3 Movement Tests Upper Quarter

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AP Mobilization to the L Sternochondral Joints to Increase Thoracic Rotation to the Left

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Mobilization, Pectoralis Minor/Posterior Capsule, Scapular Depression, Shoulder Circle, Supine Shoulder Flexion

AP Mobilization to the L Sternochondral Joints to Increase Thoracic Rotation to the Left

  • The patient is right side lying with the hips and knees flexed to about 45 degrees and places their left hand behind the head.
  • Instruct the patient to rotate back to the left without separating the knees.
  • The therapist places the pad of their right thumb on the superior border of the L sternochondral joint and applies an AP glide to promote external rotation (torsion) at each rib.
  • The therapist assesses rib mobility from T1-T7 and identifies the most significant restriction needing mobilization.
  • The anterior ribs can be very tender/painful so the therapist is looking for the most hypomobile rib, not the most tender.
  • Posterior capsule tightness resolves most commonly after AP mobilization of the hypomobile 4th and 5th sternochondral joints on the opposite side.
  • Pectoralis minor tightness often resolves after AP mobilization of the ipsilateral sternochondral joints from T3-5.

Mobilization of the Rib Cage to Restore Thoracic Spine Rotation to the Left

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, 5 Home Exercise Strategy, All Home Exercises, All Manual Therapy, All Upper Quarter, Mobilization, Self-mobilization

Mobilization of the Rib Cage to Restore Thoracic Spine Rotation to the Left

  • Top – To restore thoracic rotation to the left, mobilize the left rib cage in an anterior to posterior direction
  • Bottom – Mobilize the right side of the rib cage in a posterior to anterior direction

Traditional Treatments to Stretch a Tight Posterior Shoulder Capsule

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

Traditional Treatments to Stretch a Tight Posterior Shoulder Capsule

  • Top – Therapist applies an anterior to posterior glide through the humerus to mobilize the posterior shoulder capsule

  • Bottom – Sleeper stretch home exercise. Patient attempts to self stretch the right shoulder into further IR which was reportedly painful

Clinical Observation: What appears to be posterior capsular tightness of the right shoulder often resolves with mobilization of the rib cage to promote thoracic spine rotation to the left.

 

Assessment of Thoracic and Rib Cage Rotation Mobility with Side Lying Shoulder Circles

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

Assessment of Thoracic and Rib Cage Rotation Mobility with Side Lying Shoulder Circles

  • The patient is lying on their side with hips and knees flexed about 45 degrees and is asked to sweep the arm around in a circle keeping their elbow straight and maintaining hand contact with the floor
  • Notice limitation for left shoulder circle (left thoracic rotation) vs right

Therefore this patient presents with a loss of IR of the R shoulder and restricted shoulder circles on the L.

Posterior Capsule Tightness Confirmed by a Loss of Internal Rotation

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

Posterior Capsule Tightness Confirmed by a Loss of Internal Rotation

  • To confirm tightness in the posterior capsule the patient is placed in ¾ side lying so that the scapula is stabilized against the table
  • The shoulder is abducted to 90 degrees then IR is introduced
  • The therapist makes sure that the shoulder stays flat on the table as the arm is passively internally rotated
  • Normally the patient’s fingertips should comfortably reach the table top (70 degrees of IR)
  • The test is repeated to both sides for comparison
  • Note a limitation for IR on the right side in this patient who presented with posterior capsular tightness on the R side

Note: It is extremely important that the therapist is able to differentiate between tightness of the pectoralis minor versus a tight posterior capsule as their treatments are very different. If a patient with a tight posterior shoulder capsule is given a pec minor stretch the patient’s condition can be made much worse.

