Subscapularis Release for Loss of External Rotation

image We have a great guest post today from my friend Trevor Winnegge.  Trevor wrote a nice article last year on complications following distal radius fractures that ranked as my number 1 guest post in 2009!  This time, he presents the results of really nice case series on restoring external rotation ROM using subscapularis release massage techniques.  Great idea and some common manual techniques that I use as well with all of my patients.  Thanks Trevor!

The Role of Soft Tissue Mobilization to Subscapularis to Improve External Rotation in a Type II SLAP Repair-A Case Series

Our clinic is a smaller clinic and doesn’t have the time or resources for a full research study but we did have the opportunity to perform a very small pilot study/case series. I decided to contribute this information because I think it is an underutilized technique and is valuable in assisting our post operative shoulder patients.

We looked at the role that subscapularis has on limiting external rotation (ER) in a post operative shoulder patient. Given that subscapularis is an internal rotator and also assists with some adduction, it is stretched with abduction and ER of the shoulder[1]. Many shoulder surgeries place the patient in a sling in the internally rotated position to some degree. Standard Type II SLAP repair protocols limit the passive range of motion (PROM) into ER to anywhere from 0-30 degrees for the first four weeks, limiting the ability of the subscapularis to stretch[2]. Therefore, we felt if we could perform soft tissue mobilization to the subscapularis in the initial post operative period while range of motion is limited, then they would be less stiff once they were allowed to progress into ER. To my knowledge there has been only one study to date looking at the role of soft tissue mobilization to subscapularis on improving ER and that was published in JOSPT in December of 2003[3]. In that study, conducted by Godges et al, they excluded any patient that was in the immediate four week post operative healing phase. We felt that this immediate healing phase is when we can be most successful at preventing excessive subscapularis tightness by performing soft tissue mobilization, thereby improving ER ROM once they are allowed to progress past 30 degrees of ER.

 

Research Design

We took four patients (two males, two females) between the ages of 17 and 26 who had undergone primary Type II SLAP repair and randomly assigned them into two groups. The first group received standard ROM treatment for all motions and had ER ranged only to 30 degrees per the doctors protocol. The second group had the same exact treatment, however also received five minutes of subscapularis soft tissue mobilization[4]. Soft tissue mobilization was performed while the patient was in sidelying for the first one or two treatment sessions until the patient had enough abduction ROM to allow for good access to subscapularis in a supine position. The technique was using thumb or fingertips to hook inside the lateral border of the scapula and dig deep down between the scapula and ribs. A combination of deep pressure and soft tissue mobilization were performed for a total of five minutes. Every patient in each group was seen at the one week post operative timeframe and was seen twice a week for the next three weeks.

 

Video Demonstration

I do have two videos of the soft tissue techniques. The first is for the immediate post op patient while patient is in sidelying. The second video is while the patient is in supine. This video also incorporates the soft tissue technique with some elevation ROM.

 

 

 

Results

The results were as we had expected. The group that received the soft tissue mobilization had about twenty five more degrees of ER ROM (measured with goniometer in 45 degrees of abduction while supine) at the four week mark than did the group that did not receive the treatment.

Control Group-ER ROM

 

1 week post op

4 weeks post op

Subject 1

10 degrees

40 degrees

Subject 2

15 degrees

38 degrees

Intervention Group- ER ROM

 

1 week post op

4 weeks post op

Subject 1

12 degrees

64 degrees

Subject 2

15 degrees

63 degrees

 

I understand that these results should be taken with a grain of salt, as strong conclusions can not be made with such a small sample size. As I previously stated we simply do not have the time or resources in our clinic to perform a large scale study. It is my hope that someone reading this who works in a much larger center can take this information and use it as a stepping stone to a full blown research study. Clinically, I use these techniques on a daily basis and achieve great results. I truly feel the results of a larger study would be quite similar. What was also interesting is that shoulder elevation was also improved in the soft tissue mobilization group. This is likely due to the close proximity of the latissimus dorsi to the subscapularis, it is hard to truly isolate the subscapularis. We focused on SLAP repairs, but Bankart repairs could also benefit from this as well as rotator cuff repair patients who require sling use for extended amounts of time, provided a subscapularis repair wasn’t performed. I think the possibilities for research in this area are endless and I would love to see it published as a large research study. Please give me any feedback if you currently use this technique, or tried it after reading this. It really works well.

clip_image001Trevor has been practicing PT for over 9 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.


