ULTT 3 – Median Nerve Bias

in 3 Movement Tests Upper Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule

ULTT 3 – Median Nerve Bias

Therapist places right hand/fist above patient’s right shoulder to stabilize
Patient’s right shoulder abducted to 90º, elbow flexed, forearm pronated, wrist and fingers extended
Elbow is then maximally flexed

Maintaining all the components achieved so far, the shoulder is then abducted as though placing the palm of the patient’s right hand over the ear
The ROM and the patient’s response is noted
Patient is then asked to side bend the head away and any change in pain response is noted

ULTT 1 – Median Nerve Bias

in 3 Movement Tests Upper Quarter, All Upper Quarter, Pectoralis Minor/Posterior Capsule

ULTT 1 – Median Nerve Bias

Therapist places right hand/fist above the patient’s right shoulder to stabilize
Patient’s right arm is abducted to 90º, elbow flexed to 90º, forearm supinated, wrist/fingers extended, and shoulder ER

Maintaining wrist & finger extension, the elbow is extended and the ROM and the patient’s response noted
Therapist then asks the patient to side bend the head to the right and left and notes the patient’s response

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.

Manual Therapy to Address Pectoralis Minor Hypertonicity

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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.

Posterior Capsule Self Stretch

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Posterior Capsule Self Stretch

In comparing the sleeper stretch with the cross body stretch in a group of asymptomatic recreational athletes the cross body stretch improved IR ROM better and the results lasted longer (McClure et al., 2007). However, they performed the cross body stretch with the shoulder internally rotated which we believe can lead to impingement and therefore we prefer to have the patient perform the stretch with ER of the shoulder and emphasize contralateral upper thoracic spinal rotation instead. We believe that it is the mobilization of the thoracic spine for contralateral rotation that explains the superior results with the cross body stretch.

To stretch the left posterior capsule:

The patient is seated and is instructed to bring their left arm up until parallel to the floor with their fingers pointing up towards the ceiling and the left elbow bent to 90 degrees.
They place their right hand on the outside of the left elbow.
Instruct the patient to use their right hand to pull their left elbow across in front of them keeping the left elbow bent and their left palm facing behind them.
Have the patient rotate their trunk as far as they can to the right to enhance the stretch and increase upper thoracic spinal rotation to the right.
The patient is instructed to hold for 30 seconds and repeat 2-3 times.
It’s important that you watch to make sure that the patient does not slump as they rotate to the right.

Shoulder Circles

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Shoulder Circles

To restore thoracic rotation to the left:

The patient is lying on their right side with their hips flexed between 45-60º and their hands out in front of them.

Instruct the patient to take their left arm and sweep their hand up over the head with the hand remaining in contact with the floor and the elbow straight.
The patient is encouraged to rotate their trunk and rib cage back as they circle around, but keep the knees together. They only circle around as far as they can while keeping the hand touching the floor.
Instruct the patient to follow their hand with their eyes as they circle around with an emphasis on opening the chest.
If the hand comes off the floor the patient is instructed to reverse directions and circle around the opposite way.
Have the patient repeat the exercise 5-6 times in a clockwise and counterclockwise direction on each side.

Egyptian Self-Mobs

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Egyptian Self-Mobs

The patient is lying on their back with their legs straight and their arms straight out to the sides with their elbows bent to a right angle.
Instruct the patient to bring the palm of one hand towards the floor while the back of the other hand reaches back to touch the floor. As the arms are rotating tell the patient to turn their head to face the palm that is facing up toward the ceiling.
Instruct the patient to reverse directions with their arms and head rotation so that their eyes always look towards the palm that is turned up facing the ceiling.
The patient repeats this alternating rotation of their arms and head 8 to 10 times.
Tell the patient not to force their neck to turn any further than is comfortable, but that they can push further rotation thru their arms to increase the rotation of the neck.
Make sure that the patient maintains 90 degrees of shoulder abduction and 90 degrees of elbow flexion throughout the exercise.

Side Lying Reach and Roll

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Side Lying Reach and Roll

To restore thoracic rotation to the left:

The patient is lying on their right side with both hands out in front of them at arms length.
Ask the patient to reach forward with their left hand past their right hand and turn the thumb down to internally rotate the arm.
Instruct the patient to initiate the movement from the shoulder then shoulder blade, upper ribs, segmentally down to the lower ribs and finally move the left hip and knee forward.
To reverse this movement ask the patient to rotate back from below up so that the hip and knee move back first, then they bring the lower ribs back segmentally to the upper ribs and finally the shoulder blade and arm until the left elbow touches the floor behind them.
The goal is for the patient to be able to extend their elbow and lie the back of their hand on the floor with the palm of the hand facing the ceiling. If the patient is unable to fully extend their elbow initially they can just touch the elbow to the floor then reverse direction.
Instruct the patient to repeat the whole sequence 5-6 times then switch and repeat lying on their L 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.

Side Lying Thoracic Rotation

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Side Lying Thoracic Rotation

To increase thoracic spinal rotation to the left:

The patient is side lying on their right side with both hips flexed below 90º.
Have the patient place their left hand behind the head with their right arm straight out in front of them.
Instruct the patient to rotate back to the left as far as they can then return to midline and repeat again 5 times.
Then have them flex both hips to 90º and rotate back again 5 times.
Finally, have the patient flex both hips above 90º and rotate back 5 times.
As they flex their hips higher they move the focus of the rotation higher up their spine.
They repeat the exercise 5 times in each position to the opposite side, with the hips flexed below, at and above 90º.

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