To Evaluate for Pectoralis Minor Tightness on the R Side

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Manual Stretching, Shoulder Abduction

To Evaluate for Pectoralis Minor Tightness on the R Side

  • The therapist places their L thenar eminence on the superior border of the patient’s R 3rd thru 5th ribs.
  • The therapist’s R arm passively raises and supports the patient’s R arm overhead.
  • The therapist applies an inferior and medial glide to the ribs and pectoral fascia from ribs #3-5 to assess for hypertonicity in the pectoralis minor.
  • No restriction was detected in this patient who presented with a protracted R shoulder.

Significance of Posterior Capsule Tightness:

  • Tightness of the posterior capsule correlates to a loss of internal rotation and increased anterior humeral head translation (Tyler et al, 1999; Tyler et al., 2000)
  • Tightness of the posterior capsule is linked to increased superior migration of the humeral head (Harryman et al., 1990))
  • A positive Tyler posterior shoulder tightness test has been found in patients with subacromial impingement (Tyler et al, 2000)

Restricted Posterior Capsule and Restricted Shoulder Circles and Hypertonic Pectoralis Minor

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

Restricted Posterior Capsule and Restricted Shoulder Circles and Hypertonic Pectoralis Minor

Hypertonicity of the pectoralis minor, tightness in the posterior capsule of the shoulder and restricted shoulder circles are addressed together as each type of dysfunction is biomechanically related to the other.

Anatomy and Biomechanical Considerations:

Pectoralis Minor:

  • Attaches to the superior margins of ribs #3-5 and inserts into the medial aspect of the coracoid process.
  • Function: With the ribs fixed it anteriorly tilts and IR the scapula
  • Innervation: Medial pectoral and a branch from the lateral pectoral nerves – C(6),7,8,T1

Latissimus Dorsi Self Stretch

in 3 Movement Tests Upper Quarter, 5 Home Exercise Strategy, All Home Exercises, All Upper Quarter, Scapular Depression, Self Stretch, Supine Shoulder Flexion

Latissimus Dorsi Self Stretch

  • The patient is kneeling with their elbows on top of a bench or chair and their hips and knees flexed to approximately 90º.
  • Instruct the patient to place their hands and forearms together and rest their head on their upper arms.
  • Ask the patient to press the inner borders of their arms together to separate the shoulder blades in back.
  • Ask the patient to drop their chest toward the floor as much as possible, then perform a posterior tilt (12:00) of the pelvis without lifting up the chest. They should feel a good stretch along the sides, around their shoulder blades.
  • Have the patient hold the stretch for 30 seconds, then relax and sag the chest further toward the floor. They repeat the stretch 2-3 times.

Segmental Cat Backs – Self-Mobilization for Thoracic Extension

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

Segmental Cat Backs – Self-Mobilization for Thoracic Extension

  • The patient is in the hands and knees position with the hands directly beneath the shoulders and knees directly under the hips.
  • The patient is instructed to drop the head down and segmentally lift their spine towards the ceiling progressing segmentally from the neck then thorax and finally the lumbar spine, finishing by tucking the pelvis under with a posterior tilt.
  • From this fully flexed position the patient has the option to reverse their spine from the bottom up or from the top down.
  • If reversing from the bottom up the patient is instructed to anteriorly tilt the pelvis and drop the lumbar spine into lordosis, segmentally progressing up into the thoracic spine with the shoulder blades approximating as the chest drops forward and the neck and head are extended. The therapist observes the motion to make sure that the patient does not skip over a portion of the spine, but moves segmentally as much as possible.
  • If reversing from above down from the fully flexed position the patient is instructed to lift up their head, extend the neck and drop their chest towards the table with the scapula approximating as the mid-thoracic spine extends. As the motion approaches the lumbar spine the patient drops their belly and anteriorly rotates the pelvis, lifting the tailbone up.
  • The therapist evaluates in which direction that the patient appears to have better control, from the bottom up or from the top down, and instructs the patient to always initially start the exercise moving in the direction that they have the best control.
  • The patient repeats the movements 5 to 6 times alternating the initiation of movement from the head and from the tailbone.
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