Ep 146 – Shoulder Injuries with Dr. Ben Benjamin

Massage client holding a painful shoulder.

In this episode, Dr. Ben Benjamin discusses the three phases of frozen shoulder, how resisted stretching is used to increase range of motion and decrease pain, why friction therapy is a great method for massage therapists to use during a session, and how being a thorough communicator during assessments is key to understanding a patient’s treatment options.

Author Images: 
Dr. Ben Benjamin.
Author Bio: 

Ben Benjamin, PhD in sports medicine, has been practicing massage since 1963 and has been nationally recognized for his contributions to massage therapy, receiving an induction into the Massage Therapy Hall of Fame in 2010. With his years of experience as a therapist, educator, and author, Dr. Benjamin has been regarded as a voice of authority in the muscular therapy field. He was the founder and president of the Muscular Therapy Institute in Cambridge, Massachusetts, which began in 1974. Shortly after the Muscular Therapy Institute opened, Dr. Benjamin enhanced his practice by studying under Dr. James Cyriax, widely known for his pioneering work in orthopedic medicine. He has also integrated Aaron Mattes’s Active Isolated Stretching (AIS) techniques into his therapy. With a passion for helping individuals cope with and overcome pain, Dr. Benjamin has been lecturing internationally for more than four decades and written countless articles in publications such as Massage & Bodywork magazine. Dr. Benjamin is also the author of several works referenced by educators and students in the field, such as Listen to Your PainAre You Tense?, and Exercise Without Injury, and is co-author of The Ethics of Touch and Conversation Transformation. For more information, visit benjamininstitute.com.

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Founded by a massage therapist for massage therapists, the Elements Massage® brand is a network of independently owned and operated studios dedicated to changing lives—including yours! The Elements Massage brand believes massage therapists deserve a supportive team, business and marketing resources, and the chance to learn as much as they want, so many Elements Massage studios offer and reimburse continuing education on an ongoing basis. It’s no surprise Elements Massage therapist and client satisfaction leads the industry. That’s because from day one, the brand has kept an unmatched commitment to deliver the best therapeutic massage experiences possible for both clients and massage therapists. Elements Massage studios expects the best. So should you. If this sounds like a fit, reach out. Studios are hiring! Visit ElementsMassage.com/ABMP for more information.

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As a Certified Advanced Rolfer, Til was on the faculty of the Dr. Ida Rolf Institute for 20 years, where he served as coordinator and faculty chair of the Foundations of Rolfing Structural Integration program. The author of the Advanced Myofascial Techniques textbook series (which has been translated into 6 languages), his regular Myofascial Techniques and Somatic Edge columns have been featured in Massage & Bodywork magazine since 2009. He is the director of Advanced-Trainings.com, which since 1985 has offered short, credit-approved professional trainings and certification for manual therapists of all types, online and in person.

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Full Transcript: 

0:00:00.0 Kristin Coverly: This episode of The ABMP podcast is sponsored by Pain in the App, mobile app by Dr. Ben Benjamin, Pain in the App is a new mobile app to learn about the injury process from head to toe, quiz yourself on the theory behind why injuries happen and what we can do about it, dig into how specific treatments work and why get started on Pain in the App with dozens of free questions, then get hundreds more for only $9.99, but be careful, it's addictive. Go to the App Store or Google Play and search for Pain in the App. The Elements Massage brand believes massage therapists deserve a supportive team, business and marketing resources, linens, lotions, and the chance to learn as much as they want. So many Elements Massage studios offer education too. What's better, they're hiring. To get your foot in the door, let them know we sent you by visiting, elementsmassage.com/ABMP. That's elementsmassage.com/ABMP.

0:01:09.5 KC: Til Luchau is pleased to invite you to an amazing learning opportunity, join Til in September and October for a personalized in-depth training in advanced myofascial techniques for the legs, knees and feet, combining live online lecture, intimate small group labs and searchable recordings of Til's real life technique demonstrations you'll earn NCBTMB approved credit towards becoming CAMT certified in as little as 90 minutes per week. And check out Til's new super affordable monthly subscription. Sign up now at advancedtrainings.com.

