Case Study: Myofascial Pain of the Posterior Shoulder Relieved by Spray and Stretch

Transcription

1 /81 / $02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O 1981 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Case Study: Myofascial Pain of the Posterior Shoulder Relieved by Spray and Stretch A. JEROME NIELSEN,* BA, MA This article presents the rationale for the use of the spray and stretch technique for commonly found myofascial pain syndromes. General principles of this technique are briefly discussed, with emphasis on shoulder pain patterns. The muscles which cause anterior shoulder pain and middle deltoid pain are discussed. The muscles which cause posterior shoulder pain are examined as part of the case study. The case study describes posterior shoulder pain with radiation down the back of the upper arm and down the ulnar side of the forearm. The specific pain pattern for the subscapularis is presented. Muscles potentially referring pain to the back of the shoulder are described both for examination and treatment. Results and follow up are reported. INTRODUCTION TravellI4 has reported extensively on the spray and stretch technique. The method was based Acute and chronic musculoskeletal pains are upon the identification of the TP3s, small hypercommonly due trigger points irritable regions in muscle, fascia, or skin from (TP's). This case study describes the rationale which impulses bombard the central nervous for and use of a spray and stretch technique on system and give rise to referred pain.17 ~ ~ ~ ~ ~ l l ' s a patient with myofascitis of the right shoulder described TP,s as being active or latent, Those muscles. By identifying the various muscles har- TP,s which were sufficiently hyperirritable to proboring TP's and by using the spray and stretch duce a clinical pain were considered technique, the patient's right posterior shoulder active, When firm pressure was applied to an pain was eliminated. active TP for about 5 to 10 seconds, the patient's clinical complaint of pain was often reproduced. RATIONALE Palpation of both active and latent TP's may Musculoskeletal pain caused by myofascial cause a "local twitch response." This response TP,s has been the source of much confusion and Can be elicited by placing the patient's muscle controversy in the past. These disorders have under moderate tension, applying firm pressure, been described as fibrositis, myositis, myalgia, and briskly pulling the finger across the firm myofascitis, nonarticular rheumatism, and musband of muscle.' This maneuver produces the cular strain; characteristic pathological changes twitch by causing the band of muscle to contract; have been described by some'-3312 and no the patient may also wince and cry out, which is changes by others.''. j3 This apparent contradica "jump sign" in its original meaning. tion is explained by an initial dysfunctional phase Latent TP's, those that were less h~~erirritathat is free of pathology by routine techniques ble, may be exquisitely tender to palpation and but which can evolve into a dystrophic phase may also result in a local twitch response, origiexhibiting pa tho log^.^.^ The muscle with the TP nally misnamed "jump sign."'. lo When palpated, however, these TP's were much less likely to is free of spontaneous motor unit activity, but reproduce the pain. Normal muscle is not painful muscles in the reference zone of pain and those to pressure and does not exhibit a local twitch in protective spasm may be electromyographiresponse. Both active and latent TP's may accally active when the patient is at rest.7 count for some limitation of joint motion and for some muscle weakness. When both active and ' latent TP's are identified, it is expedient to treat Associate Professor. Physical Therapy Department. California State College at Long Beach. Long Beach. CA both. Although latent TP's may lie dormant for 2 1

