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Snow Angels

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Retraining, Scapular Depression, Scapular Stabilization, Shoulder Abduction

Snow Angels

To restore full shoulder flexion and abduction:

  • The patient is lying on their back with their hips and knees bent and feet resting flat on the floor. Their arms are at their sides with palms up.
  • Ask the patient to slowly bring the arms up along the floor keeping the shoulders and the backs of the hands always in contact with the floor.
  • They only raise the arms up as far as they can as long as they maintain contact with the floor.
  • If either hand or shoulder rises off the floor, the patient is told to stop and drop the arms back down a little. Then reach out with the arm on the restricted side to provide a longitudinal stretch before returning the arms back to the sides.
  • They repeat 3-5 times trying to bring the arms further up each time.
  • Goal: be able to sweep the arms along the floor with the shoulders and backs of the hands maintaining contact with the floor and the hands able to touch overhead.

Prone Lower Trapezius Strengthening – Bent Arm Overhead

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Retraining, Scapular Depression, Scapular Stabilization, Shoulder Abduction

Prone Lower Trapezius Strengthening – Bent Arm Overhead

To strengthen the right lower trapezius:

  • The patient is lying prone with their right arm bent and the palm of their right hand lying on the table above their head
  • Have them rest their forehead in the palm of their left hand
  • Instruct the patient to raise their right hand off the table as far as they can keeping their elbow and upper arm resting on the table/floor
  • They hold for 10 seconds and repeat initially 3-5 times increasing to 10 repetitions as they get stronger
  • The patient can be instructed to advance this exercise by raising the entire bent R arm off the table and hold for 10 seconds.
  • Tapping along the origin of the lower trapezius may help the patient “find” the muscle.
  • An alternative position is to have the shoulder abducted to 90 degrees with the elbow flexed to 90 degrees and the elbow resting on the table. From this position the patient externally rotates the shoulder lifting the hand off the table. This isolates the lower trapezius from the upper and middle trapezius better than any other exercise and avoids impingement of the shoulder that can occur in more elevated positions of the humerus (Ekstrom, Donatelli, Soderberg, 2003).

Lower Trapezius Retraining – Arm Down at the Side

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Retraining, Scapular Depression, Scapular Stabilization, Shoulder Abduction

Lower Trapezius Retraining – Arm Down at the Side

To retrain and strengthen the right lower trapezius:

  • The patient is lying prone with their left hand under their forehead and their right arm down at the side with the palm facing the ceiling.
  • Ask the patient to slowly lift their R shoulder up off the table/floor by bringing the shoulder blade down and back until their shoulder feels level with their back. The R hand remains on the table.
  • Make sure that the patient does not pinch their shoulder blades together, but that they draw the right shoulder blade down and back aiming towards their left back hip pocket.
  • They hold for 5-10 seconds and repeat 3-5 times initially. They add repetitions as their strength improves.
  • Make sure that the patient doesn’t depress the shoulder by using the latissimus dorsi.

Low Row-Scapular Retraction/Depression

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Retraining, Scapular Depression, Scapular Stabilization, Shoulder Abduction

Low Row-Scapular Retraction/Depression

To Strengthen the Right Lower Trapezius:

  • The patient is standing tall with an erect posture with the palm of their R hand facing behind them. Instruct the patient to gently push their R hand back into the edge of an immovable object such as a chair.
  • Ask the patient to inhale, then exhale as they push their R hand back into the chair, slightly extending through their mid-spine as they bring their R shoulder blade down and back. Do not let them overextend their lower or upper back.
  • Make sure that they keep their neck relaxed and they don’t hold their breath during the exercise.
  • Have them relax & slowly release and repeat 3-5 times initially, gradually increasing to 10 repetitions.