0:02:00.0 Darren Buford: Welcome to The ABMP podcast. My name is Darren Buford, and I'm Editor-in-Chief of massage and bodywork magazine and Senior Director of Communications for ABMP.

0:02:08.9 KC: And I'm Kristin Coverly licensed massage therapists and ABMP's Director of Professional Education.

0:02:14.7 DB: Our guest today is Dr. Ben Benjamin. Dr. Benjamin holds a PhD in Sports Medicine and owned and ran a massage school for over 30 years. He studied under James Cyriax MD, widely known for his pioneering work in orthopedic medicine. Dr. Benjamin has been teaching therapists how to work with injuries for over 35 years, and has been in private practice for over 50 years. He works as an expert witness in cases involving musculoskeletal injury and sexual abuse in a massage therapy setting. He's the author of dozens of articles on working with injuries as well as these widely used books, Listen to your Pain, Are you Tense? And Exercise Without Injury for more information visit benjamininstitute.com. Hello Ben and Hello Kristin.

0:02:58.2 Dr. Ben Benjamin: Hi there. Glad to be here.

0:03:00.3 KC: Hello and welcome back. We're looking forward to talking with you about understanding shoulder pain today, but listeners, this is Dr. Ben's third episode of The ABMP podcast, if you missed either of the first two take a listen to Episode 116 on low back pain, and episode 68 on muscular therapy. Let's jump right in. Ben, we often hear the term, rotator cuff injury. What does that really mean?

0:03:26.0 DB: Well, let's start out by defining what the rotator cuff is. The rotator cuff consists of four different muscles, whose tendons form a little cuff at the front and to the back of the shoulder, the subscapularis muscle tendon unit is at the anterior or front portion of the humerus, right in front of the shoulder. And it's responsible for medial rotation or internal rotation of the shoulder. It's the strongest muscle of the rotator cuff, you use it when you hug somebody, you throw a ball or you hit forehand in a racket sport, and it's commonly injured. It's very, very injured, especially at the tendon. Next is a supraspinatus muscle tendon unit, and it sits on the lateral aspect of the humerus, you use it to hold a briefcase, to make circular motions when giving a massage when you're going on a trip and you're holding a suitcase, etcetera, and putting it into your trunk. You primarily use it for the first 15 to 20 degrees of abduction, that's kind of taking it away from the side of your body, so it's the muscle that you use to prevent the briefcase if you're holding one from banging into the outside of your knee. It's much weaker than the subscapularis but much stronger than the teres minor, which is another rotated cuff, we'll get to in a minute.

0:04:43.9 DB: The supraspinatus muscle tendon unit is the most frequently ruptured of the four rotator cuff muscle tendon units. Usually happens in people who are older, and when it's ruptured, you can't really initiate lateral movement of the arm and shoulder, and you have to lift the arm to the front and take it to the side or grab your arm and pull it up like 15 degrees, and then your deltoid will take over. Then the third rotator cuff muscle, is the infraspinatus and this is the muscle that helps you reach to the back in your car when you're gonna get something.

0:05:18.0 DB: It's when you take a backhand shot in tennis, when you reach up for something on a shelf and you move over to the side, those are all infraspinatus movements. Now, this tendon is really large, and it's also frequently injured this whole muscle tendon unit, and the last rotator cuff is the teres minor, it's a really small muscle that sits right next to the infraspinatus and works along with it, and it's generally injured in people who are pretty athletic. It works a lot when you're doing a handstand or turning the wheel in a car that doesn't have power steering particularly. So most people don't use it that much, except incidentally, but when you're doing something very athletic, you might hurt it.

0:06:00.5 DB: So when somebody comes in saying they have a rotator cuff injury, it's really not all that helpful because you have to be able to identify which one it is in order to treat it or give it some exercise, rehabilitation program things to do. It's 'cause all those things are different for each one of those things, so occasionally someone indeed does injure all of their rotator cuff tendons and muscles, that's not all that common. If a therapist has the skill to test and identify which rotator cuff muscle tendon unit is injured special types of massage and body work are an excellent treatment.

