How Massage Therapists Can Deal With Acute Shoulder Injuries

 

I knew it was bad when I heard a “pop”.

I’ve given and taken several hits playing hockey over the years, but this one was different.

I got flipped over and landed directly on my shoulder and heard that “pop” on my right side.

I was slow getting up and immediately felt pain in that shoulder.

At first it didn’t seem that bad, the pain was manageable.

Skating back to the bench it started getting worse. Moving the shoulder got more difficult.

Once in the dressing room it became more painful to move. I slowly got my gear off and cracked a beer. I got up and looked in the mirror, it looked gross.

Having a shower was difficult, it got to the point I could barely move the arm and cradling it was the only way it felt comfortable. I packed up my equipment, slowly got dressed with one arm and made my way to the emergency room.

They sent me in for x-rays immediately.

I could see the guys taking the x-ray and the look on their face was terrible. I actually heard them say “oh man, that’s bad”, umm I’m right here.

Recognizing The Degree Of Shoulder Injuries

After the x-ray I sat and waited impatiently for the on-call doctor to come in and give me the bad news.

“You’ve got a third degree separation of your A/C joint”.

He called the local Orthopedic shoulder specialist, who got mad at the doc for waking him up and was informed they don’t do surgery, just put the shoulder in a sling.

With an Acromioclavicular separation they are classed from Type I – III with more severe cases being Types IV – VI.

According to the Foundations of Athletic Training, a Type I separation the ligaments are still intact and there is minimal deformity. Type II starts to show some deformity, the A/C ligaments are damaged but the coracoclavicular one is still fine. Type III shows obvious deformity and all the ligaments are damaged.

There is also more pain and restricted range of motion with a Type III compared to Type I or II.

When it comes to a Type IV – VI there is total disruption of the supporting ligaments and where surgery is necessary.

If you’ve never seen a separated shoulder injury when it happens, it can be difficult to figure out if it’s a separation or a dislocation. Magee gives some good information on how to tell the difference. There’s a few indicators that would point to a dislocation:

While it’s important to know the difference between the two, it’s not going to change how you deal with it.

First Aid For A Separated Shoulder

Whether it’s a dislocation or separation, we just want to stabilize the shoulder until we can get more advanced medical attention.

Chances are the person will be holding their arm/shoulder in the position that is most comfortable for them, you just need to work around it.

As it is with a fracture, dislocation or separation there are a few principles to keep in mind.

  • Immobilize in the position found.
  • Always check distal to the injured area for circulation.
  • Put ice on the injury to help with pain and inflammation.
  • Stabilize the injured joint or area as much as possible.
  • Keep the injured area above the heart as much as possible (but only if it can be done pain free)

The easiest way to remember is with the mnemonic RICE

 

R – Rest, stop whatever activity the person was doing.

I  – Immobilize

C – Cold, cool the area for 20 minutes

E – Elevate

When it comes to applying a sling to immobilize and stabilize a shoulder, the most common thing used is a triangular bandage. Some people hate these things, but I think they’re great because they may be the most versatile tool in a First Responder kit.

Not only can you make a sling, you can turn them into broad bandages, donut rings, stabilizing ties and various other things. One of the other reason they’re in most First Responder kits is because they’re cheap.

You can buy premade shoulder slings and braces but they cost ten to thirty dollars and when you send someone to the hospital with one, its doubtful you’re getting it back. A triangular costs anywhere from twenty five cents to a dollar.

No big deal if you never get it back.

If you ever have to deal with it, here’s some instructions on how to put the shoulder in a sling:

Anatomy Knowledge

An article published in 2012 used 24 articles to draw information from on the best practice for treating A/C separations.

For a Grade I – III range of motion and strengthening exercises within pain tolerances were recommended. Exercises were mainly to provide stability to the shoulder blade and rotator cuff. Grade IV – VI are typically dealt with by surgery.

There wasn’t much information as far as any treatment protocols. The advice was to use your  knowledge of anatomy, movement and healing process to develop the best plan for you patient.

What I can tell you from personal experience is that for that first week, having one of my buddies that is an Athletic Therapist tape the joint helped with pain management and providing stability.

Getting regular Massage Therapy to treat the muscles connected around the AC joint also helped with pain management and function. Even a year and a half later it feels like there is constant tension from the joint all the way through the shoulder.

If ever dealing with something like this, it’s important to remember that patient comfort is key. Applying a sling, icing the injured area and stabilizing the joint not only provides more comfort but also prevents further injury. Your anatomy and movement knowledge is critical not only in the acute treatment but also in the rehab of this injury. If the separation is severe enough, the person will be left with a step deformity at the joint. But because you helped take care of them properly when it happened, they should be able to get full function back. If nothing else came from this, at least I get to show students what a step deformity looks like.

How Massage Therapists Can Deal With Compartment Syndrome

The cracking sound echoed through the arena.

He went down to block a shot and when the puck hit him, we knew it was bad.

He couldn’t put any weight on one leg. Once he started to get up a teammate helped him to the bench.

