6SECTION I: OVERVIEW OF THEORY AND TECHNIQUE

239

SECTION III: THE UPPER EXTREMITIES

The Shoulder

Pain in the shoulder and shoulder girdle is common in thegeneral population, with a prevalence of 15% to 25% in the 40-to 50-year-old age group.1 With increasing life expectancy andthe aging population remaining active into advancing years, age-related degeneration is a significant factor in rotator cuf

injuries.2 Disorders of the shoulder region account for 30% to 40% of indus-trial complaints and have increased sixfold in the past decade.1 Althoughinjuries to the shoulder girdle account for only 5% to 10% of sportsinjuries, they represent a much higher percentage of physician visits, proba-bly because they are perceived as being serious or disabling by the athlete.3

In many shoulder disorders, it is the soft tissue, such as the tendons andjoint capsule, that is the source of the pain. The shoulder region may also bepainful from a referral from the cervical and the thoracic spines and fromvisceral diseases, such as gallbladder and cardiac problems.4

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spine and the thoracic spine influence mobility othe arm. The upper thoracic vertebrae must be ableto extend, rotate, and side-bend to accomplish fullelevation of the arm.1 There must also be mobilityin the upper ribs as well as mobility in theacromioclavicular and sternoclavicular joints forfull range of motion (ROM) in the arm. Stability ofthe scapula is necessary to allow proper position-ing of the head of the humerus in the glenoid fossaof the scapula.

■ Normal neurological function is necessay for ade-quate strength and stability. Dysfunction of the nerv-ous system can come from the cervical or thoracicspine, reflex inhition from irritated mechanoreceptors from the joint (arthrokinetic reflex), atrophy duto prior injury, or immobilization.

■ Most shoulder disorders are not isolated injuriesbut affect several structures in the region.

BONES AND JOINTS OF THESHOULDER GIRDLE

SCAPULA

■ The scapula or shoulder blade is a flat, triangulabone (Fig. 6-2). The resting position of the scapulacovers the second to seventh ribs, and the vertebralborder is approximately 2 inches from the midline.The poste rior aspect h as a bony ridge called thespine of the scapula that extends laterally as a bul-bous enlargement called the acromion. The acromionarticulates with the clavicle, forming the acromio-clavicular (AC) joint. Above the spine is a deep cavityor fossa that contains the supraspinatus muscle belly.Below the spine are the infraspinatus and the teresminor and major. On the anterior surface is a fossawhere the subscapularis muscle attaches. There are15 muscles that attach to the scapula.

■ On the anterior-superior surface of the scapula isa bony process called the coracoid process, whichis a point of attachment for three muscles andthree ligaments. The muscles are the pectoralisminor, the short head of the biceps brachii, andthe coracobrachialis. The three ligaments are thecoracoclavicular, the coracohumeral, and thecoracoacromial.

240 Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex

Anatomy, Function, and Dysfunctionof the Shoulder Complex

SternoclavicularjointAcromioclavicular

jointGlenohumeral

joint

Figure 6-1. Anterior view of the bones and joints of the shoul-der complex.

GENERAL OVERVIEW

■ The bones of the shoulder complex includes thebones of the shoulder girdle; the clavicle andscapula; and the humerus, sternum, and rib cage (Fig.6-1). These bones form four typical joints: the gleno-humeral (shoulder joint), sternoclavicular , acromio-clavicular, and scapulothoracic joints. There is a fiftfunctional joint, the coracoacromial arch, which de-scribes the region where the head of the humerus iscovered by the acromion and the coracoacromial lig-ament. All these joints must be considered togetherin discussing the shoulder , as any motion of theglenohumeral joint also occurs at each of the otherjoints. The shoulder is the most mobile joint in thebody with the least stability; therefore, it is one of themost frequently injured joints in the body.

■ The function of the shoulder is influenced by manjoints. The function and position of the cervical

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■ The glenoid fossa is a shallow cavity on the lat-eral aspect of the scapula that serves as the artic-ulation for the head of the humerus. In the normalresting position, the glenoid fossa faces laterally ,anteriorly, and superiorly. Two body processes lieon the top and bottom of the glenoid fossa: thesupra a nd i nfraglenoid t ubercles f or t he a ttach-ment of the long head of the biceps and triceps,respectively.

CLAVICLE

■ The clavicle or collarbone is an S-shaped bone,convex anteriorly in the medial two-thirds and con-cave anteriorly in the lateral one-third. It articulateswith the sternum medially, forming the sternoclav-icular joint, which connects the upper extremity tothe axial skeleton. It articulates with the acromionof the scapula laterally , forming the AC joint. It isthe attachment site of six muscles and a number ofligaments.

■ Dysfunction and injury: Fracture of the clavicle isquite common, particularly in sports. Although itheals quickly, it typically heals with the ends over-lapping, shortening the clavicle and narrowing thespace underneath. The brachial plexus, the groupof nerves from the neck that innervates the arm,travels under the clavicle in what is called the tho-

racic outlet. A broken collarbone or other injuriesleading to fibrosis in the fascia attaching to the clavicle or a rounded-shoulder , forward-head posture(FHP) closes down this space an d contributes tothoracic outlet syndrome.

STERNUM

■ The sternum or breastbone is a flat bone located inthe center of the chest. It is divided into three parts:the manubrium, body, and xiphoid. The manubriumarticulates with the clavicle and first rib at its superior-lateral aspect and with the second rib at the infe-rior-lateral aspect. The body provides an attachmentsite for the other ribs, forming the sternocostal joint.The xiphoid is the inferior tip. The sternum func-tions to protect the heart and lungs.

STERNOCLAVICULAR JOINT

■ The sternoclavicular joint is a synovial joint inwhich the sternal end of the clavicle articulateswith the upper lateral edge of the sternum, as wellas the first rib (see Fig. 6-1)

■ Structure: The sternoclavicular joint has a strongjoint capsule, an articular disc, and three major lig-aments.n The three ligaments of the sternoclavicular joint

are the costoclavicular ligament, the interclavic-ular ligament, and the anterior and posteriorsternoclavicular ligaments.

n The articular disc, or meniscus, is a fibrocartilage that helps to distribute the forces betweenthe two bones. It is attached to the clavicle, firsrib, and sternum.

■ Function: The sternoclavicular joint has five possible motions: elevation, depression, protraction, re-traction, and rotation.

■ Dysfunction and injury: The sternoclavicular jointis so strong that the clavicle will break or the ACjoint will dislocate before the sternoclavicular jointdislocates.1

ACROMIOCLAVICULAR JOINT

■ The AC joint is a synovial joint in which the lateralaspect of the clavicle articulates with the acromionof the scapula (see Fig. 6-5 on p. 245).

■ Structure: It has a weak joint capsule, a fibrocartilage disc, and two strong ligaments.

■ The ligaments are the superior and inferior AC lig-aments and the coracoclavicular ligament, which isdivided into the lateral trapezoid and medial

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 241

Acromion

Superior angle of scapula

Inferior angle of scapula

Greatertubercle

Spine of scapula

Medial border

of scapula

Lateral border

of scapula

Figure 6-2. Posterior view of the bones and bony landmarks ofthe shoulder complex.

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conoid portions. These ligaments function to sus-pend the scapula from the clavicle and to preventposterior and medial motion of the scapula, as infalling on an outstretched hand (FOOSH) injury.

■ Function: Approximately 30 � of rotation of theclavicle can occur at the AC and sternoclavicularjoints as the arm is elevated. The clavicle rolls su-periorly and posteriorly after approximately 90 � ofabduction.n The rotation of the scapula, and hence the up-

ward and downward movement of the glenoidfossa, occurs at the AC joint.

■ Dysfunction and injury: A fall on the shoulder cantear the AC ligament and cause the clavicle to rideon top of the acromion, which is called a shoulderseparation. This is visible when observing the clientfrom the anterior view and is called a step deformity.The AC joint may degenerate because of repetitivestresses such as heavy lifting or prior injury . Pain istypically felt on the anterior and superior aspects ofthe shoulder and refers to the anterolateral neck.

SCAPULOTHORACIC JOINT

■ The scapulothoracic joint describes the relationshipof the scapula to the rib cage (see Fig. 6-2). It is not atrue joint with a synovial capsule, but a functionaljoint, as the scapula moves on top of the thoraciccage.

■ Function: The critical functions of the scapulotho-racic joint are to allow for proper positioning of theglenoid fossa for arm motion and to stabilize thescapula for efficient arm motion. The scapulmakes approximately a 30 � to 45� angle anteriorlyas it rests on the thoracic cage. This angle is calledthe scapular plane.n There are six motions of the scapulothoracic

joint: elevation, depression, adduction, abduc-tion, and upward and downward rotation, whichdescribes the movement of the inferior angle ofthe scapula moving away from or toward the ver-tebral column.

n The scapula has static and dynamic stabilizers .The static stabilizers are the joint capsule and lig-aments, and the principle dynamic stabilizers arethe rhomboids, trapezius, levator scapula, andserratus anterior. The static and dynamic stabiliz-ers work in concert to provide a stable position ofthe scapula to allow optimum arm motion.

■ Dysfunction and injury: It is common for the dy-namic stabilizers of the shoulder to be weak. Dur-ing our assessment, this is manifested as winging ofthe scapula and excessive scapular motion whenthe client does a wall pushup (see “Shoulder As-

sessment,” p. 262). Decreased scapular stabilitycontributes to protracted scapula (i.e., the scapulamoves away from the spine). As the scapula slideslaterally, the optimal length–tension relationship ofthe muscles of the glenohumeral joint is lost, whichresults in weakness of the muscles of the arm. Thisis often caused by rounded shoulders and a FHP. Asthe scapula rides forward on the rib cage, the supe-rior portion rotates downward, and the glenoidfossa no longer faces upward. This inhibits the nor-mal abduction of the arm, contributing to impinge-ment of the rotator cuff, subacromial bursa, and bi-ceps tendon between the greater tuberosity of thehumerus and the acromion or coracoacromial liga-ment. For many other clients who have FHP , thescapula is held in a retracted position owing toshort and tight rhomboids. These clients typicallydo not develop impingement syndrome.

■ Treatment i mplications: Perform MET to releasethe muscles attached to the scapula, scapulotho-racic mobilization, and soft tissue mobilization(STM) of the short and tight muscles. May requirereferral to a physical therapist or personal trainerfor strength and stabilization training.

BONES AND SOFT TISSUE OF THE GLENOHUMERAL JOINT

GLENOHUMERAL JOINT

■ Structure: The glenohumeral joint is a ball-and-socket synovial joint consisting of the shallow gle-noid fossa of the scapula and the large, roundedhead of the humerus (Fig. 6-3). It contains a jointcapsule, a fibrocartilage rim called a labrum, andnumerous ligaments.

■ Function: The glenohumeral joint has the greatestROM of any joint in the body , but it sacrifices stability for mobility. It is described as an incongruousjoint, meaning that the humerus and glenoid fossabarely make contact with each other at rest. In armmotion, only 30% of the head of the humerus is incontact with the glenoid fossa.2 It is held in the nor-mal resting position by the superior joint capsuleand the coracohumeral ligament. This is differentfrom the hip joint, in which two-thirds of the headof the femur is within the acetabulum, and the twoarticulating surfaces fit closely togethe .

■ Because the glenohumeral joint is incongruous, themuscles play a dual role of support and motion.The muscles must maintain the proper alignmentof the head of the humerus to the glenoid fossa asthe arm is moving.4

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■ The glenohumeral joint has six basic motions: flexion, extension, abduction, adduction, and medialand lateral rotation. Abduction is easier in theplane of the scapula, which is 30� to 45� of forwardflexion, because the joint capsule is more lax, anthe greater tuberosity of the humerus is not abuttingagainst the acromion at this angle.5 This is the mostnatural and functional position of abduction. Pa-tients who have shoulder pain typically abducttheir arm in this plane.

■ Elevation of the arm is a combination of rolling andinferior sliding of the humeral head in the glenoidfossa, which requires strength of all the rotator cuffmuscles to hold the humeral head stable as the armis being elevated. As the deltoid muscle abducts thearm, the supraspinatus pulls the head of the humerusinto the glenoid fossa, and the infraspina tus, teresminor, and subscapularis contract and pull thehumeral head inferiorly. This action creates enoughroom for the humeral head to slide under theacromion. If the cuff muscles are dysfunctioningand weak, the humeral head migrates superiorlyand impinges against the acromion and coracoacro-mial ligament.

■ Scapulohumeral rhythm: The first 1 � to 30� of armmotion happens solely at the glenohumeral joint.Beginning at 15 � to 30� of abduction, the scapulamoves to contribute to arm elevation. The relation-ship of scapular movement to arm motion is calledscapulohumeral rhythm . For every 10 � movementof the humerus, there is 5 � of scapular movement.These combined movements allow for 160 � of ab-duction. To achieve 180� of abduction, the upper

thoracic and lower cervical spine bends. Thus, tho-racic hypomobility prevents full abduction.6

■ Dysfunction and injury: Because of the poor con-gruency of the humeral head in the glenoid fossa,this joint is susceptible to dislocation and subluxa-tion (partial dislocation). Acute traumatic disloca-tion is predominantly an injury of young adults,caused by forced external rotation and extension ofthe arm, dislocating the humerus in the forward,medial, and inferior direction.1 Instability of theglenohumeral joint is a common problem, and an-terior instability is the most common direction. Theinstability may be attributable to traumatic disloca-tion, rotator cuff injury or weakness, or acquired orcongenital joint laxity . Acquired instability iscaused by prior or recurrent dislocations or bytreatment failure of the initial injury .3 The jointmay develop degenerative joint disease, which in-volves a wearing of the articular cartilage, fromprior injury or chronic instability.

■ Treatment implications: It is important for the mas-sage therapist to appreciate that certain conditionsrequire stabilization and strengthening rather thanto assume that all clients need release of muscletension. If your assessment findings or doctor s di-agnosis indicate glenohumeral instability, use con-tract-relax (CR) muscle energy technique (MET) inthe rotator cuff and muscles stabilizing the scapulato help facilitate their normal function. T ypically,there is weakness in the supraspinatus and lateralrotators, which allows the head of the humerus tomigrate superiorly creating an impingement of thedelicate soft tissue structures between the humeralhead and the acromion. These clients typically re-quire treatment with a physical therapist or a per-sonal trainer to guide them in proper exercise. De-generation is treated with STM for the short andtight muscles; joint mobilization to increase acces-sory motion between the head of the humerus andglenoid fossa and to increase ROM; and MET to re-lease hypertonic muscles and recruit weak, inhib-ited muscles.

HUMERUS

■ The humerus or arm bone consists of a body andupper (proximal) and lower (distal) ends. Thehumeral head forms the upper end. On the antero-lateral surface is the greater tubercle, and on the an-teromedial surface is the lesser tubercle. Betweenthese two bony prominences is the intertuberculargroove, which contains the tendon of the long headof the biceps. The greater tubercle is an attachmentsite for the supraspinatus, infraspinatus, and teresminor. The lesser tubercle is the attachment site for

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 243

Subacromialbursa

Acromion Supraspinatusmuscle

Glenoid labrum

Articularcartilage

Joint capsule

Bicepsbrachii

Figure 6-3. Glenohumeral joint showing the articular cartilage,joint capsule, subacromial bursa, supraspinatus, and long headof the biceps.

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the subscapularis. The distal end of the humerus ar-ticulates with the radius and ulna to form the elbow.

JOINT CAPSULE

■ Structure: The joint capsule originates from the gle-noid labrum and attaches to the periosteum of theshaft of the humerus (Fig. 6-4). There is a synoviallining throughout the capsule 4 that is reinforcedposteriorly and superiorly by the rotator cuffmuscles and anteriorly by the subscapularis ten-don, pectoralis major, teres major, and the coraco-humeral and glenohumeral ligaments. The fiberof the joint capsule have a medial and forwardtwist with the arm hanging at the side in its restingposition.

■ Function: The twist in the joint capsule is in-creased with abduction and decreased with flexionThe tension in the capsule in abduction pulls thehumerus into external rotation, which allows thegreater tubercle of the humerus to clear the cora-coacromial arch. 1 The posterior capsule tightenswhen the arm rotates medially (internally), and theanterior capsule tightens when the arm rotates later-ally (externally). The joint capsule is also involvedin instability syndrome and rotator cuff tendinitis,which are addressed later in the chapter (see thesections “Instability Syndrome of the Gleno-humeral Joint” and “Rotator Cuff Tendinitis”).

■ Dysfunction and injury: A common problem to thejoint capsule is called frozen shoulder or adhesivecapsulitis. The joint capsule becomes fibrotic; thanterior portion of the capsule develops adhesionsto the humeral head, and the folds in the capsulecan adhere to themselves. This fibrosis and thickening shorten the capsule and prevent external rota-tion of the shoulder, which, in turn, restricts abduc-

tion. External rotation is necessary in abduction toallow the greater tuberosity to clear the coracoacro-mial arch. Thoracic kyphosis may be a causativefactor.4 Tightness in the posterior joint capsule re-sults in an anterior superior migration of thehumeral head, creating an impingement of the softtissue under the acromion.

■ Treatment implications: The treatment of frozenshoulder is a tremendous challenge. Passive trac-tion and MET provide the most comfortable and ef-fective therapy. The first motion to introduce forfrozen shoulder is inferior glide, which reducessustained muscle tension and stretches the jointcapsule. Next, perform CR MET to increase externalrotation, as this allows the greater tuberosity to rollunder the coracoacromial arch for abduction. Fi-nally, perform postisometric relaxation (PIR) or ec-centric MET to increase flexion and abduction, firin the sagittal plane, then in the scapular plane, andfinally in the coronal plane

LABRUM

■ Structure: The labrum i s a fibrocartilage lip thatsurrounds the glenoid fossa (see Fig. 6-3). The outersurface of the labrum is the primary attachment sitefor the joint capsule and glenohumeral ligaments.The tendon of the long head of the biceps attachesto and reinforces the superior aspect of the labrum,and the long head of the triceps attaches to and re-inforces the inferior aspect of the labrum.

■ Function: The labrum functions to deepen the gle-noid cavity, adding stability.

