3 Movement Tests Upper Quarter

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Scalene Self-Stretch

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Self Stretch

Scalene Self-Stretch

To stretch the right scalenes:

  • Instruct the patient to sit up tall and place their left hand over the right first rib and clavicle to stabilize. The patient’s right hand grasps the bench or chair to further stabilize the neck.
  • Keeping their chin down, ask the patient to bring their head straight back into extension, side bend the head to the left and rotate back to the right.
  • They should feel a stretch through the front of their neck on the right side.
  • They hold for 30 seconds and repeat 2-3 times.
  • Then have the patient repeat the stretch on the L side.

Muscle Energy Technique to Stretch the Right Scalenes

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Muscle Energy

Muscle Energy Technique to Stretch the Right Scalenes

  • The patient’s head and neck, down to T2, are brought off the end of the table and supported by the therapist’s L forearm. The patient is instructed to grasp the table with their right hand to stabilize the first rib.
  • The therapist grasps the base of the occiput with the left hand and places their left shoulder against the patient’s forehead.
  • The therapist’s right hand is placed over the top of the patient’s right shoulder to further stabilize the first rib.
  • The therapist translates the patient’s head straight down towards the floor maintaining upper cervical spine flexion by keeping the patient’s chin down at all times. The therapist then adds side bending of the head to the left and rotation back to the right, maintaining the AP translation.
  • The patient is asked to take and hold a deep breath and raise the head up against the therapist’s L shoulder for 5 to 7 seconds.
  • Upon relaxation the therapist takes up the slack by increasing the AP translation, left side bending and right rotation.
  • This procedure is repeated 3 to 4 times.
  • Assessment of right to left translation of the typical cervical spine (C3-7) before and after treatment of the right scalenes helps to confirm your success with this treatment.

Treatment of a superiorly subluxed first rib on the left

in 3 Movement Tests Upper Quarter, All Upper Quarter

Treatment of a superiorly subluxed first rib on the left

  • Patient is seated with the therapist standing behind.
  • The patient’s right arm rests on top of the therapist’s right leg.
  • The therapist places the finger pads of the 2nd, 3rd, and 4th fingers anterior to the left trapezius muscle pulling it posteriorly.
  • The finger pads are placed on top of the left 1st rib.
  • The therapist’s right hand and forearm control the right side of the patient’s head and neck. The patient’s head is flexed forward down to the level of the first rib.
  • Left side bending and slight left rotation of the patient’s head and neck are introduced to take the left scalenes off tension.
  • The therapist’s left thumb applies a firm anteriorly directed force to the posterior aspect of the first rib.
  • The patient is asked to attempt to side bend the head to the right with exhalation to reciprocally inhibit the left scalenes while the therapist applies a firm counterforce to prohibit the neck from moving.
  • Following relaxation the therapist repositions the patient’s head into more left side bending all the while maintaining a firm anteriorly directed push on the posterior aspect of the first rib.
  • After three to four repetitions and after the final contraction and relaxation effort the therapist rotates the patient’s head fully around to the left to take T1 to the left while maintaining the anterior pressure with the left thumb so that the rib can drop down without force.

Three areas of potential compression of the brachial plexus resulting in positive ULTT1 or ULTT3 tests

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

Three areas of potential compression of the brachial plexus resulting in positive ULTT1 or ULTT3 tests

  • In the intrascalene triangle
  • In the costoclavicular space
  • Underneath the pectoralis minor – hyperabduction syndrome

Intrascalene Triangle:

  • Hypertonicity of the anterior and middle scalenes
  • Brachial plexus lies between the scalenes
  • The brachial plexus and scalenes are both contained in the deep fascia of the cervical spine

Costoclavicular Space 

  • Elevated first rib due to hypertonic scalenes
  • Superiorly subluxated first rib – confirmed by the cervical rotation/lateral flexion test

Pectoralis Minor – Hyperabduction Syndrome

  • Compression of the brachial plexus during shoulder abduction secondary to a tight pectoralis minor
  • Tone of the pectoralis minor is influenced by the position and mobility of ribs 3-5

Factors Influencing the Three Areas of Compression often resulting in a diagnosis of Thoracic Outlet Syndrome:

  • Hypertonic scalenes
  • Superiorly subluxated 1st rib
  • Hypertonic pectoralis minor/hypomobility of ribs 2-5

Superiorly Subluxated First Rib:

  • Mechanism of injury – acute side bending injury to the neck, ie, broadsided MVA or a strain on the neck when transferring a patient
  • Diagnosis: Palpation reveals the rib to be elevated by a thumb’s width compared to the other side
  • Positive Cervical Rotation/Lateral Flexion (CRLF) Test
  • Positive Adverse Neural Tension signs
  • Diagnosis of Thoracic Outlet Syndrome

Palpation for a Superiorly Subluxed First Rib (Lindgren, Leino, Manninen, 1992):

  • Illustration of a superiorly subluxated first rib on the left – the rib must be at least a finger width’s difference in height to make the diagnosis.
  • Compare this palpation test with the cervical rotation lateral flexion (CRLF) test.
  • To perform the CRLF test the patient is either sitting or supine and the neck is passively rotated to the left then laterally flexed to bring the right ear towards the chest. This tests the right first rib. The test is then repeated on the opposite side for comparison.

