resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Physical Exam 101: The Hands
I am sure you are familiar with the old adage: "When the only tool in your toolbox is a hammer, everything starts to look like a nail."
The Science of Stretching
In 1986, Rob DeCastella set a course record by running the Boston Marathon in 2:07:51, just 39 seconds off the world record.
A Guide for Talking to Doctors about Acupuncture and Brain Chemistry
Before I begin any discussion of how to talk about the effects of acupuncture on brain chemistry, nervous and endocrine function, it is essential to understand just what physicians most need help with.
Immunizations by Colorado DCs: Really?
You probably didn't hear about it, but back on Nov. 21, 2013, the Board of Directors of the Colorado Chiropractic Association (CCA) adopted "immunization authority" for Colorado DCs as its No. 2 legislative goal.
Finders Keepers: The Secret to Relationship-Based Marketing
Becoming a successful practitioner has less to do with what you learned in school, and more to do with your ability to find new patients and keep them!
Vaccines and Chiropractic: Evidence-Based Medicine or Medical Dogma?
Right or wrong, the chiropractic profession has historically been against vaccinations. However, a growing trend within the profession is seeking to reverse this position.
Peer Points: Always Seeking To Grow
Ellen "Kiki" Geary has spent the last decade honing her craft. As a specialist in integrative holistic care, she went straight from completing her master's degree in acupuncture and chinese herbal medicine from Bastyr University to building a successful and thriving practice in the small community of Anacortes, Washington.
Are You a Bad Chiropractic Patient?
My father was a great DC. In fact, as you might expect, he was the doctor of chiropractic I measured all other doctors against. Sadly, he died at age 61 when I was in my early 30s.
Fibromyalgia: Put the Pain in Its Place
While some fibromyalgia patients respond favorably to regular chiropractic care, others experience minimal relief. Unfortunately, many of these patients must rely on pharmacological management to relieve their constant pain.
Building From the Bottom Up
I caught up with my dear friend Honora Wolfe, in her Colorado painting studio where, if she is not praying in Bhutan or doing charitable work in a Nepali free clinic, she spends most of her time now.
Coding for the Subluxation: ICD-9 vs. ICD-10
When I attended chiropractic school, I was taught that chiropractors approach health care differently than the traditional medical establishment.
A Chinese Medicine Story: An Interview with Mazin Al-Khafaji
Mazin Al-Khafaji's work has interested me for years. In February 2014, we invited him for the second time to speak at the Southwest Symposium in Austin, Texas.
Knee Pain From the Kinetic Chain
As practitioners of manual medicine, chiropractors often treat patients suffering from knee pain.
Why You Should Include the Single-Leg Stance Test in Every Patient Assessment
The single-leg stance (SLS) test, also known as the single-limb stance test, unipedal stance test or one-legged stance / balance test, is often used in the geriatric population to assess static postural and balance control.
Medical Qigong for the Heart: Part III
Part 1 and Part II of this series focused on the physical aspect of the Heart and mental emotional aspects of the Heart respectively. Now, I would like to focus on the spiritual aspect of the Heart.
New Medical Technologies You Need to Know
We're all familiar with how fast computers become obsolete, as well as the rapid pace of development in the field of cell phone technology. The latest smart phones are far more powerful than desktop computers were only a few years ago.
Curbing Label Overwhelm
For the average consumer, reading a food package can be overwhelming: natural, organic, non-GMO, gluten free, free range ... you get the picture.
Remembering Clarence Gonstead and 50 Years of the Gonstead Clinic
Dr. Clarence Selmer Gonstead (1898-1978) took chiropractic practice from back-alley bone setting to an understandable biomechanical science. His life was dedicated to clinical competency.
By the Numbers: 3 Common Financial Mistakes With Major Consequences
Warren Buffett is on record for sharing the hidden art of becoming wealthy and making it simple enough for anyone to grasp.
December, 2013, Vol. 13, Issue 12
Timing is Everything: Shoulder Instability and Labral Tears
By Debbie Roberts, LMT
The greatest thing about being a massage therapist is you never know who you will help next. One minute, you could be holding the hand of a hospice patient and the next, a strained quadriceps muscle of a 6-year-old.I know all of you understand what I am talking about because, in our field, we have such an opportunity to treat a very diverse clientele. I had the opportunity to help a young football player hold onto his dream of being a quarterback, his future college scholarship and the opportunity for scouts to see him throw. My goal is to help you understand the mechanisms of shoulder instability, how to access for instability and possible tears and most importantly, why your understanding of timing can be critical.
The Shoulder Joint
The shoulder joint often has been referred to as a cup hanging on a saucer or a golf ball on a tee. What this describes is how vulnerable the glenohumeral joint is. The glenohumeral joint has the largest range of motion of any joint in the human body. The shoulder ball (humerus) and socket (glenoid) have little inherent stability. The lack of stability results in a GH joint prone to instability and dislocation.
The labrum, which is a fibrocartilage tissue that forms a ring around the glenoid, adds stability to this inherently unstable joint. The labrum is connected to the capsule that links the socket loosely to the ball. The biceps tendon also attaches to the top of the labrum ring. Together with the muscles of the shoulder, the capsule/labrum complex affords stability to the glenohumeral joint. Any injury to the capsule/labrum complex causes a patient to have shoulder pain and instability (dislocation or subluxation). Damage to the labrum and capsule is a common occurrence as a result of an instability event; the damage causes the labrum to detach from the glenoid and predisposes the shoulder to future events of instability and dislocation.
