Muscle Energy Technique for ERS Dysfunctions of the Upper Thoracic Spine

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Muscle Energy Technique for ERS Dysfunctions of the Upper Thoracic Spine

For an ERS R from C7 to T5:

Patient places their R arm on your R leg with their whole arm resting and supported on your R thigh.
Place your R hand gently on top of their head and your L thumb on the L side of the interspinous space of the dysfunctional segment to monitor the motion barriers.
The patient is initially sitting in a slumped position, but with their head up. Ask the patient to sit up tall from below up by pushing their belly forward until you feel motion at your palpating L thumb.
Then with your R hand move the patient’s head from an extended position into flexion introducing flexion from above down to your palpating L thumb so that you create an apex for flexion at the dysfunctional segment.
L side bending is then introduced by translating your R leg to the R to create an apex for L side bending at your palpating L thumb.
The therapist then adds L rotation thru the head from above down to the dysfunctional segment making sure to go to just the feather edge and not beyond the motion barrier.
The patient is instructed to gently side bend their head to the R or pull their R arm down on your leg for 5-7 seconds.
When the patient relaxes you introduce additional L side bending to the new motion barrier by translating your R leg further to the R.
You repeat 3 to 4 times then reassess.

Shoulder Circles

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Shoulder Circles

How to Perform

The patient is side lying with the hips and knees flexed to approximately 60 degrees and the arms straight out in front.
The top arm is taken around in a circle overhead keeping the elbow straight and the hand in contact with the floor.
The patient is instructed to keep the knees together, but is encouraged to rotate through the thoracic spine and rib cage.

Interpretation and the most common dysfunctional patterns seen
Normally the patient should be able to keep the hand in contact with the floor with the elbow straight as they circle the hand around a full 360 degrees.

Notice in the patient above, the restriction for the left versus the right shoulder circle. This restriction is indicative of a loss of thoracic and rib cage mobility for left rotation and limits ER of the left shoulder.

Note: This patient presents with a loss of IR of the R shoulder and ER of the left shoulder secondary to a loss of left rotation of the thoracic spine and rib cage!

Pectoralis Minor Length or Posterior Capsule Tightness

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Pectoralis Minor Length or Posterior Capsule Tightness

How to Perform

With the patient lying supine and without a pillow under the head, the therapist observes the relative position of both shoulders compared to the table top.
Notice that the right shoulder appears to be more anterior than the left.

Interpretation and the most common dysfunctional patterns seen

When observing that one shoulder appears to be relatively anterior compared to the opposite shoulder the therapist needs to determine the source of this anterior displacement. Is it due to a tight pectoralis minor as originally proposed by Kendall and McCreary, 1983 or due to a tight posterior shoulder capsule on that side, as the treatment for each of these dysfunctions is vastly different.

To differentiate between the two, the therapist applies an AP glide to the head of the humerus to confirm posterior capsule tightness on this patient’s right side. Recall that the pectoralis minor does not attach to the humerus so it should not influence or restrict posterior glide.

To assess for pectoralis minor hypertonicity as the cause of the anterior displacement the therapist can apply an inferiorly directed force on the anterior 3rd-5th ribs on both sides and note any resistance in extensibility between the two sides.

In this patient a restriction for AP glide of the right shoulder was noted indicating that the tissue involved is the R posterior capsule. Studies have shown that with a tight posterior capsule the head of the humerus is pushed forward and superiorly with a resultant loss of internal rotation mobility. (Harryman et al., 1990; Tyler et al., 1999; Tyler et al., 2000).

To confirm posterior capsule tightness the therapist then examines the range of motion for IR by placing the patient in side lying with the scapula stabilized. The arm is then passively internally rotated.

Shoulder Abduction Test

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Shoulder Abduction Test

The patient is seated and instructed to raise the arms out to the sides and overhead.
The therapist observes for any faulty substitution patterns while the patient raises and lowers the arms.
Notice that this patient, who was complaining of right shoulder pain, elevates and excessively upwardly rotates the right scapula indicating a loss of scapular stability and dysfunctional biomechanics for right shoulder abduction.
After observing bilateral shoulder abduction the patient is asked to raise one arm at a time with the examiner palpating the quadratus lumborum muscles bilaterally for appropriate firing. During right shoulder abduction the left quadratus lumborum should fire, especially at about 120 degrees of abduction to offset the weight of the right arm. If the right quadratus lumborum fires while raising the right arm it indicates an abnormal/dysfunctional muscle firing pattern. The patient is then forced to compensate by elevating the shoulder girdle with the upper trapezius and levator scapula muscles which become hypertonic and shortened.

Interpretation and the most common dysfunctional patterns seen

Janda, 1990 described a normal sequential shoulder abduction firing pattern occurring as follows:

supraspinatus
deltoid
contralateral and ipsilateral upper trapezius/levator scapulae
contralateral quadratus lumborum
contralateral peronei

He did not mention the role of the serratus anterior or lower trapezius muscles. Elevation of one shoulder girdle during the test and/or scapular winging may be due to a muscular imbalance between the levator scapulae and upper trapezius which are hyperactive and tight and inhibition of the lower trapezius, serratus anterior and supraspinatus which appear to be weak. EMG analysis of the three divisions of the trapezius muscle during isokinetic shoulder abduction has shown that the upper trapezius activity is increased whereas the lower trapezius activity is decreased in overhead athletes with a history of shoulder impingement when compared to a control group of non-injured athletes (Cools et al., 2007). It has also been reported that shoulder impingement patients have delayed firing of the middle and lower trapezius during sudden perturbations of the shoulder compromising the functional stability of the scapula (Cools et al., 2003).