0:06:40.3 DB: Now, 90% of the time, it's injured at what we call the tenoperiosteal junction, what that means is where the tendon is actually attached to the bone. Now, this is the site that's usually injured, the muscle itself has a lot of give and has a lot of circulation, the tendon has a very small amount of give, but at the tenoperiosteal junction where it's attached to the bone, there's no give at all. So where most of the tendon injuries occur in the shoulder, and in fact throughout the entire body is at this place where it attaches, which we call tenoperiosteal junction. The next most common injury is what we call the tendon body. Now, which is a part of the tendon that's between the attachment and the muscle, and sometimes the injury is at the musculotendinous junction which is where the tendon transitions to the muscle. Now, this is particularly true for the supraspinatus when it's injured. Now, to learn how to do the assessments and treatments, you can take a look at my book, Listen to your Pain, or on my webinar, prescription site, Benjamininstitute.com. But once you can identify it, you can treat it successfully.

0:07:48.4 DB: Ben what is frozen shoulder and how do you treat it?

0:07:51.6 DB: Well, frozen shoulder is a common name for what's really called adhesive capsulitis or traumatic arthritis of the shoulder. Now, we don't really know what causes it, but we know what physically happens when someone has the condition and how to treat it. When a person has a frozen shoulder scar tissue adhesions develop throughout the shoulder joint structure, so the inside the joint, and these adhesions are inside the capsule, and it's not something that you can touch with your fingers. The person has increasingly limited movement in almost all directions. At first, the person can't really lift their arm above their head, then they can't laterally rotate it and reach out to the side. Next they have difficulty putting their hand behind their back, and it's very, very painful. It's a very painful condition that actually has three phases.

0:08:45.0 DB: The first phase is called freezing because of the increasing pain and limitation of movement. This happens for, I'd say, three to four months. The next phase is called frozen, and it doesn't really get better or it doesn't really get worse, and the pain is intense and pretty constant, this phase lasts again for three to four months as well. And finally in the last phase, which is also three to four months, the pain lessens and the mobility increases, so if you do absolutely nothing within about a year for most people, they recover. Now, if the person gets treatment, the pain can be gone within three or four weeks.

0:09:25.8 DB: It's actually one of the most satisfying things that I treat because the results are so dramatic and so fast. Now in the first and second phases of this treatment, it must be done in coordination with a physician, 'cause the treatment would be excruciatingly painful without it. The person requires one or two injections, followed by intense, what we call resisted stretching of the shoulder, and we stretch the joint in three or four different directions to gain the mobility and remove the internal scarring that's happened inside the joint and in the last phase this resisted stretching can be done without any medical intervention. So if they're in the third phase of the thing by themself it's not really all that painful, a lot of the movement has come back, but not all of it, the person doesn't need an injection to do that. Now, massage therapy by itself is not all that helpful, in cases of frozen shoulder, it can give some comfort, but can't really address the adhesions that occur inside the joint capsule.

0:10:26.7 DB: Let's take a short break to hear a word from our sponsors.

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0:11:05.1 KC: As a massage therapist, you know that truly the world's most beautiful machine is in your hands, you help relieve the pain and pressures that hold your clients back from fully enjoying life. The CBD clinic massage collection uses ingredients from nature to deliver strong, effective temporary pain relief with aromatic botanicals and natural emollients like CBD. Our tiered pain products let you personalize your massage to meet each client's needs, be your client's hero by giving them the massage treatment of their dreams with CBD clinic. Learn more at cbdclinic.co.

0:11:46.8 DB: Now, let's get back to the podcast.

0:11:50.3 KC: I'm curious, tell us a little bit more resisted stretching might be new to some practitioners. Can you tell us a little bit more about it?

0:11:56.6 DB: So resisted stretching is a technique that allows the person's resisted movement to slowly break the internal adhesion scar tissue that's within the joint capsule. Now, it's really painful, if you don't get an injection, if you get an injection, you see the person, and then it's not so painful. So what the person does is they assume a position that's near the end of the range of motion without pain, so let's say above your head, let's say. And they push against the therapists resistance for five or six seconds.