Dysfunctional Shoulder Abduction, Scapular Stabilization and Scapular Depression Tests

in 3 Movement Tests Upper Quarter, All Upper Quarter, Scapular Depression, Scapular Stabilization, Shoulder Abduction

Dysfunctional Shoulder Abduction, Scapular Stabilization and Scapular Depression Tests

These three functional movement tests are interrelated and therefore are addressed together when retraining is required because to normalize shoulder abduction the patient must be able to recruit with sufficient strength the normal force couple provided by the coactivation of the lower trapezius and serratus anterior muscles.

Anatomy and Biomechanics:

Normally during shoulder abduction the scapula upwardly rotates, externally rotates and posteriorly tilts, occurring as a result of a force couple involving the lower trapezius and serratus anterior. When these muscle groups are inhibited there is a loss of scapular stability and dysfunctional scapular mobility during elevation of the arm. The strength of the inhibitory influence by non-neutral spinal dysfunctions on these two muscle groups has not been fully appreciated by most clinicians. This is particularly true when attempts are made to “strengthen” the lower trapezius in the presence of a lack of spinal extension mobility that occurs secondary to FRS (flexed, side bent and rotated) dysfunctions. FRS dysfunctions from T6 thru 10 inhibit the ipsilateral lower trapezius. Likewise, ERS (extended, side bent and rotated) dysfunctions from T3-5, which limit thoracic flexion mobility, inhibit the serratus anterior. The result of this spinal inhibition on the lower trapezius and/or serratus anterior is that compensation is made by the levator scapula and upper trapezius and results in elevation, downward rotation and anterior tilt of the scapula. Also, restricted T3-5 rib mobility for anterior to posterior glides contributes to hypertonicity of the ipsilateral pectoralis minor resulting in protraction, internal rotation and anterior tilt of the scapula. The net effect of these muscle imbalances on the scapula results in an anteriorly tilted, downwardly rotated and medially facing glenoid fossa with impingement of the rotator cuff occurring during shoulder abduction.

Lower Trapezius

  • Attaches to the spinous processes and interspinous ligaments fromT4-12 and the medial end of the spine of the scapula
  • Functions: Upwardly rotates, posteriorly tilts and externally rotates the scapula and can assist in extension of the thoracic spine
  • Innervation: Spinal Accessory nerve, Cranial XI and the dorsal rami from T4 -12
  • Inhibited by FRS dysfunctions from T6-10

Serratus Anterior

  • Attaches from along the medial border of the scapula and especially to the inferior angle, to ribs 1- 8 or 9
  • Functions: upwardly rotates, posteriorly tilts and externally rotates the scapula and can assist in flexion of the thoracic spine
  • Innervation: long thoracic n., C5, 6, 7
  • Inhibited by ERS dysfunctions from T3-5

Eccentric to Concentric Strengthening in Supine

in 3 Movement Tests Upper Quarter, All Upper Quarter, Cervical Flexion Mobility, Cervical Flexion Stability/Motor Control

Eccentric to Concentric Strengthening in Supine

  • The patient is lying on their back with their hands clasped behind the head.
  • Instruct the patient to only use their arms to lift their head up so that the chin is drawn toward the chest and a stretch is felt through the back of the neck.
  • Once the head is brought up fully the patient is told to hold this position for 5-10 seconds, then slowly lower the head back to the table segmentally from below up, using the deep neck flexors eccentrically to lower the head back down to the table and assisting the movement with their hands as needed.
  • The hands only support the head as needed and an emphasis is placed upon keeping the chin down as the head is returned back to the table.
  • They repeat 3-5 times.
  • Eventually as the deep neck flexors become stronger, the hands should no longer be needed to assist in slowly returning the head back to the table.
  • The goal with this exercise is for the patient to be able to segmentally flex the neck and return back down to the table segmentally without using the hands to assist with the chin staying down throughout the entire movement.

