Injuries to the rotator cuff are one of the most common types of shoulder problems. They can arise from a traumatic episode to the area but are more often caused by repetitive movements of the glenohumeral joint. If there is any imbalance in the functioning of the rotator cuff muscles, an alteration in shoulder biomechanics will occur. This dysfunction of the cuff will cause the humeral head to shift or translate on the glenoid, eventually leading to problems in the shoulder. These underlying conditions can lead to impingement syndrome.
Subacromial impingement syndrome is defined as the “painful contact between the rotator cuff, subacromial bursa, and the undersurface of the anterior acromion”. It is a mechanical phenomenon in which there is weakness or imbalance in the strength of the rotator cuff that allows superior translation of the humerus, resulting in the repetitive compression of the supraspinatus tendon into the coracoacromial arch. Other factors can also contribute to this syndrome, such as:
- Instability patterns in the glenohumeral joint
- Anatomical concerns
- Glenohumeral capsular tightness
- Postural misalignments that change the position of the glenoid
- Dysfunctional scapular motion in which the acromion fails to rotate with the humerus
Initially, symptoms include deep pain in the shoulder that also occurs at night, crepitus, weakness, and pain over the subacromial space. Activity involving movements that are repetitive or are
above 90º of flexion or abduction will exacerbate the symptoms. A characteristic sign of shoulder impingement is the presence of a “painful arc.”
As the client abducts the arm, no pain occurs between 0º and 45 to 60º because the structures are not being compressed. Once the arm passes 60º, impingement of the structures begins, resulting in pain. This may prevent the client from abducting any further; however, if the client does abduct further, the pain will disappear after 120º. This is because the compressed structures have passed completely under the acromion and are no longer being impinged.
Repeated impingement of the rotator cuff structures will lead to tendon degeneration and the second rotator cuff injury: the eventual tearing of the supraspinatus tendon, or rotator cuff tear. The tears are almost always near the insertion and can be either partial or full thickness.
There are a few orthopedic assessments that a therapist can use to gather information about the client’s shoulder. We need to remember that we are NOT using these assessments to make a diagnosis or an evaluation but merely to help us make an informed treatment decision.
The first test is call the Neer Impingement sign.
- The client is in the seated position.
- Standing at the client’s side, use one hand to stabilize the posterior
shoulder and use the other hand to grasp the client’s arm at the elbow.
- Internally rotate the arm passively, and then flex it forcibly to its end
- Pain with motion, especially at the end of the range, indicates a positive test. It
also indicates a possible impingement of the supraspinatus or long head of the
The next test is called the Hawkins-Kennedy test:
- Client is in the seated position.
- Forward flex the shoulder to 90º, and bend the elbow to 90º.
- Keeping the shoulder at 90º of flexion, place one hand under the bent
elbow to support the arm and place the other at the wrist.
- Horizontally adduct the arm slightly across the chest, being careful not
to lower the arm and internally rotate the shoulder.
- Pain that occurs with this test may indicate shoulder impingement.
The last test is for tears in the rotator cuff, specifically the supraspinatus and is called the Empty Can Test:
- Client is standing. Have the client abduct the arms to 90º.
- Standing in front of the client, horizontally adduct the arms 30º and
internally rotate the arms so that the client’s thumbs point toward the floor (empty-can position).
- Place your hands on the proximal forearms of the client, and apply
downward force while the client resists.
- Weakness or pain in the shoulder indicates a positive test and a possible
tear of the supraspinatus tendon.
Watch this video for a demonstration of the tests and to see some treatment techniques:
We are often told not to treat any acute injury for the first 24-28 hours due to swelling and the potential to make it worse. The problem with this is that people often go untreated and end up in a worse situation than if they had treatment applied earlier. Contusions are a prime example of this. A contusion is a relatively common musculoskeletal injury that is caused by blunt trauma to the soft tissue. It is characterized by pain, localized tenderness, swelling, loss of strength and range of motion, and ecchymosis. Contusions are graded according to how impaired the range of motion is:
- First-degree contusions cause few or no limitations.
- Second-degree contusions produce a noticeable change in range of motion.
- Third-degree contusions cause severe restrictions in range of motion.