We carried him to the treatment room and started stripping and cutting gear off.

He had severe pain around his shin, where he had blocked the shot. We carefully cut away his shin pads and compression socks.

The area was getting swollen and red throughout his shin. We couldn’t feel a pulse in his foot.

I thought it looked bad, but didn’t realize just how bad. Fortunately I was surrounded by people with more experience who are much smarter than me (yes I know, that’s not difficult to find!). They immediately realized that the player had to go to the hospital.

What I thought was a contusion, could actually have been a life threatening emergency if not handled properly. After things calmed down and we got him sent to the hospital, I asked why this was such a big deal. In unison the team Doctor and head Therapist looked at me and said:

“Compartment Syndrome”

Recognizing Increased Compartment Pressure

When this happened I was still a student and honestly a pretty fresh student Massage Therapist.

I was fortunate enough to be able to start volunteering with a hockey team to get some sports experience. I had never heard the term “Compartment Syndrome” (aka: Volkmann’s Ischemia) at that point, or if I had, I didn’t remember it.

Later in Massage school we briefly talked about it, but more from the standpoint of how to treat it post surgery.

When we learned about it in school, we only talked about Compartment Syndrome happening around the shin. Turns out that it can happen in other compartments as well.

I learned that the forearm is another common place for it to happen because the Athletic Therapist used to quiz me on things like that.

Also, did you know that part of Scaphoid doesn’t have vascular supply, so if it gets broken the bone can die? More things he used to quiz me on.

Anyway, in researching for this article, I came to find out that any osteofascial compartment can have a Compartment Syndrome. Areas with deep fascia that is very strong that enclose compartments can be subject to a Compartment Syndrome.

The most common areas are the flexor compartment of the forearm and anterior tibial compartment of the leg. The hand, abdomen, glutes, thigh and upper arm can also be affected.

Acute Compartment Syndrome is a buildup of pressure in one of these compartments due to an injury. It can be both limb threatening and life threatening if not treated properly and in a timely fashion.

As swelling increases in a compartment, blood flow creates more pressure on the structures inside, causing capillaries to collapse and begins to starve the area of oxygen and nutrients.  The nerves can hold up for two to four hours and the muscles can only survive for six hours before becoming permanently damaged.  

Photo by: Hernan Pinera

Photo by: Hernan Pinera

What Causes Compartment Syndrome

There are a number of things that can cause Compartment Syndrome to take place. So having a good knowledge of the mechanism of injury is our biggest help in recognizing what’s going on:

If any of these things have happened and you’re not quite sure if this is a medical emergency, better safe than sorry, have the person sent to the hospital.

But there are some tell tale signs to look for that will help make your decision.

Pain is going to be your first indication that something is wrong. But the pain may not seem to be normal compared to the injury.

Now that you’ve established that this is a medical emergency, it can’t be treated the same way you would typically think to do it.

If there is a long bone fracture in place you can’t put a splint in place as you normally would for a fracture. Anything restricting the area must be cut away to allow the area to swell. Putting on a splint or bandage is only going to make the Compartment Syndrome worse.

However any movement is going to aggravate the pain, so you will have to manually support the injured limb/area as best you can with the help of others around you.

If there is no fracture to the area then it can be treated as you would other soft tissue injuries.

Immobilize the limb as best you can (without bandaging it) and apply ice to the area. If possible, elevate the limb above the heart to help decrease circulation to the area.

But the most important thing you can do is call 9-1-1 and get the person to more advanced medical care as soon as possible.

Once in the care of the hospital, surgical interventions will take place in order to relieve the pressure. A “fasciotomy” is performed, where surgeons cut the muscle and fascia in order to back off the pressure and hopefully save the surrounding tissues.

Massage Therapy And Compartment Syndrome

I actually wrote this article with some encouragement from a former student (thanks, Chelsea).

I wasn’t sure what topic to write on and she told me Compartment Syndrome would be a good topic because we didn’t learn a lot about it in college.

Holy was she right!

Just in doing research on this one I came to learn more about the different compartments that can be affected. I had no idea that the glutes, thigh and upper arm were also at risk. Nor did I know much about Chronic Compartment Syndrome and how it is an overuse injury from excessive vigorous exercise.

The biggest takeaways are just to remember the mechanisms of injury that can create a Compartment Syndrome. Much like the player in the story at the beginning, blocking that shot caused a bad bruise that led to Compartment Syndrome of the anterior lower leg. Always be careful and check (especially with traumatic injuries) if there is a long bone fracture or circulation impingement.

As you assess the injured area, look for pain that doesn’t seem suitable to the injury, increases with muscle stretching and burning/tingling sensations around the area. If you follow your First Aid protocols and take things step by step, you should have no problem figuring out exactly what is wrong. 

Recognizing all of the above could possibly save a limb or a life, the next time you have to treat a Compartment Syndrome.

Now if I could just get that Athletic Therapist to keep quizzing me on things, I might get a little smarter!