There are many kinds of labral tears, but this discussion will focus on one of the most common types involving throwing athletes called the SLAP tear: "Superior Labrum Anterior to Posterior." SLAP tears usually develop over time following repetitive use like in some of our golfing clients. But they can also occur when an athlete suffers direct trauma to the shoulder, just like my young quarterback.
He sustained two different tears as a high school quarterback. The first injury sustained was a small labral tear which the doctor told him he could continue to play with. The second tear wasn't yet discovered until his visit with me. Both happened as he was getting ready to release the ball. He described that his arm was externally rotated and raised to 90+/- degrees of abduction in the loaded position of cocking for a throw. Another player tackled him making contact with the arm which forced the arm backwards and further into external rotation. The blow took the glenohumeral joint beyond its normal joint range of motion. This type of impact causes the humerus to sharply rotate within the glenoid stressing tendon and ligament structures beyond their tensile strength. Tensile strength is the maximum stress that a material can withstand while being stretched or pulled before failing or breaking. Tendons have great tensile strength, but are practically inelastic and resistant to stretch. In injuries that involve a severe stretch, the muscle most likely is affected, and sometimes the tendinous attachment to the bone is affected. Tendons can also rupture. An example is when the Achilles tendon ruptures and the Gastrocnemius retracts with the soleus muscles going into spasm and acute pain.
Red Flag On The Play
The first red flag to take notice of is the way the injury happened. Anytime the shoulder is taken beyond its normal range of motion, there is potential for serious musculotendinous junction or ligament damage. I helped this boy's father out with some nagging elbow pain a couple of years ago so when his son was complaining of shoulder pain, he called me. They came into the office and told me he was having pain on certain movements, nagging pain in the back of the shoulder and the chief complaint was instability. He complained he could no longer do a bench press in his workout even when he lowered his weights. (Extra tidbit: A bench press exercise is not a good idea anyway for a valuable throwing shoulder because the bar doesn't allow for the natural rotation of the shoulder joint. The use of free-weights in a dumbbell press accomplishes the same strength goal without the potential risk of damage to the shoulder joint.)
It is always interesting to me the details left out by a client because they don't think it is necessary information to the treatment of massage therapy. He didn't tell me he had a previous tear. It was revealed during the assessments. Based on the red flags the assessments threw up, I asked him if he had ever been diagnosed with a labral issue. He looked at me and said, "yes, last year but the doctor said it was so small I could play. But this feels different and I can't throw as far or as hard (loss of power)."
Second red flag for you to take notice of is that instability is the main complaint and loss of power. This indicates a possible tear of either a muscle or the labrium.
The first assessment I performed was a length test asking him to show me his range of motion in abduction, adduction, flexion, extension, internal rotation and external rotation. I also asked him to stop at any range that caused pain and to point where he felt the pain was coming from. "There isn't any real pain it just feels unstable and aches in the back of my shoulder." I compared his active range of motion with his passive range of motion. On external rotation, he had a clunk and a slippage sensation. This is an orthopedic assessment called the "clunk" test. The third red flag for you to take notice of is a clunk, snap or pop which are signs and symptoms of a possible labral tear.
The second assessment was the use of manual muscle testing examining the strength of the shoulder complex. Manual muscle testing is used to determine the capability of muscles or muscle groups to function in movement and their ability to provide stability and support. I performed manual muscle testing to the shoulder complex of muscles which included supraspinatus, infraspinatus, teres minor/major, anterior deltoid, middle deltoid, posterior deltoid, upper trapezius, middle trapezius, lower trapezius, latissimus dorsi, pec major/minor and serratus.
When you perform manual muscle testing, there should be a definite feeling of a muscle locking into place without quivering. He had a trembling or shuddering feeling against my resistance not a firm locking in of the joint (instability).
The fourth red flag for you to take notice of is that during the manual muscle test, there was not a definite locking in place there was more of a wavering when the muscles were subjected to pressure. This can be an indication of a tear and/or extreme inflammation. For more information on how to perform manual muscle testing, I suggest reading, MUSCLES Testing and Function with Posture and Pain, Fifth Edition, Lippincott Williams & Wilkins, by Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, May McIntyre Rodgers, William Anthony Romani.
I explained to his father and to him the objective findings. I also explained that underneath my scope of practice, I am not allowed to diagnose. The reason for the assessment is to make sure they are a candidate for massage therapy and there are no contraindications to treatment. I explained that based on the instability, the poor muscle function test and his past medical history, I would recommend they go back to their orthopedic surgeon. There is always a possibility he might have done further damage since he received another direct blow to the shoulder. I told him, the sooner you get this taken care of, the faster you will be ready to play football next season and not miss out on your senior year of high school.
I received a phone call a week later from his mother thanking me immensely. She explained the new MRI showed an additional labral tear and a partial supraspinatus tear. She told me he was scheduled to have surgery right away so he would have time to rehabilitate and be able to play in his senior year. They were very grateful because they were hoping for a football scholarship to help out with the college tuition.
Without doing an assessment, you are guessing. Timing and rehabilitation are always critical when it comes to sports. Delaying the surgical intervention would have prolonged the client's recovery and return to play. He may have lost his window of opportunity to earn his chances of an athletic scholarship.
All red flags are contraindications for treatment and are indications for a medical referral. He has completed physical therapy. He is seeing me once a week for maintenance and is leading the way with his high school football team. Everything indicates he will get that college scholarship and who knows what is next. The scouts are looking at him!
Click here for more information about Debbie Roberts, LMT.
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