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

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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

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)

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).

Three-Dimensional Scapular Mobilization (Side Lying)

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Three-Dimensional Scapular Mobilization (Side Lying)

To Stretch the Right Rhomboids:

Patient is lying on their L side and the therapist is standing behind.
The therapist reaches underneath the patient’s R arm and places their hand on top of the patient’s R scapula.
The therapist’s L fingers reach under the superior medial border of the scapula.
Using both hands the therapist draws the scapula inferiorly while upwardly rotating and abducting the scapula to stretch the rhomboids.
The therapist maintains the stretch for 30 seconds and repeats 2 to 3 times.

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.

Muscle Energy Technique for the Levator Scapulae

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Muscle Energy Technique for the Levator Scapulae

To stretch the right levator scapulae:

The patient is left side lying with the head positioned in flexion, left side bending and left rotation.
The operator’s right hand is placed on the lateral aspect of the neck from C1 through C4 to stabilize the cervical spine. The operator’s left hand is placed over the patient’s right shoulder in front of the clavicle so that the shoulder can be brought into posterior tilt with depression of the medial border of the scapula. The patient’s right hand should be placed upon and remain on top of the right hip.
The patient is instructed to raise the right shoulder towards their ear which is resisted by the therapist for five to seven seconds.
Upon relaxation further posterior tilt and depression of the scapula are introduced by the therapist.
This procedure is repeated 3-4 times.

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.

Advancement of Supine Heel Slide Exercise

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Advancement of Supine Heel Slide Exercise

The patient is lying supine with their hips and knees flexed and the feet flat on the table.
Instruct the patient to find a neutral lumbar spine position, midway between 12:00 and 6:00, monitoring the ASISs with their thumbs.
Have the patient draw their belly in without flattening the low back (the ASISs should not move when they draw the belly in).
Instruct the patient to slowly extend their right leg keeping the foot off the table while monitoring the ASISs. The patient tries to touch their heel to the table only after the leg is extended. They then bring the leg back up with the foot remaining off the table. The right ASIS should remain stable as the right leg is extended. If the ASIS moves inferiorly, the patient should stop, and bring the leg back up to the starting position.
Goal – the patient should be able to fully straighten either leg without the ASISs moving and touch their heel to the table while maintaining a neutral lumbar spine.
They repeat the exercise 3-5 times initially and increase repetitions as their performance improves.

Dysfunctional Supine Heel Slide Test

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Dysfunctional Supine Heel Slide Test

Anatomy and Biomechanics:

The ability to maintain a stable pelvis (level ASISs) while performing this functional movement test requires normal hip extension ROM and flexibility of the hip flexors with appropriate tone in the abdominal muscles. The abdominals must be strong enough to counterbalance the eccentric recruitment of the iliopsoas as the hip and leg are extended. An imbalance is seen when a hypertonic iliopsoas and weak abdominals results in an ASIS dropping inferiorly during the heel slide test.

After addressing any tightness in the anterior hip capsule, lengthening the hip flexors and mobilizing the femoral nerve as presented in module #3, then proceed to retraining the abdominals.

The Abdominals and Multifidi:

Global mobilizer in the sagittal plane – rectus abdominis
Global mobilizer in the transverse plane– internal and external obliques
Segmental stabilizer in the transverse plane – multifidi
Segmental stabilizer in all three planes – transversus abdominis

Rectus Abdominis:

Global mobilizer – brings the pelvis towards the trunk or the trunk towards the pelvis.
This muscle does not contribute to core stability.
Innervation – 7th thru 12th intercostal nerves

Transversus Abdominis:

First trunk muscle to normally fire before you move your leg or arm in any direction, but in patients with a history of low back pain the transversus muscle fires late during movement of the lower limb (Hodges and Richardson, 1998) or upper limb (Hodges and Richardson, 1999).
The transversus appears to fire as part of a feedforward movement synergy pattern, but contrary to initial studies activation of this muscle is dependent on the direction of movement and often is not bilaterally symmetrical, (Allison, Morris and Lay, 2008)
Innervation – 7th thru 12th intercostal nerves, iliohypogastric and ilioinguinal nerves

Substitution Patterns to watch out for during retraining:

To retrain this movement dysfunction the patient is first instructed in how to monitor and maintain palpable symmetry at the ASISs when rolling the pelvis towards 12 o’clock. Most commonly the patient has difficulty drawing the R ASIS superiorly when rolling the pelvis towards 12 o’clock as shown in 2b.

The therapist should also observe/palpate the ASISs/PSISs when first instructing the patient in transversus abdominis retraining to insure that when performing the exercises the ASISs/PSISs remain stable and that one ASIS or PSIS does not drift inferiorly or superiorly during the active abdominal and pelvic floor engagement that occurs with these exercises.

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