arthritis)?” Arthritis Health, May 15, 2013. https://www.arthritis-health.com/types/osteoarthritis/what-acromioclavicular-arthritis-ac-joint-arthritis

3. “The Anatomy of the shoulder.” Washington University Orthopedics. https://www.ortho.wustl.edu/content/Patient-Care/3127/Services/ShoulderElbow/Overview/Shoulder-Arthroscopy-Information/The-anatomy-of-the-shoulder.aspx

4. “Rotator cuff tears.” Ortho Info, the American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases--conditions/rotator-cuff-tears/

5. Tashjian RZ. “Epidemiology, natural history, and indications for treatment of rotator cuff tears.” Clin Sports Med, 2012 Oct; 31 (4):589-604. https://www.ncbi.nlm.nih.gov/pubmed/23040548

6. “Shoulder joint replacement.” OrthoInfo, the American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement/; Claudio Chillemi and Vincenzo Franceschini. “Shoulder osteoarthritis” Arthritis, 2013; 2013: 370231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556427

7. Oliva F, Osti L, Padulo J, Maffulli N. “Epidemiology of the rotator cuff tears: a new incidence related to thyroid disease.” Muscles Ligaments Tendons J, 2014 Nov 17; 4(3):309-14. https://www.ncbi.nlm.nih.gov/pubmed/25489548

8. Yang S, Park DH, Ahn SH, Kim J, Lee JW, Han JY, Kim DK, Jeon JY, Choi KH, Kim W. “Prevalence and risk factors of adhesive capsulitis of the shoulder after breast cancer treatment.” Support Care Cancer, 2017 Apr;25(4):1317-1322. https://www.ncbi.nlm.nih.gov/pubmed/27942856

9. “Frozen shoulder.” Patient Care & Health Information: Diseases and Conditions, Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/frozen-shoulder/symptoms-causes/syc-20372684

10. Abdul-Wahab TA, Betancourt JP, Hassan F, Thani SA, Choueiri H, Jain NB, Malanga GA, Murrell WD, Prasad A, Verborgt O. “Initial treatment of complete rotator cuff tear and transition to surgical treatment: systematic review of the evidence.” Muscles Ligaments Tendons J, 2016 May 19;6(1):35-47. https://www.ncbi.nlm.nih.gov/pubmed/27331030

11. “Shoulder Joint Replacement.” OrthoInfo, the American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement

12. Bervoets DC, Luijsterburg PA, Alessie JJ, Buijs MJ, Verhagen AP. “Massage therapy has short term benefits for people with common musculoskeletal disorders compared to no treatment: a systemic review.” J Physiother, 2015 Jul;61(3):106-16. https://www.ncbi.nlm.nih.gov/pubmed/26093806

13. Yeun YR. “Effectiveness of massage therapy for shoulderpain: a systemic review and meta-analysis. J Phys Ther Sci, 2017 May;29(5):936-940. https://www.ncbi.nlm.nih.gov/pubmed/28603376 and Yeun YR. “Effectiveness of massage therapy on the range of motion of the shoulder: a systemic review and metaanalysis.” J Phys Ther Sci, 2017 Feb;29(2):365-369. https://www.ncbi.nlm.nih.gov/pubmed/28265175

14. Land H, Gordon S, Watt K. “Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: A randomized controlled trial.” Physiother Res Int, 2019 Apr;24(2):e1768. https://www.ncbi.nlm.nih.gov/pubmed/30680850

15. Massingill J, Jorgensen C, Dolata J, Sehgal AR. “Myofascial massage for chronic pain and decreased upper extremity mobility after breast cancer surgery.” Int J Ther Massage Bodywork, 2018 Aug 5;11(3):4-9. https://www.ncbi.nlm.nih.gov/pubmed/30108667

16. Bove GM, Chapelle SL, Hanlon KE, Diamond MP, Mokler DJ. “Attenuation of postoperative adhesions using a modeled manual therapy.” PLoS One, 2017 Jun 2;12(6):e0178407. https://www.ncbi.nlm.nih.gov/pubmed/28574997

17. Research studies co-authored by Susan Chapelle. https://www.ncbi.nlm.nih.gov/pubmed/?term=susan+chapelle

"AMTA has been a tremendous resource over the years."

Jenn S., AMTA member since 1994

Massage