Fascial Release and Frozen Shoulder Release

Frozen shoulder is becoming more and more of a condition in our society. Another name for it is Adhesive Capsulitis as the sheet-like capsule that surrounds the joint shortens (unable to stretch, as it should with full shoulder range of motion) and restricts the ability for the shoulder to move. The most common lack of motion includes bringing the arm up the side, up in front of you and reaching across your body.  It occurs as a secondary effect of poor biomechanics of the shoulder, occurring due to trauma, overuse, muscular imbalance, and very often occurs due to dysfunction of another segment or adjacent segment of the shoulder complex like the neck, midback,  collar bone, shoulder blade. Very often when I feel for mobility of the shoulder or parts of the shoulder complex, I’m able to sense how long the shoulder has been stuck for just by how much flex is available in the joint and very often, it feels to me like the shoulder has been stuck from much longer than the symptoms have been present.

What can often happen over time is that we are so dominant with using our front shoulder musculature much more often than our back shoulder musculature, and that creates an imbalance (as you prefer equal strength between the front and the back shoulder musculature). The shoulder joint, called the Glenohumeral joint,   is considered a joint similar to a ball and socket, like a trailer going on a trailer hitch, but because it is so mobile, the socket is quite shallow, and for that reason, the top of the arm bone (which is considered the ball of the “ball and socket joint” can translate forward a bit, pulled by the tighter front shoulder muscles. There is a little law with the soft tissues of the body called the Law of Adaptive Shortening. The dictates that if the Soft Tissue is put in a shortened position for a long period of time,  then little cross bridges will develop between the different surfaces of the tissue and will not allow that tissue to stretch. This is similar to pouring glue on a Bungy Cord and seeing how the bungy cord can’t stretch. So imagine that we have stronger, shortened front shoulder tissue, like the front chest muscles call the Pectoralis muscles. They pull the top of the arm bone forward. This causes pinching of the shoulder and pain occurring at about half of the intended movement of the shoulder. So to avoid pain, you just stop moving the shoulder as much, when you do that, then the tissue become adhered, from the Law of Adaptive Shortening, and slowly all the tissues around the joint like muscles, tendons, ligaments and other connective tissue will shorten all through the entire shoulder complex (neck, upper back, shoulder blade, collar bone ect and all of their muscles, tendons, ligaments ect) will shorten up making the shoulder movement much less and subject to discomfort at the shoulder and at adjacent areas.

So the thing about releasing all these tissues and regaining mobility of the shoulder is that you have to think more globally than just where the pain is. Tissue restriction can occur down your arm, throughout the ribs, the shoulder blade can be stuck, the vertebrae of the back and neck can be limited in movement, the collar bone can be stuck, to name a few, in addition to the actual shoulder joint. The tissues that are holding all of these segments has become dehydrated and very tough so patience is required when gaining mobility and rehydrating the tissues. It is not about the pressure to release the tissues, its about the amount of time that you hold the stretch. Many times, it can be 5 minutes or more, of which, the first two minutes there is literally no movement, then slowly the “thawing” begins. This time spent, means the tissue release will be longer and will be better received by the body.
I’ve had some really really frozen shoulders, and it has seemed that it has responded really well with this form of treatment. Myofascial Release has really proven to be the more effective form of treatment for Frozen Shoulder.

Myofascial Release

This is probably the most important blog entry for me so far as it is made the most profound effect on my philosophy and treatment protocol. The treatment is called Myofascial Release Therapy. What makes it so significant is what a profound effect Fascial Tissue has the body when the tissue is in a dysfunctional phase.

So, first of all, to appreciate what myofascia is, I think a person needs to understand what it is. Here is a good write up of what Fascia is:

Myofascia is the tough, fibrous connective tissue glue that holds us together. It spider webs throughout our body, forming organ cavities, membranes, coverings for our bones, muscle and circulatory system.

 It makes up ligament, tendon and scar tissue. Myofascia is made up of elastin, collagen, and a liquid component called ground substance.

Elastin provides a degree of pliability to the system. Collagen gives this tissue its strength.

Myofascia weaves its way throughout the body in a pattern that is unique to each individual. Unlike the muscles of the body that have a predictable origin and insertion, the route that myofascia takes is determined by each individual’s stress on the body, beginning at birth.

This fascial pattern is constantly changing. Physical stress in the form of illness, trauma, and postural changes cause a tightening down of the fascial system. Mental stress has been shown to trigger tightening as well. Over time, this can result in abnormal pressure on the nerves, muscles, bones or organs.

