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Home > Tagged "shoulder injury"

Tag: shoulder injury

Muscle Energy-Technique-for-Shoulder Rotator Cuff Pain Chapmans Reflexes
Muscle Energy Technique rotator cuff shoulder injury shoulder pain
April 9, 2022 Paula Nutting

Muscle Energy Technique (MET) for Shoulder Rotator Cuff Pain

Overview 

Learn Muscle Energy Technique Shoulder Rotator Cuff Pain today. If you’re suffering from rotator cuff pain, don’t worry! It’s completely treatable. For those with shoulder pain due to rotator cuff tendonitis, inflammation, or impingement, applying a Muscle Energy Technique (MET) may be just what you need to treat your condition and get back to your daily activities without pain interfering with your quality of life. In fact, our recommended treatment is one of the most effective non-surgical solutions available today.

Muscle Energy Technique for Shoulder Rotator Cuff Pain- Chapmans Reflexes Blog Image

Related Article: Neck and Shoulder Office Exercise

Why do we need rotator cuff muscles?

According to Athwal (2017), the rotator cuff is a set of four muscles that form a "cuff" over the head of the humerus via tendons. The scapula leads to the four muscles that make up the following muscles:

Rotator Cuff Muscles and four parts- Chapmans Reflexes Blog Image

Photo courtesy of A.D.A.M., INC.

The larger and lesser tuberosities are where the rotator cuff tendons join to the humeral head. These muscles altogether allow the rotator cuff to perform its important role of arm lifting and rotation as well as the stabilization of the shoulder's ball within the joint (Maruvada et al., 2021)

What is a Muscle Energy Technique (MET)?

Muscle Energy Technique (MET) is a type of soft tissue manipulation used to treat muscle imbalances and other issues. This was developed by Fred Mitchell, Sr. and Fred Mitchell, Jr. In MET, small contractions are used to stretch a tight muscle while they’re in their shortened state. The purpose of MET is to gain control over trigger points and improve mobility in muscles with limited range of motion. MET is an active approach in which the patient acts as in active participation, as opposed to static stretching, which is a passive technique in which the therapist does all of the work.

MET can be beneficial for improving stability in both shoulders. Athletes who perform overhead movements, like baseball pitchers or swimmers, tend to experience shoulder pain due to injuries like rotator cuff tears or labral problems. While steroids injections can help reduce shoulder pain and inflammation caused by these conditions. They only treat symptoms—not underlying causes of shoulder pain. In addition, it may have negative side effects if not administered correctly by professionals.

Related Article: Muscle Energy Technique Your Therapist Does For You

When should you use muscle energy technique (MET)?

Muscle Energy Techniques can be utilized for any issue where the goal is to relax and lengthen muscles while also improving joint range of motion (ROM). Almost any joint in the body can be safely treated with METs. A lot of athletes employ MET as a prophylactic treatment to avoid muscle and joint injury in the future. It is mostly utilized by those who have limited range of motion in their neck and back owing to facet joint dysfunction. Likewise, for larger issues including shoulder discomfort, scoliosis, sciatica, asymmetrical legs, hips, arms. It could also treat persistent muscular pain, stiffness, or injury.

Muscle Energy Technique (MET) for Shoulder Rotator Cuff Pain

How do you perform Muscle Energy Technique (MET)?

Muscle energy technique is effective for shoulder pain relief and it's easy to learn which is why its use in recent years have increased. Here's how you can do it for your patients. 

Physical Examination (Muscle Energy Technique Shoulder)

You will have to look at the natural range or passive range of movement of the patient. Have your client lie supine and you move their arm into abduction to a 90° angle.

External rotation of the shoulder, natural range or passive range of motion ROM should be between 80 and 90° degrees-Chapsman Reflexes Blog Image

Bend the elbow and passively check for external rotation of the shoulder as seen in the photo below. You are assessing their current ROM or the limits to their range of motion, normal range should be between 80 and 90°. If the range of external rotation is less than these numbers it can indicate that either the pectoralis major, the latissimus dorsi, and/or the teres major may be inhibited and shortened, which decreases this range performed within the upper extremity.

