Shoulder Abduction

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

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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.

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

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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

Self-Stretch of the Pectorals

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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.

Side Lying Rib Cage Self-Mobs

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Side Lying Rib Cage Self-Mobs

Self mobs to restore thoracic rotation to the left:

  • The patient is lying on their right side with the hips flexed to between 45-60º with their left hand placed underneath the lower right side of the rib cage.
  • Instruct the patient to roll back to the left and with your left hand pull the right lower rib cage into left rotation. They repeat 3-4 times moving their hand slightly superior with each rotation.
  • Moving up to the xiphoid process have the patient place the fingertips of their left hand on the left side of the rib cage, just off the sternum and lateral to the xiphoid process.
  • Instruct the patient to rotate back to the left and use their left hand to pull the ribs back towards the floor.
  • After the patient returns to the midline they move their fingers up to the next rib and they repeat the rotation drawing the next rib back to the floor.
  • The patient should always start from below, approximately the 7th or 8th rib, and work their way up until they reach the collarbone.
  • The patient is instructed to rotate back approximately 7 times moving their hand up approximately 1 inch each time to draw back a new rib. To enhance the stretch, the patient takes a deep breath in, then exhales as they draw the rib back further.

Quadratus Lumborum Self Stretch

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Quadratus Lumborum Self Stretch

To stretch the left quadratus lumborum:

  • The patient is supine with hips and knees flexed and feet flat on the floor.
  • Instruct the patient to cross the right leg over the left and drop both legs to the right.
  • Ask the patient to push the legs together for 5 to 7 seconds and then relax. Upon relaxation the right leg pulls the left leg further over to the right to increase the stretch.
  • Repeat 3-4 times progressively then repeat on the R side.
  • Goal – for the patient to try to touch the inside of the left knee to the floor while keeping the left shoulder on the floor.

To Evaluate for Pectoralis Minor Tightness on the R Side

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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)

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).

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.

Dysfunctional Shoulder Abduction Test

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Dysfunctional Shoulder Abduction Test

Patients who present with complaints of neck and/or shoulder pain often state that one of their most pain provoking activities is raising their arm overhead. The shoulder abduction test helps us to determine if the patient has a normal or abnormal scapulo-humeral rhythm and to determine if their scapular stability is compromised when they raise their arm overhead. This test, if abnormal, may also indicate that the patient has abnormal neurobiomechanics with involvement of the brachial plexus. If this is the case the patient may hold their shoulder in an elevated position even when at rest and side bend their head to the ipsilateral side during the shoulder abduction test in an attempt to diminish tension on the plexus.

Anatomy and Biomechanical Considerations:

Normally during shoulder abduction the scapula upwardly rotates around an AP axis, posteriorly tilts around a horizontal axis running along the spine of the scapula and externally rotates around a vertical axis (Ludewig et al., 1996). This three-dimensional movement of the scapula occurs as a result of a force couple between the lower trapezius muscle working in tandem with the serratus anterior. If either of these muscles should become inhibited/weak then normal scapular mobility and stability is compromised.

According to Janda (1990) shoulder abduction also requires activation of the contralateral quadratus lumborum as part of the shoulder abduction muscle firing sequence. This would appear to be especially important at approximately 120 degrees of abduction, when the weight of the movement arm must be counterbalanced. Palpation of the quadratus lumborum during unilateral shoulder abduction is used to assess the appropriate firing of this muscle as part of the shoulder abduction test. In a dysfunctional test we often find that the ipsilateral rather than the contralateral QL will fire making it difficult for the patient to elongate that side of the trunk during abduction of the arm and result in compensatory superior translation of the scapula. Excessive superior translation of the scapula has been found in subjects with shoulder impingement (Lukasiewicz et al., 1999). Ipsilateral FRS dysfunctions at T12,L1 are most often the cause of hypertonicity in the quadratus lumborum and therefore must be looked for and treated, when present, before considering to stretch this muscle. A muscle energy technique to address the FRS dysfunction will often result in normalizing the tone of the ipsilateral quadratus and restore the ability of the contralateral quadratus to fire normally during shoulder abduction.

Considering the effect that dysfunction of the postural muscles, as described by Janda in the Upper Crossed Syndrome, can have upon scapular mechanics during shoulder abduction, we look for and most often treat the following:

  1. Hypertonicity of the levator scapula and pectoralis minor that restricts posterior tilt of the scapula.
  2. Hypertonicty of the levator scapula and upper trapezius that restricts upward rotation of the scapula.
  3. Hypertonicity of the pectoralis minor that restricts external rotation of the scapula.
  4. Hypertonicity of the ipsilateral quadratus lumborum that forces substitution by the upper trapezius and levator scapula resulting in excessive superior translation of the scapula.
 

Wall Press Self-Mobilizing Exercise

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Wall Press Self-Mobilizing Exercise

To Self-Mobilize ERS Dysfunctions in the Upper TS:

  • The patient is standing approximately three feet from a wall and places their hands on the wall at shoulder height.
  • Instruct the patient to drop their head down and push their arms against the wall fully extending their elbows and rounding their upper back. They should feel a stretch in their upper back.
  • Make sure that the apex of spinal flexion occurs in the upper and not the middle or lower back when they extend their arms.
  • Instruct the patient to rotate their head to the R to stretch L sided ERS dysfunctions or rotate their head to the L to stretch R sided ERS dysfunctions as they extend their arms fully.
  • Ask the patient to hold for 5-10 seconds.
  • Then have the patient stand up straight and lean into the wall maintaining a neutral low back. Ask the patient to try to touch the wall with their forehead.
  • The shoulder blades should draw close together as they drop into the wall.
  • Instruct the patient to hold this position for 5-10 seconds and repeat the entire exercise 3-5 times.