We are literally being squeezed from the inside, and numerous symptoms begin to emerge. We may experience pain, loss of motion, decreased energy, difficulty concentrating, and inability to relax and sleep. The myofascia becomes very hard and sticky. It doesn’t allow proper distribution of fluid throughout the body.

I think that description is totally brilliant and to the point.  One of the important facts about it is that it is totally unpredictable and different for each person so there is no “one way to approach it”.  Restrictions in Fascia can great large, traveling up the outside of the leg to the lower back, or can be very focused, as in an adhesion that forms between the vertebrae  (bones) in the back, causing one vertebrae to rotate, causing low back pain, sciatica, with a myriad of symptoms that can be local  or manifest  anywhere in the body.

The important thing is to think  of the body as a whole. It’s not just a foot, or leg, or pelvis or low back. Very often an adhesion in the body can force the rest of the body to adapt to compensate. For example, if an adhesion form in the tissue and muscles on the right side of your neck and it pulls your head over to the right. The balance system in your inner ear really really wants your head to be level but the tight tissue on the right side of your neck doesn’t let your head level, so your body will choose to do it in another part of your body, like your mid back, or your lower back, and that strain is where your symptoms will be. It’s very unpredictable. I will have several cases of Frozen Shoulder and each one will be treated differently as each restriction in the shoulder will be different. I’ve had to adapt to listening to the body to find out what has to be done and what the body is willing to do at that point. You can’t force a body that is in pain. You have to assist the body, not force it.

The next important aspect of Fascia is the physical properties of the Fascia itself. To recap, the Fascia is mainly comprised of Collagen fibers, Elastic Fibers and the fluid ground substance. The important consideration is the extraordinarily high fluid content. This can be applied to the entire body. Do not treat the body like a solid when it is more fluid. The tissues can be like a sponge. When you want it to work properly, like wiping down a counter, you add water to it. Similar to tissue. You want fascia to function well, rehydrate the tissue.  That’s a big component of regaining mobility of Fascia, whether it  is big, traveling up the side of your body, or a tiny portion  that has pulled your neck out of position. The position of your framework (the skeleton) is strongly influenced by the tension of the connective tissue that surrounds it. Imagine wearing a tie or long necklace, learning forward a bit and attaching the other end to your belt, then trying to straighten up, but you can’t because of the tension of the tie/necklace. This is what tight fascia in the front can do. I see a lot of this as we’ve become a society that sits and leans forward a lot, but it’s such a missed component of rehab because often it is the mid/upper back that will be strained and hurt as a result. Just from tight fascia in the front of the torso, can manifest in hip, low, mid and upper back pain, neck pain (as the neck tightens to pull the head level, shoulder pain (as shoulders are pulled forward and cannot move properly without pinching and causing pain down the arm) just to name a few. The essence of Fascial work is to release the Fascia that is restricting the body from moving in the manner that it was designed to move in. The body has an amazing ability to self regulate providing that it has an ability to do so. Allow the joint to move in the manner that they were intended to move in and re-enable the tissues that support them and allow them to move.

The other important physical property of the Fascia is the Collagen component. This is the stronger structural component of fascia. When the fascia shortens,  the collagen portion will as well. As we apply force to lengthen it, the nature of the Collagen, is that it generally takes at least 1 1/2 to 2 minutes before it even begins to lengthen. As the tissue lengthens, you follow it as it may change directions.  Again, fascia is not linear and as it releases, and it’s really about following in the direction that the tissue releases. The time spent releasing the tissues (which can be 3 – 5 minutes) is needed so that the tissue will not rebound and return to it’s original length. It’s not about the deeper pressure that you use, but the time that you spend waiting for the tissue release to occur. It’s about creating a long term effect.

 

I’m moving.

After 6 years of working at Cedar Hill Sports Therapy, I am relocating to a new office with some of my workmates. The new office is
Good To Go Sports Therapy, located at #106-1175 Cook Street in Victoria. It’s nestled in a great spot in a great building so it will be good to work here. Online booking is available at

goodtogo.cliniko.com/bookings

So you can make an appointment any time of the day and see exactly when I have availability. More news to come.

