"Frozen" shoulder

[emad]

Hi Bernard :

Frozen shoulder is a very wide /general diagnosis ;includes
post -traumatic
capsulitis
unknown cause (diabetic patient)

any paiful shoulder could easly with neglegnce referred as frozen.

i will write more then
cheers
emad :lol:

[bernard]

Absolutely, but here, forget the diagnosis and concentrate your thoughts on consequences: motion.

Where is the origin of motion loss?

[Green Hornet]

Regardless of the causes of the motion loss, people have neuromuscular holding. Whether they know that they are not exploring full functional possibility of the shoulder or not, they are not using it much.

Thomas Hanna describes in his book that latissimus dorsi has a lot of tension in the case of motion loss. It seems more than that (more than one muscle that is holding tension in my experience), but lat muscle is one of biggest tension holder.

I don't want to forget about emotional and psychological contribution, whenever people experience excessive neuromuscular holding.

[emad]

Hi takao & bernard;

Yes ,seems all those use somatic education give particular attention to latissimius dorsi !!!


cheers
emad :lol:

[nari]

The ubiquitous 'frozen shoulder' is a curious thing. It can change sides - one improves, then the contralateral shoulder is affected.

If we can see these peole early (pain+, starting to lose ROM), I think we can prevent the full syndrome effect. Once we see them in Phase 2 (late) it is probably too late.
Inevitably there are neural signs, early in the process, and these become harder to test once loss of ER/AB occurs. Posturing also occurs early - IR of the huneral head, loss of AB, and the characteristic dropped and curved shoulder. It is at this stage I have reversed the process, and had good results within a few months. Doing what? Nothing more than attention to the cervico-thoracic joint and lots of neural mobilisation. I do not do any strengthening at all - strength is not the issue here. Once pain is mostly relieved, and ROM starts to improve - I might. Scapulohumeral action is almost always affected, and the person needsd to control that.
Awareness of the dysfunction is important education- the patients quickly forget what is normal for them in that shoulder.

I think it is a chemical process, originating around the cervico-thoracic area. But I do not know; I just concentrate on scapular awarness and neural movements. It really remains an enigma.

The histology of the glenohumeral joint changes is the same as is seen in Dupuiytren's (I msut refer to that article, later, and send it) and Duputren's seems linked quite closely with median nerve dysfunction. Painful shoulders and Dupuytren's seem to go together.


Nari

[rolf]

Hi Nari and all!

What comes first the hen or the egg?Muscle ,neve,jointcapsule??Yes ive seen some of them during the years and their difficult to threat.
Sometimes its quite obvius a capsulitt ,decreased joint play,in al directions constant chronic pain with more or less no lat .rotation, i just let them "burn out" no physio approch just some acupuncture for reducing pain, or a spasm in m.subscapularis and mlatissimus dorsi,which are more "easy" to treat.Deactivation of triggerpoints by dry needeling is very good help in decreaseing muscular spasm together with sensomotor awareness/training.
Green Hornet i do agree with your emotional approach.
RIN

[Diane]

Like many of you I would lay odds on abnormal lat dorsi tension playing a big role. Not only does it anchor the underside of the humerus down to the pelvis, it covers up half the back and does a whole spiral thing around teres before inserting! Furthermore there are numerous exit spots for cutaneous nerves to traverse all the way up its edge (laterally down the side seams of the body) where it's overlapped with abs. Treacherous territory. Lots of possibilities for it to go awry. I always lay people on their sides and treat it first, just to eliminate it as a likely suspect. Lots of shoulders improve with just that much.
Cheers,
Diane

[nari]

Takao and Diane

Are you saying that you can 'fix' shoulder pain with soft tissue work to muscles around about the shoulder?

I am amazed; reveal more. I have never found that doing anything to muscle altered its behaviour and pain very much, and if so, only temporarily.