■ Dysfunction and injury: Injuries to the labrum canresult from shearing forces if the humerus is forcedthrough extreme motions, repeated or excessivetraction of the long head of the biceps tendon fromits attachment, shoulder trauma such as disloca-tions, falls on an outstreched arm, throwing sports,and overhead work. 2 The two most common tearsare the Bankart lesion, which is a tear of the labrumfrom the anterior glenoid, and the SLAP (superiorlabral anterior to posterior) lesion, which is a de-tachment of the superior labrum–long head of thebiceps complex. These tears lead to instability ofthe joint. Clients complain of poorly localized painover the anterior aspect of the shoulder , exacer-bated by elevation of the arm overhead and move-ment of the arm behind the back. Examination maydemonstrate pain at the anterior shoulder with iso-metric contraction of the long head of the biceps(Speed’s test).

■ Treatment implications: The treatment is to pro-mote strength and stability of the glenohumeral

244 Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex

Joint capsule

Triceps

Teres minor

Infraspinatus

Supraspinatus

Figure 6-4. Joint capsule, interweaving rotator cuff musclesand long head of the triceps.

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joint. MET is applied to help recruit inhibited mus-cles a nd r educe e xcessive t esion i n t he m uscles.Gentle STM to promote circulation is helpful. Pa-tients need exercise rehabilitation.

LIGAMENTS

■ The ligaments of the glenohumeral joint are theglenohumeral, the coracohumeral, the coracoacro-mial, and the transverse humeral (Fig. 6-5). Thejoint capsule thickens in bands that are sometimesreferred to as capsular ligaments. As in all joints,there is a reflex from the mechanoreceptors withithe joint capsule and ligaments to the muscles sur-rounding the joint.7

n The glenohumeral ligament lies underneath thecoracohumeral ligament, reinforcing the jointanteriorly and tightening on external rotation ofthe humerus.

n The coracohumeral ligament is further dividedinto the superior, middle, and inferior portions.It is a broad band reinforcing and interweavingwith the upper part of the joint capsule. It at-taches to the lateral border of the coracoidprocess, passing laterally to blend with the ten-don of the supraspinatus, capsule, and trans-verse humeral ligament.

n The coracoacromial ligament is a strong triangu-lar band attached to the edge of the acromion justin front of the articular surface for the clavicleand to the entire length of the lateral border ofthe coracoid process.

n The transverse humeral ligament crosses the in-tertubercular groove to stabilize the tendon ofthe long head of the biceps.

CORACOACROMIAL ARCH

■ Structure: The coracoacromial arch consists of thecoracoid process anteriorly, the acromion posteri-orly, and the coracoacromial ligament in betweenthem (see Fig. 6-5). In the arch space lie the headof the humerus below; the coracoacromial liga-ment and acromion above; and the joint capsule,the supraspinatus and infraspinatus tendons, thelong head of the biceps, and the subdeltoid bursain between.

■ Function: The coracoacromial ligament preventsdislocation of the humeral head superiorly, and alongwith the acromion and coracoid process, it forms animportant protective arch. It also acts as a soft tissuebuffer between the rotator cuff and the bony surface ofthe acromion. The coracoacromial arch may be de-scribed as an accessory joint that is lined with thesynovial membrane of the synovial bursa.8

■ Dysfunction and injury: The greater tubercle of thehead of the humerus may impinge or compress thesupraspinatus and infraspinatus tendons, the jointcapsule, the bicipital tendon, or the subdeltoidbursa against the coracoacromial ligament and an-terior acromion. This is called impingement syn-drome. The causes of this syndrome are diverse butinclude postural causes such as thoracic kyphosisor a habitual rounded-shoulder FHP. It may also becaused by muscle weakness from the scapular sta-bilizers or the rotator cuff muscles and the longhead of the biceps, which provide a downwardforce on the humerus.

■ Treatment implications: The first intention is tcorrect the client’s posture, if indicated. Next, useCR MET to facilitate and strengthen the external ro-tators. Then perform transverse massage on thecoracoacromial arch to reduce any adhesions andscar tissue in the coracoacromial ligament and tocorrect any positional dysfunction in the deltoidand rotator cuff muscles.

BURSAE

■ Structure: A bursa is a synovial-lined sac fillewith synovial fluid

■ Function: The function of a bursa is to secrete a lu-bricant to neighboring structures, which decreasesfriction.

■ Of the eight or nine bursae that are about theshoulder, only the subacromial bursa is commonly

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 245

Glenohumeralligament

Clavicle

Coracoclavicularligament (conoid)

Coracoclavicularligament (trapezoid)

Acromioclavicularligament

Coracoacromialligament

Acromion

Subscapularbursae

Coracohumeralligament

Transversehumeral ligament

Subscapularistendon

Biceps brachii

Figure 6-5. Ligaments of the glenohumeral and theacromioclavicular joints and of the subscapular bursa.

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involved clinically, and two others are occasion-ally involved.n The subacromial or subdeltoid bursa lies over the

greater tubercle of the humerus and supraspina-tus tendon and under the coracoacromial liga-ment, acromion, and deltoid muscle (Fig. 6-6).

n The subscapular bursa lies over the anterior jointcapsule and under the subscapularis muscle at-tachment to the lesser tubercle of the humerus.

n The subcoracoid bursa lies between the cora-coid process and the clavicle.

■ Dysfunction and injury: The subacromial bursa canbecome inflamed due to overu e, postural stresses,or trauma and can become impinged under the

acromial arch. Because of its closeness to thesupraspinatus tendon, any scarring or calcium de-posits in the body of the tendon can irritate thisbursa. It is also susceptible to irritation from a typeIII acromion, also called a hooked acromion. Thistype of acromion has a bony protuberance on theundersurface, which can irritate the supraspinatustendon that travels underneath it.

■ The subscapular bursa can become irritated be-cause of increased tension in the pectoralis minorand subscapularis muscles.

■ The subcoracoid bursa can become irritated be-cause of the forward tipping of the scapula causedby pectoralis minor hypertonicity.

■ Treatment implications: Lauren Berry, RPT, taughtthat the bursae can be manually drained if they areswollen. They can also be manually pumped to in-crease their synovial fluids if they are dried out because of adhesions. These techniques are clinicallyeffective for both conditions.

CAUTION: When treating an acute bursi-tis, be extremely gentle, or you mayaggravate the condition.

NERVES OF THE SHOULDER REGION

■ Most of the nerve supply of the shoulder and armarise from the brachial plexus, which begins as fivnerve roots from C5 to C8 and T1 (Fig. 6-7). As was

246 Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex

Clavicle Coracoclavicular ligament (trapezoid)

Subdeltoid bursa

Subscapular bursa

Coracoclavicular ligament (conoid)

Figure 6-6. Subdeltoid and subscapular bursa.

Medial antebrachialcutaneous nerve

Median nerve

Biceps muscle

Coracobrachialis muscle

Musculocutaneous nerveRadial nerve

Lateral cordMedial cord

Posterior cord

Brachial plexus roots

Subscapularis muscle

Thoracodorsal nerve

Long thoracic nerve

Latissimus muscle

Upper and lowersubscapular nerve

TricepsUlnar nerve

Figure 6-7. Brachial plexus leaves the neck between the anterior and the middle scalenes. It thentravels under the clavicle, subclavius, and pectoralis minor and enters the medial arm.

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mentioned in Chapter 5, “Cervical Spine,” thesenerve roots travel through the anterior and the mid-dle scalenes. The roots of the brachial plexus unitejust above the clavicle to form the superior, middle,and inferior trunks. The middle part of the clavicleis convex anteriorly , and the axillary artery andvein and brachial plexus pass posterior to this.

■ The brachial plexus then travels over the first riand under the clavicle and subclavius muscle. Thiscostoclavicular space can become compromisedbecause of previous trauma, such as a fracturedclavicle, or because of postural imbalances, such asrounded shoulders.

■ The nerves then travel between the pectoralis mi-nor and the rib cage, medial to the coracoidprocess. At the level of the pectoralis minor, thebrachial plexus forms the medial, lateral, and pos-terior cords. Distal to the pectoralis minor, the threecords divide into many branches, including the ra-dial, median, and ulnar nerves that travel into thearm and down to the hand.

■ The medial and ulnar nerves travel along the me-dial arm in the medial bicipital groove, bounded bythe biceps and triceps. The radial nerve leaves thisgroove at the margin of the proximal and middlethird of the arm and travels to the posterior surfaceof the humerus in the radial groove.

■ In addition to the brachial plexus, there are severalperipheral nerves in the shoulder region that we ad-dress in the treatment section of this chapter: Thelong thoracic nerve travels on the thoracic wall overthe serratus anterior; the subscapular and thora-codorsal nerves lie on the subscapularis muscle; thesuprascapular nerve travels through the supras-capular notch of the scapula and supplies thesupraspinatus and infraspinatus; the axillary nervetravels over the posterior and inferior aspect of theposterior j oint c apsule t o s upply t he d eltoid a ndteres minor; and the radial nerve (see above). Thesenerves can become entrapped because of shortenedfascia or sustained contraction in the muscles.

■ Dysfunction and injury: As was mentioned inChapter 5, thoracic outlet syndrome is a result ofcompression or entrapment of the brachial plexus.As Kendall and colleagues9 point out, the diagnosisof thoracic outlet syndrome is often ambiguous be-cause it includes many similar entities, includingcostoclavicular, anterior scalene, hyperabduction,and pectoralis minor syndromes.

■ Nerves become compressed for several reasons:poor posture and faulty alignment of the neck, up-per back, and shoulders. A rounded-shoulder FHP,creates a forward depression of the coracoid

process, shortening the pectoralis minor and weak-ening the lower trapezius. This posture also predis-poses to an adduction and internal rotation of theshoulder. This leads to compression. Brachialplexus compression may also result from pro-longed overhead activities, such as painting, inwhich the clavicle rotates posteriorly, compressingthe nerves between the clavicle and the first rib

■ Clinically, the brachial plexus can become com-pressed at several different sites:n Between the anterior and middle scalenes.n Between the clavicle and the first rib, called

costoclavicular syndrome. This syndrome iscaused by rounded-shoulder posture; thoracickyphosis; or previous trauma to the clavicle, ACjoint, or glenohumeral joint.

n At the pectoralis minor, as the plexus travels be-tween the muscle and the rib cage.

■ Brachial plexus co mpression symptoms include ageneralized numbing, tingling, and pain. The medialcord, the most inferior part of the brachial plexus, ismost vulnerable to compression; therefore, ulnarnerve symptoms along the ulnar border of the fore-arm and hand are most commonly reported.4

■ Treatment implications: Four distinct areas mustbe released when the therapist considers peripheralentrapment of the brachial plexus: the region of thescalenes, the supraclavicular space, the infraclavic-ular space, and the pectoralis minor. Refer to Chap-ter 5 for further discussion of the scalenes.

■ Begin with instruction in postural awareness.Next, perform CR MET to reduce the hypertonicityin the tight muscles. Then use PIR MET tolengthen the short anterior muscles and fascia,and use CR MET and home exercises to strengthenthe weak lower trapezius. Treat the pectoralis mi-nor, pectoralis major, and subscapularis first. Aftefacilitating the lower trapezius, perform manualrelease on the supraclavicular and infraclavicularspaces.

MUSCLES OF THE SHOULDERREGION

■ Structure: The muscles of the shoulder region maybe divided into two major groups: muscles that sta-bilize the scapula and muscles of the rotator cuff.n Four main muscles stabilize the scapula: the

rhomboids, trapezius, levator scapula, and ser-ratus anterior (Figs. 6-8 and 6-9). To perform ele-vation of the arm, these muscles must contractfirst to stabilize the scapula against the rib cageThen the rotator cuff muscles and the deltoidscontract to elevate the arm.3

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 247

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 247

n The four muscles of the rotator cuff are thesupraspinatus, infraspinatus, teres minor (Fig. 6-10), and subscapularis (see Fig. 6-9). They at-tach to the posterior, superior, and anterior headof the humerus as a continuous cuff, not as dis-crete tendons. The fibers of the cuff blend witthe articular joint capsule.

■ Function: The chief function of the rotator cuff mus-cles is dynamic stabilization of the glenohumeraljoint. In most joints, the close fit of the articulatinbones, the ligaments, and joint capsule offers pri-mary stability. As has been mentioned, there is littlecongruence between the humeral head and the gle-noid fossa. When the arm hangs at the side, littlecontraction of the deltoid or cuff muscles is required,as the superior joint capsule and the coracohumeralligament provide a reactive tensile force that pullsthe humeral head against the glenoid cavity.6 Whenthe arm is elevated, the superior joint capsule is lax

and no longer stabilizes the joint, so the muscles ofthe rotator cuff must hold the humerus in proper ori-entation to the glenoid, playing an essential role instabilizing the joint. They create joint compressionand downward depression, creating a fixed fulcruso that the deltoid can rotate the arm upward. If thecuff muscles are weak, the contraction of the deltoidcauses an abnormal upward movement of thehumeral head, causing an impingement of the softtissue into the coracoacromial arch.

■ Dysfunction and injury: The rotator cuff is a com-mon site of acute injuries, degenerative conditions,and acute injuries that are the end stage of chronicdegeneration caused by cumulative stresses. Rota-tor cuff injuries may vary from mild irritation andpartial strains (tears) to full thickness tears. Themost commonly affected muscle is the supraspina-tus. The supraspinatus should receive its primaryblood supply from the thoracoacromial artery. This

248 Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex

Trapezius muscleRhomboid minor

Rhomboid major

Supraspinatus

Infraspinatus

Teres minor

Teres major

Triceps

Latissimus dorsi

Figure 6-8. Muscles of the posterior shoulderregion.

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 248

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 249

artery is frequently absent, leaving the tendon hy-povascular.6 The infraspinatus may also be hypo-vascular but to a much lesser extent. This de-creased blood supply makes the area susceptible tofatigue and degeneration.n Two common conditions decrease the stability of

the joint:n Thoracic kyphosis, which causes the tension in

the superior joint capsule to be lost, and the ro-tator cuff muscles must maintain constant con-traction to stabilize the arm, making it suscepti-ble to fatigue and degeneration.6

n Weakness in the scapular stabilizing muscles, espe-cially the serratus anterior and the lower and mid-

dle trapezius. This allows the acromion to migrateforward, into a position of greater impingement.

n As was mentioned previously , according toJanda,10 there are predictable patterns of muscledysfunction. In the upper body, he describes thisas the upper crossed syndrome. 10 Below arelisted the muscles of the shoulder girdle com-plex that are typically imbalanced and partici-pate in the upper crossed syndrome.

Muscle Imbalances of the Shoulder Region

■ Muscles that tend to be tight and short: Pectoralismajor and minor , upper trap ezius, subscapularis,

Sternocleidomastoid muscle

Pectoralis minor

Serratus anterior

External abdominal oblique

Pectoralis major:

Serratus anterior

Deltoid

Trapezius

Sternocostal head Abdominal head

Figure 6-9. Muscles of the anterior shoulder.

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 249

and levator scapula. Overdevelopment of the pec-toralis and the subscapularis result in a protractedscapula and a stretch weakness of the rhomboidsand middle trapezius.11

■ Muscles that tend to be inhibited and weak: Lowerand middle parts of the trapezius, rhomboids, andserratus anterior , supraspinatus, 12 infraspinatus,and teres minor. Weakness in the scapular stabiliz-ing muscles allows lateral sliding of the scapulaand results in anterior motion of the humeral headduring abduction and external rotation, stressingthe anterior joint and contributing to impingement.

POSITIONAL DYSFUNCTION OFSHOULDER REGION MUSCLES

n In dysfunction, the shoulder internally rotatesand adducts. The humeral head migrates superi-orly, leading to impingement. This internally ro-tated position can cause the bicipital tendon totrack abnormally against the medial side of theintertubercular groove, irritating it.11

n The anterior and posterior deltoid, infraspina-tus, and teres minor tend to drop into an inferiortorsion.

■ Treatment implications: To treat muscular dys-function, it is important to treat the short and tightmuscles first, as they have an inhibiting effect o

their antagonists. Regarding the positional dysfunc-tion, Lauren Berry, RPT, theorized that the humeralhead migrates upward after an injury or cumulativestress to the rotator cuff muscles and that the ante-rior and posterior deltoid and the rotator cuff mus-cles tend to roll into an inferior torsion, parting themidline. The treatment implication is that thehumerus must be mobilized inferiorly and the ante-rior and posterior muscles about the head of thehumerus must be lifted superiorly . As has beenmentioned, it is important to assign home exercisesto strengthen the external rotators and thus help de-press the humerus. It is also important to strengthenthe scapular stabilizers, especially the lower trapez-ius and the serratus anterior.

SHOULDER MUSCLE ANATOMY

See Table 6-1.

MUSCULAR ACTIONS OF THESHOULDER

See Table 6-2.

MUSCULAR ACTIONS OF THESHOULDER GIRDLE

See Table 6-3.

250 Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex

(Teres major)

Supraspinatus

Infraspinatus

Teres minor

Figure 6-10. Supraspinatus, infraspinatus, and teresminor are three of the four rotator cuff muscles.

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 250

An

atom

y of

th

e M

usc

les

of t

he

Sh

ould

erTa

ble

6-1

Med

ial

one-

thir

d o

f su

per

ior

nu

chal

lin

e, s

pin

ous

pro

cess

es o

fC

7 an

d a

llth

orac

ic v

erte

brae

.

Sp

inou

s p

roce

sses

of

C7

and

T1

Sp

inou

s p

roce

sses

of

T2,

3, 4

, 5

Pos

teri

or t

ube

rcle

s of

th

etr

ansv

erse

pro

cess

es o

f C

1, 2

, 3, 4

.T

his

att

ach

men

t si

te i

s si

gnif

ican

as t

her

e ar

e fo

ur

maj

or m

usc

les

that

ble

nd

in

to e

ach

oth

er a

t th

isp

oin

t: t

he

sple

niu

s ce

rvic

is,

pos

teri

or s

cale

ne,

lon

giss

imu

sca

pit

is, a

nd

th

e le

vato

r.

Su

rfac

e of

th

e u

pp

er n

ine

ribs

at

the

sid

e of

th

e ch

est,

an

d t

he

inte

rcos

tal

mu

scle

s in

bet

wee

n.

Trap

eziu

s

Rh

ombo

idM

inor

Rh

ombo

id

Min

or

Lev

ator

Sca

pu

la

Ser

ratu

sA

nte

rior

(s

ee F

ig. 6

-9)

Sp

ine

and

acr

omio

n p

roce

sses

of s

cap

ula

an

d l

ater

al t

hir

d o

fcl

avic

le.