Cervical Rotation/Lateral Flexion Test (CRLF) to Diagnose a Superiorly Subluxated First Rib:

To test for a superiorly subluxated first rib on the right:
Therapist passively rotates the patient’s head to the left then attempts to laterally flex the head to the right bringing the right ear towards the chest.

A comparison is made with the opposite side. A positive test is indicated when the range of lateral flexion is reduced and a bony or hard end feel is felt by the therapist when the transverse process of C7 contacts the superiorly elevated rib.

Related

ULTT 3 – Median Nerve Bias

in 3 Movement Tests Upper Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule

ULTT 3 – Median Nerve Bias

  • Therapist places right hand/fist above patient’s right shoulder to stabilize
  • Patient’s right shoulder abducted to 90º, elbow flexed, forearm pronated, wrist and fingers extended
    Elbow is then maximally flexed

 

  • Maintaining all the components achieved so far, the shoulder is then abducted as though placing the palm of the patient’s right hand over the ear
  • The ROM and the patient’s response is noted
    Patient is then asked to side bend the head away and any change in pain response is noted

ULTT 1 – Median Nerve Bias

in 3 Movement Tests Upper Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule

ULTT 1 – Median Nerve Bias

  • Therapist places right hand/fist above the patient’s right shoulder to stabilize
  • Patient’s right arm is abducted to 90º, elbow flexed to 90º, forearm supinated, wrist/fingers extended, and shoulder ER
  • Maintaining wrist & finger extension, the elbow is extended and the ROM and the patient’s response noted
  • Therapist then asks the patient to side bend the head to the right and left and notes the patient’s response

Self-Stretch of the Pectorals

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule, Scapular Depression, Scapular Stabilization, Self Stretch, Shoulder Abduction, Shoulder Circle, Supine Shoulder Flexion

Self-Stretch of the Pectorals

To stretch the right pectorals:

  • Initially the patient stands facing the wall and places their outstretched right hand on the wall at shoulder height.
  • Ask them to turn their trunk to the left so that their feet are parallel to the wall.
  • Have them bend their right elbow as they bring the right shoulder blade down and back.
  • Instruct the patient to place their left hand on the wall to help turn the trunk further to the left.
  • Make sure they hold the right shoulder down and back so that the right shoulder is no higher than the left.
  • Instruct the patient to lean into the wall to increase the stretch.
  • They should feel a stretch through the front of the chest and right shoulder.
  • Have them hold for 30 seconds and repeat 2-3 times.
  • Then have them repeat on the opposite side.

Manual Therapy to Address Pectoralis Minor Hypertonicity

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Manual Stretching, Pectoralis Minor/Posterior Capsule, Shoulder Circle

Manual Therapy to Address Pectoralis Minor Hypertonicity

Note that applying AP glides to the Sternochondral Joints in side lying from T3-5, which helps to diminish tone in the pectoralis minor, should precede manual stretching of this muscle.

Manual Stretching of the Pectoralis Minor:

The therapist’s left hand is placed over the 3-5th ribs to stabilize the origin of the pec minor.

  • The patient’s right arm is taken into horizontal abduction with varying amounts of flexion depending on the direction of greatest restriction.
  • The stretch is applied by tractioning the patient’s R arm longitudinally as the arm is taken into further horizontal abduction.
  • The stretch is held for 30 seconds and repeated 2-3 times.

Posterior Capsule Self Stretch

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule, Self Stretch

Posterior Capsule Self Stretch

In comparing the sleeper stretch with the cross body stretch in a group of asymptomatic recreational athletes the cross body stretch improved IR ROM better and the results lasted longer (McClure et al., 2007). However, they performed the cross body stretch with the shoulder internally rotated which we believe can lead to impingement and therefore we prefer to have the patient perform the stretch with ER of the shoulder and emphasize contralateral upper thoracic spinal rotation instead. We believe that it is the mobilization of the thoracic spine for contralateral rotation that explains the superior results with the cross body stretch.

To stretch the left posterior capsule:

  • The patient is seated and is instructed to bring their left arm up until parallel to the floor with their fingers pointing up towards the ceiling and the left elbow bent to 90 degrees.
  • They place their right hand on the outside of the left elbow.
  • Instruct the patient to use their right hand to pull their left elbow across in front of them keeping the left elbow bent and their left palm facing behind them.
  • Have the patient rotate their trunk as far as they can to the right to enhance the stretch and increase upper thoracic spinal rotation to the right.
  • The patient is instructed to hold for 30 seconds and repeat 2-3 times.
  • It’s important that you watch to make sure that the patient does not slump as they rotate to the right.
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