ASSESSMENT - Client standing
Humeral Abduction: Scapula shouldn't upward rotate until about 45 degree. There is a hard-end feel. There is no way I can separate the humeral head from the scapula because there is adhesion. See the humero-scapular fixation.
On the table SUPINE
One of the first thing I do, I was reading a research online and they would inject the shoulder to numb the nerves to break the holding pattern of the nerve pathways. By applying the CreoDerm in the area, I am calming the pain receptors. Unlocking the gatekeeper.
Spray Cryo Derm (MSM, Arnica, Boswella) on the shoulder.
In adhesive capsulitis the patient will always splint that shoulder. It's a protective mechanism. We have to break that pain spasm cycle, overriding the guarding responses. letting that work itself into the tissue.
Lateral rotation to see how guarded he is. If I get to that point and there's hard and kind of bone and bone end feel. You CAN NOT stretch or manipulate that joint.
Stretching and Counter-straining (decompression and compression)
We've calmed down the pain receptors with the Cryo Derm, everything of that capsule.
By Jones research and chemistry, this must be held for 30 ~90 seconds. It takes 30 ~ 90 seconds for the proprioception of the brain to calm down. Now I can feel the shoulder relaxing. Then I do just a little capsular stretch (decompression) then I do a little counter-strain then capsular stretch and counter-streain...
Now he is going to be very guarded because he is used to somebody pulling on that capsule.but I want him to know that his arm call fall out further. Let it relax. I want you to know if you relax those muscle that we can go to the new range.
Go back to that new end-feel then we can go bak to our counter-strain (compression) that new hard-end feeling. Go back to counter-strain but I'm holding in the counter-strain for another 30 seconds. This is the hardest part. To learn the patience to allow the proprioception of the pain to relax, to allow the guarded splinting pattern to release. I'm felling the pain receptors are calmer that I'm breaking that pain spasm cycle sooner and then I'll get in and I'll release that. Now you will have full ROM on lateral rotation. You have to trust me that I'm going to move, you have to let it move and let if fall out with full ROM.
Some osteopath said pec minor is the most problematic muscle. Now I apply the CryoDerm Myofascial cream or lotion. It doesn't give me glide, it gives me resistance. I'm not going to slip. Through resistance I can engage in deeper myofscial tissue and I'm able to stretch pec minor more effectively and roll the shoulder back.
When I stretch pec minor, there will be a secondary capsule pattern. You can see it's very guarded. You can see he doesn't want me to let his shoulder relaxed. There is a hard end-feel right there. If I stretch it he's not going to like it. What I'm going to do at that I'll hold the arm with full support to relax the capsular pattern and counter-strain (compress), hold for 30 seconds. I'm going to stretch that. I felt the release before 30 seconds. I move on.
I want him to be aware the nervous system controls the fascia system. He'll splint me if I don't tell him what he's going to get. Now I want to see if he begins to trust me so that we can now stretch out the pec minor to get rid of shoulder impingement. Now he's able to raise his arm above head (passive).
Upper Trapezius and Middle Deltoid release - Sidelying Position -
Now recall that upper traps and middle deltoid elevate the humeral head so we get that humero-scapular fixation.
This is critical for bursitis, supraspinatus impingement, adhesive capsular patters are from the contact of the humeral head into the acromion, so if I get into those from upper traps (from cephalad pressing caudad, with fist knuckles) and put a drop of CryDerm Myofascial Cream. I am creating resistance while I glide. I'm looking at fascia and engaging those traps. Now don't press on the acromion. Press on the adhesive pattern and bursa and supraspinatus which is injured (with fingertips). Humeral head is fixated into acromion. One I get that released, I elevate the humerus (lift clients relaxed bent arm with two hands) to create space and get in, feeling the adhesion... released. Now it moves freely.
Now he is easily able to stretch his subcpapularis (passive external rotation).
Relax the Rhomboid and Infraspinatus, Teres minor with myofascial release (longitudinal knuckle glide). This stimulate the spindle cells (knuckle shaking). I'm waking up these muscle beucasue they need to stabilize the scapula
I want you to know that you can trust me, right. I'm going to move your shoulder where it hurts. What I want you to know is that when you relax that shoulder we can stretch out that Pec Minor and see the muscle are firing. Now its moving completely free (shoulder flexion = anterior abduction, passive).
Now you can trust me you know you can bring that all the way to you.(abductdion up to head, passive).
You have changed a lot of stuff. You had njury of the supraspinatus. We calm down the pain receptor. This is a valuable tool in my toolbox (CryoDerm). It allows me to do more effective therapy to break pain spasm cycle so that I can get into the Supraspinatus and under the Traps (rocking, shaking, loosening movement).
Face-rest cushion in the armpit; Arm on the side "Subtraction"
Externally rotate using the cuchion as a pivot. Pull the injured fibers out in the Supraspinatus (fingertip massage). Using the cushion as a lever, press elbow towards the body and create space on the top of shoulder joint (friction on Supraspinatus attachment). It's tender right now, right? Now I'm treating the injured Supraspinatus that tested positive.
Frictioning by itself does not realign the scar tissue. Frictioning soften the scar tissue matrix. The only thing that realign is an eccentric muscle contraction. So I'm going to stabilize the scapula and bring his elbow just barely barely resistant and let it move. Eccentric pain-free movement will prevent them from having rotator cuff surgery. Because it realigns the scar tissue and now you push your elbow towards me do you still have pain in Supraspinatus?
...See his smile.
Now we'll stand up. It was about 10 minute treatment. It works every time. 30, 40years of doing this. It works every time.
Lateral rotation (with bent elbow, hand went more posterior to his back)
Flexion (about 135 degree went more posterior to his back ).
Abduction completely (arm straight up)
Massage Tutorial by Mufeed Naaji
Subscapularis : the Medial Rotator
Sink in and feel that interesting landscape you'll know that you're on Subscapularis if you internally rotate and press against your other elbow, you'll feel it jumps up. If you just feel a very lateral muscle jump up that's Teres Major and you're not far enough to your armpit yet so sink a little further, feel for resistance coming. from your scapula and then try the test again. Once you've found that, move your arm a little and see if you can feel all of the landscape on the front of that scapula. Explore more medially, more laterally, explore superiorly and inferiorly because Subscapularis covers the entire front of that scapula.
Anytime you are internally rotate your arm, Subscap is involved. It's helping Pectoralis Major out. Also with the other rotator cull muscles, it's forming a cuff, pulling the head of the humerus in and keeping it well seated in that Glenoid Fossa. If they are pulling too hard or if one is pulling too much that can cause Gleno-Humeral joint to dysfunction a bit and some of these movement that used to be so easy suddenly become difficult of even anxiety inducing because it can feel like bone to bone contact as things get really squished up in here.
Befor you work on your client, I would like you to feel subscap on yourself. Take your thumb and place into the darkest stinkiest part of your armpit and sink that in as you drop your arm. Your hand is going to get sandwitched under your arm, and you'll be able to press posteriorly, press against the front of your scapula.
Caution:There is a lot of vascular and nervous and lymphatic tissue in there so don't do a lot of digging. don't feel like you need to friction this area out. Also be kind both to yourself and your client when you work on this muscle because it's probably the first time this muscle has been touched.
First technique "Scapula Sandwich" (Prone):
Therapist sits facing the lateral border of her scapula
I don't recommend specific friction but feel free to sink. Do think broad. I'm using my thumb PAD here. I'm not using my thumb tips.
Second technique Fingertip Hook/Mobilization (Prone):
Therapist stands facing upper trap using his weight to press caudadly
I'm going to press inferiorly with one hand. I've got this elbow sunk into my hip so this is coming from mu stance. The other hand comes under. These fingers are aimed up toward the Subscapular Fossa and pressing up toward the ceiling and with this I can get wither quite specific using my fingertips, just one finger or two or it can be quite broad using three fingertips at once or using my finger PADS. Pinky isn't doing a lot here. Just by shifting my position I'm doing mobilization of this scapula. As you do this work, remember there's a lot to the Subscapularis to be worked with.
There's the region that's more superior, so sink your fingers up toward the AC joint, then a region that's more inferior, and lateral. If you come out more laterally you're also going to be interacting with Teres Minor and Major. And you can work with all these tissue at once.
Third technique (Supine )
Therapist sits on her side, brings her arm up into relaxed abduction
Use your fingertips and press down into her axillary region. If you're not quite sure where you are, have your client come into medial rotation and release. If you feel that muscle jump up you're definitely on Subscapularis and you'll find that you can access quite a bit of a Subscapularis from this position. If you want to sink in for a prolonged period in the most comfortable way possible, bring her arm over her chest and have her take a hold of the oter arm and grab a hold of this elbow. She can let both her arms rest.
Now you can take the other hand and draw the shoulder downward as your right hand continues to palpate Subscapularis. Again, I'm not going to do any specific digging. I'm just sinking in and exploring the topology and I'm waiting for some melting to happen.
Come out very slowly.