Ver

tebr

al b

ord

er o

f th

e sc

apu

la,

sup

erio

r to

sp

ine

of s

cap

ula

.

Ver

tebr

al b

ord

er o

f th

e sc

apu

labe

low

th

e sp

ine

of t

he

scap

ula

Su

per

ior

angl

e of

th

e sc

apu

laan

d t

o th

e ba

se o

f th

e sp

ine

ofth

e sc

apu

la.

Cos

tal

asp

ect

of t

he

wh

ole

len

gth

of

the

med

ial

bord

er o

fth

e sc

apu

la.

Th

e u

pp

er f

iber

s el

evat

e th

scap

ula

, th

e lo

wer

fib

ers

dep

res

it, a

nd

th

e m

idd

le f

iber

s re

trac

the

scap

ula

an

d h

ave

an e

ssen

tial

role

in

sta

bili

zin

g th

e sc

apu

la.

Bot

h m

ajor

an

d m

inor

dra

w t

he

scap

ula

up

war

d a

nd

med

iall

y;h

old

s th

e sc

apu

la t

o th

e tr

un

kal

ong

wit

h t

he

serr

atu

s an

teri

orm

usc

le; r

etra

cts

the

scap

ula

alo

ng

wit

h t

he

fibe

rs o

f th

e m

idd

ltr

apez

ius.

Pu

lls

the

scap

ula

up

war

d a

nd

med

iall

y (a

lon

g w

ith

th

etr

apez

ius)

; if

the

scap

ula

is

fixe

dp

ull

s th

e n

eck

late

rall

y; a

cts

sim

ilar

to

the

dee

p f

iber

s of

the

erec

tor

spin

ae i

n h

elp

ing

top

reve

nt

forw

ard

sh

ear

of t

he

cerv

ical

sp

ine.

Lev

ator

act

s li

ke a

pos

teri

or “

guy

wir

e” h

old

ing

up

and

sta

bili

zin

g th

e h

ead

an

d n

eck

alon

g w

ith

th

e sc

alen

es, t

he

ante

rior

“gu

y w

ires

.”

It i

s a

maj

or s

tabi

lize

r of

th

esc

apu

la, h

old

ing

the

scap

ula

agai

nst

th

e ri

b ca

ge. I

t p

erfo

rms

abd

uct

ion

(p

rotr

acti

on),

i.e

.,d

raw

s th

e m

edia

l bo

rder

of

the

scap

ula

aw

ay f

rom

th

e ve

rteb

rae.

Als

o p

rovi

des

up

war

d r

otat

ion

.T

he

lon

ger,

low

er f

iber

s te

nd

td

raw

th

e in

feri

or a

ngl

e of

th

esc

apu

la f

arth

er f

rom

th

e ve

rteb

rae,

thu

s ro

tati

ng

the

scap

ula

up

war

dsl

igh

tly.

It

is t

he

anta

gon

ist

of t

he

rhom

boid

s.

Th

e u

pp

er f

iber

s te

nd

to b

e ti

ght

and

sh

ort,

wh

ile

the

low

er f

iber

ten

d t

o be

wea

k an

d l

ong,

all

owin

gth

e sc

apu

la t

o m

igra

te h

ead

war

d,

dec

reas

ing

stab

ilit

y of

th

e sc

apu

lafo

r m

ovem

ent

of t

he

arm

.

Rh

ombo

ids

ten

d t

o be

wea

k,w

hic

h c

ontr

ibu

tes

to a

rou

nd

edsh

ould

ers

pos

ture

.

Ten

ds

to b

e sh

ort

and

tig

ht,

con

trib

uti

ng

to r

oun

ded

shou

lder

s, b

ut

is i

n a

n e

ccen

tric

con

trac

tion

in

th

e fo

rwar

d-h

ead

pos

ture

(FH

P).

As

leva

tor

is a

ctiv

em

ain

tain

ing

opti

mal

hea

d a

nd

nec

k p

ostu

re, F

HP

wil

lec

cen

tric

ally

loa

d l

evat

or.16

Th

e se

rrat

us

ten

ds

to b

e w

eak,

dem

onst

ated

by

win

gin

g of

th

esc

apu

la d

uri

ng

the

scap

ula

rst

abil

izat

ion

(p

ush

-up

) te

st.

Wea

knes

s of

th

e se

rrat

us

lead

s to

inst

abil

ity

of t

he

scap

ula

,co

ntr

ibu

tin

g to

im

pin

gem

ent,

an

dim

pai

rs t

he

abil

ity

to l

ift

the

arm

over

hea

d w

ith

str

engt

h.

Mu

scle

Ori

gin

Inse

rtio

nA

ctio

nD

ysfu

nct

ion

Sca

pu

lar

Sta

bil

izin

g M

usc

les

(see

Fig

. 6-8

)

251

(con

tin

ued

)

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 251

An

atom

y of

th

e M

usc

les

of t

he

Sh

ould

er (

Con

tin

ued

)Ta

ble

6-1

Su

pra

spin

ous

foss

a of

th

e sc

apu

la.

Low

er m

argi

n o

f th

e sp

ine

of t

he

scap

ula

, in

fras

pin

atu

s fo

ssa.

Low

er p

orti

on o

f th

e in

fras

pin

atu

sfo

ssa

and

lat

eral

mar

gin

of

the

scap

ula

.

En

tire

an

teri

or s

urf

ace

of t

he

subs

cap

ula

r fo

ssa.

Su

pra

spin

atu

s(S

ee F

ig. 6

-10)

Infr

asp

inat

us

Tere

s M

inor

Su

bsca

pu

lari

s(S

ee F

ig. 6

-9)

Su

per

ior

face

t of

th

e gr

eate

rtu

berc

le o

f th

e h

um

eru

s.

Mid

dle

fac

et o

f th

e gr

eate

rtu

berc

le o

f th

e h

um

eru

s.

Low

er f

acet

of

the

grea

ter

tube

rcle

of

the

hu

mer

us.

Th

e le

sser

tu

berc

le o

f th

eh

um

eru

s, a

nd

th

e jo

int

cap

sule

.

Init

iate

s ab

du

ctio

n b

yco

mp

ress

ing

the

hea

d o

f th

eh

um

eru

s in

to t

he

glen

oid

fos

sa,

stab

iliz

ing

the

hu

mer

us,

so

that

the

del

toid

can

rot

ate

the

arm

up

war

d.

Lat

eral

rot

atio

n; d

ynam

icst

abil

izer

of

the

glen

ohu

mer

aljo

int

by c

omp

ress

ing

and

pu

llin

gth

e h

um

eral

hea

d d

own

du

rin

gel

evat

ion

of

the

arm

. Th

ein

fras

pin

atu

s is

mor

e ac

tive

th

anth

e su

pra

spin

atu

s w

ith

th

e ar

mab

du

cted

120

-150

�, w

hic

hex

pla

ins

wh

y it

is

com

mon

lyir

rita

ted

wit

h e

xces

sive

ove

rhea

dac

tivi

ties

.

Lat

eral

rot

atio

n a

nd

ad

du

ctio

n;

dyn

amic

sta

bili

zer

of t

he

glen

ohu

mer

al jo

int

by c

omp

ress

ing

and

pu

llin

g th

e h

um

eral

hea

dd

own

du

rin

g el

evat

ion

of

the

arm

.

Med

ial

rota

tion

an

d a

dd

uct

ion

;d

ynam

ic s

tabi

lize

r of

th

egl

enoh

um

eral

join

t by

com

pre

ssin

g an

d p

ull

ing

the

hu

mer

al h

ead

dow

n d

uri

ng

elev

atio

n o

f th

e ar

m.

Th

e m

ost

com

mon

ly i

nju

red

mu

scle

of

the

shou

lder

. It

isp

red

isp

osed

to

deg

ener

atio

n d

ue

to h

ypov

ascu

lari

ty. T

his

con

trib

ute

s to

a p

oor

rep

air

afte

ran

in

jury

, an

d a

lso

pre

dis

pos

es i

tto

fat

igu

e th

at d

evel

ops

from

sust

ain

ed c

ontr

acti

on. T

his

sust

ain

ed c

ontr

acti

on d

evel

ops

from

an

alt

ered

pos

itio

n i

n t

he

glen

ohu

mer

al jo

int

from

rou

nd

ed-

shou

lder

pos

ture

, or

thor

acic

kyp

hos

is. T

end

s to

be

wea

k,w

hic

h p

reve

nts

hu

mer

al h

ead

from

bei

ng

seat

ed p

rop

erly

in

th

egl

enoi

d f

ossa

du

rin

g ar

mm

ovem

ents

, lea

din

g to

in

stab

ilit

yof

th

e gl

enoh

um

eral

join

t.

As

wit

h t

he

sup

rasp

inat

us,

th

ein

fras

pin

atu

s h

as a

dim

inis

hed

bloo

d s

up

ply

rel

ativ

e to

th

e ot

her

mu

scle

s of

th

e sh

ould

er, a

nd

ther

efor

e is

com

mon

ly i

nvo

lved

clin

ical

ly. T

he

infr

asp

inat

us

ten

ds

to b

e w

eak

eith

er d

ue

to i

rrit

atio

nor

in

jury

, or

du

e to

in

hib

itio

n f

rom

the

shor

t an

d t

igh

t su

bsca

pu

lari

s,w

hic

h a

llow

s th

e h

um

eral

hea

d t

om

igra

te s

up

erio

rly,

con

trib

uti

ng

toim

pin

gem

ent

syn

dro

me.

Ten

ds

to b

e w

eak,

wh

ich

all

ows

the

hu

mer

al h

ead

to

mig

rate

sup

erio

rly,

con

trib

uti

ng

toim

pin

gem

ent

syn

dro

me.

Ten

ds

to b

e sh

ort

and

tig

ht,

lead

ing

to a

su

stai

ned

ad

du

ctio

nan

d m

edia

l ro

tati

on o

f th

e ar

m,

and

con

trib

uti

ng

to i

nh

ibit

ion

of

the

exte

rnal

rot

ator

s. W

eakn

ess

con

trib

ute

s to

an

teri

or i

nst

abil

ity

of t

he

glen

ohu

mer

al jo

int.

Rot

ato

r C

uff

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252

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 252

253

Ou

ter

thir

d o

f th

e cl

avic

le, b

ord

erof

th

e ac

rom

ion

, an

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geof

th

e sp

ine

of t

he

scap

ula

.D

ivid

ed i

nto

th

ree

par

ts, t

he

ante

rior

, mid

dle

, an

d p

oste

rior

.

Sh

ort

hea

d f

rom

th

e co

raco

idp

roce

ss; l

ong

hea

d f

rom

th

esu

pra

glen

oid

tu

berc

le a

bove

th

egl

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nd

th

e su

per

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um

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ree

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ds:

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m t

he

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rcle

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eral

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lp

oste

rosu

per

ior

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th

eh

um

eru

s; a

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ial

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d f

rom

the

pos

teri

or s

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t of

th

e h

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s.

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toid

(se

e F

ig.

6-9)

Bic

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Bra

chii

Tric

eps

Bra

chii

(See

Fig

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)

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that

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nd

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ith

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eep

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ia o

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w.

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elto

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ins

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vate

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e in

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scap

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, wh

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rior

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rior

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or o

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. Lon

g h

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lved

in

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, th

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ort

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d i

n a

dd

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nd

on o

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d i

s fi

xed

, an

d t

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um

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s m

oves

rel

ativ

e to

it.

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oac

ts l

ike

a cu

ff m

usc

le a

s a

dyn

amic

sta

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zer

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he

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mer

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ead

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rin

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ctio

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mer

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epre

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n f

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llie

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ates

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at t

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test

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nw

ard

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de

of t

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mer

us

has

bee

n a

ttri

bute

d t

o th

em

ech

anic

al f

orce

of

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con

trac

tin

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ng

hea

d o

f th

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cep

s.3

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mar

ily

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lbow

ext

enso

r; a

lso

exte

nd

s th

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m a

nd

ad

du

cts

it.

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ord

ing

to L

aure

n B

erry

, R.P

.T,

the

fasc

icle

s of

th

e d

elto

id r

oll

into

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abn

orm

al a

nte

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feri

or t

orsi

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ers

pos

ture

. Th

is p

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rete

nd

s to

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mot

e ad

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ctio

n a

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rnal

rot

atio

n o

f th

e h

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tin

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is t

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g w

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inat

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e d

etac

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ent

ofth

e su

per

ior

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um

-bic

eps

com

ple

x is

des

crib

ed a

s a

SL

AP

lesi

on (

sup

erio

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bral

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)

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 253

An

atom

y of

th

e M

usc

les

of t

he

Sh

ould

er (

Con

tin

ued

)Ta

ble

6-1

Low

er t

hir

d a

nd

in

feri

or a

ngl

e of

the

late

ral

bord

er o

f th

e sc

apu

la.

Cor

acoi

d p

roce

ss o

f th

e sc

apu

la.

Med

ial

hal

f of

th

e an

teri

or s

urf

ace

of t

he

clav

icle

, an

teri

or s

urf

ace

ofth

e co

stal

car

tila

ges

of t

he

firs

t si

ribs

, an

d a

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g p

orti

on o

f th

est

ern

um

.

3rd

to

the

5th

rib

s

Fro

m t

he

jun

ctio

n o

f bo

ne

and

cart

ilag

e of

th

e fi

rst

rib

Tere

s M

ajor

Cor

acob

rach

iali

s

Pec

tora

lis

Maj

or

Pec

tora

lis

Min

or

Su

bcla

viu

s

Inn

er l

ip o

f th

e in

tert

ube

rcu

lar

groo

ve o

f th

e h

um

eru

s, a

nd

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ds

wit

h t

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ante

rior

join

tca

psu

le.

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ial

surf

ace

of t

he

hu

mer

us,

in m

id-s

haf

t.

Fla

t te

nd

on 2

” or

3”

wid

e to

late

ral

lip

of

the

inte

rtu

berc

ula

rgr

oove

of

the

hu

mer

us,

an

dbl

end

s w

ith

th

e an

teri

or jo

int

cap

sule

.

Cor

acoi

d p

roce

ss o

f th

esc

apu

la.

Into

th

e su

lcu

s fo

r th

esu

bcla

viu

s m

usc

le o

n t

he

low

ersu

rfac

e of

th

e cl

avic

le.

Ext

ensi

on—

dra

ws

the

arm

fro

mth

e fr

ont

hor

izon

tal

pos

itio

n d

own

to t

he

sid

e. I

nw

ard

rot

atio

n—

as i

td

epre

sses

, it

rota

tes

the

hu

mer

us

inw

ard

. Ad

du

ctio

n—

dra

ws

the

arm

fro

m t

he

sid

e h

oriz

onta

lp

osit

ion

dow

n t

o th

e si

de

and

rota

tes

inw

ard

as

it a

dd

uct

s.

Fle

xes

and

ad

du

cts

arm

.

Con

trac

tion

of

both

th

e st

ern

alan

d c

lavi

cula

r h

ead

s p

rod

uce

sad

du

ctio

n a

nd

med

ial

rota

tion

.C

lavi

cula

r h

ead

s is

on

e of

th

ep

rim

e fl

exor

s of

th

e sh

ould

e,

alon

g w

ith

th

e an

teri

or d

elto

id.

Dep

ress

ion

of

shou

lder

gir

dle

, so

that

th

e gl

enoi

d c

avit

y fa

ces

mor

e in

feri

orly

; abd

uct

ion

an

del

evat

ion

of

the

scap

ula

—d

raw

sth

e sc

apu

la f

orw

ard

an

d t

end

s to

tilt

th

e lo

wer

bor

der

aw

ay f

rom

the

ribs

. Pro

vid

es d

own

war

d f

orce

on s

cap

ula

to

stab

iliz

e it

aga

inst

up

war

d f

orce

, su

ch a

s u

sin

g ar

ms

to g

et u

p f

rom

a c

hai

r.

Pu

lls

the

clav

icle

tow

ard

th

est

ern

um

an

d s

o st

abil

izes

th

est

ern

ocla

vicu

lar

join

t.

Tere

s m

ajor

con

trib

ute

s to

rou

nd

ed s

hou

lder

pos

ture

by

pu

llin

g sc

apu

la i

nto

abd

uct

ion

(pro

trac

tion

).

Pec

tora

lis

maj

or t

end

s to

be

tigh

t,ro

llin

g in

to i

nfe

rior

tor

sion

wit

hF

HP

an

d r

oun

ded

sh

ould

ers.

Ten

ds

to b

e ti

ght

and

sh

ort,

lead

ing

to r

oun

ded

-sh

ould

erp

ostu

re, c

reat

ing

an e

xces

sive

load

on

th

e th

orac

ic e

xten

sors

,le

adin

g to

th

orac

ic p

ain

. A s

hor

t,ti

ght

pec

tora

lis

min

or c

an a

lso

com

pre

ss t

he

brac

hia

l p

lexu

sag

ain

st t

he

rib

cage

, lea

din

g to

pai

n, n

um

bin

g an

d t

ingl

ing

dow

nth

e ar

m, a

typ

e of

th

orac

ic o

utl

etsy

nd

rom

e.

Mu

scle

Ori

gin

Inse

rtio

nA

ctio

nD

ysfu

nct

ion

Ad

dit

ion

al

Mu

scle

s

254

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 254

Chapter 6: The Shoulder | Anatomy, Function, and Dysfunction of the Shoulder Complex 255

Flexion

■ Deltoid (anterior)—also causes abduction and medial rotation■ Pectoralis major (clavicular part)—also causes horizontal

flexion, adduction, and medial rotation; and the sternal portion of the pectoralis causes shoulder adduction, horizontalflexion, and medial rotatio

■ Biceps brachii—short head also assists in horizontal flexioand medial rotation; long head also assists in abduction; andbiceps also flexes and supinates the elbo

■ Coracobrachialis—also assists in adduction

Extension

■ Teres major—also adducts and medially rotates■ Latissimus dorsi—also adducts and medially rotates■ Triceps (long head)—also adducts and extends the elbow■ Deltoid (posterior part)—also abducts and laterally rotates

Horizontal Flexion (Horizontal Adduction)

■ Deltoid (anterior)■ Pectoralis major■ Coracobrachialis■ Biceps (short head)

Horizontal Extension (Horizontal Abduction)

■ Deltoid (posterior)■ Triceps (long head)■ Latissimus dorsi■ Teres major

Muscular Actions of the ShoulderTable 6-2Adduction

■ Pectoralis major■ Latissimus dorsi■ Teres major■ Triceps brachii (long head)

Abduction

■ Deltoid—middle and anterior■ Supraspinatus—may assist in lateral rotation■ Biceps brachii (long head)

The primary muscles of abduction are the middle and anteriordeltoid and the supraspinatus. There is debate in the literatureas to the function of the supraspinatus. It is easiest to test thesupraspinatus at 15� abduction and the deltoid at 90 �

abduction.