The primary result of a contusion is the formation of a hematoma, or local accumulation of blood, in the tissue space because of the biomechanical failure of the muscle and connective and vascular tissues. There are two types of hematomas that can form, depending on the severity of the trauma:
- Intramuscular hematomas are less severe and consist of damage only to the muscle tissue, with the connective tissue sheath remaining intact, thus localizing the symptoms.
- Intermuscular hematomas are more severe and involve the muscle. They occur when fascia is damaged and bleeding spreads, expanding the area of injury.
Treatment of a contusion will be similar regardless of where the injury is located, but each individual situation must be taken into consideration. The primary goal is to remove the excess blood and fluid from the area as quickly as possible to provide the optimal environment for healing.
Direct manual techniques are contraindicated during this phase; the area is better treated using other modalities such as ice and compression treatment. Once the swelling is under control, meaning that any activity or therapy does not create additional swelling, massage in conjunction with other modalities can be used to hasten the healing process. This may take 1 day or several days, depending on the severity. To treat during this phase:
- Apply ice to the contusion for 10 to 20 minutes, using a barrier between the ice and the skin.
- After the ice has sufficiently cooled the area, apply gentle effleurage strokes, radiating out from the center.
- Once the tissue starts to warm up, reapply the ice and repeat the process two to three times, applying the ice last, followed by a compression wrap.
If additional swelling is generated from this treatment, the injury has not sufficiently begun to heal and only ice and compression should be continued. By expanding the surface area of the hematoma, it is reabsorbed more quickly and less residual scar tissue remains.
Treatment during this phase involves the application of the same radiating strokes over the contusion to expand the surface area. Ice may be necessary only after the massage is performed, but each situation will be different. During this phase of healing, the goal is to facilitate the proper amount and orientation of the new tissue. Because new-tissue formation begins when the hematoma reduces in size, early treatment will lead to faster healing. The accumulated formation of connective tissue and blood vessels is a highly vascularized mass and is transformed into the necessary structures in the third and final phase of healing.
The newly formed mass from the repair phase is transformed into scar tissue in a process that includes decreased fibroblast activity, increased organization in the matrix, reduced vascularity, and a return to normal histochemical activity. Since scar tissue is less elastic, more fibrous, and less vascular than the original tissue, the focus of the treatment should be on creating a functional scar.
A therapist may encounter a contusion in any of these stages of healing. It is important to determine what phase it is in by performing a thorough assessment so that appropriate treatment is administered.
Check out this video I recorded when I visited Oakworks on treating contusions:
Creating a resume for a sports massage position is quite different than for other positions. I am extremely fortunate to work with the top women’s tennis players in the world but my job goes beyond the treatment room. Part of my role with the Women’s Tennis Association is also to hire the massage therapists that work with our players. Check out this video on what to include in a resume that will help you get your foot in the door.
I get asked all the time “How do I get involved in sports massage”. While there are many ways, check out this video on some of the challenges of breaking in and some strategies to help you gain an edge over the competition.
As massage therapists, we often run into conditions that may not be directly effected through our treatment and are helped through creating the most supportive environment in the body to facilitate healing.
Two conditions that fall into this category are sponylolysis and spondylolisthesis. Nicknamed the “Scottie Dog” fracture because of the resemblance to a Scottish Terrier, these conditions create a lot of controversy in their etiology and treatment because of poor correlations between clinical symptoms and radiographic evidence.
Spondylolysis stems from the Greek words spondylos, which means vertebra, and lysis, which means break. It is a defect or break in an area of the vertebra between the superior and inferior facets of the vertebral arch known as the pars interarticularis.
There are two theories that have been developed to explain the causes of spondylolysis. The congenital explanation proposes that there is a predisposed weakness in the pars interarticularis, a theory which is supported through the studies of family histories. The developmental theory is that a fracture in the pars occurs as a result of continued microtraumas which weaken the structure. These microtraumas can occur from a variety of sources including postural conditions, activities, and repetitive movement patterns.
