AP Mobilization to the L Sternochondral Joints to Increase Thoracic Rotation to the Left

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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.

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

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.

Costovertebral Joint Mobilization with Long Sitting Slump Stretch

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Costovertebral Joint Mobilization with Long Sitting Slump Stretch

Treatment for Regional Pain Syndrome involving the Right Leg (Adapted from Cleland and McRae, 2002).:

Patient is long sitting with a belt wrapped around the balls of the feet.
The patient attempts to straighten the knees as much as possible and pull the toes up using the belt.
The patient flexes forward as far as possible and drops the head down.
The therapist side bends and rotates the patient to the left and holds the patient in this position.
The therapist then applies a PA grade III or IV mobilization to ribs 8 through 12 to mobilize the costovertebral joints from T8-12 on the right side.
Patient reports on any relief or change in symptoms in the R leg.

Slump Sitting Mobilization

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Slump Sitting Mobilization

Patient sitting at the edge of the table with the neck and trunk flexed, arms behind the back.
Therapist stabilizes the head and neck in flexion and passively straightens the leg to the barrier.
The therapist then immediately releases the tension by bending the knee.
Therapist repeatedly straightens and bends the knee 8-10 times.
Patient is then instructed to sit up tall and rock the pelvis forward (6:00) and backward (12:00) to release any tension in the low back.
Repeat this sequence with the other leg and then with both legs.
Further mobilization can be done by holding dorsiflexion of the ankle while straightening of the knee.

Counter Stretch with Manual Pressure at L5 or L4

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Counter Stretch with Manual Pressure at L5 or L4

Patient stands with the feet approximately hip width apart and places both hands on top of a counter or table top with the hands shoulder width apart. Patient pushes their hands against the table to assist in extending the thoracic spine.
Patient instructed to bend their knees but keep the heels flat on the floor, lift their sit bones up and back, towards the ceiling to achieve a neutral spine.
Actively the patient straightens the elbows and attempts to elongate the spine, dropping the chest towards the floor.
Finally, have the patient straighten the knees while maintaining a neutral lumbar spine, keeping the sit bones lifting towards the ceiling.
Patient notes where they feel pain
Therapist then applies strong PA pressure on the spinous process of L5 and the patient attempts to straighten the knees again and reports any change/improvement in pain behind the knees or down the leg.
If there is no change in symptoms therapist applies unilateral PA pressure on the lamina of L5, first on one side then the other and patient reports any change in symptoms
If no change is reported with manual pressure at L5 the process is repeated at L4
The goal is for the patient to report an improvement in their symptoms (less pain behind the knee or leg) when the therapist maintains a PA glide at L4 or L5

Soft Tissue Mobilization of the Posterior Hip Capsule

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Soft Tissue Mobilization of the Posterior Hip Capsule

Patient is positioned with the right hip off the table, but the PSIS is still on the table.
The therapist uses both arms to laterally distract the hip.
A strap can also be placed around the hip to apply lateral distraction.
Therapist slightly adducts and IR the hip then applies a posterior glide thru the femur.
If painful in the groin or SI, abduct the hip slightly.

Soft Tissue Mobilization of the Posterior Hip Capsule

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Soft Tissue Mobilization of the Posterior Hip Capsule

Patient is side lying with the treatment side up. The therapist uses the elbow to scour around the posterior aspect of the hip capsule feeling for areas of tension. The therapist can also work from the posterior aspect of the greater trochanter back across the gluteal area to the sacrum and address any tension in the external rotators of the hip with deep friction massage.

Hip Diagonals

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Hip Diagonals

Hip Diagonals

To treat an ERS Right and/or high tone in the Right Erector Spinae:

The patient starts this exercise in the hands and knees position and is instructed to sit back diagonally as though attempting to sit onto their right hip.
Instruct the patient to sit back as far as they can without holding onto the table with their hands.
Have them hold the position for 5 seconds then come back up to the original hands and knees position without pulling up with their arms.
Have them repeat 8 to 10 times.

Mobilization