Medial (internal) Rotation

■ Subscapularis—also adducts■ Pectoralis major■ Teres major■ Latissimus dorsi

Lateral (external) Rotation

■ Infraspinatus—performs greater lateral rotation than theteres minor, deltoid (posterior), and supraspinatus combined

■ Teres minor■ Deltoid (posterior)■ Supraspinatus

Elevation

■ Levator scapula—also laterally flexes the nec■ Trapezius (upper)■ Rhomboid major—also retracts the shoulder girdle and

rotates the scapula downward■ Rhomboid minor—same as the rhomboid major

Depression

■ Pectoralis minor—rotates the scapula downward and abducts it■ Serratus anterior (lower)■ Trapezius (lower)

Protraction (Abduction)—Scapula Moves Away from Spine

■ Serratus anterior—also rotates the scapula upward■ Pectoralis major and minor

Retraction (Adduction)—Scapula Moves Toward the Spine

■ Rhomboid major■ Rhomboid minor■ Trapezius (middle)

Upward Rotation—The Lower Part of the Scapula MovesAway from the Spine, as in Lifting the Arm Overhead

■ Serratus anterior■ Trapezius (upper and lower)

Downward Rotation—In the Anatomic Position the ScapulaIs Almost to Maximum Downward Rotation

■ Levator scapula■ Rhomboid major■ Rhomboid minor

Muscular Actions of the ScapulaTable 6-3

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 255

256 Chapter 6: The Shoulder | Shoulder Dysfunction and Injury

FACTORS PREDISPOSING TOSHOULDER PAIN

■ Instability of the glenohumeral joint

■ Weakness in the scapular stabilizing muscles

■ Previous injury, including previous dislocation ofthe glenohumeral joint or separation of the AC joint

■ Hypomobility of the cervical or thoracic spine,which limits full ROM of the glenohumeral joint

■ Postural dysfunction, such as rounded shoulders,FHP, and thoracic kyphosis

■ Muscle imbalances

DIFFERENTIATION OF SHOULDER PAIN

■ Once you have ruled out pathology and pain fromvisceral diseases such as gallbladder irritation andcardiac problems (see the section “Contraindica-tions to Massage Therapy: Red Flags” in Chapter 2,“Assessment and T echnique”), shoulder pain thathurts at night or pain that increases at night indi-cates that there is an active inflammation. It may bcaused by rotator cuff tendinitis, bursitis, capsuli-tis, or nerve root irritation, called cervical radiculi-tis (meaning “root inflammation”)

■ Dysfunctions and injuries of the cervical facets anddisc degeneration commonly refer to the inter-scapular region. Scapular motion rarely increasesthe pain, but active motion examination of the cer-vical spine reveals limited motion that may referpain to the scapular region at the end ranges. Aswas mentioned in Chapter 5, “The Cervical Spine,”irritation of a sensory nerve root elicits sharp pain,numbing, and tingling in a specific area of skincalled a dermatome. The cervical dermatomes in-clude the shoulder region: C4, top of the shoulder;C5, upper arm and shoulder; and C6, elbow , andthe radial side of the forearm and thumb. A my-otome includes those muscles innervated by a spe-cific motor nerve. Cervical nerves innervate thshoulder muscles. Irritation of the motor nerve elic-its a deep aching in the corresponding muscle and

a weakness in that muscle. The myotomes in theshoulder region are C4, shoulder elevation; C5,shoulder abduction; C6, elbow flexion and wrist extension; and C7, elbow and finger extension andwrist flexion. The shoulder is also a referral sitefrom the fascia, ligaments, and joint capsules in thecervical spine that are innervated by the same seg-mental nerve. This is called sclerotomal pain and isdescribed as deep, aching, and poorly localized.

■ To help differentiate shoulder pain from pain thatis being referred from the neck, there are certainguidelines:n Pain originating from the neck is often elicited or

increased from neck motion.n Pain originating from the shoulder is typically

elicited or increased from active shoulder mo-tion and relieved by rest.

n Isometric challenge of the muscles of the shoul-der will be painful with a localized lesion in theshoulder.

n Often, a painless weakness occurs in the arm andshoulder muscles that have a motor nerve rootproblem from the cervical spine.

■ Rotator cuff injuries typically manifest as pain atthe lateral portion of the upper arm, and a painfullimitation when elevating the arm overhead. Theinvolved muscles are identifed by isometric testing.

■ Bicipital tendinitis (long head) manifests as a well-localized pain at the anterior portion of the head ofthe humerus and aggravation with Speed’s test.

■ Stiffness in the shoulder is typically adhesive cap-sulitis, which presents as a dramatic loss of armmotion, especially external rotation.

■ Impingement m anifests a s p ain o ver t he a nteriorhumerus, with a loss of internal rotation and apainful Neer’s impingement test.

■ Instability manifests as clunking in the shoulderwith active circumduction and excessive joint playin the passive motion test for the glenohumeral joint.

■ Pain that originates in the glenohumeral joint israrely felt at the joint, but over the lateral brachialregion. This is explained by the concept of sclero-tomal pain, because the tissue that is irritated ismainly the joint capsule and interweaving tendonsof the rotator cuff, which are innervated by C5–C6nerves; the lateral brachium is the C5 dermatome.

Shoulder Dysfunction and Injury

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Chapter 6: The Shoulder | Shoulder Dysfunction and Injury 257

COMMON DYSFUNCTIONS ANDINJURIES OF THE SHOULDER

ROTATOR CUFF TENDINITIS(SUPRASPINATUS TENDINITIS)

Tendinitis of the rotator cuff most commonly involvesthe supraspinatus tendon and then the infraspinatus.

■ Cause: Rotator cuff tears are described as partial- orfull-thickness tears. They are further categorized asacute tears due to trauma, or chronic tears, whichare those that are degenerative and slowly tear overtime. The supraspinatus is most commonly involvedfor many reasons. The supraspinatus tendon has apoor blood supply, and the demands of the musclecan overwhelm the nutritional supply.6,13 This is-chemia, or low oxygen in the tissue, combined withmechanical stress leads to a breakdown of fibrilswhich leads to an inflammatory response with consequent scar tissue and potential calcium deposits.The supraspinatus is the only muscle of the rotatorcuff that travels through a tunnel, which is formedby the head of the humerus below and the acromionabove. Any swelling will compress the tendon be-cause of the confines of the tunnel, compromisinthe blood supply . This lesion is common in swim-mers, tennis players, and baseball pitchers as wellas clients who have poor posture. In the rounded-shoulder posture, the supraspinatus is under con-stant tension, leading to fatigue and degeneration.

■ Symptoms: Clients experience a generalized, dull,toothache-like pain that refers to the lateral aspectof the humerus and that is often worse at night,with an inability to lay on that shoulder . Calcifitendinitis can cause a hot, burning pain.

■ Signs: Tendinitis signs are limited, painful eleva-tion; a painful arc, which can be sharp, during ac-tive abduction between 60� and 120�; painful resis-ted abduction at 15 �; positive supraspinatus test(empty-can test); and weak external rotators. Palpa-tion reveals tenderness over the supraspinatus ten-don proximal to or at its insertion on the greatertuberosity of the humerus.

■ Lesion Sites: Tendinitis lesions occur at the tenope-riosteal junction and the musculotendinous junc-tion. The tenoperiosteal junction will have theabove signs, whereas the musculotendinous lesionwill have a painful resisted abduction but will nothave a painful arc or impingement test.

■ Treatment: For acute supraspinatus tendinitis per-form Level I, second and third shoulder series, withemphasis on releasing the pectoralis minor and

major and deltoid to open the area over thesupraspinatus tendon. As you perform the strokes,palpate the tissues to assess for hypertonicity, andperform MET and wave mobilization as indicated.Perform CR and reciprocal inhibition (RI) MET forthe supraspinatus (MET #9) with light pressure toassess the degree of irritability . Repeat MET withincreasing pressure to engage more of the muscleif the technique remains within client’s comfortlevel. Finally, perform Level I, fourth series of STMstrokes. Use very gentle touch and slow move-ments. For chronic conditions, first perform PIRMET #10 to lengthen the supraspinatus. Performtransverse friction massage (TFM), Level I, fourthseries, at the myotendinous and tenoperiostealjunctions to dissolve adhesions if you palpate anyfibrosis. Perform MET for the external rotators tohelp increase their strength (METs #4 and #5). Per-form MET to stretch the posterior capsule and in-crease medial rotation (METs #4 shoulder, #5 tho-racic). Clients need to participate in a strength andstabilization program for the rotator cuff andscapular stabilizers.

INFRASPINATUS TENDINITIS

■ Cause: Infraspinatus tendinitis commonly occursin musicians, carpenters, swimmers, tennis play-ers, and others who perform activities that involvesustained abduction, external rotation, and over-head activities. The infraspinatus is more acti vethan the supraspinatus with the arm abducted 120�to 150 �, which explains why it is commonly irri-tated with repetitive overhead activities.7

■ Symptoms: Clients typically experience pain at theinsertion over the posterior aspect of the greatertuberosity at the myotendinous junction or any-where in the belly of the muscle.

■ Signs: Pain on resisted lateral rotation.

■ Treatment: For acute infraspinatus tendinitis, firsperform CR and RI MET (METs #4 and #5) to reducepain, swelling, and hypertonicity . Next, performgentle STM (fifth and sixth series) to promote nutritional exchange and cellular synthesis. In chronicconditions, the infraspinatus tends to be weak andinhibited and has degenerative fibers rather thaninflammation. First perform CR and PIR MET fothe subscapularis and other medial rotators (MET#3) to ensure that they are not inhibiting the infra-spinatus. Next, perform CR MET to strengthen theinfraspinatus (METs #4 and #5). Finally, performthe fifth and sixth series of STM strokes to dissol eany fibrosis and to lift the fibers superior , as thefibers are typically in a sustained inferior torsion

LWBK325-C06-239-291.qxd 5/1/09 3:51 PM Page 257

SUBSCAPULARIS TENDINITIS

■ Cause: Causes of subscapularis tendinitis are activ-ities involving repetitive or excessive internal rota-tion and adduction, as in carpentry , or cleaning orin throwing or racquet sports.

■ Symptoms: Clients typically experience pain at thelesser tuberosity.

■ Signs: Pain on resisted medial rotation is a sign ofsubscapularis tendinitis, as are painful arc, whichis a lesion at upper site of the insertion point, andpainful passive horizontal adduction, as it ispinched against the coracoid process.

■ Treatment: For acute subscapularis tendinitis, firsperform CR and RI MET (MET #3) to reduce pain,swelling and hypertonicity. Next, perform gentleSTM (first series) to promote nutritional exchangand cellular synthesis. In chronic conditions, thesubscapularis tends to be short and tight. First per-form CR MET for the medial rotators (MET #3) toreduce hypertonicity in the subscapularis. Next,perform PIR MET to lengthen the subscapularisand other medial rotators (MET #11). Finally , per-form the first series of STM strokes to dissolve anfibrosis

ADHESIVE CAPSULITIS (FROZEN SHOULDER)

■ Cause: Adhesive capsulitis begins as an inflammatory lesion of the anterior and inferior portion ofthe glenohumeral joint capsule that leads to achronic, degenerative thickening and shortening ofthe tissue. There is no known cause. It affectswomen more than men and the middle-aged andelderly more than younger clients. Hertling andKessler6 theorize that thoracic kyphosis and theconsequent alteration in the scapulohumeral align-ment is a predisposing factor.6

■ Symptoms: Adhesive capsulitis symptoms developin three stages. 2 The first stag is the initial freez-ing stage with an abrupt loss of motion and pain inthe shoulder that refers pain to the lateral brachialregion with movement. The second stage is thefrozen stage, which may manifest as a persistent,dull ache, present at night or painful only withmovement, and a dramatically reduced ability to el-evate t he arm. The pain may disturb t he client’ssleep, especially when the client rolls onto thatshoulder, and the pain may radiate to the elbow .The third stage, or thawing stage, usually manifestsas a slow recovery of motion, which make take oneto three years. Muscles of the rotator cuff andscapula stabilizers may atrophy.

■ Signs: In the first stage active and passive lateralrotation may be limited, but this movement is usu-ally painless. Active and passive abduction is thenext most limited motion. A thick, capsular endfeel with passive lateral rotation and abduction ispresent. Resisted movements are not painful. In thesecond stage, active and passive movements maybe limited and painful, but resisted movements arepainless. In the third stage, active and passive mo-tion may be restricted in all planes and painful onlyat the end ranges of movement.

■ Treatment: In the acute phase, perform inferior glideof the humerus (MET #12), which is helpful in de-creasing pain and relieving muscle spasms. PerformCR MET #3 to reduce the hypertonicity in the medialrotators, which interweave with the joint capsule.Next, perform the third series of STM strokes. Em-phasize compressing the head of the humerus intothe glenoid fossa as you unwind the anterior soft tis-sue. For the chronic phase, first repeat the work described above for the acute phase. After the superficial soft tissue has released, concentrate onlengthening the joint capsule. Perform PIR MET toincrease external rotation (MET #13). Finally, PIR oreccentric M ET i s u sed t o i ncrease e levation ( MET#14), first in the sagittal plane, then in the scapularplane, and finally in the coronal plane. If indicatedprovide instruction in postural awareness, includingretracting and depressing the scapula and engagingthe lower and middle trapezius. Encourage the clientto use the arm as much as possible within comfort-able limits to minimize disuse atrophy.

IMPINGEMENT SYNDROME

■ Cause: Impingement syndrome is defined as a com-promise of the space between the coracoacromialarch and the proximal humerus. The rotator cuff(usually the supraspinatus), subacromial bursa,and biceps tendon are compressed between thehumeral head and the acromion or coracoacromialligament. Impingement may be caused by an acutetraumatic impingement from a fall on the shoulderor an outstretched hand. In chronic conditions, im-pingement syndrome has structural and functionalcauses. Structural causes include thickening of therotator cuff tendons, inflamed bursa, and hookedacromion. Functional causes include rotator cuffweakness, scapular instability (weakness of scapu-lar stabilizers), thoracic kyphosis, with either fibrosis and thickening of the posterior joint capsule ora lax capsule. Typically, the client presents withupper crossed syndrome, which includes tight pec-toralis minor (which pulls the scapula into a pro-tracted position), upper trapezius, levator scapula,

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and internal rotators and weakness in the lowertrapezius and external rotators. Neer14 describesthree stages: an initial overuse syndrome; the de-velopment of thickening and fibrosis; and the development of bony changes, including spurs.

■ Symptoms: Clients usually experience a gradualonset of pain at the anterior acromion or greatertuberosity, but this pain may refer down the C5–C6sclerotomes.6 It also may present as sharp twinges,especially with abduction.

■ Signs: Painful arc of abduction between 90 � and120� and a positive Neer’s impingement test. Inter-nal rotation is the most restricted (opposite the typ-ical capsular pattern), and elevation next, with onlya slight loss of external rotation. The posterior cap-sule is typically thick and fibrotic

■ Treatment: The primary goal of assessment is to de-termine whether the client has instability due toweakness in the rotator cuff and scapular stabiliz-ers and a lax capsule, or rotator cuff thickening anda fibrotic posterior joint capsule. The typical treatment is to release the posterior capsule, and recruit(strengthen) the rotator cuff and scapular stabiliz-ers. In the acute phase, perform CR MET to reducethe hypertonicity in the tight muscles and to recruitthe weak or inhibited muscles that have been iden-tified by palpation and isometric challenge. Thgoal is to reduce the swelling in the joint and bal-ance the muscles that stabilize the joint. In chronicconditions, the goal of treatment depends onwhether the region is deconditioned or thick andhypertonic. For deconditioned muscles and laxcapsules, perform CR MET to help recruit the mus-cles, and refer your client to a physical therapist orpersonal trainer for strength and stabilization exer-cises. Emphasis needs to be placed on strengtheningthe posterior cuff muscles and scapular stabilizers,especially the scapular retractors.15 For hypertonicmuscles and fibrosis in the posterior joint capsulefirst perform MET for the hypertonic muscles anLevel I, sixth series, and Level II, third series, to re-lease adhesions in the capsule. Perform MET to in-crease internal rotation (MET #4) and stretch theposterior capsule. Next, perform manual release ofany fibrosis that was palpated in the cuff tendonand the coracoacromial ligament.

INSTABILITY SYNDROME OF THEGLENOHUMERAL JOINT

■ Cause: Instability may result from rotator cuffweakness; lack of scapular stabilization; or damageto the anterior capsule, glenohumeral ligament, andglenoid labrum. Instabilities are classified as trau

matic, nontraumatic, and acquired. T raumatic in-stability usually involves a history of shoulder dis-location or rotator cuff injury , such as a fall on anoutstretched hand. Nontraumatic causes involverotator cuff weakness and lack of scapular stabiliza-tion. Acquired instability describes either congenitallaxity in the ligaments or poor treatment outcomeafter a dislocation.2

■ Symptoms: Clients experience diffuse pain in theshoulder region with the feeling of the shoulder“going out.”

■ Signs: Excessive passive anterior and posteriormovement (joint play) of the glenohumeral jointand sulcus sign indicate glenohumeral joint insta-bility syndrome.

■ Treatment: Instability typically involves sustainedcontraction in the pectoralis minor and subscapu-laris and weakness in the external rotators, pullingthe humerus forward. First, use palpation and iso-metric testing to identify the tight and weak pat-terns of the shoulder. Perform CR MET on the tightmuscles first—typically the pectoralis minor ansubscapularis—to reduce the hypertonicity. Next, fa-cilitate (strengthen) the external rotators with CRMET. Because the shoulder is too loose, it is impor-tant to work selectively on the tighter muscles ratherthan creating a generalized release in the shoulderregion. The client needs exercise i nstruction tostrengthen the rotator cuff muscles and scapularstabilizers.

BICIPITAL TENDINITIS

■ Cause: Bicipital tendinitis is usually the result ofrepetitive microtrauma as a result of overhead ac-tivities that involve flexion and internal rotationsuch as swimming, tennis, or throwing. As the longhead attaches to the supraglenoid labrum, an acuteor cumulative trauma to the biceps can tear thelabrum.

■ Symptoms: Clients experience pain over the ante-rior aspect of the humerus at the bicipital groove(tenosynovitis) and at the superior labrum with in-sertional tendinitis of the long head.

■ Signs: Pain on resisted forward flexion of the shoulder with the elbow extended and the forearmsupinated (Speed’ s test) and pain on resistedsupination.

■ Treatment: In the acute phase, perform CR MET tothe biceps. This is accomplished by using the sameposition as Speed’s test. The intention is to reducepain and swelling and decrease muscle spasms. Iflight pressure elicits pain, perform RI for the biceps

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by having the client resist as you attempt to elevatethe arm. Perform Level I strokes to gently mobilizethe soft tissue and joints. Perform the second seriesof Level II strokes with light pressure and a slowrhythm to help normalize the position of the tendonin the bicipital groove. In chronic bicipital tendi-nosis (tendinopathy), recent evidence indicates thatinstead of an inflammatory condition, the tissue isdegenerated, with the collagen in disarray and poorblood supply compared with normal tissue. 16 Ourintention is to create a micro-inflammatory environment to induce revascularization and remodeling ofthe tissue. Repeat the treatment protocol describedfor acute conditions, but use greater pressure withthe METs and greater depth with the strokes. Thefourth series of Level I strokes and the second seriesof Level II strokes are emphasized to dissolve adhe-sions in the rotator cuff and bicipital attachments atthe supraglenoid rim and to dissolve adhesions inthe bicipital groove and on the bicipital tendon.

SUBACROMIAL (SUBDELTOID) BURSITIS

■ Cause: Excessive overhead activities can irritatethe bursa, leading to an acute bursitis in which thebursa swells. This is a rare condition. Typically,the supraspinatus tendon is involved. Over time,calcific deposits from this tendon, which lies under the bursa, may irritate or even rupture thebursa.6

■ Symptoms: Clients experience the following symp-toms with acute or chronic subacromial bursitis:n Acute: Pain can be excruciating, and the patient

loses the ability to move the arm.n Chronic: Pain can be diffuse and achy over the

proximal humerus and is often painful at night.

■ Signs: Acute and chronic subacromial bursitissigns are as follows:

■ Acute: All active ROM is painful. Heat and swellingmay be palpable. Resisted abduction is painful. T opassive motion testing, there is an empty end feel;that is, the client reports pain, but you do not feelthe tension barrier in the tissue.

■ Chronic: A painful arc in the middle of active andpassive abduction. Resisted movements are usuallypainful.

■ Treatment: For acute bursitis, perform manualdraining of the bursa with Level II, fifth series, buuse extreme caution. Students are always surprisedat how gentle these strokes are. If the bursitis ischronic, assess the rotator cuff muscles. Often, anunderlying tendinitis in the supraspinatus is

found, and any fibrosis at the tenoperiosteal junction must be released (Level I, fourth series). Y oucan perform the manual draining of the bursa withgreater depth for a chronic bursitis, but always be-gin with light pressure.

ACROMIOCLAVICULAR LIGAMENT SPRAIN

■ Cause: AC ligament sprain is usually a traumaticevent, such as a fall on an outstretched hand or a di-rect fall onto the shoulder.

■ Symptoms: Clients experience well-localized painover the AC joint.

■ Signs: Pain at the AC joint from 90� to the end rangeof active abduction and pain at the AC joint on pas-sive horizontal adduction.

■ Treatment: For acute conditions, perform Level Istrokes to help normalize the soft tissue of theshoulder. Identify strength/weakness imbalancesthrough palpation and MET, and use MET to reducehypertonicity in the tight muscles and to strengthenweak muscles. Next, perform very gentle back andforth strokes on the AC ligament (Level II, first series). For chronic conditions, repeat the protocol de-scribed above but with greater depth, includingtransverse friction massage to the AC ligaments.

SUPRASCAPULAR NERVE ENTRAPMENT

■ Symptoms: Clients experience poorly localizedpain at the posterolateral aspect of the shoulder.The pain may refer to the arm.

■ Signs: Weakness without pain to resisted tests ofsupraspinatus and infraspinatus, possible pain atthe posterolateral aspect of the scapula with over-pressure in passive adduction of the arm, and painafter application of digital pressure on the nerve inthe suprascapular or the spinoglenoid notch.

■ Treatment: Perform Level I, fifth series, to releasthe suprascapular nerve.

COSTOCLAVICULAR SYNDROME (PART OF THORACIC OUTLETSYNDROME)

■ Cause: Costoclavicular syndrome is defi ed as acompromise of the space between the clavicle andthe first rib. It may be caused by a rounded-shoulder posture or previous trauma to the clavicle, ACjoint, or glenohumeral joint, which lead to fibrouadhesions in the costoclavicular space.

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■ Symptoms: Clients experience a generalized pain,numbing, or tingling down the arm, especially tothe ulnar border.

■ Signs: A positive elevated-arm stress test (see “As-sessment” in Chapter 5).

■ Treatment: For acute conditions, perform Level Istrokes to help normalize the soft tissue of theshoulder. Identify strength/weakness imbalancesthrough palpation and MET , and use MET to re-duce hypertonicity in the tight muscles and tostrengthen weak muscles. Next, perform cervicalspine Level I, third series (Chapter 5). For chronicconditions, repeat the protocol for acute condi-tions with greater depth, and perform back andforth and transverse friction strokes for the costo-clavicular space, Level II, first series. It is important to instruct the client in good posture and pro-vide exercises to strengthen the weak muscles andlengthen the tight muscles. If you are not fluent iexercise rehabilitation, refer your client to a physi-cal therapist or personal trainer.

PECTORALIS MINOR SYNDROME (PART OF THORACIC OUTLETSYNDROME)

■ Cause: Pectoralis minor syndrome is caused by sus-tained contraction of the pectoralis minor , whichcauses forward depression of the coracoid process,

narrowing the space between the pectoralis minorand the rib cage, compressing the brachial plexus.The client typically has rounded shoulders, FHP ,and the muscle imbalances that are typical of uppercrossed syndrome.

■ Symptoms: Clients experience generalized pain,numbing, or tingling down the arm, especially tothe ulnar border.

■ Signs: Symptoms are elicited with the applicationof digital pressure over the pectoralis minor andwith the elevated-arm stress test (see “Assessment”in Chapter 5).

■ Treatment: It is important to realize that a tightpectoralis minor is usually only one piece of amore global imbalance, described as upper crossedsyndrome. For acute conditions, perform Level Istrokes of the cervical spine and shoulder to helpnormalize the soft tissue of the entire neck andshoulder region. Identify strength/weakness im-balances through palpation and MET, and use METto reduce hypertonicity in the tight muscles and tostrengthen weak muscles. Concentrate on the CRand RI for the pectoralis minor. For chronic condi-tions, repeat the protocol described for acute con-ditions. Perform PIR MET for the pectoralis minorto reduce the hypertonicity and to lengthen it. Re-member that the STM for pectoralis minor is per-formed in a superior direction, as it rolls into a sus-tained inferior torsion in dysfunction.

HISTORY QUESTIONS SPECIFIC TO SHOULDER PAIN

■ Where is the pain? What is the quality of the pain?n Strains of the rotator cuff usually produce a dull

ache that worsens at night, referred to the ante-rior and lateral shoulder, in the area of the deltoidtuberosity. Shoulder pain from emotional stressor FHP manifests as a dull pain in the uppertrapezius and levator muscles. Persistent grip-ping pain in the arm and elbow—even at rest andespecially if there is also numbing and tingling inthe hands—could be a nerve root irritation from

the cervical spine. An acute onset of throbbingpain that worsens at night can indicate an acutebursitis. Pain with lying on the shoulder is oftena rotator cuff tendinitis, adhesive capsulitis, orbursitits. Chronic, severe, gripping pain thatworsens at night needs a referral to a doctor.

■ Is there a loss of motion in the arm?n Rotator cuff injuries are most inhibited in abduc-

tion. Impingement syndrome is reproduced withactive flexion with the arm in medial rotation.Adhesive capsulitis can present as a drastic lossof external rotation and abduction, with or with-out pain. Acute bursitis presents as a drastic lossof motion with pain, especially at night.

Shoulder Assessment

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wall at shoulder level, keeping the elbows straight.Stand behind the client (Fig. 6-11).

■ Action: Ask the client to lean into the wall to per-form a push-up against the wall.

■ Observation: When the client is performing thepush-up, the scapula should remain stable againstthe thoracic cage. The inferior angle of the scapulashould not wing off of the thoracic cage, and the me-dial borders of the scapula should not move morethan approximately 1 inch. Winging indicates a weakserratus anterior or an injury to the long thoracicnerve. Excessive movement of the scapula indicatesweakness of scapular stabilizers, including the serra-tus anterior, middle trapezius, or rhomboids.

ABDUCTION

■ Position: Client stands with his or her back to you(Fig. 6-12).

■ Action: Instruct the client to rotate his or her armsexternally by turning the palms out. Then have theclient raise the arms, trying to touch the palms to-gether overhead.

■ Observation: Notice if the top of the shoulder hikesupward at the beginning of the motion. This hikingtypically indicates that there is a tight and short up-per trapezius and levator scapula and a weak lowertrapezius, serratus anterior , and supraspinatus.This muscular imbalance predisposes to impinge-ment syndrome. Also notice if the client needs to

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Figure 6-11. Scapular stabilization test. Notice the slight wing-ing of the right scapula, indicating a slight weakness of the ser-ratus anterior.

OBSERVATION: CLIENT STANDING

ANTERIOR VIEW

■ Are the clavicles level? Is shoulder height even?The shoulder is often elevated in rotator cuff andfrozen shoulder conditions. The shoulder or clavi-cle is normally lower on the dominant side. Lookfor redness, swelling, and atrophy.

■ Notice if there is a smooth contour to the area of thelateral shoulder or if the clavicle lies superior to theacromion at the AC joint. This is called a step de-formity and indicates a previous AC separation.

■ Is there a sulcus sign (i.e., an indentation below theacromion) resulting from a flattening of the normallyround deltoid? This indicates an instability of theglenohumeral joint, a weak deltoid muscle, or aninferior subluxation.

POSTERIOR VIEW

■ Is there scapular winging? If the inferior angle (orangles) of the scapula juts away from the thoracicwall, there may be a loss of scapular stabilization.Winging of the scapula in the resting position of thearm may be caused by scoliosis. It may also resultfrom muscular injury; inhibition (weakness) of thescapular stabilizers, which are tested below (see“Scapular Stabilization Test”); or a nerve injury.

SIDEVIEW

■ Are there rounded shoulders and FHP?

MOTION ASSESSMENT

To assess active movements, always begin on the non-involved side to establish a benchmark of normal mo-tion for that client. Observe the ROM on the involvedside, and ask the client whether the motion is painful.There may be an arc of pain; that is, there is pain duringone part of the movement and then the pain disappearswhile the client continues the motion. If the motion ispainful, ask the client to describe the location and qual-ity of the pain. If the client knows what the painful mo-tions are, ask him or her to perform these motions last.Have the client perform active cervical motions to as-sess ROM and symmetry between the sides and to seewhether cervical motion elicits pain in the shoulder.

SCAPULAR STABILIZATION TEST

■ Position: Have the client stand at arm’s distancefrom the wall and place his or her hands on the

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move in the scapular plane, that is, approximately30� of forward flexion. This position is assumewith acute and chronic problems. An arc of pain in-dicates supraspinatus tendinitis, subacromial bur-sitis, calcific deposits, or an AC joint irritation. Ab-duction is the best motion to indicate a rotator cufftear. It may be impossible to perform the motion be-yond 90� if there is a significant tea , especially inthe supraspinatus.

MEDIAL ROTATION

■ Position: Client stands with his or her back to you(Fig. 6-13).

■ Action: Beginning with the non-involved side, ask theclient to reach the hand up the back and try totouch the scapula. Measure the vertebral level thatthe fingertips or thumb touches. If measurinwith the thumb, have the client place the thumb in the“hitchhiking” position. Compare with the other side.

■ Observation: It is normal to be able to reach to ap-proximately T5–T10. The client might be able toreach the only greater trochanter or sacrum on oneside. This motion elicits pain in the anterior shoulderwith an impingement syndrome, as you are forcingthe greater tuberosity against the coracoacromial lig-ament. If the movement is not painful, have the clientattempt the “lift-off” test, lifting the hand off theback. This tests the strength of the subscapularis.

FLEXION WITH INTERNALROTATION (NEER’S IMPINGEMENT TEST)

■ Position: Client faces you and medially rotates thearm so that the thumb faces posteriorly.

■ Action: Ask the client to raise the involved arm upto the side of the head. The thumb now faces ante-riorly. The therapist then puts overpressure on theelevated arm.

■ Observation: The range is normally approximately170� to 180 �. With the arm medially rotated, thesupraspinatus, which attaches to the greatertuberosity, n eeds t o s lide u nder t he c oracoacro-mial ligament. If there is irritation, swelling, orscarring of the tendon, it impinges against this lig-ament.

LATERAL ROTATION

■ Position: Client faces you (Fig. 6-14).

■ Action: There are two actions. Ask the client toclasp his or her hands behind the head, with elbowspulled as far back as possible. If this is difficulthave the client place his or her arms at the sides,with the elbows at 90�, and laterally rotate the arms.

■ Observation: The first motion allows for easy comparison of both sides. It combines elevation and ex-ternal rotation, a position of function for daily ac-tivities, such as getting dressed. In the secondmotion, the normal range is approximately 75 � to90�. Compare both sides. Lateral rotation is the firsmotion to be lost in adhesive capsulitis.

HORIZONTAL FLEXION (ADDUCTION)

■ Position: Client faces you.

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Figure 6-12. Shoulder abduction test. Notice if the top of theshoulder hikes toward the ear as the arm is abducted. Thiswould indicate a tight upper trapezius and a weak lowertrapezius.

Figure 6-13. Active medial rotation. Notice how far up thespine the client can reach. Compare sides.

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■ Action: Client is instructed to elevate his or herarm to 90� and move the arm across the front of thebody, attempting to place the hand on the oppositeshoulder.

■ Observation: If there is pain at the top of the shoul-der, it implicates the AC joint; pain at the posteriorshoulder implicates the posterior -inferior capsule;anterior joint pain may be the anterior labrum, sub-coracoid bursa, or subscapularis tendon. If there isanterior joint pain, differentiate bursitis from ten-dinitis by first performing the same movement passively, which would typically be painful with bur-sitis but not tendinitis. Isometrically challenge thesubscapularis, which may be painful with tendini-tis but not bursitis.

PASSIVE MOVEMENTS

Passive movements are performed for those move-ments that do not have full and pain-free active ROM.Note the range, pain, arc of pain, pain with overpres-sure, and end feel. The following passive shouldermovements are performed with the client sitting.

ABDUCTION

■ Position: Stand to one side of the client. Hold thelower scapula with your thumb and index fingewith one hand and the distal forearm with yourother hand (Fig. 6-15).

■ Action: Slowly abduct the client’s arm until the re-sistance barrier is met or until the arm is against theclient’s head, and feel for when the scapula beginsto move.

■ Observation: Normally, the range is approximately170� to 180�. The scapula should not move until 90�of abduction. If there are adhesions of the joint cap-sule, anchoring the scapula to the humerus, thescapula begins moving before 90 �. If there is nopain in passive abduction and active abduction waspainful, it indicates a tendinitis of the rotator cuff,typically the supraspinatus. If there is pain in pas-sive abduction before there is tissue tension, this isthe “empty” end feel of bursitis, in this case, of thesubacromial bursa.

LATERAL ROTATION

■ Position: Stand to one side of the client, and placeone hand on the client’s elbow to stabilize it againstthe client’s body and the other hand on the client’sdistal forearm, holding it.

■ Action: Slowly pull the forearm laterally, whichlaterally rotates the arm.

■ Observation: Lateral ROM is limited in adhesivecapsulitis, as the anterior capsule has developed fibrotic adhesions. The end feel is thick and leathery.It might or might not be painful.

CIRCUMDUCTION

■ Position: Stand behind and to one side of the client.Place one hand on the top of the glenohumeraljoint, and hold the distal forearm with the otherhand (Fig. 6-16).

■ Action: Slowly draw the arm backward to begin acircumduction motion. Move the arm in a forwardcircle, like the “crawl” swimming motion.

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Figure 6-15. Passive abduction. The therapist places one handon the scapula to detect when it moves. If the scapula movesbefore approximately 90� of abduction, then adhesion in thejoint capsule is indicated.

Figure 6-14. Lateral rotation with abduction performed bilat-erally is an easy way to compare the ROM of both sides at thesame time.

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■ Observation: Circumduction motion helps to dif-ferentiate joint, muscle, and ligament lesions.There will be a loose feel or clunking with joint in-stability. You will feel crepitus (grinding sounds)with calcific deposits or arthrosis. There is a thickened feel and limited range with capsular lesions.With muscle hypertonicity, fascicular torsion, andsoft tissue misalignment, there is a “cogwheel” pat-tern (i.e., there are resistances and dips in an other-wise smooth motion). Over time, you can learn tofeel the subtleties of resistance under your hand.

ISOMETRIC TESTS

The client should be able to provide strong resistanceto the following tests. Note if the client has difficulty iproviding resistance. Ask whether the resisted action ispainful. If it is painful, ask about the location and qual-ity of pain. Remember that the shoulder and arm arecommon referral sites for neck problems. Painlessweakness may be indicative of a nerve root problem. Ifthe client remains weak after treatment, he or she needsa referral to a chiropractor or an osteopath. All of thefollowing muscles are innervated by C5 and C6.

MIDDLE DELTOID

■ Position: The client’s arm is placed at 90� of abduc-tion, with the elbow flexed 9 � (Fig. 6-17).

■ Action: Instruct the client to resist as you pressdown on the elbow.

■ Observation: Pain indicates irritation or injury inthe middle deltoid.

(EMPTY-CAN TEST)

■ Position: The client’s arm is abducted 90�, 30� for-ward flexion, and maximally internally rotatedthat is, with the thumb turned down (Fig. 6-18).

■ Action: Ask the client to resist as you press downon the distal forearm.

■ Observation: The empty-can test isolates the actionto the supraspinatus and also challenges thelabrum-biceps complex. Pain at the lateral andanterior shoulder indicates irritation, injury , orscarring of the supraspinatus tendon or the biceps–labrum complex.

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Figure 6-16. Passive circumduction. Lauren Berry, RPT,prefers this method to determine whether the shouldercomplaint is muscular, capsular, or articular.

Figure 6-17. Isometric test for the middle deltoid.

Figure 6-18. The empty-can test to isolate the supraspinatus.

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RESISTED LATERAL ROTATION

■ Position: The client’s arm is elevated 90� and inter-nally rotated, with the elbow flexed to 9 �. Placeone hand on the client’ s elbow to stabilize it andthe other at the distal forearm (Fig. 6-19).

■ Action: Instruct the client to resist as you pressdownward on the client’s distal forearm.

■ Observation: The external rotators are typicallyweak. This weakness may be due to FHP , overuse,or prior injury. Pain at the posterior humerus indi-cates involvement of the infraspinatus and the teresminor. It is important to instruct the client in astrengthening program for the external rotators ifthey are weak. One possible home program forstrengthening the external rotators is shown inMET #5. Patients are instructed to use a handweight and lift it to about 70�. Repeat to fatigue.You determine how much weight to use by deter-mining how much weight fatigues them with thetenth repetition. Perform three sets of ten.

LONG HEAD OF BICEPS (SPEED’S TEST)

■ Position: The client’s arm is flexed 3 � in the scapu-lar plane, with the elbow extended and the forearmsupinated (Fig. 6-20).

■ Action: Ask the client to resist and you press downon the client’s distal forearm.

■ Observation: Pain in the anterior humerus impli-cates the long head of the biceps.

ADDITIONAL TEST

MOTION PALPATION ANDMOBILIZATION OF THEGLENOHUMERAL JOINT

■ Intention: This test is performed to assess both mo-tion restrictions of the humeral head in the glenoidand to assess excessive motion/instability (Fig. 6-21). The test is shown here for teaching purposes,but in the context of the treatment, it is typicallyperformed after METs and Level I strokes.

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Figure 6-20. Speed’s test for the long head of the biceps.

Figure 6-21. Motion palpation of the glenohumeral joint. Thistest is performed to assess both motion restrictions of thehumeral head in the glenoid and to assess excessivemotion/instability.

Figure 6-19. Isometric test for lateral rotation.

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Chapter 6: The Shoulder | Techniques 267

GUIDELINES TO APPLYINGTECHNIQUES

A thorough discussion of treatment guidelines can befound on p. 86 in Chapter 2. In the method of treat-ment described in this text, we make two underlyingassumptions. The first is that an injury or dysfunctioin one structure causes compensations in the entireregion of the injury, as well as in other areas of thebody. A rotator cuff injury, for example, is not isolatedto only the fibers of the rotator cuff but typically creates tightening of the pectoralis minor and upperchest muscles, tightening of the extensors of the cervi-cal spine, and weakness of the scapular stabilizers. Itis important for the therapist to refer to other chaptersto learn the protocol for assessment and treatment ineach area involved.

The second assumption is that an injury or dys-function that localizes i n one tissue affects manyother tissues in the area. Rotator cuff injury, for ex-ample, typically involves not only the muscles ofthe rotator cuff, but also the ligaments and jointscapsule of the shoulder, as well as the alignmentand motion of the glenohumeral joint. It is impor-tant for the therapist to assess and treat the sur-rounding muscles, tendons, ligaments, and joints ofthe shoulder in addition to treating the rotator cuffmuscles.

The treatments described in this text address all thestructures of the region through three techniques: mus-cle energy technique (MET), soft tissue mobilization

(STM), and joint mobilization. These techniques can beapplied to every type of shoulder pain, but the “dose”of the technique varies greatly from slow movementsand light pressures for acute conditions to strongerpressures and deeper -amplitude mobilizations forchronic problems. Each aspect of the treatment is alsoan assessment to determine pain, tenderness, hyper-tonicity, weakness, and hypomobility or hypermobil-ity. We use the philosophy of treating what we finwhen we find it. Remember that the goal of treatment ito heal the body, mind, and emotions. Keep your handssoft, keep your touch nurturing, and work only withinthe comfortable limits of your client so that he or shecan completely relax into the treatment.

THE INTENTIONS OF TREATMENTFOR ACUTE CONDITIONS ARE AS FOLLOWS

■ To stimulate the movement of fluids to reducedema, increase oxygenation and nutrition, andeliminate waste products.

■ To maintain as much pain-free joint motion as pos-sible to prevent adhesions and maintain the healthof the cartilage, which is dependent on movementfor its nutrition.

■ To provide mechanical stimulation to help alignhealing fibers and stimulate cellular synthesis

■ To provide neurological input to minimize muscu-lar inhibition and help maintain proprioceptivefunction.

Techniques

■ Position: The client is supine with the arm at ap-proximately 70 � of abduction and elbow flexed t90�. Hold the distal forearm with one hand, andplace the palm of the other hand over the head ofthe humerus.

■ Action: Gently push the humeral head posteriorlywhile stabilizing the arm with your other hand.This anterior to posterior mobilization can be re-peated several times if the movement of thehumeral head feels restricted.

■ Observation: The typical motion restriction andpositional dysfunction of the head of the humerus

is an anterior fixation. Mobilizing the head of thhumerus posteriorly helps to reestablish its normalposition and movement. Excessive movement ofthe humeral head indicates joint instability. An-other method to assess instability is to hold thedistal forearm as described above and grasp thehead of the humerus between your thumb and fingertips. Move the head of the humerus back andforth in an anterior-to-posterior (A–P) direction. Anunstable glenohumeral joint will be “sloppy” andloose. Compare to the non-involved side and toother healthy shoulders to get a feeling for what isnormal.

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CAUTION: Stretching is contraindicatedin acute conditions.

THE INTENTIONS OF TREATMENTFOR CHRONIC CONDITIONS ARE AS FOLLOWS

■ To dissolve adhesions and restore flexibilit , lengthand alignment to the myofascia.

■ To dissolve fibrosis in the ligaments and capsulatissues surrounding the joints.

■ To rehydrate the cartilage, restore mobility andROM to the joints.

■ To eliminate hypertonicity in short, tight muscles;strengthen weakened muscles; and reestablish thenormal firing pattern in dysfunctioning muscles

■ To restore neurological function by increasing sen-sory awareness and proprioception.

Clinical examples are described below under “SoftTissue Mobilization.”

MUSCLE ENERGY TECHNIQUE

THERAPEUTIC GOALS OF MUSCLEENERGY TECHNIQUE (MET)

A thorough discussion of the clinical application ofMET can be found on p. 76. The MET techniquesdescribed below are organized into one section forteaching purposes. In the clinical setting, the MET sand STM techniques are interspersed throughout thesession. METs are used for assessment and treatment.A healthy muscle or group of muscles is strong andpain-free when isometrically challenged. MET will be painful if there is ischemia or inflammation in thmuscles or their associated joints. The muscle will be weak and painless if the muscle is inhibited or thenerve is compromised. During treatment, MET is usedas needed. For example, when you find a tight andtender pectoralis minor, use CR MET to reduce the hy-pertonicity and tenderness. If the pectoralis minor ispainful while contracting, perform an RI MET, induc-ing a neurological relaxation. If the external rotatorsare weak and inhibited, first release the tight internalrotators, then use CR MET to recruit and strengthenthe external rotators.

MET is very effective for an acute, painful shoulder,but the pressure that is applied must be very light so

as not to induce pain. Gentle, pain-free contractionand relaxation of the shoulder flexors and extensorand related muscles provide a pumping action to re-duce swelling, promote the flow of oxygen and nutrition, and eliminate waste products.

THE BASIC THERAPEUTICINTENTIONS OF MET FOR ACUTECONDITIONS ARE AS FOLLOWS

■ Provide a gentle pumping action to reduce pain andswelling, promote oxygenation of the tissue, and re-move waste products.

■ Reduce muscle spasms.

■ Provide neurological input to mimimize muscularinhibition.

THE BASIC THERAPEUTICINTENTIONS OF MET FOR CHRONICCONDITONS ARE AS FOLLOWS

■ Decrease excessive muscle tension.

■ Strengthen muscles.

■ Lengthen connective tissue.

■ Increase joint movement and increase lubricationto the joints.

■ Restore neurological function.

The internal rotators are typically short and tight,and the external rotators are typically weak. W e willfirst assess the ROM of internal and external rotation.Next, we will assess and treat the muscles that tend tobe tight (described in the upper crossed syndrome ofJanda). In the muscles of the shoulder in the uppercrossed syndrome, we usually find the pectoralis major and minor and subscapularis (an internal rotator)short and tight. Next, we will assess and facilitatethe muscles of the rotator cuff that tend to be weak: thesupraspinatus, and the primary external rotators, theinfraspinatus, and teres minor.

The MET section below shows techniques that areused for most clients. In acute conditions, use MET #4to increase external rotation and METs #7 and #8 to re-lease the hypertonicity in the pectoralis major and mi-nor. PIR MET, which lengthens muscles and fascia, iscontraindicated for acute conditions.

Remember that MET should not be painful. Milddiscomfort as the client resists the pressure is normalif the area is irritated or inflamed. Refer to Chapters and 5 for METs for the thoracic spine and the cervicalspine.

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ASSESSMENT OF MUSCLE LENGTHOF GLENOHUMERAL JOINT ANDPASSIVE RANGE OF MOTION

1. Assessment of the Range of Motion ofLateral Rotation of the GlenohumeralJoint

■ Intention: For full external rotation, there must benormal length in the medial rotators—the pec-toralis major, the latissimus, the teres major, andthe subscapularis—and the anterior joint capsule(Fig. 6-22).

■ Position: Client is supine, with the knees f exedand the feet on the table and with the low back flaon the table. Client then rests the arm at shoulderlevel (90 � abduction) and lowers the forearm to-ward the head of the table without lifting the lowback off the table.

■ Observation: The normal ROM allows the forearmto lie flat on the table (9 � of external rotation). Thismotion is drastically reduced in frozen shoulderand slightly reduced with shortness of the medialrotators.

2. Assessment of the Range of Motion ofMedial Rotation of the GlenohumeralJoint

■ Intention: For full internal rotation, there must benormal length in the lateral rotators—teres minor ,infraspinatus, and posterior deltoid—and the pos-terior joint capsule.

■ Position: Client is supine, with the knees f exedand the feet on the table and with the low back flaon the table. Client then rests the arm at shoulderlevel (90 � abduction) and lowers the forearm to-ward the foot of the table without lifting the lowback off the table.

■ Stabilization: Hold the head of the humerus downto prevent it from moving forward.

■ Observation: The normal range of medial rotationis 70� (i.e., for the forearm to be 20� from the table).This motion may be reduced in impingement syn-drome, bicipital tendinitis, supraspinatus tendini-tis, and shortening of the posterior joint capsule.

CONTRACT-RELAX ANDPOSTISOMETRIC RELAXATIONTECHNIQUES

3. Contract-Relax and PostisometricRelaxation Muscle Energy Techniquefor the Medial Rotators of the Shoulderand to Increase External Rotation

■ Intention: The intention is to relax the medial rota-tors, to increase the strength of the medial rotatorsif they test weak, to increase their length if theywere found short by the previous assessment, andto increase external rotation of the shoulder (Fig. 6-23).

■ Position: Client is supine, with the knees f exedand the feet on the table and with the low back flaon the table. Client then rests the arm at shoulderlevel (90 � abduction) and lowers the forearm intolateral rotation as far to the table as comfortable,without lifting the low back off the table.

■ Stabilization: Hold the head of the humerus downto prevent it from moving forward. As the arm is be-ing moved into lateral rotation, clients with a his-tory of dislocation might feel apprehensive. It iscritical that you prevent the humeral head frommoving anteriorly while you place the arm in lat-eral rotation.

■ Action: To release the medial rotators, have theclient r esist as you attempt to press into f urther

Chapter 6: The Shoulder | Techniques 269

Figure 6-22. Assessment of the ROM of glenohumeral joint inlateral rotation and length of the medial rotators.

Figure 6-23. CR and PIR MET of the shoulder medial rotators.

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lateral rotation for approximately 5 seconds on thedistal forearm. Relax and repeat to reduce hyper-tonicity. To lengthen the muscle and to increase lat-eral rotation, move the arm into further lateral rota-tion, and have client resist again for 5 seconds.Repeat three to five times

4. Contract-Relax and PostisometricRelaxation Muscle Energy Technique ofthe Lateral Rotators of the Shoulder

■ Intention: The intention is to relax tight lateral ro-tators, to increase the strength of the lateral rotatorsif they test weak, to increase the length of thesemuscles if they were found short by the previousassessment, to stretch the posterior joint capsule,and to increase medial rotation of the shoulder (Fig.6-24).

■ Position: Client is supine, with the knees f exedand the feet on the table, and with the low back flaon the table. Client then rests the arm at shoulderlevel (90 � abduction) and lowers the forearm intomedial rotation as far to the table as comfortable,without lifting the low back off the table.

■ Stabilization: Hold the head of the humerus downto prevent it from moving forward.

■ Action: Have the client resist as you attempt topress into further medial rotation on the distal fore-arm for approximately 5 seconds. Relax and repeatto reduce hypertonicity. To lengthen the muscle,move the arm into further medial rotation and havethe client resist again for 5 seconds. Repeat three tofive times

5. Contract-Relax and ReciprocalInhibition Muscle Energy Technique inthe Side-Lying Position for the LateralRotators

■ Intention: The intention is to reduce the hyper-tonicity of the infraspinatus, teres minor, and teresmajor with the client in a position that allows formassage of the region after the MET (Fig. 6-25).

■ Position: Client is in the side-lying position. Placethe client’s arm on the side of the body with theelbow flexed to 9 �. Place one hand on the client’ selbow to stabilize the arm and the other hand onthe distal forearm.

■ Action: Have the client resist as you press downon the distal forearm for 5 seconds. To engage theteres major, which is an internal rotator of the arm,have the client resist as you pull up on the distalforearm for 5 seconds. Repeat these two MET sseveral times and throughout your session asneeded.

6. Contract-Relax Muscle EnergyTechnique for the Pectoralis Major

■ Intention: The intention is to reduce hypertonicitywith CR MET if the pectoralis major palpates astight (Fig. 6-26).

■ Position: Client is supine with knees bent, feet onthe table. Place the client’s arm in 90� of flexion

■ Action: Hold the client’s distal forearm, and havethe client resist as you attempt to pull the arm awayfrom the body (abduction) for approximately 5 sec-onds. Have the client relax, and then repeat the

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Figure 6-24. CR and PIR MET of the shoulder lateral rotators.

Figure 6-25. Side-lying position CR and RI MET for the lateralrotators.

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procedure. To reciprocally inhibit the pectoralismajor, have the client resist as you press the arm to-ward her body.

7. Postisometric Relaxation Muscle EnergyTechnique for the Pectoralis Major

■ Intention: The intention is to lengthen the pec-toralis major using PIR MET (Fig. 6-27).

■ Position: Client is supine with the knees bent, feeton the table. To lengthen the upper fibers, place th

client’s arm at 90� of abduction, and to lengthen thelower fibers, place the arm at 13 � of abduction.

■ Stabilization: Place one hand on the opposite clav-icle when working with the upper fibers; place onhand on the glenohumeral joint on the same sidewhen working with the lower fibers

■ Action: To lengthen the upper fibers, hold thclient’s distal forearm, and slowly move the arm toits tension barrier . Have the client resist as youpress the arm toward the floo . Repeat this seriesuntil the arm can hang over the side of the table at90� abduction.

For the lower fibers, move the arm overhead at approximately 135� abduction to its tension barrier, andhave the client resist as you press the arm toward thefloo . Relax, move the arm to a new length, and repeat.

CAUTION: If the stretch of this musclecauses numbing and tingling, you arestretching the brachial plexus and needto perform CR technique without thestretch.

8. Contract-Relax and PostisometricRelaxation Muscle Energy Technique of the Pectoralis Minor

■ Intention: The intention is to relax and lengthenthe pectoralis minor (Fig. 6-28).

■ Position: Client is supine with the knees bent andfeet on the table. Place the palm of one hand over

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Figure 6-26. CR MET for the pectoralis major.

Figure 6-27. PIR MET of the pectoralis major. Figure 6-28. CR MET of the pectoralis minor.

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the head of the humerus, and place the other handunder the posterior humerus. Lift the shoulder for-ward and medially , bringing the origin and inser-tion of the pectoralis minor toward each other.

■ Action: Have the client resist as you press on thehead of the humerus, attempting to press it backto the table. Press for approximately 5 seconds,relax, and repeat. Move the head of the humeruscloser to the table to lengthen the pectoralis mi-nor, and have the client resist as you press towardthe table again. Relax, and move the humerus asclose to the table as is comfortable and have theclient resist again. To reciprocally inhibit the pec-toralis minor in its lengthened state, have theclient resist as you attempt to lift the scapula offthe table.

9. Contract-Relax Muscle EnergyTechnique of the Supraspinatus

■ Intention: The intention is to relax the supraspina-tus.

■ Position: Client is supine, with arms at the sides.Bring one arm away from the client’s body approx-imately 6 inches, to approximately 15 � abduction.Place one hand on the client’ s distal forearm andthe other hand on the belly of the supraspinatus inthe supraspinous fossa of the scapula.

■ Action: Have the client resist as you press towardthe client’s body. Press for 5 seconds, relax, and re-peat. T ap on the belly of the muscle in thesupraspinous fossa and say , “Feel this muscleworking,” to bring sensory awareness to the mus-cle. The RI is to have the client resist as you attemptto pull the arm away from the body.

10. Postisometric Relaxation MuscleEnergy Technique for theSupraspinatus

■ Intention: The intention is to lengthen the connec-tive tissue of the supraspinatus and the superiorportion of the joint capsule. This procedure is forchronic conditions only (Fig. 6-29).

■ Position: Client is sitting and places one hand onthe low back. Hold one hand on the client’ s distalforearm, and stabilize the client’s trunk with theother hand.

■ Action: Have the client resist as you attempt to pullthe client’s arm toward you, across the back. Pull for5 seconds. Relax for a few seconds, and while theclient is completely relaxed, pull the arm slowlyinto a further stretch across the back. Repeat three to

five times. This may also be done as a CRAC ME .After the relaxation, have the client actively reachacross the back as you gently pull the arm across.

11. Postisometric Relaxation MuscleEnergy Technique to Increase Medial Rotation

■ Intention: The intention is to increase medial (in-ternal) rotation of the glenohumeral joint and tostretch the posterior capsule and subscapularis(Fig. 6-30).

■ Position: Client is sitting and places one hand onhis or her low back. If this is difficult, the hand isplaced on the sacroiliac joint or the greatertrochanter area. Hold one hand on the client’ s el-bow and one hand on the distal forearm.

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Figure 6-29. PIR MET for the supraspinatus.

Figure 6-30. PIR MET to increase medial rotation.

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■ Action: Have the client resist as you attempt to pullthe distal forearm away from the lower back (i.e., intogreater medial rotation). Pull for 5 seconds. Relax fora few seconds, and while the client is completely re-laxed, pull the distal forearm slowly away from thelower back into a new resistance barrier or until it be-gins to be painful for the client. This is usually onlyapproximately 1 inch. If it is painful, release the pulluntil it is comfortable again. Repeat three to fivtimes. This position may also be used to increase theclient’s ability to reach up her back. Have the clientresist as you attempt to lift the client’ s hand up theback. Relax. As the client is relaxing, lift the hand upthe back to the next comfortable limit.

12. Muscle Energy Technique to IncreaseInferior Glide of the GlenohumeralJoint

■ Intention: The intention is to reduce the hyper-tonicity of the muscles of the shoulder , to relievepain, and to stretch the joint capsule (Fig. 6-31).

■ Position: Client is supine, with the involved arm atthe side. Stand in the 45� headward position, tuck theclient’s forearm against your body, and hold it therewith your arm. Place one hand in the client’s axillato stabilize the shoulder , and hold the distalhumerus with your other hand.

■ Action: While the client is completely relaxed,press headward slightly with the stabilizing handwhile you rotate your trunk away from the table,gently pulling the humerus inferiorly (toward thefeet). Hold for 30 to 90 seconds.

■ Alternate Method: This MET movement is per-formed with the therapist sitting. Take your shoe offand place your foot in the client’ s axilla and holdthe distal forearm. Lean back to traction the client’sarm. Hold for 30 to 90 seconds.

TREATMENT FOR LOSS OFSHOULDER MOTION

13. Contract-Relax Antagonist Contract to Increase External Rotation in Abduction

■ Intention: The intention is to increase the ROM andlength of the internal rotators and anterior jointcapsule. In chronic shoulder problems, clients losethe ability to abduct and externally rotate theshoulder fully. This technique is a comfortable wayto correct these problems (Fig. 6-32).

■ Position: Client is supine, with the feet on the tableand the low back against the table. Place a pillowunder the arms if the arms cannot rest comfortablyat the end of their tension barrier . Have the clientinterlace the fingertips and place the hands undethe head. Face 45� headward, and place your palmson the client’s elbows.

■ Action: Have the client resist as you attempt topress the elbows toward the pillow or table forabout 5 seconds. Relax, then have the client pullher elbows back toward the table to a new resist-ance barrier. Relax, and repeat the resist, relax, pulltoward pillow/table cycle five times

■ Home exercise: To increase the ROM of the shoul-der, have the client perform the following exerciseat home: The client should attempt to pull the

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Figure 6-31. MET to increase inferior glide of theglenohumeral joint.

Figure 6-32. PIR MET to increase external rotation in abduc-tion.

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elbows into the pillow for 5 seconds, relax, and re-peat five times

14. Eccentric Muscle Energy Technique toIncrease Shoulder Elevation

CAUTION: This technique is not to beperformed on geriatric clients.

■ Intention: The intention is to help dissolve adhe-sions in the anterior joint capsule, as elevation ofthe shoulder is one of the primary motions lost infrozen shoulder (Fig. 6-33).

■ Position: Client is supine and elevates the arm tothe comfortable limit. Hold the distal humerus, andplace one hand on the forearm.

■ Action: Have the client resist as you attempt tomove the arm overhead with moderate pressure.Tell the client, “Let me win, and allow me to moveyour arm very slowly, as long as it is not painful.”Move the arm slowly to the pain-free limit for ap-proximately 10 seconds. Relax, but hold the arm inits new range if it is not painful. Bring it backslightly if it is painful. Repeat three to five timesand rest the arm. Repeat another three to five times

■ Variations: Eccentric MET movement can be per-formed at increasing degrees of abduction, up to ap-proximately 80�.

SOFT TISSUE MOBILIZATION

BACKGROUND

A thorough discussion of the clinical application ofSTM can be found on p. 68. In the HendricksonMethod of manual therapy described in this text, theSTM movements are called wave mobilization and area combination of joint mobilization and STM per-formed in rhythmic oscillations with a frequency of50 to 70 cycles per minute, except in performing brisktransverse friction massage (TFM) strokes, which canbe two to four cycles per second. These mobilizationsare presented in a specific sequence, which has beefound to achieve the most efficient and effective results. This allows the therapist to “scan” the body todetermine areas of tenderness, hypertonicity, and de-creased mobility. It is important to “follow the recipe”until y ou h ave m astered t his work. T he t echniquesdescribed below are divided into two sequences:Level 1 and Level II. Level I strokes are designed forevery client, from acute injury to chronic degenera-tion, to enhance health and bring the body to opti-mum performance. Level II strokes are typically ap-plied after Level I strokes and are designed for chronicconditions. Guidelines for treating acute and chronicconditions are listed below.

GUIDELINES FOR THE THERAPIST

Acute

The primary intention of treatment is to decrease painand swelling as quickly as possible, maintain as muchpain-free joint motion as possible, and induce relax-ation. In this method of treatment, the soft tissue iscompressed and decompressed in rhythmic cycles.This provides a pumping action that helps to promotefluid exchange, reducing swelling. The strokes thatare applied to the client in acute pain need to be per-formed with a very gentle touch, a very slow rhythm,and small amplitude. There is no uniform “dose” ordepth of treatment. The depth of treatment is based onthe client’s level of pain. If the soft tissue does not be-gin to relax, use more MET s to help reduce discom-fort, swelling, and excessive muscle tension. As wasmentioned previously , intersperse your STM workwith MET. Remember that stretching is contraindi-cated in acute conditions.

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Figure 6-33. Eccentric MET to increase shoulder elevation.

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Chapter 6: The Shoulder | Techniques 275

Chronic

The typical exam findings in clients with chronicshoulder problems are FHP, rounded shoulders,short and tight pectoralis minor and major , andweakness in the external rotators, lower trapezius,and scapular stabilizers. The glenohumeral joint istypically hypomobile, fixated anteriorl , with thick,fibrous ligaments and capsular tissues in the anterior and superior aspects of the joint. Some patientsdemonstrate the opposite: instability in the joints,weak, deconditioned muscles, and atrophy in theligaments and capsular tissues. The primary goals oftreatment depend on the patient. For patients whoare hypomobile, the treatment goals are to reducethe hypertonicity of the muscles; promote mobility

and extensibility in the connective tissue by dis-solving the adhesions in the muscles, tendons, liga-ments, and capsular tissues surrounding the joints;rehydrate the cartilage of the joint; reestablish nor-mal joint play and ROM in the joints; and restorenormal neurological function by stimulating theproprioceptors and reestablishing the normal firinpatterns in the muscles. Patients who are unstableneed exercise rehabilitation. Our treatments cansupport their stability by reducing tension in thetight muscles with STM and MET and strengtheningweak muscles, reestablishing normal firing patternsand rehabilitating the proprioceptors with MET .With chronic shoulder conditions, it is also impor-tant to treat tightness in the cervical and thoracic

Subjective: CS is a 64-year -old male health-care ad-ministrator who presented to my office complaininof acute left shoulder pain. He reported that the painbegan upon awakening a few days previously, after anintense exercise class the previous day. He describedthe pain as an ache at the mid-arm that could be sharpwith certain movements, especially reaching, and thathe was unable to elevate the arm overhead.

Objective: Examination revealed active arm elevationlimited to 70�, eliciting pain at the anterior portion ofthe proximal humerus. Active abduction was approx-imately 20 �, at which point pain was elicited in theleft mid-humerus region. External rotation was 50%of normal, with pain at the proximal humerus.Speed’s test and the empty-can test were both posi-tive, eliciting pain at the superior glenoid. Motion pal-pation revealed a limitation of posterior glide of thehead of the humerus, indicating an anterior fixation othe humeral head. Palpation revealed tight and tendertissue in the area of the anterior humerus.

Assessment: Inflammation of the bicipital tendo(long head), and supraspinatus, with a fixation of thglenohumeral joint.

Treatment (Action): Treatment began with the Level ISTM strokes. The subscapularis was tight and tender,which limited external rotation. CR MET was per-formed to reduce the hypertonicity in the internal ro-tators and allow more external rotation. In palpatingthe soft tissue of the second series of Level I strokes,very tight and tender pectoralis major and minor were

Clinical Example: Acutenoted. RI and CR MET were performed on both thesemuscles (METs #7 and #8). The third series of strokeswere then performed to unwind the muscles of the an-terior humerus. After unwinding the tissue, I returnedto the third stroke of the second series and placed mythumb on the tendon of the long head of the biceps. Ipalpated that the tendon was riding on the medial rimof the bicipital groove. Next, I mobilized the tendon inan M–L direction to center it in the groove. I per-formed the fourth series of strokes for the supraspina-tus. The tenoperiosteal junction was very tender . Iperformed CR MET for the supraspinatus (MET #9), tohelp reduce the inflammation and help increase thnutritional exchange. After the MET, the tissue wasmuch less tender . I then performed gentle STMstrokes on the supraspinatus. Next, I perfromed anA–P mobilization on the head of the humerus. Afterseveral oscillations, the head of the humerus had nor-mal passive glide. I ended the session with some softtissue therapy on the cervical spine. I had the clientperform active ROM after the session, and elevationwas 120�.

Plan: I recommended weekly visits for one month. CSreturned to our office in a week and stated that he wasfeeling significantly less pain and had increasedROM. Elevation was approximately 140 �. I repeatedthe treatment described above. There was much lesstension in all of the muscles. CS returned to my officone week later , symptom-free, with full ROM andnormal strength. I told him to call as needed for fur-ther treatments, and he was discharged from activecare.

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276 Chapter 6: The Shoulder | Techniques

Subjective: RM is a 53-year-old realtor who presentedto my office complaining of intense pain and limitemotion in the left shoulder . He reported that he wasplaying basketball with his son a couple of monthsprior to our visit and jammed his shoulder going forthe ball. He immediately felt intense pain at the gle-noid area. He went to an orthopedist, and X-rays andMRI were negative for fracture or frank tears of the ro-tator cuff. He was given anti-inflammatory medica-tion, but his condition did not improve. At the time ofour first visit, he described an intense pain at the toof the shoulder that was sharp with certain motions, adeep ache at night, and an inability to lift his armoverhead.

Objective: Examination revealed an elevation of theshoulder on the left side. Active ROM was limited to90� in flexion, 6 � in abduction, and only being able toreach to his back pocket when attempting internal ro-tation, which elicited pain at the superior glenoid.Passive motion was only slightly better. Isometric test-ing revealed pain at the superior glenoid with theempty-can test, with only very light pressure. His ex-ternal rotators were very weak with a light challenge.His pectoralis minor was very tight and tender , andthe head of the humerus was fixated anteriorl .

Assessment: Joint and muscle inflammation, especially the supraspinatus, and a fixation of the glenohumeral joint.

Treatment: My first treatment goal was to reduce thpain and swelling. I had the patient lie on his back,and I performed METs #6, #8, and #9 for the pectoralisminor and major and gentle CR MET for thesupraspinatus. After the series of METs, I passively os-cillated the arm in very small arcs of internal-externalrotation to induce relaxation and disperse the fluidin the joint. I next performed MET #3 to reduce thehypertonicity of the internal rotators. The muscles ofthe anterior chest began to relax and allow greater mo-tion in the arm. I performed the first three series oLevel I strokes to unwind the soft tissue of the anterior

Clinical Example: Chronicshoulder, concentrating on both the pectoralis minorand the supraspinatus. Because he had such limitedmotion, the circumduction mobilization of the gleno-humeral joint (MET #2 of the third series of strokes)was performed very slowly and in very small arcs inthe beginning. As he became comfortable with themovement and his muscles began to relax, I pressedthe head of the humerus more firmly into the joint anperformed larger arcs of motion. I ended the sessionwith an A–P mobilization at the head of the humerus.I had him test the ROM at the end of the session, andhe was able to elevate the arm to 120 � without pain. Ishowed him simple stretching exercises and onestrengthening exercise for the external rotators.

Plan: I recommended a series of weekly visits for onemonth. I repeated the same basic treatment describedabove on the second visit. His pain level was reducedso significantly that I was able to begin to stretch thsoft tissue of the anterior chest and shoulder and in-struct him in exercises to strengthen the external rota-tors. On the third visit, I began the treatment with himsitting and performed PIR MET s to lengthen thesupraspinatus and increase internal rotation (METs#10, and #11). Then I had him lie supine and usedMETs to release and lengthen the pectoralis minor andmajor (METs #6, #7, and #8), and to increase elevation(MET #14). Because the tissue was much less tenderto the touch, I penetrated deeper into the tissue withthe STM. I used shorter, more brisk transverse frictionstrokes on the supraspinatus and anterior joint cap-sule (Level I STM, fourth series, and Level II, secondseries). At the fourth visit, he reported that he wascompletely pain-free, that he was sleeping well, andthat his ROM was dramatically better . On examina-tion, his elevation was 160� without pain, and internalrotation was to the T10 vertebrae. I recommended fouradditional treatments. W e performed the same basicprotocol described above. At the time of his last visit,he had only slight limitation in his ROM comparedwith the other side, and isometric testing was strongand pain free. He continued with his strengtheningand stretching exercises.

spine, including the tight upper trapezius, stern-ocleidomastoid, suboccipitals, and levator scapula.With chronic conditions, we use stronger pressureon the soft tissue and more vigorous mobilizationson the joints. In the Level II sequence, we add

deeper soft tissue work as well as work on attach-ment points, using transverse friction strokes if wefind fibrosis (thickening). As was mentioned in t“Acute” section above, intersperse your soft tissuework with METs.

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Chapter 6: The Shoulder | Techniques 277

Table 6-4 lists some essentials of treatment.

LEVEL I: SHOULDER

1. Release of Serratus Anterior and Subscapularis

■ Anatomy: Subscapularis (Fig. 6-34), serratus ante-rior, long thoracic nerve, and median and ulnarnerves (see Fig. 6-7).

■ Dysfunction: The typical position of dysfunction ofthe shoulder is a forward and internally rotated po-sition. The subscapularis is typically short andtight. It holds the humerus in an adducted, inter-nally rotated position. The serratus is typicallyweak in a head-forward, kyphotic posture. The longthoracic nerve lies over the serratus anterior , andthe subscapular nerve lies over the subscapularis.These nerves may be entrapped in the overlyingfascia.

Position■ Therapist position (TP): Standing, facing 45� head-

ward or facing the table.

■ Client position (CP): Supine, with arm abductedand externally rotated to its comfortable limit. Ifthis position is difficult or painful, keep the arm inthe scapular plane without external rotation. Asyou work toward more external rotation, place asupporting pillow under the client’s arm.

Strokes1. If the shoulder cannot reach 90 � of external rota-

tion, perform PIR MET to increase external rotation(see “Muscle Energy Technique” above).

2. With the client’ s arm abducted and externally ro-tated, use your fingertips to perform a series oshort, scooping strokes on the lateral rib cage to re-lease the serratus anterior and long thoracic nerve(Fig. 6-35). Perform the strokes both posteriorlyand toward the axilla. Cover the entire lateral ribcage. The supporting hand rests on the lower ribcage, gently compresses the rib cage, and movesslightly in the same direction with each stroke.

3. Using your superior hand to hold the client’s distalforearm, place the fingertips of your inferior hanon the anterior scapula, and perform short, scoop-ing strokes in a headward direction on the sub-scapularis as you rock the client’ s arm in a back-stroke-type motion (Fig. 6-36).

4. With the client’s arm in the abducted and exter-nally rotated position, place the thumb of your su-perior hand on the anterior surface of the scapula,and perform short, scooping, headward strokes torelease the subscapularis (Fig. 6-37). Grasp the

Essentials of Treatment

■ Rock the client’s body while performing the strokes.■ Shift your weight while performing the strokes.■ Perform the strokes rhythmically.■ Perform the strokes about 50 to 70 cycles per minute.■ Keep your hands and whole body relaxed.

Table 6-4

Deltoid

External oblique

Serratus anterior

Subscapularis

Latissimus dorsi

Figure 6-34. Serratus anterior and subscapularis. Figure 6-35. Fingertip release of the serratus anterior.

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entire scapula with your hand. Y our fingertips arunderneath, and your thumb is on the anterior sur-face. Gently squeeze with your hand as your thumbperforms the stroke.

2. Rolling Soft Tissue of AnteriorShoulder Superiorly

■ Anatomy: Pectoralis major and minor, rotator cuffmuscles, joint capsule, anterior and middle deltoid,coracobrachialis, and biceps (long and short head)(Fig. 6-38).

■ Dysfunction: With most dysfunctions, the pec-toralis major and minor and the anterior deltoidtend to roll into an anterior, inferior, medial torsionas the humerus is held in an adducted and inter-nally rotated position. This pattern is present withrounded-shoulder FHP; kyphotic thoracic spine;and anterior subluxations of the head of thehumerus. The pectoralis minor is typically tightand can entrap the neurovascular bundle that trav-els under it. The long head of the biceps may be-come misaligned and rest against the medial rim ofthe bicipital groove, which can lead to bicipital ten-dinitis.

Position■ TP: Standing

■ CP: Supine

Strokes1. Hold the client’s distal forearm with your superior

hand, and move his or her arm into small arcs ofexternal rotation as you perform 1-inch, scoopingstrokes with the fingertips of your other hand othe upper part of the pectoralis major and minorand the anterior deltoid (Fig. 6-39). Sink into thetissue until you take it into tension, and then scoopthe fibers headward in a rhythmic, oscillating fashion, coordinated with the movement of the arm.Change the angle of your strokes so that you areworking perpendicular to the line of the fibe .

