Australian Papers - Shoulder Impingement Part 5

Shoulder Function.

In recent discussion papers, I have concentrated on the posterior aspect – the limitations placed on the travel of the scapula, because of contractions, or adhesions, in the back muscles, rhomboids, levator, and the like.

I met a client this month, Mrs. C., who presented with the usual symptoms of gleno-humeral limitations – or, frozen shoulder, as we hear sometimes – and she was equipped with the common side-effects:

• Reduced gleno-humeral abduction range, (about 25 degrees )
• Aching sensation in the arm, especially on waking after a night’s sleep,
• Feeling of weakness in the limb, or in her ability to elevate the limb, and,
• Some loss of sensation in the hand and fingers.

On examination, there were signs of fibrosis in the muscles around the scapula, but shortly after I had commenced the exam, she revealed that she had had breast surgery on the right side, only six months prior. I would point out here that it was her husband, not she, who had telephoned for the appointment; he had accompanied her to the clinic, and had gently asked if he could be with her during my examination and treatment.

I have never had issues with requests such as these; where children are involved, I would generally insist that a parent be present. In this case, what I had categorized as a somewhat shy adult, accompanied by a partner, was perfectly entitled to be a part of the proceedings. Once the breast surgery was openly discussed, the reasons for reticence were obvious, and the partner was re-classified in my mind. Not someone displaying power, authority and control, but care and affection.

Surgery can be regarded, depending on your circumstances at the time, as a welcome procedure, or a radical invasion of the body’s resources; I had the opportunity, some years ago, to study under the supervision of the talented Australian medical specialist  Dr. John Casley-Smith. In his field of micro-circulation, he introduced me to the mechanism of scar-tissue development, which, unchecked, develops into fibrosis.

It quickly became obvious that Mrs. C’s gleno-humeral problem was more than the usual scapulo-thoracic lock-up; today, I want to speculate with you the possible side effects of this drastic, life-saving, surgery.

Mrs. C. had a LS mastectomy about 4 months prior to this photo; this procedure included the removal of many ( she thought maybe 14 or 15,) lymph nodes from the pectoral and biceps/triceps zones.

This extensive, laterally applied incision would not have had a direct impact on the pectoral muscle at the time, as the breast tissue normally sits over the pectoralis, with an intervening layer of fascia.

However, the formation of scar tissue, after such a significant event, is quite vigorous, and, with a period of rest and rehabilitation that must of necessity, follow, the scar tissue will have an adhesive effect. After all, this is its primary task – binding together, support, and immobilization, during a fragile period.

In effect, the fibroblast cells responsible for laying down this much-needed tissue tend to work with a remarkable enthusiasm, even to the point of straying outside their designated area. Where a breast unit would normally be free and able to move vertically and laterally over a pectoral muscle, within the limits set by fascia, Mrs. C. had almost none of this mobility. Her gleno-humeral abduction was restricted from the rear, by the scapula mechanics, and from the front, by the pectoral units.

I would mention here, that Dr. Casley-Smith had quoted instances where, following mastectomy, some clients had detectable traces of  excess fibrous tissue not only in the shoulder region, but as far away as the elbow joints on the affected side. We could imagine, therefore, that not only was scar tissue holding Mrs. C’s skin layers together, but the repaired skin was also attached to the underlying muscle – the muscle units could also be attached to the thorax……

I will report further on Mrs. C’s progress in the coming months – for the present, the three of us are concentrating on pectoralis stretches – they’re difficult, and at times uncomfortable, but, other than further surgery, there is no alternative.

Keep your letters coming – we are sharing our knowledge, and our ideas – this is becoming a school of research, and there are no exams !!

BERNARD SCULLY,
NEWCASTLE, AUSTRALIA, FE B., 2012