Pectoralis Minor/Posterior Capsule

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Rib Cage Mobilization from the Back with IR and ER of the Shoulder

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

Rib Cage Mobilization from the Back with IR and ER of the Shoulder

  • Once the therapist identifies the most restricted rib, he applies an anteriorly directed pressure to the superior border of the rib to promote internal torsion/IR of that rib
  • The patient is then instructed to IR and then ER the arm while the therapist maintains steady pressure on the superior border of the rib
  • Since IR of the arm promotes IR rotation of the rib, the therapist follows the rib during IR and blocks the rib from moving into ER when the patient ER their arm
  • The patient is instructed to ER/IR their arm repeatedly 7-8 times while the therapist maintains steady PA pressure to the rib angle

PA Mobilization to the Rib Angles to Increase Thoracic Rotation to the Left

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Lower Quarter, All Manual Therapy, All Upper Quarter, Mobilization, Pectoralis Minor/Posterior Capsule, Scapular Depression, Scapular Stabilization, Shoulder Circle

PA Mobilization to the Rib Angles to Increase Thoracic Rotation to the Left

  • The patient is lying on their left side with their right arm resting on top of the left
  • The therapist places a reinforced thumb on the rib angle of each rib and assesses mobility for anterior glide and IR of the rib

AP Mobilization of the L Sternochondral Joints with IR and ER of the Shoulder

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

AP Mobilization of the L Sternochondral Joints with IR and ER of the Shoulder

  • Once the therapist has located the restricted rib(s) further specificity for mobilization can be made by having the patient IR and ER their arm while the therapist maintains AP pressure on the superior border of the rib at the sternochondral joint
  • Since ER of the arm promotes ER rotation of the rib, the therapist follows the rib during ER and blocks the rib from moving into IR when the patient IR their arm
  • The patient is instructed to ER/IR their arm repeatedly 7-8 times while the therapist maintains steady AP pressure to the superior border of the rib

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.

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.

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

Posterior Capsule Tightness: Restricted IR Right vs Left Side

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

Posterior Capsule Tightness: Restricted IR Right vs Left Side

  • Patient is side lying with the scapula stabilized underneath.
  • The shoulder is abducted to 90º then internally rotated to its limit without the shoulder rising off the table. Normally the fingertips should be able to touch the table (approximately 70º of internal rotation).
  • Note the loss of IR of the R shoulder versus the L in the patient above.
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