2 22 NIELSEN JOSPT Vol. 3, No. 1 years, they may be activated by minor stress, overuse, and chilling. Mechanical stress due to a leg length difference, a small hemipelvis, short upper arms, and a long second metatarsal bone can be critically important perpetuating factors in myofascial pain syndromes.16 Many other factors can be contributory to these muscle problems, such as nutritional deficiencies (low vitamin C, Bl, B6, B12, and folic acid levels), reduced thyroid function, hypoglycemia, calcium deficiency, and low serum potassium. Other sources of muscle irritability are chronic infections and uncontrolled allergy l6 Patterns of referred pain from TP's are centrally mediated and do not follow the distribution of sclerotomes, dermatomes, or peripheral nerves. The area to which a TP refers pain is called a reference zone. The zone could be near but is usually located at a considerable distance from the TP. Body forms that illustrate many TP's and their reference zones have been published." TECHNIQUE The spray and stretch technique requires the positioning of the patient in a well-supported, relaxed position with the specific muscle containing the TP on a maximal but tolerable stretch. The therapist sprays the skin overlying the muscle in sweeps parallel to and covering the muscle, spraying in only one direction, from the TP toward the reference zone. The sweeps are usually about millimeters (lh-% inch) apart and cover the skin once or at most twice. The skin should be only transiently cooled and not the underlying muscle. Refrigeration anesthesia is a~oided.~ Of the two vapocoolant sprays commercially available, Fluori-Methane (Fluori-Methane Spraya; Gebauer Chemical Co., Cleveland, OH) is superior to ethyl chloride because it is nonflammable, not explosive, not a general anesthetic, nontoxic to the skin, a'nd not excessively cold. Once the liquid stream (not mist) has touched the warm skin and cooling is produced by evaporation, a sensory message travels to the central nervous system permitting the muscle to tolerate ~tretch.~ The spray influences deep, inaccessible TP's by neurogenic effects from the skin.'= Passive stretching is gradually applied during spraying. After a muscle has been passively stretched to its maximal normal range, the therapist should return the part to a neutral position before asking the patient to activate the treated muscle. To avoid possible spasm, the muscle should not be loaded during the first contraction. The TP on palpation may have disappeared completely or may have been reduced in tenderness and h~perirritability.~ SHOULDER PAIN PATTERNS Active TP's in the scalene muscles may refer pain in three directions, anteriorly with two finger-like projections to the anterior chest, down the arm to the fingers, and posteriorly to the upper back over the scapular attachment of the levator scapulae.17 This posterior pain pattern is very common. Active TP's in the scalene muscles also commonly refer pain down the arm.17 Active TP's in the scalenus anticus and medius may refer pain to the thumb and index finger." Additional entrapment symptoms may be caused by TP shortening of the scalene muscles. When the anterior and middle scalene muscles entrap the brachial plexus, neuritic pain is also felt in the ulnar side of the hand along with paresthesia and sensory impairment.'' Ten muscles can cause anterior shoulder pain: anterior deltoid, infraspinatus, biceps brachii, brachialis, scaleni, pectoralis major and minor, sternalis, lumbar level latissimus dorsi (rare), and coracobrachialis. Three muscles can cause middle deltoid pain: middle deltoid, teres minor, and supraspinatus. Seven muscles can refer pain to the posterior shoulder and nearby scapular region: teres major, subscapularis, rhomboids, serratus posterior superior, triceps brachii, latissimus dorsi, and levator scapulae. CASE STUDY History A 59-year-old male dentist was referred to physical therapy complaining of right shoulder pain with radiation down the back of the upper arm and some down the ulnar side of the forearm. He played racquet ball regularly three to four times per week. His pain started about 1 month prior to treatment and became increasingly painful despite his efforts to continue playing. Hot showers and massage had been tried but did not afford any significant relief. Because of radiating arm pain, he sought medical help and was referred to this examiner.

3 JOSPT Summer 1981 MYOFASCIAL PAIN OF THE POSTERIOR SHOULDER 2 3 Examination Before examining the patient's shoulder muscles, it was important to rule out cervical radiculopathy as a cause for his pain in the ulnar distribution. The patient had neither pain in his neck nor increased pain down his arm when actively completing all movements of his neck. He did exhibit a lack of approximately 15' of neck rotation to both right and left. Passively, all neck movements were then performed through full range with no change in pain. With the patient seated, downward pressure was applied to the head while it was held in slight extension; this did not increase nor change his pain pattern. Next, the scalene muscles were palpated and found clear of TP's. While going through the active and then passive movements of the shoulder, the examiner discovered that the patient had marked shortening of his pectoral muscles and possible tightness of the subscapularis. When the patient was supine with both arms abducted to 90, external rotation of his shoulders lacked 25" of touching the table. Since this patient's pain was over the back of the shoulder, the seven muscles referring pain to this area were examined with the patient sitting. The latissimus dorsi TP was located through palpation by grasping the muscle between the thumb and index finger in the posterior axillary fold. The muscle was raised up and rolled between the finger and thumb. Tense firm bands were identified and the region of maximum tenderness located in each band. These TP's were tender to palpation and elicited a local twitch response, as well as increased posterior shoulder pain and pain down the ulnar side of the arm. This duplicated the pain pattern for this muscle, as well as his pain complaint, and indicated it was an active TP.I5 Next, the teres major was palpated by moving slightly above the location of the latissimus dorsi. It was palpated directly against the scapula following its lower border of the teres major fibers onto the scapula from the posterior axillary fold. This muscle responded with a local twitch response when the TP was rolled between the fingers. Stimulation of the teres major TP by sustained pressure reproduced his posterior shoulder pain. The rhomboids were palpated along and medial to the vertebral border of the right scapula by using a flat pressing type of examination with the thumb or index finger. These muscles were tender and sensitive to pressure but did not show a local twitch response or refer pain to the shoulder. The serratus posterior superior was palpated with the patient's shoulder protracted to uncover this TP. The serratus posterior superior is covered by and therefore was palpated through the trapezius. This TP was exquisitely tender to pressure of one finger but did not show a local twitch response or radiate pain to the shoulder, therefore indicating a latent TP.I5 The subscapularis was examined by palpating the thick upper band of muscle that lies on the deep surface just inside the axillary border of the scapula. With the arm passively abducted to 90, it was now possible to draw the scapula to the side exposing its ventral surface for palpation. The examiner then reached deeply into the axilla between the ribs and the scapula, palpating the subscapularis against the inside of the scapula, including the cephalad portion of the muscle. Pressure on this TP caused pain referred to his posterior shoulder region but not to his wrist, as it sometimes does (Fig. 1 ). The sixth muscle was the triceps brachii. The commonly seen TP in the long head was found deep in the midbelly just below the lower edge of the posterior deltoid muscle. When pressed, it referred pain to the posterior shoulder and down the forearm. The seventh muscle, the levator scapulae, did not have any tenderness or signs of a TP. Having thus determined that the patient had myofascial pain due to TP activity in the latissimus dorsi, teres major, subscapularis, and triceps, the spray and stretch techniques were employed. Subsequently, examination of the extensor SUBSCAPULARIS Fig. 1. The X in the axilla locates a TP in the subscapulan's muscle. The solid black area shows the primary pain pattern, and stippled areas indicate additional patterns seen in some patients.