There is a higher rate of occurrence in the adolescent population which is primarily believed to be caused by these microtraumas being placed through immature spines. Another demographic that has a higher than normal occurrence is the young athletic population. Up to 40 % of sports-related back pain can be attributed to pars damage and is common in sports which combine extension with rotation. The most common site of a fracture is at L5 but defects can occur at L4 and above. The common symptoms that are associated with spondylolysis include:
- Loss of mobility
- Paraspinal muscle spasm
- Flattening of the lumbar curve
- Changes in gait
The pain is usually very localized over the spine, gluteals and posterior thigh.
Spondylolisthesis is a very similar condition and is characterized by the forward slippage of one vertebra on another and the spine’s inability to resist the shear forces that are associated with this. It was first described in the late 1700′s by obstetricians who noted it caused a barrier to the passage of the infant through the birth canal. The reported incidence of occurrence is estimated to be between 2 and 6 percent with the most common level affected being L5-S. There is a higher rate of occurrence in the adolescent population, especially girls. This is thought to be due to the increased mobility of the adolescent spine and the fact that facets are more horizontal in orientation than adults. Despite being a different condition than spondylolysis, the two frequently occur together. Radiographic studies have reported that 50 to 81 percent of cases of spondylolisthesis also contain a fracture of the pars interarticularis.. This shows that one condition will typically lead to the other.
There are five classifications of spondylolisthesis that were created by the International Society for the Study of the Lumbar Spine (ISSLS). The first is dysplastic or congenital spondylolisthesis and affects the posterior facets of L5-S1 and will only occur at that level. Elongation of the pars interarticularis allows for significant slippage up to 100% if bilateral fractures occur. The second classification is known as isthmus spondylolisthesis. This occurs secondary to a defect in the pars and may be attributed to hormonal influences since the slippage can progress during adolescence along with postural and gravitational forces. The next classification is degenerative spondylolisthesis. This occurs as a result of the degeneration of the posterior facet joints and is more likely to occur at the L4-L5 level. Because of its etiology, it is not seen in the under 50 population and the degree of slippage does not exceed 30 degrees. The last two classifications, traumatic and pathological spondylolisthesis have other conditions that are associated with them. Traumatic spondylolisthesis occurs as a result of fractures through other parts of the vertebra such as the body and pedicles and are not discrete entities within the pars. Pathological spondylolisthesis also occur as a result of an overall process and do not result from isolated defects in the pars. A disease process will affect the entire segment and indirectly affect the pars and causing the slippage. Clinical presentation can vary depending on the type of deformity that is present. Some common symptoms are:
- Chronic midline ache at the lumbosacral junction that is exacerbated with extension
- Hamstring tightness
- Abnormal gait
- Cramping in the legs
Depending on the degree of slippage, neurologic symptoms may occur along the L5 nerve root and there is a “giving way” feeling when moving from flexion into extension. There is a high incidence of disc herniations associated with spondylolisthesis, up to 25%; therefore care should be taken to make sure all the possible causes of dysfunction are investigated.
How can we assess this in our clients? The test is actually quite simple and can guide us in our decision to treat them or refer out to a different health care practitioner.
The test is called the Stork (single-leg) Standing Test and here is how it is performed:
- Have the client stand on one leg.
- Stand behind the client to prevent him or her from falling
- Have the client extend the spine.
- Repeat on the other leg.
- A positive test is pain in the low back, which is associated with a fracture of the pars.
Note: If the fracture is only on one side, standing on the ipsilateral leg will cause more pain. Have the client perform true extension; combining movements will not give an accurate result.
So how do we treat this?
The primary structure involved with these two conditions cannot directly be treated with massage; however, massage therapy can support the normal healing process of the skeletal system by affecting the surrounding tissue directly. Muscle spasm, congestion in the tissues, and pain in the area are all treated effectively through massage. The focus of soft-tissue treatment is to relieve pressure on the site of the fracture caused by tight tissues, and assist with correcting posture, which will reduce the force causing the slippage of the vertebra. Use caution not to cause hyperextension of the spine, which can exacerbate the condition. Place a pillow or cushion across the front of the hips when the client is in the prone position or under the knees when in the supine position to add to the client’s comfort if necessary.
Always remember…When in Doubt – Refer Out!