Next, check the internal range of the arm. Move the arm passively into internal rotation. The normal range is 70° to 90° with any limitations perhaps coming from dysfunctions in either or both the subscapularis or teres minor muscles. We also note for any ‘hard end feel’ which may indicate bony issues which means we would do further joint assessments.

internal rotation, internal range of the arm should be between 70 and 90° degrees- Chapsman Reflexes Blog Image

Performing Muscle Energy Treatment (MET) Shoulder

Move their forearm into an external rotation to perform MET. It is important that you stop at the first point where you feel restriction of the tissues. This is called Point of Bind and is at this length of the tissues that we get optimum results. They contract back towards internal rotation at 40% of the effort and no more; it is an isometric contraction where you are stabilizing the wrist and elbow to keep the joints motionless. This contraction is held for approximately 7 to 10 seconds. Ask your patient to take a deep cleansing breath and as they exhale they stop applying pressure of the muscle contraction. Keep in mind that it's important that their arm doesn't move. You will still be holding the wrist and elbow through the entire procedure and finding a new point of bind after each of the post-contraction relaxation phases.

Post-contraction Relaxation Phase

This time called Post-contraction Relaxation is when the tissues that had been contracting relax even further. We stay in limb ‘stiffness’ for up to 90 seconds and in this time the muscles relax even further so that we find the new passive end range or apply our new point of bind. Ask the patient to apply the contraction into internal rotation, still at 30% to 40% of their effort. This contraction again should be a minimum of 7 - 10 seconds. We get them to take cleansing breaths on each exhalation to improve the parasympathetic effect on the tissues; they can relax their muscle contraction as they breathe out.

Important Notes

Do the technique 3 times to see the most effective changes. Tell them to take a deep cleansing breath and that they relax the muscle contractions as they exhale. We reassess the ROM of external rotation after the third contraction and relaxation phase and we should see greater evidence of improved length through that range of motion.

This is a gentle technique for patients that feel pain and/or for those with issues in their range of motion. You might not want to use this treatment when there's a bony block when you test out the ranges. Be aware that if there's a joint restriction, we'd apply a mobilization technique or we'll adjust something deeper into that joint capsule.

Related Article: Best Pain-Free Subscapularis Massage for Shoulder Pain

Watch this Video

Here's the most effective video where you can see how to do this Muscle Energy Technique. It's a simple yet effective way to address the restrictions created by hypertonic internal rotators and gives more balance to their external rotator counterparts! Watch to go through these steps so you can practice from your clinic and also what homecare you can offer your patients when they are not in your practice.

References

Athwal, G. S. (2017, March). Rotator Cuff Tears. American Academy of Orthopaedic Surgeons. Retrieved February 20, 2022, from https://orthoinfo.aaos.org/en/diseases--conditions/rotator-cuff-tears-frequently-asked-questions/

Maruvada, S., Madrazo-Ibarra, A., & Varacallo, M. (2021, May 8). Anatomy, Rotator Cuff - StatPearls. NCBI. Retrieved February 20, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK441844/

Blog-Banner-Glenohumeral-Treatment-Techniques-for-Shoulder-Pain-and-Problems
joint pain shoulder injury shoulder pain
April 9, 2022 Paula Nutting

Myotherapy: Glenohumeral Joint Pain Treatment

Patients can come in with pain and stiffness from the neck that can refer to and causes elbow wrist and shoulder pain- acromioclavicular (AC) joint and the glenohumeral (GH) joint. Typically, it impedes movements such as lifting of the arms, brushing the teeth, or holding a golf club. It may be described as a moderate pain or a chronic pain that could affect sleep especially if it’s the shoulder you sleep on.

Shoulder Anatomy

You can help them by applying a variety of techniques to relieve uncomfortable pain or sensations in and around that area. But first, let's understand the shoulder anatomy. Since it is one of the most unstable joints in the body with the most movement, it can be complex to understand its structure and functionality.

Shoulder Structure and the three kind of bones, glenohumeral joint- Chapmans Reflexes Blog Image

The two shoulder joints that are prone to injury are the acromioclavicular (AC) joint and the glenohumeral (GH) joint. 

  • The acromioclavicular joint is situated where the clavicle is in contact with the acromion and the scapula. 
  • The glenohumeral joint is where the socket of the scapula connects with the rounded head of the humerus. It is responsible for the wide range of motion of the shoulder including flexion, extension, internal and external rotation, adduction and abduction and circumduction. 

There are  eight muscles attached to the bones of the shoulder. They are responsible for the form we see of the shoulder and underarm, they aid in its range of movement, and help protect the GH joint which is the main primary joint involved in function.

The deltoid muscle, which you may also know as the deltoideus muscle, is the shoulder muscle considered to be the largest and responsible for stabilization of the shoulder joint for the prevention of dislocations. 

The other muscles which work with the deltoid for shoulder movement and its functions include:

  • Infraspinatus - for arm raise and lowering
  • Triceps brachii - arm straightening
  • Pectoralis major - connects to the sternum
  • Pectoralis minor - stabilizes the scapula
  • Teres major - arm rotation 
  • Biceps brachii - rotates the forearm; flexes the elbow
  • Latissimus dorsi - helps with arm rotation and movement away from and close to the body
  • Subscapularis - aids to rotate the humerus 
  • Supraspinatus - help to raise arm away from the body

Shoulder Pains and Problems

Muscle Energy Technique

When any of the aforementioned muscles become dysfunctional, inhibited and reduced in their passive resting length, they tend to pull the humerus forward. According to OrthoInfo, shoulder problems that patients can experience fall into these categories:

  • Tendon inflammation - can be bursitis or tendinitis
  • Shoulder Instability - stretched lining of the shoulder joint, labrum, or ligaments 
  • Arthritis - joint tenderness and swelling
  • Fracture - can be caused by trauma or injury from a fall, sports activities, vehicular accident, or a direct hit to the shoulder

Other causes for shoulder pain that are less common include infections, tumors, and nerve related problems.

See Related Video: Shoulder Pathologies: Different Causes and Cool Tubing Treatments

In this article, we are going to focus on glenohumeral joint pain and an amazing muscle energy technique that could improve the humerus’s resting position. This will improve the quality and range of motion and reduce the notable pain felt by your patient. 

Almost any joint in the body can be safely treated with these techniques. Many sportsmen utilize them to avoid future muscle and joint injuries. It's primarily used by people who have restricted range of motion in their neck and back due to facet joint dysfunction found in the neck and back, for those who have broader issues like shoulder pain, sciatica, scoliosis, unsymmetrical legs, hips, or arms, and to treat chronic muscle pain, stiffness, or injury.

See Related Video: BEST exercises for the majority of shoulder problems using the water

Conducting the Assessment

You can clearly see how  far forward the humerus of the patient is. To conduct the test, ask them to be seated comfortably. Stand behind the patient and place your hand over their shoulder. Press your thumb into the tissue, as is in the picture below, until you can palpate the humerus. Note how far forward the humerus is, you can apply a second finger along with your thumb for a more clearer view.

Conducting the assessment for shoulder pain, glenohumeral joint and problems-Chapmans Reflexes Blog Image

Upon confirming that the humerus is anteriorized and checking if any symptoms of pain locally, and/or radiating up in the neck down to the elbow and wrists are present, you can go ahead with this simple muscle energy technique that will improve length of restricted tissue and bring the humerus back into the glenohumeral joint.

Related article: Shoulder Pathologies: Different Causes and Cool Tubing Treatments

Treatment

Let’s begin with the treatment steps. Here’s what you can do:

  1. Have your patient lie on their back (supine).
  2. Put your four fingers behind the humerus while your thumb and wrist sits on top of the humerus.
  3. Slide your thumb down until you get into a firm position.
  4. Push the top end of the humerus down, letting it press onto the table. At the same time, let your other hand elevate the elbow. Continue to do this seesaw-like motion that gently moves the humerus in the capsule a couple of times. Since it can be quite tender, remember not to apply too much force. 
  5. Apply gentle pressure until you can feel the bony end range and ask the patient to push their elbow to the floor and hold it for about 10 seconds. 
  6. Let the patient take a deep breath and when they release their breath you reduce the pressure applied to the limb whilst ensuring that the joint remains in an isometric position. 
  7. Repeat steps four to seven: You apply a rhythmic rocking back and forth motion of the humerus within the joint space for approximately 30 - 45 seconds or until it has a softer feel on the movement, it will start to have a smoother end feel. Continue with the gentle push while the patient takes a deep breath. When they breathe out, stop applying pressure as a counterforce on their humerus. When you apply the muscle energy technique, here are several tips to remember. When pushing down gently, hold it for about 10 seconds and ask the patient to exert 30% to 40% of their effort. Let them take a deep cleansing breath in and when they breathe out, that's when they stop contracting. You can do this three times before reassessing the joint position again. This should make headway into better movement patterns and reduced myofascial pain of the shoulder and surrounding compromised structures.

Watch This Video

Here's a short video where you can see how the steps are carried out. Watch to learn more how to follow through with the muscle energy technique. Try it from your clinic and you will see positive changes in your patients pain and function.

woman holding her left shoulder pain
chapmans reflexes chiropractor lower back pain shoulder injury
December 24, 2020 Paula Nutting

Shoulder Injury, Neurolymphatic Point Stimulation Case Study

Clinical features

This is a shoulder injury and neurolymphatic point stimulation case study.  A 44-year-old healthy female came to me presenting a 5 ½ months-post fall that caused a fracture to her greater tubercle and dislocated the humerus posteriorly.

Intervention and Outcomes Before using Chapmans Reflexes

A variety of interventions were performed by her physiotherapist before commencing treatment with me and the application of Chapmans reflexes.Non-surgical relocation of the humerus was performed by her surgeon followed up with weekly rehabilitation therapy with physiotherapy using closed chain small exercises. To date, she has a humeral elevation close to 80 degrees. She was also seeing her regular chiropractor, Dr. Sandy [10 years +]. She has included acupuncture to try for more movement in the shoulder complex. Dr. Sandy referred her to me to address the still limited range of motion.

Interventions using Chapmans Reflexes and Various NMT

For the interventions using Chapmans reflexes, one treatment was applied per week for three weeks. Then one more 14 days later with follow-up in so that she could return to full ROM and strength. This also enables her to perform push-ups from a toe stance. The pain was significantly reduced to VAS less than 1/10. I also addressed her underlying chronic lower back pain complaint.

METHODS

INITIAL PRESENTATION

Mrs. W showed:
  1. tension/hypertonicity
  2. tight left lateral neck and shoulder
  3. some altered sensation
  4. numbness over the region of the lateral humerus. Her description of the region included "feels like a block" and
  5. "has a heaviness when trying to reach overhead".
Over the last 10 weeks, she stated that the medial and anterior deltoid muscle "now finally getting the tone and feels like it is activating". She had actively been doing her home care as instructed by the physiotherapist assigned to her. The home care included the use of heat packs to alleviate the tight and tense soft tissue.

Assessment

Her levels of stress were reported were extremely high. She stated that she felt like she was holding everything internally. She was unable to take full diaphragmatic breaths and her thoracic range of movement was limited in all ranges.Strength testing was performed and showed moderate weakness on the diaphragm-supraspinatus isometric test. There is also a moderate weakness to the latissimus dorsi, the thoracic extensors, posterior deltoid/shoulder complex, and the external humeral rotators.

Treatments

Treatments for Mrs. W included the following:
  1. Chapmans Reflexes – Commenced by stimulation of the neurolymphatic points feeding the diaphragm and then teaching her diaphragmatic breathing to elicit the “relaxation response” and trigger the parasympathetic nervous system. Chapmans Reflexes were applied to the neurolymphatic points for the latissimus dorsi anterior and posterior points and the Tx and shoulder extensors, where I followed the protocol of vigorous but not deep rubbing for 30 seconds in each region. Once these areas were stimulated her strength had improved to very strong isometric holds of the shoulder muscles and increased ROM of humeral extension and internal adduction.
  2. Muscle Energy Technique - Following the neurolymphatic stimulation, I added a muscle energy technique to the humeral internal rotators. This will allow greater resting length in these muscles and increase mobility and ROM of humeral external rotation. During the post isometric relaxation phase, the resting length of the muscle will be greater. This technique has been found to effectively reduce capsular restrictions noted at the glenohumeral joint through ROM.
  3. Low load muscle activation - She then performed a low load muscle activation of the subscapularis in its closed position. The action of the subscapularis is internal humeral rotation as well as adduction of the humerus. This allows the target muscle to contract independently from the other muscles used in the action of the primary muscle.
  4. Neuromuscular techniques - Various neuromuscular techniques including glides and gentle cross fiber movements to the biceps, pec minor, posterior deltoid, and the fascial line between the triceps in supine were applied. Seated active movements of the head and neck in rotation to the left upper and mid trapezius and thoracic erector spinae, prone to the left latissimus dorsi, around the scapula, rotator cuff, and levator scapula were also applied. Mobilization of the bilateral Cx joints to address the left-sided stiffness. Both sides were painful but became less painful after 3 applications on each side.
  5. Homecare - This included activating the neurolymphatic points of the diaphragm, 10 diaphragmatic breathing, and breathing full breaths often through the day.
Mrs. W had plenty of resentment issues over the fall and the lack of support with those around her during the incident. So, we also discussed ways for her to do self-anger management and let anger become less of an impediment to her treatment progress.

2ND TREATMENT

Mrs. W did her homework using the breathing exercises to manage her stress and chest restrictions. She also wrote her resentment issues down on butcher paper and stated that she was “feeling like moving forward a bit more”. Her shoulder’s range had improved but still with pain and some mild swelling for a few days post-treatment. She attempted to do toe push-ups (did 3 this morning) which she had been unable to do.

Assessment

There were still some weaknesses with thoracic and humeral extensors and latissimus dorsi. Also, there was still weakness in recruiting the neck muscles to assist in the strength testing with a note to actively retracting the jaw in every movement. Strength testing also included weakness in neck flexion so the neurolymphatic point for the region was included. Assessment of supine rotations of the lower limbs to assess the balance of the soft tissues of the trunk lateral flexors, obliques, and deep lumbar rotatores, multifidi, and intertraversii muscles were done. Looking at the Anatomy trains and links to the functional backline, lateral line and spiral line with the connections from the shoulder and pelvis have led me to include lumbar muscle energy techniques to address rotations or torsions of the sacrum and/or ilia.

Treatments

  1. Chapmans Reflexes - These were applied to the left latissimus dorsi, thoracic flexors/humeral extensors, and sternocleidomastoid/deep neck flexors. Re-assessment of strength was markedly improved with almost complete full range of shoulder abduction.
 
  1. Local cross-fiber friction and neuromuscular techniques - These were applied to the upper anterior humerus/anterior deltoid tendon, subclavius, 2nd/3rd ribs at the sternalis region - using forced inspiration and expiration; myofascial ringing of my hands across the lateral humerus/ interosseous membrane just inferior to the deltoids with active humeral rotation, compression/stripping into the thenar muscle. These techniques were chosen to include the fascial arm lines of the Anatomy Trains. Studies show that restrictions along these superficial and/or deep arm lines will alter the biomechanical efficiency of the shoulder complex and cervical ROM. Lumbar muscle energy technique and gluteal stretches were included in this treatment. [Shoulder Injury & Neurolymphatic Point Stimulation - A Case Study]
 
  1. Homecare – A 30-second stimulation of the neurolymphatic points of the latissimus dorsi, thoracic flexors/humeral extensors, deep neck flexors/SCM, and diaphragm were prescribed including 2 minutes of diaphragmatic breathing. I started Mrs. W on the functional stabilizing activity of wall springing push-ups x 20 daily. This reduces the load of the shoulder complex and still offers eccentric and concentric contractions to any of the muscles with attachments to the scapula, humerus, or ribs.
 

3RD TREATMENT

Mrs. W had been doing the Chapmans activations each day. She has full pain free range of the humerus in all ranges, has been doing wall springing push-ups and today performed 15 toes push-ups for her physician. He has commented that her post-non-surgical relocation recovery has accelerated far greater than usual progressions. He is very happy with her outcomes.

Assessment

The latissimus attachment pain is finally settled and latissimus strength is 100%. Shoulder ROM was considered to be full range in all planes, though a painful taut band was noted on the left teres major. We are now focusing on an ongoing episodic complaint of lower back pain which is 6-7/10 on the VAS scale and can flare up with long hours standing at work. Strength testing showed the weakness of the left lateral sling including lateral trunk flexors, gluteus medius/minimus; weak right gluteus maximus, right hip flexor iliopsoas, right superficial front and back fascial lines with weakness in strength testing of the quadriceps, gastrocnemius, and tibialis anterior.

Treatments

  1. Neurolymphatic points stimulation  - This was applied to the weakened muscles tested listed above. Neurolymphatic points relevant to musculoskeletal dysfunction are found primarily on the anterior of the body, when there is chronic weakness/stress we also need to treat the associated posterior Chapmans Reflex points housed near the erector spinae of the relevant spinal nerves.
  2. Low load activation - I added low load muscle activation to the left rhomboid to increase the stability of the left rotator cuff of the scapula which affects the spiral line of the anatomy trains.
  3. Prone various neuromuscular techniques - These techniques were applied to the gluteus maximus, minimus, and medius, adding compressive mobilizing techniques to the sacral ILA, sacrotuberous and iliolumbar ligaments, complimenting with myofascial release/passive internal rotations of the deep hip rotators, also applied XFF to the tendon of the right quadriceps in supine with Mrs. W adding active femoral rotations.
  4. Homecare – Mrs. W continued to apply her 30 seconds of vigorous but not hard rubbing to the neurolymphatic points associated with the latissimus dorsi, thoracic flexors/humeral extensors, deep neck flexors/SCM, diaphragm and continue her diaphragmatic breathing each morning and if she felt she was going into a stress state. She will also include the low load muscle activation of the rhomboid muscle to address any dysfunction of the spiral line of the anatomy train.
 

4TH TREATMENT

Mrs. W booked in 2 weeks later – she had increased her University assignment load and she works full time as a registered nurse which added more stress to the shoulder and back. One episode of neuralgia from the right side of the neck resulted in a silent migraine occurred with excessive hours in front of the computer. Her shoulders were still maintaining full range of motion but last week, a feeling like a band or pressure developed across the posterior deltoid and over the shoulder which is still present today. No complaints of lower back pain since the last treatment.

Assessment

Full strength when testing the shoulder muscles which was encouraging. There was also a full range of movement though a feeling of the band over the deltoid still present. The taut band and pain commonly referred to as a "Trigger Point" was no longer present on palpation of the teres major. Lumbar rotations in supine were equal and full range. Sacral hypertonicity and painful areas were no longer a concern.

Treatments

  1. Local neuromuscular treatment - This was applied to the left shoulder commencing with positional release techniques to the external rotators of the humerus, glides to the pectoralis minor and major.
  2. Prone neuromuscular techniques - These techniques were also applied to the full-back, latissimus dorsi, lumbosacral and thoracolumbar fascia, shoulder rotator cuff, upper trapezius, and levator scapulae.
  3. Homecare - Activation of the Chapmans Reflexes three times a week and increase to daily if the range reduced in any of the humeral movements were advised. She would continue with the low load muscle activation of the rhomboid before stronger shoulder exercises. She would have to find strategies to add small breaks into the assignment writing tasks so that long hours working at the computer are broken up.

LAST TREATMENT

Two weeks further to follow up and all ranges are full, pain-free, and feel easy throughout the entire range. I added a bike exercise to help with stress management. She would continue with the low load muscle activation and Chapmans Reflexes point stimulation.

Treatments

  1. Therapeutic management - She asked to have a more relaxed treatment so I removed any neurolymphatic point stimulation or exercises to the treatment protocol and gave a general treatment including glides, effleurage, petrissage, myofascial release techniques, positional release techniques, some active and passive stretches.
  2. Homecare - She would continue with the physiotherapist's exercise routine adding the low load and neurolymphatic point stimulation before these rehabilitation activities.
I followed up 6 and 12 months later and Mrs. W had no further need to intervene on her shoulder.  
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