The emotional approach is part of every treatment for whatever condition that presents with pain - the sneaky bit is to balance it out with what we are 'supposed to do'. I find myself going overboard sometimes with the psych approach and forget about assessing some poor guy's back - but the psych approach works neatly!!

nari

[Diane]

Hi Nari,
I am pleased to offer my own perspective:
First off, the whole shoulder girdle could be visualized as sort of a soft tissue "funnel" applied to the body with the arm bone sticking out the narrow neck of the funnel. The wide end of the "funnel" has a bunch of intertwined layers of contractile tissue with nerves that have to weave through them. It projects (via latissimus) all the way down to the pelvis.

The thing to remember is that it's not the muscle (eg: latissimus) that is hurting... it's some nerve that's trapped up in it somehow, and it could even be down around the pelvis. Only palpation will reveal this bit. It will feel like a gummy bear or something congealed, under the skin, and may be tender or may not.. usually is. I deal with the tender ones first and the silent ones next. Look at a picture in Netter of a body with just the skin removed, and you'll be able to image how easy it is for nerves to hang up in various layers or sheets of flat expanses of muscle down the lateral strip of the body, all of which have to glide over each other all the time. The nerves are sort of laced through all of this, and if one gets stuck in any layer or with any of its branches (from simple lack of exercise or practicing of full range), it seems clear to me that there will be a really fast sensory motor amnesia if that's what we'd like to call it, the brain saying to the limb, "Don't move! If you do you'll make a nerve complain and I won't be able to stand the noise!" and the poor shoulder 'joint' is blamed. Conscious awareness may never register that a nerve lower down on the body wall is hung up. It might not hurt there, but the shoulder hurts because it's a victim of latissimus, pulling the humeral head down in the glenoid. At least that's how I see a logical sequence of events happening...

Treatment? Have that individual lie down sore shoulder side up, with a roll under the waist to lift it up. The arm might be able to be held up in the air by the individual away from the side, maybe straight up, quite easily. Get on the lat and palpate it, decide where it might be hanging up something sensitive (i.e.: a nerve) and finger stretch the skin over it. I actually like to park both forearms on the patient's side, and use them to stretch most of the skin in opposite directions a bit, then get my fingers on the gnarley bit and give it a second order stretch.

Do this gently and steadily for a couple minutes at least. After awhile it will feel like it's giving way without you adding any more force. And that m'dear is reflexive relaxation of underlying tissue that is being talked to by the skin over it, through the little used or stimulated skin stretch receptors... What's important is that the nerve under there (the thing that feels like a 'gummy bear' under the skin) gets more oxygen. Sometimes it feels like a silent earthquake is starting to happen; you can feel tissue "shudder" a little. Sometimes you can feel sudden and distinct temperature changes going on in the body under your hands...all that stuff is autonomic and perfectly normal. Anyway, when you feel nothing more is happening, take a look at the arm. You haven't even touched it yet, but it's often already hanging into way more elevation (gravity assisted) than it was before.

Let me know your thoughts.
Cheers,
Diane

[bernard]

http://www.somasimple.com/flash_anims/abduction.gif

gif=>
www.somasimple.com/flash_anims/abduction.gif
flash=>
www.somasimple.com/flash_anims/abduction.swf
with flash test=>
www.somasimple.com/flash_anims/abduction_test.html

:oops: It seems that I provided not the good ones (images). I'll try to put the ones I wanted tomorow!

[Green Hornet]

Bernard,
Thanks for the pictures!

Nari,
Until the excessive neuromuscular holding cycle is broken at the neurological level, the nervous system seems to continue to overactivate the muscle. If you find yourself keep releasing the same muscle, you may have to zoom out to see what in the rest of the body is possibly making the muscle tight.

Again, Bernard,
After and as the muscle tone is being normalized (it sounds like you have got there), I would retrain shoulder-scapula-rib/spine complex dynamically. Even if the muscle tone can be normalized, when the neuromuscular system is not trained well to know how to use the neuromuscle connection, we could continue to use the body in a habitual and pathological pattern.