4 2 4 NIELSEN JOSPT Vol. 3, No. 7 muscles of the patients right forearm elicited a local twitch response in the middle finger extensor. The patient did not report any wrist pain. Treatment Before proceeding with spray and stretch to the muscles causing his posterior shoulder pain, the pectoral muscles were given several rounds of spray and stretch treatments with warming of the muscles between each stretch. This was done to permit the arm position necessary for stretching of the latissimus dorsi and subscapularis muscles and also to relieve a cause of the overloaded rhomboid muscles. This was a precaution to prevent reactive cramping, which can occur. With the patient seated, the triceps muscle was sprayed and stretched first. With the elbow fully flexed, the arm was then placed in as much forward flexion as tolerable while the therapist sprayed along the axillary fold toward the elbow, continued downward over the forearm, and included the fourth and fifth fingers (Fig. 2). Next, the examiner proceeded to spray and Fig. 2. Position of the patient and therapist in the technique for spraying and stretching the triceps brachii muscle. Fig. 3. Position of the patient and therapist in the technique for spraying and stretching the latissimus dorsi muscle (lateral fibers). stretch the latissimus dorsi and teres major. Since these two muscles have a similar direction of pull, they can be stretched simultaneously. Seated, the patient hooked his right foot around the front leg of the chair to help stabilize the pelvis. The patient's right elbow was fully flexed, the arm and forearm were brought behind the head, and at the same time the trunk was laterally flexed to the left. Keeping the arm behind the head maintained some external rotation, and pulling the arm back increased the amount of external rotation. As the patient's trunk was laterally flexed, the spray was started at the pelvis and was directed upward, covering the muscle to the posterior axillary area. Then, the spray was continued over the right posterior shoulder area and down the arm on the side of the fourth and fifth fingers. This stretched the lateral fibers of the latissimus dorsi, as well as the teres major (Fig. 3). The horizontal fibers of the latissimus dorsi were sprayed and stretched using a rotational stretch (Fig. 4). The subscapularis was then sprayed and

5 JOSPT Summer 1981 MYOFASCIAL PAIN OF Tt ie POSTERIOR SHOULDER Fig. 4. Position of the patient and therapist in the technique for spraying and stretching the latissimus dorsi muscle (horizontal fibers). stretched. The patient was seated, and the arm of the patient was placed in abduction and external rotation. Meanwhile, the forearm was drawn behind his head as the axillary wall of the trunk was sprayed in an upward direction toward the axilla and over the posterior shoulder and the scapula. The spray was continued down the posterior aspect of the arm (Fig. 5), while the examiner stretched the arm in the direction toward the opposite shoulder, maintaining as much external rotation as possible. The rhomboids and serratus posterior superior were next sprayed and stretched. The patient was seated. By bringing the patient's right arm across the front of his body, toward the opposite hip, a strong pull on the shoulder was applied. At the same time, the skin from the spine across the muscles to the posterior shoulder were sprayed. Stretching continued until the scapula was protracted to its full range (Fig. 6). Following this, the levator scapula was sprayed and stretched with the patient seated. The shoulder was depressed while the head was rotated toward the opposite shoulder and flexed, and the spray was directed from the occiput downward to the scapula. Having completed the spray and stretch technique to these seven muscles, the patient was completely free of any posterior shoulder pain and no longer had any radiating pain down the arm. Actively, he could perform all motions of the shoulder and stated he was free of pain. Fig. 5. Position of the patient and therapist in the technique for spraying and stretching the subscapularis muscle. (Note external rotation of shoulder.) Lastly, the middle finger extensors were sprayed and stretched while the middle finger was held in full flexion as the wrist was gradually brought into full flexion to complete the stretch. The patient was instructed to follow a stretching program on a daily basis for the latissimus dorsi,. subscapularis, teres major, and triceps muscles. For the tight pectoral muscles, the patient stood in an open doorway with his palms placed on the doorjambs at about the height of his shoulders and leaned through the doorway stretching the lower fibers of the pectoralis major. Next, sliding the hands upward, he placed both his forearms and palms against the doorjamb and leaned forward. He then placed his arms on the doorjambs as high as possible to stretch the lowest fibers of the pectoralis major and the pectoralis minor muscles. Follow-up treatment was needed the next day not because of pain but because of tightness in the pectoral muscles. Spray and stretch to the posterior neck muscles was added to the first day's treatment. This time treatment included the levator scapula and upper trapezius, which returned his neck rotation to normal range.