Dysfunctional Cervical Flexion Test

in 3 Movement Tests Upper Quarter, All Upper Quarter, Cervical Flexion Mobility, Cervical Flexion Stability/Motor Control

Dysfunctional Cervical Flexion Test

Anatomy and Biomechanical Considerations:

The cervical flexion test assesses the ability of the patient to segmentally flex the cervical spine using the longus colli, longus capitis and rectus capitis anterior assisted by the SCMs, anterior scalenes and infra and suprahyoid muscles. When the primary deep neck flexors are inhibited/weak the SCMs and anterior scalenes substitute for this weakness and become the primary neck flexors resulting in the chin tipping up and the upper CS extending rather than flexing during the performance of this test (Janda, 1994).

Abnormal afferent information that can contribute to this muscle imbalance can occur when ERS dysfunctions of the cervical and especially upper thoracic spine are present. These ERS dysfunctions can result in inhibition of the longus colli and longus capitis due to restricted active and passive ROM for neck flexion. In addition, hypertonicity of the scalenes occurs in apical chest wall breathers as the scalenes, which are normally only accessory muscles recruited with deep inhalation, become recruited with every breath. Palpation of the scalenes in these patients will confirm the recruitment of these muscles even during relaxed breathing. This typically is felt to occur more on the R side than the L. Asking these patients to take a deep breath while the therapist palpates the lower lateral rib cage for normal bucket handle motion will reveal restricted excursion on the R side in these patients.

Self Mobilization for Adverse Neural Tension in the Cervical Spine

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Cervical Flexion Mobility, Self-mobilization

Self Mobilization for Adverse Neural Tension in the Cervical Spine

To treat the right side of the neck:

  • The patient is lying on their back and places their left hand under the neck with their fingers wrapping around to the right side of the neck. The therapist instructs the patient as to the specific location for the patient to place their finger contact.
  • Tell the patient to gently pull their neck to the left using their left hand and hold this position.
  • The patient’s R arm is down at their side with the palm facing the ceiling.
  • Have the patient slowly abduct their arm as far as they can without allowing the cervical spine to translate back to the R.
  • The patient returns the R arm back down to the side and is instructed to take up any slack that they feel for additional R to L translation and repeat again.
  • The patient repeats the movement 8-10 times holding their neck still and translated to the L as they try to abduct their R arm higher with each successive repetition.

Mobilization of Adverse Neural Tension on the R side of the Cervical Spine

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Cervical Flexion Mobility, Manual Stretching, Mobilization, Shoulder Abduction

Mobilization of Adverse Neural Tension on the R side of the Cervical Spine

  • The therapist introduces translation from right to left with his/her contact on the dysfunctional articular pillar.
  • The patient is instructed to slowly abduct their R arm along the table as far as they can while the therapist maintains the right to left translated position of the cervical spine and prevents the dysfunctional segment from translating back to the right.
  • This is repeated several times. Each time the patient lowers their arm to their side the therapist takes up any additional slack for right to left translation.
  • Goals for treatment: translation from right to left at the previously noted dysfunctional segment is now free and the patient should be able to fully and comfortably abduct the right shoulder overhead without the therapist feeling the cervical spine translate to the right at any segmental level.

Assessment and Treatment of Adverse Neural Tension That Occurs During Active Shoulder Abduction

in 3 Movement Tests Upper Quarter, All Upper Quarter, Shoulder Abduction

Assessment and Treatment of Adverse Neural Tension That Occurs During Active Shoulder Abduction

To assess for adverse neural tension on the right side of the neck:

  • Assess translational mobility of the cervical spine from right to left with your right hand contact on the articular pillars of the cervical spine.
  • If you find multiple levels are restricted for right to left translation, then translate the level of greatest restriction to the left with your right hand contact on the articular pillar of the cervical vertebrae.
  • Hold this translation and ask the patient to slowly abduct or slide their right arm up along the table.
  • Ideally the patient should be able to fully abduct the arm without the therapist feeling the articular pillar pushing back toward the right against their R hand contact.
  • When there is adverse neural tension in the R brachial plexus the cervical spine will be drawn to the R side by the hypertonic R scalenes and even more so during active R shoulder abduction.
  • Repeat on the left side and note any difference.
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