0:12:27.6 DB: And you hear a little popping sound sometimes, and that breaks the adhesions in that position. Then the arm is moved a quarter inch further, stretch it just a little bit further, I mean just a little bit. And this is followed by the same resistance, and this process allows the person by themselves to actually break the scar tissue adhesions with the positioning and resistance done by the therapist, and this is done in every position possible for the shoulder and over the next several weeks, the pain recedes and the range of motion gradually increases. So the three places are, over the head, one is with the arm laterally rotated and one is with the arm turned in as if you were putting it behind your back. And once you get those three, full range of motion, the person is so happy, they wanna hug you and kiss you, and they're so relieved because the pain is really terrible, as you just said.

0:13:17.1 DB: Ben, what shoulder injuries can we help with massage therapy and which ones is massage therapy not the right treatment.

0:13:23.6 DB: Well, a special type of treatment called friction therapy can help many injuries in the shoulder. Friction therapy is very effective with all four of the rotator cuff injuries that I described earlier, it's also effective with injuries to the muscle-tendon units of the biceps, the triceps, the pectoralis major, as well as the common superior acromioclavicular ligament, so that's a lot, that's like seven or eight different injuries in the shoulder that hands-on massage work, if you know how to do the friction kind of massage work can really help. Massage and bodywork are not appropriate for acute bursitis, chronic bursitis, acromioclavicular joint sprains, or that frozen shoulder or adhesive capsulitis that we mentioned before, unless you know how to do this resisted stretching, you're not gonna do massage on it, you're gonna do the special treatment that gets rid of the adhesions which are deep inside the shoulder joint.

0:14:19.6 KC: Ben, you mentioned friction massage, can you tell us a little bit more about that for listeners that may not know as much about that as others...

0:14:26.5 DB: Sure, it's a massage technique that was popularized by a doctor in England named James Cyriax, now he was the English physician, often referred to as the father of orthopedic medicine. Now, he wrote a big huge book which outlines how to assess and treat every major musculoskeletal injury throughout the whole body, he is the first person I actually studied with when I began my journey to learn about the assessment and treatment of most injuries. Friction therapy is done with no lubricants whatsoever. If you put your finger on the structure that's injured, generally a tendon or a ligament like in the tendon it would be an attachment, if you're working on the front of the shoulder and you would perform a cross-fiber motion at a 90 degree angle to the tendon. Now this action rubs away the scar tissue, if it's done for a period of five to 10 minutes, you just can't do it for a minute, you gotta do it for quite a while, and this treatment is repeated usually twice a week to be effective. This can be done in coordination with a series of gentle movements and exercises that ensure that the newly formed scar tissue gets proper alignment so there's no adhesions when the person heals.

0:15:37.4 DB: Now people, when they leave the treatment room, that scar tissue starts to form again, but it's very weak, and if the person just does very gentle movements, you can get rid of that, they can get rid of that by themselves, so that when they come again, you can treat them and keep getting rid of more and more scar tissue. In the 1980s, I learned this technique from Dr. Cyriax, and I teach it as part of my courses in orthopedic manual treatment and assessment. Friction therapy is not difficult to learn, the hard part is knowing the anatomy so well that you could put your finger on every possible injured structure and have that assessment skill, so you can really figure out what's actually injured. In the shoulder, there are four or five, six different things, and throughout the body, there are hundreds of places you wanna be able to know to put your finger to get that work to be effective.

0:16:24.7 DB: Ben, why can't massage do anything to help bursitis of the shoulder? I've heard people say that it can.

0:16:31.0 DB: Yeah, I've heard that too. When I meet a therapist that says they can help bursitis of the shoulder, I asked them several questions. First, I ask if they know how to differentiate the two different types of bursitis acute and chronic. Now, mostly they never heard of the difference between it and they don't usually know. Then I ask them, "How do you assess the shoulder for frozen shoulder?" And they usually don't know. So sometimes people get confused with which type of injury the person has, and if they don't know those tests, then they don't know that the person had a particular bursitis they might have had somebody come and say that but that doesn't mean anything.

