4 Manual Therapy Strategies

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TFL Self Stretch – Kneeling

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, All Manual Therapy, Hip EXT Firing Pattern, Self Stretch, Supine Heel slide

TFL Self Stretch – Kneeling

TFL Self Stretch – Kneeling

To Stretch the Left TFL:

  • The patient starts in half kneeling with a pillow or towel under the left knee and the hip externally rotated (foot turned in). Their right hand may be placed on a chair or against the wall for balance.
  • Have them place their left hand on their left buttocks. They are instructed to tighten the left buttocks muscle and tuck the hips under (12:00). They draw the belly button in and keep the shoulders centered over the hips so that they don’t arch the back.
  • Instruct the patient to translate their hips to the left while maintaining a strong buttocks contraction and posterior pelvic tilt.
  • The patient should report feeling a stretch on the outside or lateral portion of the left thigh.
  • They hold the stretch for 30 seconds 2-3 times or use a series of isometric contract/relax stretches repeated several times.
  • Then instruct the patient to switch sides and repeat on the right side.

Stretch the Left Iliopsoas

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, 5 Home Exercise Strategy, Active Trunk Rotation, All Home Exercises, All Manual Therapy, Manual Stretching, Self Stretch, Supine Heel slide

Stretch the Left Iliopsoas

To Stretch the Left Iliopsoas:

  • The patient starts in half kneeling with the left knee placed on a towel or pillow on the floor with the hip internally rotated and the right hip and knee flexed to 90º. Their right hand may be placed on a chair or against the wall for support.
  • Have them place their left hand on their left buttocks. They are instructed to tighten the left buttocks muscle and tuck the hips under (12:00). They draw the belly button in and keep the shoulders centered over the hips so that they don’t arch the back.
  • Instruct the patient to use their right leg to pull the pelvis forward leading with the front of the left hip. They should feel a stretch in the front of the left leg/thigh. Further stretch can be obtained by maintaining this stretch position and side bending the trunk away (toward the right).
  • They are instructed to hold the stretch for 30 seconds 2-3 times or perform a series of isometric contractions attempting to pull the left hip forward for 5-7 seconds then relaxing and stretching further.
  • Then have the patient switch sides and repeat with the right leg.

Mobilization of Adverse Neural Tension on the R side of the Cervical Spine

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Cervical Flexion Mobility, Manual Stretching, Mobilization, Shoulder Abduction

Mobilization of Adverse Neural Tension on the R side of the Cervical Spine

  • The therapist introduces translation from right to left with his/her contact on the dysfunctional articular pillar.
  • The patient is instructed to slowly abduct their R arm along the table as far as they can while the therapist maintains the right to left translated position of the cervical spine and prevents the dysfunctional segment from translating back to the right.
  • This is repeated several times. Each time the patient lowers their arm to their side the therapist takes up any additional slack for right to left translation.
  • Goals for treatment: translation from right to left at the previously noted dysfunctional segment is now free and the patient should be able to fully and comfortably abduct the right shoulder overhead without the therapist feeling the cervical spine translate to the right at any segmental level.

Muscle Energy Technique to Stretch the Right Scalenes

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Muscle Energy

Muscle Energy Technique to Stretch the Right Scalenes

  • The patient’s head and neck, down to T2, are brought off the end of the table and supported by the therapist’s L forearm. The patient is instructed to grasp the table with their right hand to stabilize the first rib.
  • The therapist grasps the base of the occiput with the left hand and places their left shoulder against the patient’s forehead.
  • The therapist’s right hand is placed over the top of the patient’s right shoulder to further stabilize the first rib.
  • The therapist translates the patient’s head straight down towards the floor maintaining upper cervical spine flexion by keeping the patient’s chin down at all times. The therapist then adds side bending of the head to the left and rotation back to the right, maintaining the AP translation.
  • The patient is asked to take and hold a deep breath and raise the head up against the therapist’s L shoulder for 5 to 7 seconds.
  • Upon relaxation the therapist takes up the slack by increasing the AP translation, left side bending and right rotation.
  • This procedure is repeated 3 to 4 times.
  • Assessment of right to left translation of the typical cervical spine (C3-7) before and after treatment of the right scalenes helps to confirm your success with this treatment.

Manual Therapy to Address Pectoralis Minor Hypertonicity

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Manual Stretching, Pectoralis Minor/Posterior Capsule, Shoulder Circle

Manual Therapy to Address Pectoralis Minor Hypertonicity

Note that applying AP glides to the Sternochondral Joints in side lying from T3-5, which helps to diminish tone in the pectoralis minor, should precede manual stretching of this muscle.

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.

Rib Cage Mobilization from the Back with IR and ER of the Shoulder

in 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Manual Therapy, All Upper Quarter, Mobilization, Pectoralis Minor/Posterior Capsule, Scapular Depression

Rib Cage Mobilization from the Back with IR and ER of the Shoulder

  • Once the therapist identifies the most restricted rib, he applies an anteriorly directed pressure to the superior border of the rib to promote internal torsion/IR of that rib
  • The patient is then instructed to IR and then ER the arm while the therapist maintains steady pressure on the superior border of the rib
  • Since IR of the arm promotes IR rotation of the rib, the therapist follows the rib during IR and blocks the rib from moving into ER when the patient ER their arm
  • The patient is instructed to ER/IR their arm repeatedly 7-8 times while the therapist maintains steady PA pressure to the rib angle

PA Mobilization to the Rib Angles to Increase Thoracic Rotation to the Left

in 2 Movement Tests Lower Quarter, 3 Movement Tests Upper Quarter, 4 Manual Therapy Strategies, All Lower Quarter, All Manual Therapy, All Upper Quarter, Mobilization, Pectoralis Minor/Posterior Capsule, Scapular Depression, Scapular Stabilization, Shoulder Circle

PA Mobilization to the Rib Angles to Increase Thoracic Rotation to the Left

  • The patient is lying on their left side with their right arm resting on top of the left
  • The therapist places a reinforced thumb on the rib angle of each rib and assesses mobility for anterior glide and IR of the rib

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

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

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.
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