Here is what I do and have been doing clinically:
1) Pt is side-lying with treating side up.
2) Have pt swing the arm forward (shoulder flexion) in a slow, controlled, and continuous movement pattern, but have pt keep the motion in control, so that he/she does not go into a painful range.
3) Practitioner (we) facilitate the desired movement of the scapula/rib/thoracic spine and/or cervical spine ---- It is Mulligan's mobilization with movement type approach, but what I do is much more general vs. specific segmental approach.
4) Do this type of reprogramming with pt's active extension, abduction, and ER/IR.

You can choose to do this in pt standing. It is like pendulum exercises (but do NOT forget to have pt move not only the arm but trunk, leg especially hip --- it is more important to have pt use the trunk and legs as the main driver and arm and shoulder as a passive passenger) with manual facilitation. It works great and instantly.

[nari]

Diane, Takao, Bernard..

Thank you for your responses. I have never considered 'frozen shoulder' to be a local problem, so I felt that local muscle management was just temporary. It is very similar to the shoulder pain of post-stroke patients, which responds well but slowly to neural applications. (Re-education)

The fact that it can switch from one side to the other tells us it is central in origin, or that is how I interpret it anyway.

I still find it astounding that some health professionals do not consider that a positive ULNT1,2, or 3 or all three as 'relevant' !!! Doctors seem to be still in pigeonhole thinking.


Nari

[BB]

Hi Bernard,
Your three guys are the major humeral internal rotators. They are also scapular depressors. They are probably trying to do too much in comparison to their counterparts.
Try this:
Starting position- make sure your humerus is in neutral rotation..elbow crease facing forward.
Motion- Abduct up to 90 degrees if you can with out pain. If not without pain bring the hand more forward into plane of scapula until it is able to be done pain free. Keep you humerus in neutral rotation throughout the motion.
Once you get to 90 degrees, begin to shrug your shoulder gradually so that by the time your humerus is fully ABducted, you are also fully shrugged.
Think about a string being attached between your elbow and the inferior angle of the scapula so that as you bring your arm up, you are also upward rotating your scapula.
Only go as far as you can with out pain each time for several repetitions.
Let me know how it goes.

Cory

[bernard]

Ouch!!!

It is worse. I can abduct only if I had relaxed first the 3 "bads". If I try as you say, motion is limited to 70/80° and pain is horrible at attaches and when shrug near/on tuberculum minus. Pain is deep, constant but under control.

In my view, I suspect some bone injury because autonomic protection is high?

[rolf]

Hi Bernard!
Iam wondreing why you dont find m.subscapularis interesting?Most of mine "frozen shoulders "have increased tension in this muscle,and it in my point of view has to be treated in one way or another to increase the range of movment and decrease pain.
Bernard ,try to palpate this muscle in your axilla and try to spot an active triggerpoint there.It hurt as hell,but slowly the tension will decrease if your not to hard on it.Sitting and leaning forward on a chair ,let your bad arm hand down.Palpate your axilla with your good hand for triggerpoints behind the scapulae."Anything out there!"
RIN

[bernard]

Hello SomaSimplers,

Good news and bad ones!

Good => no fracture on RX. :D
Bad => Radiologist said that I have arthritis. :wink:

I'll begin seriously to do my homework!!!

[Diane]

Don't worry Bernard, we all get 'arthritis' (xray changes), and usually it isn't painful or inflammatory! If you have a lot of pain and no #, arthritis is probably the "junk" Dx. Maybe it's time for you to do contrast packs (thermal) then exercises... really slow, careful arm elevation ex with trunk flexed downward, (or different ways) with lots of deep breathing, and a telescoping out motion. Really slow so that you can watch and manage the pain patterns. Also taping over the top of the shouder with kinesiotape for 3 or 4 days would likely help.
Sorry, can't seem to resist dishing out advice...
Cheers,
Diane

[bernard]

Diane,

I was joking. Arthritis does not really hurt (it was not painful before the fall). I think that I was a bit stressed before an tight => arthritis.

The only problem is that *z*jdkj* pain, I can't lift something heavy. horrible at the attaches of teres major... but disapears if I work with the three bads?!