0:17:09.5 DB: I've rarely met a massage therapist who says they can help bursitis who could correctly answer any of the questions that I just posed. So I think what's really happening is the person has some other condition that massage and hands-on therapy can help, the therapist works with them, they help them and they just assume it's a bursitis. I've done this test with chiropractors as well and they don't usually know the difference either. And if you don't know how to assess all the different injuries in the shoulder, it's not easy to know which ones you can help and which ones you cannot.

0:17:41.0 DB: The bursa is a fluid-filled sac deep inside the shoulder that swells up when you get inflamed and you can't really touch it with your hand. And when a person has acute bursitis massage therapy or movement can make it even worse. So that's how I explain it when somebody says to me, "They've had massage that's helped their shoulder." Certainly it does, but it's not a bursitis.

0:18:04.5 KC: Let's talk a little bit about shoulder dislocation. So when a client tells us they've had several shoulder dislocations, first we feel sorry for them, but then what do we need to know to be careful of, and what does that mean for the general health of the shoulder?

0:18:19.0 DB: Well, first of all, you wanna verify what the client has told you, 'cause it can happen in various ways, there are three joints of the shoulder, two of which can dislocate. The first is the glenohumeral joint, which can dislocate, especially if the person is very flexible genetically. Second is the acromioclavicular joint, which is referred to when dislocated as a separated shoulder, so if you're watching a football game and they say, "A separated shoulder," that's what they mean, the acromioclavicular joint has popped apart. Now, if you're really flexible, it means that you were born with ligaments that are longer than they are supposed to be. For example, if you have a ligament that's supposed to be an inch long, and it's actually an inch and a quarter and inch and a half long, that joint is gonna be very unstable, and the function of ligaments is to stabilize the joints and create limits on how far they can move.

0:19:14.0 DB: Now for a joint to be healthy, the ligaments that hold it together have to be really tight. Now, if anyone ever says... Which they do, "I'd like you to loosen up my ligaments" they don't really mean that because if you would loosen up the ligaments, you would destroy their body because the ligaments are what you hold you together.

0:19:31.7 DB: Now, what they wanna feel is more relaxed and an easier range of motion, which is reasonable, but people often get their terms mixed up because they don't exactly know and they're not supposed to know. People who are unusually flexible are usually the ones who tend to get shoulder dislocations and knee dislocations, etcetera. So now to your question, if a person dislocates or separates their acromioclavicular joint, it's fairly easy to tell. Even if you don't know how to test for it, if you just look at the shoulder, you're gonna... Without any clothes on the shoulder, top of the shoulder, you will see an unusually large bump at the distal end of the clavicle as opposed to the other shoulder. Now, this is what happens when the ligament that holds the AC joint together is severely stretched or ruptured. If a client comes in with a pain in the shoulder and tells me that they've had multiple shoulder dislocations, they are usually talking about the glenohumeral joint, the larger shoulder joint, and the first thing to ask is, "Did it locate to the front or the back?" Now if it dislocates anteriorly, that means they have stretched the subscapularis tendon, which is an important tendon in the front of the portion of the shoulder.

0:20:45.2 DB: Now, this means that the tendon is now really vulnerable to injury because it's been really stretched and it's got some tears in it and it's looser, so gotta be careful with that. Now, if it dislocated to the back posteriorly, that means they've stretched the infraspinatus and teres minor tendons, making those tenants more vulnerable to injury. Now if the shoulder dislocated to the front, the work is likely going to be with the subscapularis tendon, which tends to get injured when its fibers have been disrupted or stretched, and if it's dislocated to the back, you're gonna pay attention to the infraspinatus and teres minor. So here's where the assessment skills come in. There are just a few assessment tests you need to differentiate which one you should work on, so let me mention here that before you work on a shoulder pain or a shoulder injury, be sure that the client has seen a physician.

0:21:40.2 DB: Now, there are several important serious medical conditions that show up as pain in the shoulder that don't involve muscles and tendons or ligaments that must be addressed medically. If you're skilled at doing assessment, you can figure out what kind of work you can do and what would be effective, and that's what I teach people to do, but if people have a serious condition, you wanna make sure it's diagnosed by a doctor.

0:22:04.4 DB: Remember that we can't diagnose as massage therapists any conditions, and when you do your assessment, you cannot give it a label and tell the person what they have 'cause that's out of your scope of practice. Assessment skills make you safer and a better therapist because you know what you can and can't do, and all you can do is feel for the tender areas, and you tell the person, "Well, this feels tender on this muscle, this tendon, this ligament. Let's see if we can get rid of that." So if a person has a shoulder pain when they lift their arm, for example, they could have a tumor in their lung. That's something that they could have... That you're not gonna know anything about. They could also have a growth of a calcium deposit that sort of pinching something or stretching something that's getting pinched when you raise your arm. So wanna be careful whenever anybody has any injury, I have all of my practitioners that I train, make sure they've seen a doctor and most have, but if they haven't, very important to have them see a physician to make sure you're doing work that's safe.

0:23:03.2 DB: Ben, what are the most common injuries in the shoulder?

0:23:06.5 DB: The most common injuries that a massage therapist can treat are injuries to the tendon attachments of the subscapularis, infraspinatus, supraspinatus and teres minor, and those are the most common injuries that people have, particularly the subscapularis. Now when somebody walks in the door, I tell my students, "70% of the time, they're gonna have a subscapularis injury," so really look hard for that one, and that one can be confusing to find, so you need a lot of training to understand that one. The infraspinatus and teres minor and supraspinatus are relatively easy to verify. The subscapularis, if you just know that the person's under 40, it's likely they're gonna have that. If they're over 40, there could be other things; the joint and bursas start getting involved. The assessment skills for the subscapularis are more difficult to acquire. And I remember when I first started with Dr. Cyriax, I opened up a free clinic in New York City with a doctor friend of mine, and we saw people free for three days a week for like eight or 10 months, and we were just trying to hone our new assessment skills, and one area of the body that was really difficult, was the shoulder, and we had many people that confused us.

0:24:16.9 DB: It was only when a physician friend of mine went to a conference and he found this guy named Dr. Ongley that my confusion disappeared. This Dr. Ongley, in my opinion, was the most brilliant physician in orthopedic medicine that I've ever met and had the privilege to work with. That's very rare in life to actually meet a genius. You hear about them, but you don't meet them too often, but Dr. Ongley was a genius of orthopedic medicine. One physician I know that worked with him, he used to call him the Mozart of medicine, and if you know anything about Mozart and music, he was the best or one of the best. So Dr. Ongley was a protege of Dr. Cyriax, but soon overtook Cyriax in his knowledge and skill. And one reason it's so difficult to assess the subscapularis, is that it's very, very strong muscle, and it really evades detection, especially if you test it in the normal position. I remember the day I called Dr. Ongley and I told him that I had seen seven or eight clients with shoulder injuries that I really couldn't understand, and he actually instructed me on the phone how to alter my testing techniques so that I could verify that it was a subscapularis injury, and he knew that that's what I was talking about even before I told him.

0:25:32.6 DB: And if a person just waits, do most shoulder injuries usually disappear?

0:25:37.4 DB: Depends on what it is. If it's a frozen shoulder, it usually goes away within a year, but sometimes the person is left with very limited movement and a vulnerable shoulder that can get hurt again. If it's a tendon injury and the person is fairly healthy and rests for a while, sometimes, absolutely, it will go away. However, most of the time, injuries linger for years or abate for a while, and then come back when you do something that's strenuous, and if you don't get rid of the adhesive scar tissue in the tendon, the ligament or the fascia, your shoulder is vulnerable to getting hurt again if you stress it a little bit. I remember I saw one woman who had chronic bursitis for 15 years, so I would say no, most shoulder injuries don't disappear by themselves, they just go into hiding for a while and come out when you stress yourself again. And for those individuals, they live with chronic pain that gets worse and better and worse again over time, and with appropriate treatment, most shoulder injuries can really disappear.

0:26:38.6 KC: I'm curious about how that conversation goes with the client who might have been in pain for 10 plus years with the shoulder injury, they come in, they see you and you think that you can be effective in treatment. How does that conversation go? Do they believe you or are they in disbelief?

0:26:52.7 DB: It depends on the person. I wrote a book on communication, so that's my thing, and when I train students, I often train them in communication skills as well. And you have to do it by being thorough and being a good communicator and educating the client. So by thorough, I mean taking the time to take a full history, to do a series of anywhere from 12 to 30 assessment tests depending on the complexity of the injury, knowing how to palpate every structure in the shoulder so that you can put your finger on the exact spot that's injured and causing the client's pain. And you do that by taking your time and not rushing, and the client is very impressed if you can put your finger on exactly what's hurting them, and they can feel it referring down their arm. That's really... Gets their attention. For me, the assessment session where you meet with the client for the first time is the most important session because this sets the stage for all of your work together. Now, most people have never often had the experience even with a physician or physical therapist of the person taking their time. People don't take enough time; the individual needs to be really hard, and you hear this a lot. You're in and out in 10 minutes or 15 minutes.

0:28:05.2 DB: I do a thorough job and your thoroughness and knowledge is obvious to the client when they've rarely seen anybody to do that. So it also helps to have experience in helping people get better that you can rely on, you have stories to tell and you have the confidence because you've done it before. And before that, when I train practitioners, they often use my experience and say, "Well, my teacher has experience in doing this, etcetera," and they often do these assessments actually with me in the room. They bring the client to me, or if they live far away and they've studied with me in California, or New Mexico, they do it online with me, and that builds their confidence and it builds their client's confidence and skill more quickly.

0:28:46.0 DB: Ben, I'm sure our listeners are curious. What kind of exercises help shoulder injuries?

0:28:51.2 DB: There is a tendon injury exercise program that I learned from a sports medicine physician and physical therapist about 30 years ago that really help people recover from muscle tendon injuries in about half the time that it would normally take without these special exercise programs. Now in this program, there are three types of exercises done daily that are crucial to helping the client get better and stay better from a shoulder injury in particular. And these exercises apply to the seven muscle tendon units that get strained in the shoulder that we've talked about. First, a client has to warm up the shoulder. Second, they gently stretch the muscle tendon unit for 30 seconds for five times. Third, they do a strength exercise until that muscle is tired and it's a specially targeted exercise, they do these exercises in a special sequence, and there are several different stretches and different exercise for each different... Of those four different muscles or six different muscles that we talked about. Having these exercise programs brings the client into the process and lets them participate in the healing process, which they really like.

0:30:00.0 KC: I'm curious, Ben, if you're working with a client who has a shoulder injury, do you recommend that they stop their regular exercise programs while you're working with them?

0:30:08.9 DB: Well, it depends. If the shoulder injury is very severe and doing their regular exercises are painful, they have to stop and wait for a while. The rule of thumb for exercise is if it hurts while you're doing it, or right after you do it, don't do it. Exercise programs that are targeted to the particular muscle tendon unit, that's what you need to do, and that only begins after a number of treatments that have lessened the person's pain, and you have them do the exercise program in the office to see if they can do it. If they can't do it without pain, they don't start. The exercise program is not to be painful ever, and the intensity of the exercise increases very, very gradually, so there's no pain whatsoever, 'cause when you're having pain, you're injuring yourself. When you're not having pain and you're exercising, you're building your fibers and the person starts with a very light weight, usually one or two pounds, and then increases weekly as their shoulder improves and they may go up to 10, 50 and 20 pounds depending on the person.

0:31:12.2 KC: Let's clarify, please. What's the difference between tendonitis and tendinosis?

0:31:17.7 DB: Yeah, that's a really important distinction. Tendons are connective tissue that primarily are composed of collagen and elastin fibers. The collagen fibers give the tendon its strength, the elastin fibers give it a small amount of flexibility. Since the tendon fibers are primarily designed to transmit a strong tensile or pulling load from the muscle directly to the bone, the tendon is not really designed to be very flexible. The tendon gets its strength, not only from the amount of collagen fibers it contains, but also how the fibers are arranged and which type of collagen it is.

0:31:57.5 DB: With tendons, the collagen fibers are arranged mostly in parallel and in line with how the muscle fibers are arranged, so you are in the same line of movement. This configuration gives a tendon the greatest amount of strength in the direction that the muscle fibers are pulling. Tendonitis refers to strain or micro-tearing of the tendon. Tendonitis is the symptomatic degeneration of the tendon with an inflammatory repair response, that's the important thing is inflammatory cells. Tendinosis is defined as intertendinous degeneration due to atrophy, which means aging, micro-trauma, vascular compromise, meaning the blood supply is not so great. And histologically, if you look at it under a microscope, there's a non-inflammatory intertendinous collagen degeneration with fiber disorientation and scattered vascular in-growth and occasionally local necrosis or calcification, and that means the tendon is kinda dying on you a little bit; it's really not in good shape.

0:33:01.4 DB: The term tendinosis is used to mean really pathology of the tendon, tendon degenerating. The term tendonitis specifically refers to inflammation in the tendon fibers, and in recent research, many tendonitis complaints have been found to be lacking in inflammatory cells, and the main issue in these tendon disorders, it's referred to as tendinosis when there are no inflammatory cells, which is where the collagen is degenerating from over use or lack of use, a lot of different things. The tendon is breaking down and losing its function. Now, massage therapy can stimulate collagen production and encourage the healing process, particularly friction therapy. Now, these studies have found that the primary benefits of this friction therapy in tendinosis may be the stimulation of collagen production in the damaged tendon rather than in breaking up a fiber scar tissue in inflamed tendons, so the friction work actually helps in both cases, but the method is a little different. And the thing to be aware of when a person has tendinosis, it's gonna take them a long, long time to get better. So if I friction somebody's tendon, it's probably gonna take a month or so, six weeks, two months maybe. But if I do the same tendon that has tendinosis, that is gonna take four to six months to do the same exact thing because it's a different condition.

0:34:26.0 DB: And one final question, Ben. What causes muscle weakness after a person has an injury?

0:34:31.6 DB: A weakness comes from disuse. So as the saying goes, "If you don't use it, you lose it." And during the first flights into space, they found that the astronaut's bones were de-mineralising after they've been weightless for just a few weeks. Now astronauts use various contraptions to exercise in space to keep their bodies healthy. And when you have an injury, this means that there's a disruption of the tissue, like a micro-tear in a muscle or a tendon, or a sprained ligament, bruise, pressure on a nerve, adhesive scar tissue or swelling in a joint. Now, if this occurs, your brain tells your body not to use it, not to use it fully, to rest it, and if you don't use your body even for a week, you get weak and your surrounding muscles begin to break down a little bit. Try lining in bed for a week or two, you're really weak when you get up, and the process of atrophy will start pretty quickly. And if you don't pay attention to that and build yourself up, you're going to have a lot of atrophy, which is the weakness.

0:35:32.9 DB: Now, this is can be reversed by proper treatment and exercise, so you get the whatever is injured better and you start exercising slowly and build your body up. People atrophy and become weak from all sorts of injuries, even being just sick with a cold for a month will make you very weak and vulnerable to injury as well. So if you just pay attention, a person gets their injuries assessed, gets 'em treated, does their exercises, you can come back from it. I've come back from being hurt for months and built up, but it may take several months to do that.

0:36:07.8 DB: I wanna thank our guest today, Dr. Ben Benjamin. To find out more information about Ben, visit benjamininstitute.com. The ABMP podcast is produced by the team at ABMP, Associated Body Work and Massage Professionals, a professional membership organization supporting massage therapists and body workers. Membership includes liability insurance, free continuing education, and the award-winning massage and bodywork magazine. Go to abmp.com to learn more about becoming a member. Thanks, Ben, and thanks, Kristin.

0:36:39.7 KC: Thanks so much for another great podcast.

0:36:41.7 DB: Thank you.

0:36:46.0 KC: Members are loving ABMP Five-Minute Muscles and ABMP Pocket Pathology, two quick reference web apps included with ABMP membership. ABMP Five-Minute Muscles delivers muscle-specific palpation and technique videos plus origins, insertions and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology, created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the featured benefits section of your member home page. Not a member? Learn about these exciting member benefits at abmp.com/more.

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