[1] Palastanga, et al. Anatomy and Human Movement. Boston MA:Butterworth Heineman; 1993.

[2] Wilk K, Reinold M, Andrews J. Postoperative Treatment Principles in the Throwing Athlete. Sports Medicine and Arthroscopy Review. 2001;9:69-95.

[3] Godges et al. The Immediate Effects of Soft Tissue Mobilization with Proprioceptive neuromuscular Facilitation on Glenohumeral External rotation and Overhead reach. JOSPT. 2003; 12: 713-718.

[4] Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore MD:Williams and Wilkins; 1983.

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10 Responses to “Subscapularis Release for Loss of External Rotation”

  1. Christie Downing, PT, DPT, Dip. MDT August 9, 2010 at 5:47 am

    Trevor, I do this frequently with post operative patients who lack ER…even in rotator cuff repair. I find it to be a helpful technique and I use it often. It begs to highlight the notion that perhaps in post operative patients, it's not really post operative "frozen shoulder" we see, but rather its guarding.

    Case series are still important parts of the research hierarchy. They highlight need for ongoing research. To take this study a step further, one could add a third group who receives a "placebo" non-specific massage. One could also have a blinded therapist complete the measurements.

  2. I frequently use the Graston tools in a myofascial release technique to help release the Subscap and I find the Subscap is the most overlooked rotator cuff muscle by many patients who come to me from other healthcare professionals with shoulder problems….

  3. Harrison Vaughan, PT, DPT, Cert. SMT August 9, 2010 at 10:02 am

    Trevor,
    Good work! Agreeing with Christie, I think small case work has a huge impact on everyday clinical work. It makes the interventions easier to perform with what we have in a small clinic as well.

    Not with post-op patients, but I find "tapping" or "releasing" this area with PROM and sometimes GHJ mobs helps with increasing ROM as well with the general shoulder client. But, this also could be just a technique to take the patient's mind off of what the therapist is doing; similar to a dentist shaking the cheek while performing an injection. Either way, great post and definitely is an area underserved for the shoulder.

    Harrison

  4. Brian Phillips, PT August 9, 2010 at 10:05 am

    I too have used this technique while stretching patients in supine. I have found it also works well in helping patients achieve abduction ROM. In our clinic, we don't typically stretch patients in true abduction above 90 degrees, but rather in the plane of the scapula for overhead flexibility to try and avoid impingement possibilites. I feel that it is very important to be able to achieve 90* of abduction as this is a stepping stone in being able to stretch someone into an adbucted/externally rotated postion to allow them to have the available ROM to perform ADL's such as combing the back of their hair. While most of our patients can easily achieve 90* of abduction, this technique has helped with those "problematic patients" who are stiff in this plane.

  5. Carlyle Schomberg August 9, 2010 at 10:42 am

    I agree with the notion that restricted ROM often occurs due to gaurding/pain and not capsular tightness….at least in the early post-op phase. Any recommendations on continuing education courses for these techniques? "Old timers" like me didn't get much (if any) of these techniques in school, but I feel they are needed, and work well.

  6. Trevor Winnegge PT,DPT,MS,OCS,CSCS August 11, 2010 at 1:08 pm

    @ Christie and others….I agree this technique does help improve ER, as well as flex and abduction ROM in a lot of shoulder patients lacking that rom. I use it as a treatment technique a LOT! What sets this case series apart is we were only looking at using it as a maintenance technique. Hoping to maintain flexibility, prevent stiffness i the subscap during the initial 4 week immobilization period after a slap repair. I think there was a pretty significant difference between intervention and nonintervention groups at that 4 week mark when ER rom was allowed. So even though we cant stretch into ER there are treatment techniques that we can do to maintain flexibility.
    @ Carlyle…..the best shoulder course I have been to (and I am not just saying this because he is my friend) is the Kevin Wilk/Mike Reinold shoulder course.

  7. Nice job Trevor. I use the techniques Godges published in JOSPT quite frequently with excellent results. I've always waited until they were released from ER restrictions post-op to see if there was a deficit, but now I may start incorporating it a bit earlier.

    Looks like you're on your way to back to back Top Guest Article awards… congratulations!

  8. @Carlyle – did you see my last post? Made it partly for your question here to help you find a course.

  9. Interesting post… however, is it really the subscap that is being treated? I have spent some time in the anatomy lab and with a msk us unit, and the only part of the subscap that I think is palpable is the distal tendon attachment. In my opinion this technique, which I also use and is very effective, is a release of the teres major and lat dorsi.

  10. Great!