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

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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

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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.

Latissimus Dorsi Self Stretch

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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.

Manual Stretch of the Latissimus Dorsi

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Manual Stretch of the Latissimus Dorsi

To Stretch the Left Latissimus Dorsi:

The patient is supine with the arms brought up overhead to the shoulder flexion barrier without pinching or producing pain in the shoulders.
The patient’s arms are supported with a gentle longitudinal traction applied by an assistant.
The therapist flexes the patient’s knees to chest to reduce the lumbar lordosis and to initiate the stretch from below up.
With the knees held to the patient’s chest the therapist reaches around and grasps the left side of the patient’s pelvis with his R hand.
The therapist then pulls the patient’s pelvis to the right to side bend the trunk to the right and stretch the L latissimus dorsi.
The therapist holds the stretch momentarily and repeats the stretch 4 to 5 times before repeating on the opposite side.

Mobilization of the Thoracic Spine in the Lat Dorsi Stretch Position

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Mobilization of the Thoracic Spine in the Lat Dorsi Stretch Position

In kneeling, have the patient place their elbows on top of a bench or chair and walk their knees back until their hips are flexed to approximately 90º.
Their hands and forearms should be together with the head resting on their upper arms.
Ask the patient to press the inner border of their arms together to separate the shoulder blades in back.
The patient is instructed 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.
The therapist can then apply a posterior to anterior mobilization glide on the spinous process or transverse processes of any segment that appears to be restricted for extension while the patient maintains the stretch or the therapist can perform a myofascial stretch using the fists to draw the soft tissues towards the midline.
The goal is to increase extension in the mid to lower thoracic spine before instructing the patient in self-stretching of the latissimus dorsi.
Remember that the lower trapezius not only contributes to mobility of the shoulder, but is also a thoracic spinal extensor. Consequently studies have found that both mobilization and manipulation techniques to increase extension in the thoracic spine result in an increase in lower trapezius muscle strength, at least in the short term (Liebler et al., 2001 and Cleland et al., 2004).

Dysfunctional Scapular Depression and Shoulder Flexion Tests

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Dysfunctional Scapular Depression and Shoulder Flexion Tests

Anatomy and Biomechanical Considerations:

The scapular depression tests are used to evaluate the strength/tone of the lower trapezius muscle. The lower trapezius works together with the serratus anterior in a force couple that results in upward rotation, posterior tilt and external rotation of the scapula that is required during elevation of the arm. Note that the lower trapezius is also an extensor of the lower thoracic spine so with restricted thoracic spinal extension (FRS dysfunctions from T6-10) the lower trapezius is inhibited. When the lower trapezius is inhibited the patient may substitute by using the latissimus dorsi to depress the shoulder resulting in downward rotation of the scapula and limited external rotation of the humerus. In addition, hypertonicity in the latissimus dorsi contributes to increasing the thoracic kyphosis and the lumbar lordosis. The bilateral shoulder flexion test in supine allows us to evaluate the length of the latissimus dorsi as well as observe that when it’s hypertonic the patient will compensate by arching the lower back as the latissimus dorsi reaches its end range.

Therefore before attempting to retrain the lower trapezius we must assess for and treat any FRS Dysfunctions from T6-10 and lengthen the latissimus dorsi.

Lower Trapezius:

Attaches to the spinous processes and the interspinous ligaments from T4-T12 and along the medial border of the scapula and medial end of the spine of the scapula.
Function: It upwardly rotates, posteriorly tilts and externally rotates the scapula and assists in extending the thoracic spine from T4-T12.
Innervation: Spinal Accessory Nerve Cranial XI and the dorsal rami from T4-T12.
Inhibited by FRS Dysfunctions from T6-T12.

Latissimus Dorsi:

Attached to the lower 6 thoracic spinous processes and all the lumbar vertebrae, sacrum, crest of ilium and lower 3-4 ribs
Function: adduction and internal rotation of the shoulder, depression of the scapula; extension of lumbar spine and anterior tilt of the pelvis
Innervation: thoracodorsal nerve – C6,7,8

Muscle Energy Technique for FRS Dysfunctions T6-10

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Muscle Energy Technique for FRS Dysfunctions T6-10

For an FRS R from T6-10:

The patient places their R hand on their L shoulder and the therapist reaches under the patient’s R arm and grasps the patient’s L shoulder.
The therapist palpates the L side of the interspinous space monitoring the superior aspect of the inferior spinous process, ie., FRS R T8,9 the therapist monitors the superior aspect of the spinous process of T9 on the L side.
Initially the patient is sitting with their spine flexed and the therapist asks the patient to slowly sit up by pushing the belly forward to introduce extension from below up to the palpated interspinous space.
The therapist introduces slight L rotation down to the palpating finger.
The therapist then translates the patient from L to R to introduce L side bending without closing down and pinching at the interspinous space.
The patient attempts to R SB for 5-7 seconds which the therapist blocks.
When the patient relaxes the therapist repositions the patient to the new motion barrier by first standing up to decompress the segment, then rotating the patient to the L and finally translating the patient from L to R to the new L side bending barrier.
No pinching should be felt at the palpated segment by the therapist or the patient.
This entire sequence is repeated 3 to 4 times then mobility is reassessed.

Scapular Depression Test: A test of lower trapezius strength/recruitment

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Scapular Depression Test: A test of lower trapezius strength/recruitment

How to Perform

Scapular Depression: Lower Trapezius Activation

The patient is prone lying with the tested arm overhead and the arm abducted to 140º.

The patient lifts the arm off the table and the therapist palpates the lower trapezius for activation/tone.

An alternative test can be done in prone lying with the tested arm resting at the patient’s side.

The examiner lifts the patient’s shoulder off the table and asks the patient to hold the shoulder blade down and back to activate the lower trapezius.

Lower Trapezius Segmental Assessment:

Therapist palpates for activation of the lower trapezius along its length of attachment from T6-12 and identifies an area where the muscle appears to be inhibited.

Interpretation and the most common dysfunctional patterns seen

The lower trapezius muscle normally contributes to a force couple, along with the serratus anterior, to upwardly rotate, externally rotate and posteriorly tilt the scapula during arm elevation.

Inhibition of the lower trapezius significantly decreases the scapular stability that is needed when raising the arm over the head resulting in elevation of the shoulder and scapular dyskinesis. The net result that often occurs is impingement of the shoulder and/or cervical strain/pain.

When the patient is asked to hold the scapula down and back they often will substitute by using the ipsilateral latissimus dorsi resulting in depression of the shoulder girdle rather than depression of the scapula. Overutilization of the latissimus dorsi also results in downward rather than upward rotation of the scapula.

Often a specific thoracic segmental level of inhibition can be identified by palpating along the length of the lower trapezius attachment to the spine from T6-12. It should be noted that the lower trapezius muscle not only receives its innervation from the spinal accessory nerve (Cranial Nerve 11) and C3,4, but we also believe it’s segmentally innervated by the dorsal primary rami found at each thoracic spinal segment to which the lower trapezius is attached.

Note that the lower trapezius not only contributes to mobility of the shoulder, but is also a thoracic spinal extensor. Consequently, studies have found that both mobilization and manipulation techniques to increase extension in the thoracic spine result in an increase in lower trapezius muscle strength, at least in the short term (Liebler et al., 2001 and Cleland et al., 2004). Clinically what we have found is that an FRS R dysfunction found anywhere from T6 thru T10 results in lower trapezius inhibition at the same segmental level as the FRS. Thus restoration of thoracic extension mobility and especially treating FRS dysfunctions needs to occur first before any attempt to “strengthen” the lower trapezius muscle is initiated.

Scapular Depression