The homecare exercise regime

When in process of rehabilitation, the work that you do at home is just as important as the work done during the treatment. Its a case of maintaining or continuing what progress was made during the treatment. I think it’s great as it helps to put some control into the hands of the patient so that the condition is manageable. I think we’ve all become accustomed to the philosophy that a person has a treatable condition, they come in to be treated and then they’re better and can continue on without any self-intervention.
As someone that experienced some severe low back issues in the past, I think it’s really important to have solid knowledge as to what is happening and exactly how my home exercises will be improving the condition.
It always seemed to be such an inconvenience though. Something where I had to take time away from my daily activities to do and without a solid understanding as to why I was doing it. People say to me that they just don’t have the time during the day. I think it’s very very important to have even just a little bit of time for yourself during each day. I think that taking that time away and spending it doing the self care is possible. For myself, my favorite thing is to watch a movie. I don’t think of it as watching a movie while I do my stretches. I think of it as stretching while I watch a movie. There is a difference. Watching a good movie is my prime motivation and stretching is just a position that I’m in while I watch the movie. This way, the whole process is more enjoyable and I’m more likely to do it. I have an attention span of about 1 minute. I call it EADD (exercise attention deficit disorder). But watching a movie and stretching is great because time flies so fast. I also play games on my iPad while I’m on the inversion table or I’ll go for a walk in the morning and have a coffee at my destination.
As a therapist, I’m a bit of a talker and usually spend my time talking about what I’m finding and how it is affecting the current condition. Then when it comes to the exercises at the end, I talk about how the exercise will improve the condition that I’ve been talking about during the treatment. Understanding and knowledge makes a person more in control of their condition I believe. It leads them to understand why they are in pain and what message the pain is telling them. It’s no different than having your finger above a candle. Your finger warms up and you pull it away as the low grade pain is telling you a message. An example is the shoulder. If the shoulder falls forward, it may cause a pinching pain when you raise it up. If you feel the pinching pain, then you need to recenter your shoulder so it tracks more efficiently. So it’s my job to tell you what the pain is telling you and what your body is doing and how you can improve your posture/biomechanics to where it is moving more efficiently and the pain is reduced. This makes you more knowledgeable and in control of the condition throughout the entire day.

The importance of Rib and upper back mobility

One constant that I’m finding in a lot of cases from low back pain to shoulder and neck pain is the decreased mobility of the ribs and mid/upper back portion of the spine. The body is intended to maintain some movement in this area, and in it’s absense, can produce symptoms above and below in the shoulder/neck and low back area. As we breath in and out, lean forward, back, side to side and rotate, the ribs will move in relation to each other and the vertebrae of the spine will move in relation to each other. There are several reasons that these areas can stiffen up from immobility of the area, trauma, surgery or past illness (perhaps bronchial or cardiovascular).

The body should be likened to a tree. A tree from the trunk up to the very top has the ability to be flexible along to entire length (obviously more flexible than other areas) but this flexibility is what helps it be strong so when a wind comes up, the forces are distributed along the entire length, so (unless there is an extremely strong wind) it should maintain it’s integrity. Now imagine that you put a metal collar around the middle 2/3d’s of the tree and not allow that portion to flex and reintroduce the wind to the tree. In the absence of the flexibility of the middle 2/3rd’s of the tree, the part of the tree just below now is having to bear the burden that the middle 2/3rd should be doing. The chance of the tree breaking just below the collar increases. Obviously, we will not “break” like a tree but in our instance, the forces inposed on the lower back in absence of good movement in the ribs and mid back will be present.
A person may have very tight shoulders that are pulled forward and a very stiff middle back. When I ask if they can pull their shoulders back, most of the movement involves arching at the lower back to bring the shoulders back. The lower back is an important area and needs to be kept in a neutral position while in a static position as well as movements but is often asked to move out of it’s optimal position to compensate for things like stiff mid back/ ribs or stiff hips.

An area that has become stiff is very difficult often to become aware of as the body is very good at compensating. Personally, I have had an issue with low back pain. My biggest improvement occurred when I worked on mobilizing my ribs, middle and upper back and increased my hip range of motion. Both my hips didn’t extend (move back) very well and my left hip didn’t turn inwards very well and my low back was doing that work. There is only up to 20 degrees of rotation available in the low back so it needs to be used sparingly and shouldn’t be used making up for lack of movement in other joints.
Part of my job is to ensure good movement in the joints that are lacking to the degree that the patient is able to maintain the proper range of motion at home with stretching. Often the less mobile joint is stuck enough that my work is needed to get it going to the point that the patient can maintain it’s flexibility at home.

The second part of the process is often harder and involves the patient being aware now that the joint or body part is now mobile and integrating it into their functional movements such as turning or picking something up or simply walking. A home exercise may be something as simple as sitting and placing your hands on the sides of your abdomen and turning but not allowing your hands to move so that all your movement is in your mid back, just to get the person used to being able to move through the midback.
Each case is different but the philosophy remains the same in that a body’s stability depends very much in it’s systemic flexibility and any rigidity can produce instability.

TMJ and Shoulder/Head Position

I have had people come in with complaints of jaw pain. There can be many reasons for this discomfort. It may come from sudden trauma like impact to that area. It may be from a recent visit to the dentist with work being done or simply having the jaw open for a long period of time. Trigger points (focused hyper-irritable points) in the muscles that move the jaw can refer pain to that area. There has been one consistant factor that I have noticed with people with jaw discomfort and it is the position of the shoulders and head in relation to the rest of the body. Most often the shoulders are rolled in and slightly forward and the head is also in a forward position.
There is an important relationship with head position and jaw position. The more the head is forward, the more the jaw will move back. Do a test on yourself. Gently close your teeth with your jaw relaxed and gently let your teeth touch each other so everything is relaxed and natural. Now jut your head forward slowly until it stops and your lower teeth should feel like they are moving back in relation to the upper teeth. At this point, the jaw joint (just in front of your ear) is being compressed in the same manner that if you were sitting and someone pushed your shoulders down, your spine would be compressed. Keeping the jaw compressed will doing simple actions like talking and chewing can put low grade strain on the joint and eventually causing problems down the line. This all ties in with the general benefits of good posture.
There is an interesting biomechanic that is not well known with the jaw as well. The joint is made up of two parts. One part has small forward and backward motions and the other is the “hinge” type movement that does the main opening part. When the jaw opens, first there is a slight forward movement, the the second joint hinges open (similar to a hinge in a door). The first forward movement is critical for good movement and if there is a “head forward – jaw back” presentation, then the jaw will not be able to make that first crucial jaw forward movement.
A “shoulder forward – head forward – jaw stuck in back position” can start often in the mid to upper back with tissue tightness and joint fixations that can be literally holding a person there making it very difficult for a person to get themselves in a position where they should be. That is where I come in to remind a patient where they should be and release the tissues and joints and give them home care to make it possible for them to be where they should be.
The biggest comment that I get when I reposition a patient to their optimal position is “that just feels weird” but often at the same time, there is better range of motion and less pain. So I tell them to use that as a beacon rather than the weird position that they feel in. Go where there is reduction of symptoms.
Watch out for things that draw your head forward. It is okay for short periods of time but things like computer use and work positions should have some attention paid to them.
Here’s a link to some good pictures of the jaw joint and some of the surround tissue that can become inflamed in the process.

http://www.google.ca/search?q=pictures+of+jaw+joint&ie=UTF-8&oe=UTF-8&hl=en&client=safari#biv=i|17;d|AGhp8EGhpOON2M:

It’s kind of a chicken and egg scenario. In my case, I assume it’s both the chicken and egg and cover both bases. Release the muscles and surrounding connective tissue, make sure the joint is positioned well and moving properly during it’s movement, ensure that the body is positioned well enough that the jaw is not forced into a position and will affect good motion and empower the patient to maintain that good position.

Neck pain and difficulty turning

To follow with my previous post about form and function, I wanted to discuss the problems with neck pain and spasm with difficulty turning the head. Often I might find that there is an imbalance with the shoulders and that the neck is extending the twisting to compensate so that you are looking straight forward. This reaction is subconscious and we don’t realize that we are doing it. We only know that our neck really hurts.

My job would be to help to realign the vertebrae in the neck using tissue release and other techniques to allow the movement necessary to return the neck to it’s original position but also to consider why the shoulders are out of position, forcing the neck to do what it is doing to compensate. There may be something further down that is pulling the shoulders out of position, so we chase the cause as far as it goes so that the trigger doesn’t pull your neck out of position again. As in my last post, part of the success is me and part will be the patient as we stretch, strengthen and create awareness of what they might be doing that causes the trigger to re-occur. Some triggers are completely avoidable, and some are only modifiable (if that’s a real word). It is very difficult to stop doing what we might have been doing for years and years so we need to use discomfort as a reminder that we have fallen into this pattern again. Pain isn’t such a bad thing if we know what it means and how we can change to reduce it.

I have seen a cases where there is a fallen arch in the right foot. This translates to the right pelvis being rotated forward, pulling the whole body forward and turned to the left, so the right low back tightens the pull the body back up right. It often might go too far so that the left shoulder is forward and higher than the right shoulder so your head is tilted to the right. The left neck muscles tighten to pull the head so it is level (subconscious righting mechanism) so the vertebrae in the neck are compressed on the left and open and unstable on the right with there being a possibility of pain occurring on either side for different reasons.

This whole thing can cause foot, knee, hip, low-mid back, shoulder and/or neck pain just because of one little fallen arch. If I only look at your neck, I’m probably not doing you a favour. We need to look at the whole body to see the general picture.

Crazy these bodies we have.