We have observed that overutilization of the upper trapezius and levator scapulae may also occur when the ipsilateral rather than contralateral quadratus lumborum fires limiting the patient’s ability to elongate the spine on that side resulting in excessive compensatory superior translation of the scapula during abduction of the shoulder.

Normally during shoulder abduction the scapula upwardly rotates, externally rotates and posteriorly tilts (Ludewig, Cook, Nawoczenski, 1996), occurring as a result of a force coupling involving the upper and lower trapezius and serratus anterior. Lukasiewicz et al., 1999 reported that when comparing subjects with signs and symptoms of shoulder impingement to an asymptomatic matched control group that the impingement patients presented with a decrease in posterior tilting during humeral elevation with excessive scapular superior translation. Interestingly, they did not find a difference in the amount of upward rotation between the two groups. Based upon their findings they proposed that exercise programs for shoulder impingement patients should probably include stretching of the pectoralis minor and strengthening of the serratus anterior to address this loss of posterior tilt.

Therefore, it is well known that when the lower trapezius and serratus anterior are inhibited/weak there is a loss of not only scapular stability, but also all three planes of normal scapular mobility during humeral elevation. Hyperactivity of the levator scapula and upper trapezius results in elevation, downward rotation and anterior tilt of the scapula. Hyperactivity of the pectoralis minor protracts, internally rotates and anteriorly tilts the scapula.

We propose that a strain of the cervical spine occurs due to the hypertonicity of the levator scapula muscle as it attaches to the upper four cervical segments. Stretching the levator scapula not only reduces the strain in the neck, but, if properly done, allows posterior tilting of the scapula to occur unimpeded during shoulder elevation.

Half Kneeling Chops with Resistance

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Half Kneeling Chops with Resistance

Chopping is the downward oblique movement across the body from a high position to a low position.
The patient starts in half kneeling with the left knee down and right knee flexed to 90 degrees and with the R knee centered over the right foot. Both arms are raised up over the right shoulder holding onto handles that are attached to resistance bands.
Ask the patient to find a neutral lumbar spine then draw the belly in to maintain it throughout the exercise.
Instruct the patient to keep their eyes and head facing forward as they pull obliquely down and across their body towards the left knee extending both arms.
Their trunk should remain still and their spine in neutral as they perform 6-8 repetitions.
Then have them switch their hand positions and repeat the chopping motion in the opposite direction.
The patient can begin this exercise with their legs initially separated for a more stable base and then bring the legs closer together to increase the level of difficulty.

Kneeling Chops with Resistance

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Kneeling Chops with Resistance

Chopping is the downward oblique movement across the body from a high position to a low position.
The patient starts in kneeling with both arms raised up over the right shoulder holding onto handles that are attached to resistance bands.
Ask the patient to find a neutral lumbar spine then draw the belly in to maintain it throughout the exercise.
Instruct the patient to keep their eyes and head facing forward as they pull obliquely down and across their body towards the left knee extending both arms.
Their trunk should remain still and their spine in neutral as they perform 6-8 repetitions.
Then have them switch their hand positions and repeat the chopping motion in the opposite direction.
The patient can begin this exercise with their knees initially separated for a more stable base and then bring the knees closer together to increase the level of difficulty.

Half Kneeling Chops and Lifts

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Half Kneeling Chops and Lifts

The patient starts in half kneeling with the left knee down and right knee up, with their right knee bent to a right angle so that their right knee is position over the right ankle.
The patient grasps a dowel in both hands with the palm of the right hand facing upwards (supinated) and the palm of the left hand facing down (pronated).
The patient is instructed to raise the dowel upwards to the right (lift). Then bring the dowel downwards towards the left (chop) so that they always lift towards the upside knee and always chop toward the downside knee.
Ask the patient to keep their head and eyes facing forward as they raise (lift) and lower (chop) the dowel in front of their body, keeping their trunk tall.
The trunk should remain still and the patient should try to maintain a neutral lumbar spine during the movement
Instruct the patient to repeat the movements 6-8 times then reverse their leg and hand positions to repeat the chop and lift to the left side.
The patient can begin this exercise with their knees initially separated for a more stable base and then bring the knees close together to increase the level of difficulty.

Tall Kneeling Chops and Lifts

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Tall Kneeling Chops and Lifts

Chopping is the downward movement across the body from a high position to a low position and lifting is the upward movement from a low position to a high position.
The patient starts in kneeling with a dowel in both hands with the palm of the top hand facing upwards (supinated) and the palm of the lower hand facing down (pronated).
Ask the patient to keep their eyes and head facing forward as they raise and lower the dowel in front of their body with both arms.
Their trunk should remain still and their spine in neutral as they perform 6-8 repetitions.
Then have them switch their hand positions and repeat the chop and lifting motions in the opposite direction.
The patient can begin this exercise with their knees initially separated for a more stable base and then bring the knees close together to increase the level of difficulty.

Pectoralis Minor Hypertonicity

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Pectoralis Minor Hypertonicity

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.

Shoulder Abduction