6 NIELSEN JOSPT Vol. 3, No. 1 cles and 2) very tight pectoral muscles, as well as tightness of the subscapularis. The myofascial pain of the patient's shoulder was relieved by spraying and stretching the muscles that showed active and latent TP activity. The tight pectoral and subscapularis muscles required 10 weeks of diligent stretching on the patient's part in his home program. The patient also reported once a week for 10 weeks for spray and stretch by the therapist. Fig. 6. Position of the patient and therapist in the technique for spraying and stretching the rhomboid muscles and the serratus posterior superior muscle. This patient was seen on follow-up once a week for the next 10 weeks due to the persistent tightness of his pectoral muscles. Hanging from the stall bars was added during the weekly visits. He tolerated a 30-second hang. Long axis distraction of the shoulders was used during the weekly visits as well. DISCUSSION It was the author's opinion that the patient's tightness in his pectoral muscles was due to his working posture in his dental profession. The author has found that a number of posterior shoulder pains are related primarily to the latissimus dorsi and teres major muscles. In this case, the pain came from more than just these two muscles. Frequently, if one muscle has TP's, nearby muscles become involved. SUMMARY In summary, this case presented two problems: I ) a myofasciitis of the right shoulder mus- Appreciation is extended to Janet Travell, MD, for her inspiring demonstrations and to David G. Simons, MD, for his helpful discussions. REFERENCES 1. Abel 0 Jr, Siebert WJ, Earp R: Fibrositis. J Missouri Med Assoc 36: , Awad EA: Interstitial myofibrositis: hypothesis of the mechanism. Arch Phys Med Rehabil 54: Brendstrup P. Jespersen K, Asboe-Hansen G: Morphological and chemical connective tissue changes in fibrositic muscles. Ann Rheum Dis 16: , Mennell JM: Treatment of myofascial pain secondary to facet joint dysfunction by cold. Manuelle Med 10:78-79, Nielsen AJ: Spray and stretch for myofascial pain. Phys Ther 58: Popelianskii II. Zaslavskii ES, Veselovskii VP: Medico-social significance, etiology, pathogenesis, and diagnosis of nonarticular disease of soft tissues of the limbs and back. Vopr Revm 3:38-43, Simons DG: Muscle pain syndromes: I and II. Am J Phys Med 54: , 1975 and 55:15-42, Simons DG: Electrogenic nature of palpable bands and "jump sign" associated with myofascial trigger points. In: Bonica JJ, Albe-Fessard D (eds), Advances in Pain Research and Therapy, Vol 1. New York: Raven Press, Simons DG: Traumatic fibrositis or myofascial trigger points? West J Med 128: Simons DG, Huntington Beach, CA (personal communication) 11. Slocumb CH: Fibrositis. Clinics 2: , Stockman R: The causes, pathology and treatment of chronic rheumatism. Edinb Med J 15: and , Travell JG: Temporomandibular joint dysfunction. J Prosthet Dent 10: Travell JG: Office Hours Day and Night, pp New York: The World Publishing Co, Travell JG: Myofascial trigger points: clinical view. In: Bonica JJ, Albe-Fessard D (eds), Advances in Pain Research and Therapy, Vol 1. pp 91 9 and 926. New York: Raven Press, Travell JG, Washington DC (personal communication) 17. Travell J. Rinzler SH: The myofascial genesis of pain. Postgrad Med 1 1 : , 1952