One of the great challenges of working with professional tennis players is the fact that the sport is played on a variety of surfaces. Just like other variables that factor into injuries, playing surface lends itself to its own injury trends. We are just beginning the US Open Series which is a group of hard court tournaments leading up to the US Open. The players have just come back after the post Wimbledon break and are starting the long grind to the final grand slam of the year.
The majority of the tournaments on the WTA calendar are played on hard courts. The year begins in Austraila with a series of hard court events before moving to Europe and the clay season. The shortest number of events are played on grass and then the season shifts back to the hard court to end the year. With each change of surface, new stresses are placed on the body as the athlete gets accustomed to the new style of game. Unlike clay where we see more shoulder issues along with adductor problems from the sliding that is the trademark of the surface, grass lends itself to sore glutes and legs because the players must get lower to hit the balls that tend to bounce lower. Hard court events come with their own set of challenges. The trends tend to be more foot, ankle and knee problems along with lower extremity muscle strains. This is due to the intense stop and start nature of the hard court game. The surface is less forgiving than the other two and puts more stress on the body.
As a massage therapist working with these amazing athletes, we must understand the trends based on the surfaces to be sure to provide the most effective care possible.
Check out this video on one way we can help deal with the stresses of tennis
I just came across this research study that was done by one of my former colleagues when I worked at Wingate University. It shows some very positive results for therapists who work with overhead or throwing athletes. Those athletes commonly develop a condition known as GIRD (Glenohumeral Internal Rotation Deficit) which can be a precursor for a variety of shoulder pathologies. This study demonstrates the rapid improvements that Muscle Energy Stretching techniques can have. As massage therapists, we can utilize these same tools to improve the shoulder mobility of our clients.
Here is a summary of the study…
OBJECTIVES: To compare a muscle energy technique (MET) for the glenohumeral joint (GHJ) horizontal abductors and an MET for the GHJ external rotators to improve GHJ range of motion (ROM) in baseball players.
BACKGROUND: Overhead athletes often exhibit loss of GHJ ROM in internal rotation, which has been associated with shoulder pathology. Current stretching protocols aimed at improving flexibility of the posterior shoulder have resulted in inconsistent outcomes. Although utilization of MET has been hypothesized to lengthen tissue, there are limited empirical data describing the effectiveness of such stretches for treating posterior shoulder tightness.
CONCLUSION: A single application of an MET for the GHJ horizontal abductors provides immediate improvements in both GHJ horizontal adduction and internal rotation ROM in asymptomatic collegiate baseball players. Application of MET for the horizontal abductors may be useful to gain ROM in overhead athletes.
Click HERE to read the entire study…
This was a study that was just published in the Annals of Internal Medicine on the use of massage therapy for chronic low back pain. It follows several other studies done on massage therapy and low back pain and finds the same results.
Massage is one of the most popular complementary and alternative medical therapies for neck and back pain (1), conditions that account for more than one third (2) of the more than 100 million annual visits to massage therapists in the United States (3). Almost all massage therapists in the United States use Swedish massage techniques aimed at relaxation, but only a minority take courses in such techniques as structural massage for treatment of chronic low back pain. Recent reviews have found limited evidence that massage is an effective treatment of chronic back pain (4, 5), and no studies have compared relaxation massage with structural massage, which focuses on correcting soft-tissue abnormalities. We therefore conducted a trial to determine whether relaxation massage reduces pain and improves function in patients with chronic low back pain and compared relaxation and structural massage for treating this condition.
The conclusion was that massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.
Click HERE to read the entire study…
Standing on the sidelines at the Superbowl, sitting courtside at the finals of the US Open, watching the World Series from the dugout; these are the situations that lead many massage therapists into the field of sports massage. The possibility of living something we may only have watched on television since we were young is a powerful motivator and being part of a team or working with the top athletes in their field can be a very appealing aspect to the profession. For those who have experienced that, there is something to be said for sharing in such a memorable experience and feeling like you helped contribute to the success of the athlete or team.
To many of those looking in from the outside, being a sports massage therapist may seem like a glamorous job. Don’t get me wrong, being involved in a professional sport is a fantastic job and I appreciate every day I get to do it. I travel to fantastic places in countries I would never have gone to were it not for my job. I get to see and learn about other cultures, experience amazing things, and best of all meet wonderful people from around the world.