[emad]

Hi Bernard:

I think the issue is not so serious for you ,we know what is pain ,its end ,we deal with a lot daily ...

me as a physio when i suffer pain , i negelct the issue and it goes ...

the problem is those patients , who think that pain is seriuos ,complex,unapplicable ,unexplained,sometimes i feel they put the most seriuos hypothesis , so they enter the cycle of being sick , visting us ,and our health teams , complex ,complex,........and no one know when they are allowed to go out of the cycle ...after we and our colleges gain money ethically & unethically ....

sorry bernard that you feel pain , but you can control that oain very well it is so easy ....

cheers
emad :lol:

[rolf]

Hi bernard!
Good to hear that the xray is ok,iam usuallly not interested in them in the first place.
What about your m.sclenii?Have you palpeted it prox to the clavicula?Spasm in the ant.and med.part can give functional armproblems and pain as you have mentioned earlier.At the same time ,have you palpeted the peripher nerves in your axilla and compared to the good side?What have you found?
:wink: :wink: :wink:
rin

[nari]

Hi Bernard

Like the others, I would not take any notice of the arthritis on XR.
I have to ask.... have you excluded neural component? Very common in shoulder injuries, and contributes to pain very effectively.


Nari

[Green Hornet]

I have just introduced visualization to clean up the articular surface to one of my patients (severe shoulder arthritis on x-ray). He totally likes the idea.

I saw a TV show about a kid (about 7 yr old) who got brain tumor, which is unoperable. He was told that he could only live for another year. He got to work with a psychologist, who introduced to him visualization of the tumor and had him imagine that he was fighting against some enemies. He loved the Star Wars (movie); he nicely could associate the visualization training with him being the hero in the Star Wars. He made the exercise in his head as real as possible. He did the visualization exercise every day, 1 hr a day for one year.
1 year later, guess what? His tumor is totally gone. He is now 35 years old and is still living as a pilot.
That is the power all of us have wihtin. People eliminate a huge brain tumor. Why can't we eliminate arthritis?

Bernard, hope you like the story.

[Diane]

Bernard, it sounds like the long head of triceps could be entrapping the axillary nerve as it swings round the head of the humerus buried in the meat in the posterior axilla, perhaps it is pulled this way and that by different stabilizers... I had this problem myself for 12 years or more after an MVA.. It responded permanently to one session of trigenics. But you would need another practitioner for that.

I show people the following radial nerve glide: stand with feet internally rotated a little, tall spine, breathing deeply and slowly, fully exhaling with belly button pulled closer to spine with each exhale, stiffen elbows and internally rotate arms fully, take arms into as much extension behind body as possible, make little circles from the shoulders, clockwise for a few seconds and counterclockwise (counterirritation), lift arms higher up behind body as it becomes possible, do this as long as humanly possible (maybe a minute) then s-l-o-w-l-y relax. To be repeated once each hour for two days.
Cheers,
Diane

[Diane]

I think you're right... the exercise is not simple, it is heavily stacked:

1. Turning the feet into internal rotation anchors the physical nervous system down into the feet. Standing stably that way provides some challenge for the balance mechanisms.
2. Standing tall provides a challenge to the anti-gravity muscles of the trunk.
3. Deep breathing, controlling ab wall meanwhile provides a challenge to diapragm and the trunk.
4. Taking the arms back challenges a whole lot of motor programs including, again, balance.
5. Twisting the arms in , again, pulls the physical nerves through the arms.
6. Lifting them backwards challenges the motor programs to expand (how often do we do that in the course of a day, functionally?) and provides novelty.
7. Rotating the arms is to keep the frontal lobes busy doing something while the rest of the brain gets to work, and to provide lots of non-painful sensory input, to that the uncomfortableness of the whole experience is dampened.
8. In little bits frequently mastery is soon obtained but the body gets to feel better before the exercise gets boring.
:),
Diane

[nari]

Bernard

I teach quite a few of the sort of exercises Diane suggested - and they are really not complex. They look wordy+++ on a page.

They are quite fun to do, and can be very effective.


Nari :o

[bernard]

Bonjour Nari,

It will be fine if Diane and you, put a topic on the try it section => you have a guinea pig that can say that exercise worked. :wink: :wink: