Massage Case Study: Shoulder pain after surgery

Author: Massage Sloth

Hi, everyone. I'm Ian Harvey, massage therapist. Today we're going to be working with a client who had a shoulder surgery a few years ago. It still gives her some trouble, and I kind of wanted to give you a case study on how I would work with this client. This won't apply to every single shoulder surgery client, but I think that a lot of it will be broadly applicable.

If you'd like to skip ahead, you can click on the table of contents down in the description. I've got Shelby here. Hello. Shelby, tell me about your shoulder. Now, which shoulder is this? It's my right shoulder. Okay. And when ... So, you had surgery, correct? Mm-hmm.

I had surgery three years ago. Three years ago. Why did you need that surgery? I had a torn labrum, so they had to do a SLAP repair. Pretty much there's three anchors holding everything together, is what they told me. Okay. Okay. Now, what were your symptoms prior to the surgery? I was just having a lot of pain, my range of motion was impaired, I couldn't really carry any weight or anything like that.

Gotcha. And so eventually you just had to go to the doctor. Yeah, I had to go in and they put me in physical therapy, they couldn't really figure anything out.

Massage Case Study: Shoulder pain after surgery

They actually had to do an MRI with contrast to see the tear. Okay, so they noticed this tear, and they did an endoscopic surgery, just with a tiny incision. Oh, yeah.

There's this tiny little scar that I have. So there's no incision site I have to worry about, is one reason I asked about that. Now, these three anchors, and I'm sorry, when I talk to those guys, just ignore them. Just ignore them. Exactly. So there's three anchors. Can you feel them? No.

Okay. Even if you press in there? Nope. Okay. And so when someone has hardware following a repair, just ask whether it is palpable, and if it's not, try not to worry about it too much. But if there is a palpable piece of hardware, screw or what have you, just make sure that it's not a painful area, and make sure that you're not causing it any distress. If I'm ever pressing in this area and I hit a point that just seems oddly painful or sensitive, please do let me know, okay? Okay.

How is your range of motion now? It's pretty good. I have issues at night going to unhook my bra, but otherwise I can do whatever crazy arm motions. Now, when you try to move your arm behind your back, where do you feel that restriction? It pulls right up in this area. Okay, so you're feeling it on the front. So, one thing to note is that when someone points something out on your body, I always recommend that you point it out on yourself, so they know that you understand, so they feel heard. Also, later, when I'm doing the massage, I'll remember touching my own shoulder, and it'll help me remember where that pain was.

So as I'm working near or around this area, if that area ever starts to become sensitive, if it ever starts to become more and more sensitive with every contact, please do let me know. And if any of this hurts, if anything's too much, please do give me a heads up, alright? Okay. Alright, so to start, I'm going to just do a general warm-up of both sides.

I'm not going to concentrate on one side more than the other. I've got some jojoba oil on my hands here. By the way, I've never talked about this secret technique, but if I'm ever working on someone's head and neck region, and I need to breathe, I like to breathe out the side of my mouth. So if you see me doing that with my face, it's so I don't breathe in her face. So just some general warming strokes. Include the upper chest. Include the upper traps.

Allow your techniques to come around the deltoids. And I like to end up toward the base of the skull. Very frequently with shoulder dysfunction, it's not a problem that you find in isolation. There will be other parts that come with pain and dysfunction in the shoulder. So during the intake, I asked about headache and there was some of that going on. Do you mind if I tell them about that? Oh, yeah. So there was some headache at the base of the skull, and that's not directly related to shoulder pain, but if the shoulder is acting up, I expect for there to be tension in the traps, and for that to have effects all the way up. So, if your client tells you about shoulder pain, make sure to ask about other things in the region.

As I'm warming this area up, I'm not doing anything too specific with my fingers or my thumbs. One part of massage for an area that becomes chronically sensitive or chronically inflamed is proving to that client's nervous system that this area is capable of feeling good. I want to not just provide that sharp, painful stimulus for this entire treatment, because they already have enough painful stimulus. Giving them something else, giving their brain and their spine something else to think about, might help them realize that this shoulder's capable of more than just pain and spasm and tightness. Once I've done some nice bilateral work, I will move to unilateral, and I've been asked whether I should work with the part that isn't in pain or the part that does have pain first. I think that both are fine choices. If you work with the painless side first, that can kind of prepare this side for contact.

It can kind of set an example of what that massage is going to be like, in a less high-pressure environment. So it might allow your client to ease into this pressure a little bit more if you start with that painless side. That said, going straight to the side that has issues is a good way of letting your client know that you have heard them, that you are listening, and that you have the same priorities that they do. I'm going to do the head turning maneuver right here.

If you'd like to see a whole video on that, you can click down in the description. This gives me some space so I can work more specifically with this right trap, and this is a good way of establishing that connection between the chest and the neck. Shelby, you might have noticed your head turning as I was going this way without that supporting hand. There's an interesting fascial connection between the chest and the neck. I've got a suspicion that bilateral tightness of the chest has a pretty profound affect on the neck. So, now I'm going to work more specifically with the traps, and start including this painful area, kind of generally. So, her pain was centered right around the coracoid process, and going inward along this collar bone, just inferior to it. So I do want to make direct contact with this area, but I don't want to start with pinpoint pressure.

I'm not here to work with trigger points. Trigger points are a perfectly fine thing to work with here, but it's not something I want to do in this area that is distressed. If it already has that sensitivity, I see no need to provoke it any further. So I'm going to start it with this nice, supportive contact. So in the spirit of applying that supportive stimulus, I'm going to start introducing some movement.

I'm compressing this head of the humerus into the glenohumeral joint. I'm compressing the entire shoulder girdle, and working upward. And this compression inward can be a strong stimulus to turn off sensitivity and to turn off spasm. And it's an excellent way of introducing movement.

People who have post-surgery pain, tightness, they might do a lot of unconscious holding of the shoulder, keeping it in a very specific configuration. Just by gently using your body weight to apply pressure, allowing this to come from the rocking of your body, that can convince this area to let go just a little bit. Now I'm going to start working more directly with this region that has some pain. I'm still outlining this inferior clavicle, and just around this coracoid process, and going down into the deltoids. Not using a ton of pressure here. I'm creating that outline, but I'm not trying to strip anything out. I don't think that there is anything that I need to break up here.

The body is done with the remodeling phase, mostly. The scar tissue that was created during the endoscopic surgery has mostly been remodeled to be functional. There is still some dysfunction, but I'm suspecting the nervous system, rather than any adhesions that need to be broken up or what have you. And if there are adhesions between sliding surfaces, I'm not going to be the one to break them down or break them up. That's going to take time and it's going to be through her movement, and her stretching and exercise, and just living her life. If we were able to break up those adhesions, we would also be breaking up the local vasculature, there would be internal bleeding, it's not really something we can do.

Now I'd like to start introducing contact with the scapula. Even though the pain is up here, I suspect that the dysfunction is back here. I can't work directly with the labrum. I can't change anything about it. The pain that's up here, I suspect of coming from the posterior aspect of this shoulder.

My main suspects are infraspinatus, and I'm betting that the teres muscles are involved as well. And I'd like to make contact with subscapularis. My main suspect is infraspinatus, and we'll see more about that in a moment. But for right now I'm just doing some gentle strips toward myself. I'm outlining the features of that scapula. I'm coming just under the spine of the scapula. I'm coming toward each edge of the scapula, and coming all the way out toward this humerus.

Again, I'm telling the story of this shoulder. I'm not trying to work on any specific points. That's something that I will work with later, especially in future sessions. This is my first time working with this shoulder, so I don't want to overdo it with the specific work. I want to see what we can accomplish with this moderate contact, and a moderate duration. In the future, we can increase that duration, we can increase that specificity, and possibly that pressure as well. But if that's now it ends up working out, if she gets good relief from this, then I might not increase that specificity. If we eventually hit a wall where there's no further improvement, then I might tweak my approach just a bit.

Once I've warmed this area up and started mobilizing it, I'd like to increase the amount of mobility that I'm introducing to this area. I want to rotate the shoulder in a way that is safe, that feels safe, for the client, for her nervous system, and I want to kind of prove that this area can rotate painlessly. I'm not going to be taking it toward her endpoint where she feels that pain, but I still want to play with that painless rotation. This can apply for all sorts of shoulder impingements. No matter what their limitation is, if you work within their range of motion, gently and slowly, then you can send a message to the nervous system that that movement can be safe.

To do that, drape the client's arm over your arm. Her right hand is resting in my right inner elbow. Now I can apply pressure down toward the table, so down toward that area where she feels that pain, and I like to use a nice, big, supportive hand here, and bring the other hand around to the other side. I'm compressing upward with this hand and downward with this hand, and as I rock my body, I'm creating movement at the level of her shoulder girdle, and I'm rotating her arm just by moving in this little circle here. Something that I do to increase the effectiveness of this holding and rocking is to apply my own body to this elbow. So, Shelby, is it okay if I press my ribcage against your elbow? Okay. So, I will press forward against that elbow, and so now I'm compressing this humerus up into that glenohumeral joint. That can turn off some of that pain and some of that spasm.

And as I'm doing that, I can continue to mobilize this shoulder. I can continue to outline the deltoid, and I can work more specifically with this region around the coracoid process. By having the arm so thoroughly cradled, it can feel much safer for movement to happen, and for a little bit of specificity to be introduced. And so I'm still making those little strips, using my bottom hand, up along the scapula, and compressing just below that coracoid process, and just inferior to the clavicle.

Once I have them flipped over, I don't want to over-focus on that area that's in pain. I want to work on it in the context of the entire back. That's not to say that I'm not going to give specific pressure in that area, because I do want to acknowledge that pain, I want to acknowledge that shoulder that she told me about, and I also don't want to overwork it this first session, or leave my client feeling cut up into little bits. If I over-focus on that shoulder, I can nonverbally reinforce the idea of the “bad shoulder.” Once I've warmed the general area up, I want to start by working broadly with this region. Again, I don't want to make this part feel excluded from the rest of the body so I'm frequently going to be using these broad connecting strokes. Even though I suspect that there is some dysfunction in this scapular region, I still want to make contact all around it.

Think locally, act globally. Don't just work where the pain is. I still want to be mobilizing this area, so I've got my elbow connected to my hip side region. I've got a nice broad hand conforming to the side of her body, considering the three-dimensionality of the body.

I’m going to straighten my arm and continue using my body weight to apply pressure up the side of this entire thoracic region. Right now I'm making contact with the teres muscles and all these lateral muscles, and I'm mobilizing the shoulder. I'm bringing it up just a bit, and proving to this area that it can painlessly move. Once I've brought it up, I like to bring it back down. Then, if I want to work more specifically, I can use a nice broad, soft hand. If your fingers don't bend this way, there's another way of applying these metacarpophalangeal joints.

So, I'm coming at this from the other direction. This lets my fingers be a little more extended as I work. I've got this mother hand that I'm applying to her back, just a broad, supportive contact, and I am applying pressure with my knuckles here, then along this scapula. I'm using this other hand to apply that nice, comforting pressure, and to create a bit of fascial traction. These two hands are moving away from each other, and the pressure is happening at 45-degree angles. So I'm pushing and pulling at the same time, but in both cases, I'm using my body weight.

I like to do a couple of passes down this scapula. And then I'll start to work more specifically. This time I'm going to use my paired thumbs to travel along this lateral border of the scapula.

You're going to find the teres muscles there. Stay in communication with your client. Let me know if any of this ever becomes a little more sensitive, okay? Mm-hmm. And go slowly with this. Feel free, even if your client hasn't alerted you to any extra sensitivity, feel free to just hang out for a bit. The body can make some interesting changes during these static contacts.

And, Shelby, I just want to check in and make sure that this isn't too much pressure. No, it's fine. Okay. Good. I'll repeat that along this posterior surface of the scapula, so in this infraspinous fossa, and I'm not trying to really target anything too specifically, I'm just trying to outline the scapula. If I happen to come across an area of heightened sensitivity, or that refers pain forward, that's something that I'll make a mental note of.

I might spend a little extra time there. But this is something that I want to work with over many sessions. This isn't something that I want to try to fix in one single session. Finally, make sure to work with this area in a lot of different configurations. With the arm, rotate it downward like this, so that's external rotation. You can have the arm up in front of the head.

If I were to put my stool over here, she could have her arm up on that. And you can always do the hand in the small of the back bit, which usually feels pretty good, but I wouldn't do it with this particular client. I don't want to provoke a spasm or for there to be too much soreness the next day. So mobilize this shoulder with the arm in different positions, work with this shoulder blade, with the arm in different positions. You can do some gentle rocking and some gentle compression inward of this humerus region, and all of these associated muscles are going to act and feel different when you have the arm in a different position. These are just different stimuli that you can give to this region to convince it that there's not any imminent danger, that they can let go of some of that guarding.

Eventually, some of that sensitivity. Alright, that's my post-shoulder surgery demo. Thanks to all of my Patreon supporters who make this possible, I really appreciate it. If you'd like to help me reach my goal of 500 people supporting this channel directly, check that out down in the description.

Let me know what you think down in the comments, consider subscribing, and I'll see you next time.

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