2. To reset the entire segment into an externally ro-tated position from the dysfunctional internally ro-tated position, perform a backstroke-type circularmotion with the arm as you perform several addi-tional strokes in this area. The arm is adductedslightly as the backstroke begins and is abductedand externally rotated as it finishes

3. An alternative method to release both the superficial muscles and the deeper rotator cuff musclesand joint capsule, is to switch hands, and hold thedeltoid muscle with your superior hand such thatthe shaft of your thumb is in line with the shaft ofthe humerus (Fig. 6-40). Hold the client’s arm withyour inferior hand at 90 � abduction, then lift it offthe table slightly to bring the superficial tissue intslack. Perform a series of short, scooping strokes ina superior direction with your thumb as you rockthe client’s arm in small arcs of external rotation.Imagine rolling the tissue around the bone, un-winding it. Cover the entire area of the anterior andsuperior glenohumeral joint.

4. The technique described above may also be used tomobilize the long head of the biceps in the bicipitalgroove. Place your thumb on the medial side of thebicipital tendon, and mobilize the tendon medially

278 Chapter 6: The Shoulder | Techniques

Figure 6-36. Fingertip release of the subscapularis. The fingertips scoop headward as the arm is rocked into a backstrokemotion.

Figure 6-37. Thumb release of the subscapularis.

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to laterally as you rock the client’ s arm into exter-nal rotation. You might need to repeat this manytimes.

3. Unwinding the Soft Tissue andMobilization of the Glenohumeral Joint

■ Anatomy: Superficially—the pectoralis majo , ante-rior and middle deltoid, coracobrachialis, and bi-ceps brachii (Fig. 6-41); deeply—the joint capsule(see Fig. 6-4).

■ Dysfunction: The position of dysfunction is for thehumerus to sustain an internally rotated position.

The soft tissue winds into an abnormal internal tor-sion, decreasing the normal lubricant between thefascicles. Eventually, the glenohumeral joint maydevelop adhesions and begin to dry out, losing fullROM, which leads to calcific deposits

Position■ TP: Standing. Place the client’s arm under your ax-

illa. If the client’s shoulder is stiff, it may be morecomfortable in your inferior axilla. Otherwise, thearm is better placed on your superior side. If thearm is too heavy, place a pillow under the elbow.

■ CP: Supine

Chapter 6: The Shoulder | Techniques 279

Sternocleidomastoid muscle

Pectoralis minor

Serratus anterior

External abdominal oblique

Pectoralis major:

Serratus anterior

Deltoid

Trapezius

Sternocostal head Abdominal head

Figure 6-38. Muscles of the anterior chest and shoulder.

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Strokes1. Hold the proximal humerus with both hands, and

compress it slightly into the glenoid cavity to bringthe superficial tissues into slack (Fig. 6-42). In thiseries of strokes, the entire surface of both hands isused to unwind the soft tissue of the anterior andmiddle humerus. Externally rotate the tissue aroundthe bone. The thumbs of both hands lie next to eachother and also perform short, scooping strokes.Cover the anterior and middle portions of the prox-imal humerus down to the deltoid tuberosity.

2. Mobilize the shoulder . Perform circumduction tohelp normalize the movement characteristics of theglenohumeral joint and to rehydrate the joint bystimulating the synovial microvilli. Hold the armas described in the first stroke. Move the entir

humerus in a superior direction and then posteri-orly, inferiorly , anteriorly , and superiorly again.Repeat this motion either in slow, gentle, small-amplitude circles for acute conditions or in morevigorous, brisk, larger -amplitude circles forchronic conditions. If there is a loss of normal ex-ternal rotation, you may externally rotate thehumerus as you move it superiorly . This stroke isan assessment and a treatment. Perform this move-ment gently and in small circles if the client is hy-permobile or unstable.

280 Chapter 6: The Shoulder | Techniques

Figure 6-39. Fingertip release of the anterior shouldermuscles. This stroke releases the torsion and unwinds the tis-sue in a superior and posterior direction.

Figure 6-40. Scooping strokes with the thumb for the anteriorshoulder muscles.

Deltoid

External oblique

Serratus anterior

Subscapularis

Latissimus dorsi

Figure 6-41. Anterior shoulder muscles.

Figure 6-42. Hands used to unwind the torsion that developsin the soft tissue of the glenohumeral joint.

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4. Release of the Supraspinatus

■ Anatomy: Supraspinatus and coracoacromial liga-ment (Fig. 6-43).

■ Dysfunction: The supraspinatus is the only muscleof the rotator cuff that travels through a tunnel andis therefore susceptible to loss of oxygen when in-flamed; the swelling compresses the tissue and caleave a scar on the tendon. The tendon can impingeunder the acromion when the arm is abducted orduring flexion, especially when combined with in-ternal rotation. The coracohumeral ligament blendswith the superior joint capsule and the supraspina-tus tendon.

Position■ TP: Standing

■ CP: Supine

Strokes1. Release the supraspinatus muscle belly and my-

otendinous junction using single-thumb or fingertips technique. Place the client’ s flexed elbow ohis or her chest so that the arm rests across thechest. With your inferior hand, grasp just above theclient’s elbow, and gently impulse the arm head-ward and posteriorly in the scapular plane. At thesame time, the thumb or fingertips of your superiohand perform 1-inch, scooping strokes in the A–Pdirection in the supraspinous fossa (Fig. 6-44).Reposition the thumb slightly, draw the arm back,and repeat a series of strokes covering the entiresupraspinous fossa. If you find thick, fibrotic tisue, stroke back and forth in the A–P direction.

2. To locate the supraspinatus attachment on thegreater tuberosity, first have your client rest thhand on the ASIS to internally rotate the humerus.The tendon is located just under the anterolateralaspect of the acromion on the anterior -superiorportion of the greater tuberosity.

3. Using the thumb or fingertips of your superiohand, perform TFM strokes on the tenoperiostealjunction of the supraspinatus tendon (Fig. 6-45).The pressure of a TFM stroke is applied in both di-rections, transverse to the line of the fibe. Hold theclient’s distal forearm, and rock the arm with eachstroke. As the fingertips move forward, the armoves forward; as the fingertips move back, thearm moves back. This may also be performed as ashearing stroke, with the fingers and arm moving iopposite directions. Palpate for a thickened feel tothe tendon, as these strokes are used only asneeded. The tendon is usually tender . Perform ap-proximately six to ten strokes on the same spot,

Chapter 6: The Shoulder | Techniques 281

Clavicle

Coracoacromial ligament

Humerus

Rotator cuff

Scapular spine

Supraspinatus

Subscapularis

Figure 6-43. Superior view of the supraspinatus and the cora-coacromial ligament.

Figure 6-44. Thumb release of the belly and myotendinousjunction of the supraspinatus muscle.

Figure 6-45. Fingertips perform TFM at the tenoperiostealjunction of the supraspinatus. Oscillate the arm with eachstroke, which makes the treatment much more comfortable.

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and then move to another spot. Work for 3 to 4 min-utes per session on the tendon. It often takes six toeight sessions to dissolve the fibrosis. To exposemore of the tendon, horizontally adduct thehumerus across the client’s chest.

5. Release of the Infraspinatus, TeresMinor and Major, and Supraspinatus

■ Anatomy: Infraspinatus, supraspinatus, teres mi-nor and major, and suprascapular nerve (Fig. 6-46).

■ Dysfunction: These muscles tend to roll into an in-ferior torsion as the humeral head migrates superi-orly in dysfunction. The external rotators are usuallyweak, losing their normal function, which is to de-press the humerus during arm elevation. This infe-rior torsion is also created with slumping posture,kyphosis, and weak scapular stabilizers. The supras-capular nerve travels under the infraspinatus on topof the scapula. A site of potential injury to this nerveis under the lateral aspect of the spine of the scapula.

Position■ TP: Standing

■ CP: Side-lying, with elbows flexed, arms and handresting on each other . Place a pillow between theclient’s arms to help support and stabilize the arms.

StrokesThere are three lines of strokes: on the superior aspectof the scapula inferior to the spine of the scapula, inthe middle of the scapula, and on the inferior aspectof the scapula. These strokes should be across thebone, not into the bone.

1. To release the hypertonicity or to recruit an inhib-ited muscle on the posterior scapula, perform CRand RI MET with the client in the side-lying posi-tion (see Fig. 6-25, p. 270).

2. Using a double-thumb technique, begin at the su-perior portion of the scapula inferior to the spine ofthe scapula, and perform 1-inch, scooping strokesin a superior direction (Fig. 6-47). Begin the seriesof strokes at the vertebral border , and continue tothe posterior humerus.

Note: The suprascapular nerve travels under the in-fraspinatus and lies on top of the scapula. It is mostexposed inferior to the most lateral aspect of the spineof the scapula. A sharp radiating pain is elicited if thenerve is compressed. It can be released with gentlescooping strokes.

3. Begin a second and third line of strokes on the mid-dle and inferior aspects of the scapula, continuingto the posterior humerus.

282 Chapter 6: The Shoulder | Techniques

(Teres major)

Supraspinatus

Infraspinatus

Teres minor

Figure 6-46. Teres minor, infraspinatus, andsupraspinatus.

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4. As an alternative method to release the supraspina-tus, face 45 � headward. Tuck your arm under theclient’s arm, and place both hands on thesupraspinous fossa of the scapula (Fig. 6-48). Usingyour fingertips, perform back and forth strokes ian A–P direction on the supraspinatus muscle.Move your arms and the client’ s arm with eachstroke. Cover the entire area of the supraspinousfossa.

6. Prone Release of the Posterior RotatorCuff and Posterior Deltoid

■ Anatomy: Supraspinatus, infraspinatus, teres mi-nor, and posterior deltoid (Fig. 6-49).

■ Dysfunction: As has been mentioned, the musclesof the posterior shoulder tend to roll into aninferior torsion and need to be moved superiorly .

With a loss of the normal thoracic curve and a re-tracted scapula, the posterior cuff muscles shorten.

Position■ TP: Standing

■ CP: Prone

Strokes1. Place both thumbs on the posterior aspect of the

proximal humerus, and perform a series of gentle,scooping strokes, rolling the soft tissue fibers supe-riorly (Fig. 6-50). The intention is to unwind the

Chapter 6: The Shoulder | Techniques 283

Figure 6-47. Double-thumb technique to release theinfraspinatus and the teres minor.

Figure 6-48. Fingertip release of the belly and myotendinousjunction of the supraspinatus.

Supraspinatusmuscle

Infraspinatusmuscle

Deltoid Teresminor

Teresmajor

Figure 6-49. Posterior rotator cuff muscles, the posterior del-toid, and teres major.

Figure 6-50. Release of the posterior shoulder muscles. Bothhands wrap around the soft tissue of the posterior shoulderand roll the tissue in a headward direction.

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tissue around the bone. This releases the adhesionsthat develop from sustained contraction and infe-rior torsion. Grasp the entire arm with your hands,and move all the soft tissue that wraps around thehumerus with each stroke. Release the pressure atthe end of each stroke, place your hands in aslightly new location, and perform another stroke.Cover the entire posterior humerus.

LEVEL II: SHOULDER

1. Release of the Clavicle and theCoracoid Process Attachments

■ Anatomy: Pectoralis major and minor, anterior del-toid, subclavius, and coracobrachialis; and cora-coacromial, coracohumeral, coracoclavicular, andAC ligaments (Figs. 6-51A and 6-51B).

■ Dysfunction: Thoracic outlet syndrome can becaused by a thickening in the fascia and a shorten-ing of the musculature in the areas above and belowthe clavicle. Causes include rounded-shoulder FHPor previous injury, such as a fall on an outstretchedhand. The ligaments attaching to the coracoidprocess are often fibrotic because of FH , roundedshoulders, or impingement syndrome.

Position■ TP: Standing, facing the direction of your stroke

■ CP: Supine

Strokes1. Press the base of your superior hand under the

clavicle as you wrap your fingertips over the ster-num or clavicle (Fig. 6-52). Perform a series ofshort, back-and-forth strokes in the medial to lat-eral plane. Rock your body with your strokes. Thistechnique cleans the superior and posterior por-tions of the medial clavicle and sternum for thesternocleidomastoid and superficial and deep cervical and pectoral fascia. Place your other hand onthe lower rib cage. Press posteriorly and superiorlyon the lower rib cage with your strokes to givesome slack to the area being worked. Alternatively,

284 Chapter 6: The Shoulder | Techniques

Biceps

Coracobrachialis

Tendon of shorthead of biceps

Tendon of longhead of biceps

Coracoid process

Coracoacromial ligament

Coracoclavicular ligament(trapezoid)

Coracoclavicular ligament (conoid)PectoralisminorAcromioclavicular ligament

Coracobrachialis and biceps muscle(short head)

Coracobrachialis

A B

Deltoid

TrapeziusSubclavius

Pectoralismajor

Subscapularis muscle

Latissimus dorsi

Teres major

Brachialis muscleBrachioradialis muscle

Deltoid

Pectoralis major

Supraspinatusmuscle

Pectoralis minor

Figure 6-51. A. Attachments to the coracoid process. B. Attachments to the anterior shouldercomplex.

Figure 6-52. Fingertip release of the clavicle attachments.

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you can hold the client’s distal forearm and movethe arm into small arcs of abduction and adductionwith your strokes to help mobilize the clavicle.

2. Perform short, back-and-forth strokes in the medial-to-lateral plane with your thumb on the anteriorand inferior clavicle. This technique releases theclavicular portion of the pectoralis major, the ante-rior deltoid, and the subclavius on the inferior por-tion of the clavicle.

3. Using the thumb of your superior hand, performback-and-forth strokes on the inferior border of thecoracoid process to relea se the pectoral is minor,coracobrachialis, and short head of the biceps (Fig.6-53). Hold the client’s distal forearm to abduct thearm, and elevate it slightly to bring the tissue intoslack.

4. Holding the client’s arm as in the previous stroke,perform transverse strokes with the thumb orf ngertips beginning on the superior portion of thecoracoid process for the coracoclavicular andcoracoacromial ligaments and continuing yourstrokes to the clavicle and acromion. Move yourfingertips to the AC joint and perform back-andforth strokes in the A–P plane for the AC liga-ment. Rock the client’ s arm in the direction ofyour stroke, and coordinate the movement of thearm with the stroke.

2. Release of the Joint Capsule andMuscle Attachments on the AnteriorHumerus

■ Anatomy: Subscapularis, long head of the biceps inthe bicipital groove, pectoralis major , teres major ,latissimus dorsi, transverse humeral ligament, cora-cohumeral ligament, and joint capsule (Fig. 6-54).

■ Dysfunction: The m uscles a ttaching t o t he a nte-rior humerus are usually short and tight, pulling

the arm into an adducted and internally rotatedposition. The tenoperiosteal and myotendinousjunctions become fibrotic from the cumulativestress of poor posture, previous inflammationcaused by overuse, or injury. The long head of thebiceps is irritated with an internally rotatedhumerus because it forces the tendon to rubagainst the medial aspect of the groove. The ante-rior joint capsule is often thick and fibrotic afteinjury or cumulative stress and may develop ad-hesive capsulitis.

Position■ TP: Standing

■ CP: Supine

Strokes1. Facing 45� headward, use a single-thumb technique

to release the transverse humeral ligament by mov-ing in the inferior -to-superior (I–S) plane on bothsides of the bicipital groove (Fig. 6-55). Rock theclient’s arm as you rock your entire body with eachstroke. Let your hand and thumb stay relaxed, andlet the thumb move with the arm motion. Next, re-lease any adhesions to the bicipital tendon by keep-ing your thumb on the bicipital tendon and movingthe client’s arm into small arcs of medial and lateralrotation, letting the tendon roll under your thumb.

2. With the client’s arm at his or her side and the el-bow flexed to 9 �, place your thumb or fingertips tthe most medial part of the lesser tuberosity . Youcan palpate the subscapularis by having your client

Chapter 6: The Shoulder | Techniques 285

Figure 6-53. Thumb release of the inferior border of the cora-coid process.

Pectoralis minor

Coracobrachialis and biceps muscle(short head)

Deltoid

Trapezius Subclavius

Pectoralismajor

Subscapularismuscle

Latissimus dorsi

Teres major

Brachialis muscleBrachioradialis

muscle

Deltoid

Pectoralismajor

Supraspinatusmuscle

Coracobrachialis

Figure 6-54. Attachments to the anterior shoulder complex.

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resist as you attempt to pull laterally on the distalforearm. Perform a series of back-and-forth strokesapproximately 30 � headward on the broad, tendi-nous attachment of the subscapularis. T o exposethe tendon more fully, move the arm into more ex-ternal rotation.

3. From the lesser tuberosity, slide your thumb distallyalong the humerus to find the attachments of the teremajor, latissimus, and coracobrachialis. Lift the armoff the table slightly to bring the tissue into slack. Per-form back-and-forth strokes in the I–S plane on themedial side of the humerus to release these muscles.

In this technique, the strokes are along the bone andnot into the bone. W ith each stroke, rock the entirearm in the direction of your stroke.

4. Using single-thumb technique, release the attach-ment of the pectoralis major on the lateral side ofthe bicipital tendon with short back-and-forthstrokes in the I–S plane.

3. Release of the Attachments of theRotator Cuff, Posterior Joint Capsule,Long Head of the Triceps, and theRadial Nerve

■ Anatomy: Attachments of the posterior rotator cuff,posterior joint capsule, triceps, and radial nerve(Figs. 6-56A and 6-56B).

■ Dysfunction: With an irritation or inflammation ofthe infraspinatus or teres minor, the tenoperiosteal at-tachment points thicken and become fibrotic. Athese muscles interweave with the posterior joint cap-sule, the capsule also thickens. Thickening of the pos-terior joint capsule draws the head of the humerus an-teriorly and superiorly, contributing to impingementsyndrome and limiting medial rotation.

Position■ TP: Standing

■ CP: Prone, with forearm over edge of table, in 90� ofabduction

286 Chapter 6: The Shoulder | Techniques

Figure 6-55. Release of the muscle attachments to the anteriorhumerus.

Supraspinatus

Teres minor

Radial nerve

Triceps: Long head Lateral head

Medial head

Teres major

Infraspinatus

Triceps (lateral head)

Triceps (medial head)

Teresmajor

A B

Teres minor

Infraspinatus

Brachialis

Rhomboid major

Supraspinatus

Rhomboid minor

Levator scapula

Sternohyoid

Sternocleidomastoid SubclaviusPectoralis major

Trapezius

Deltoid

Supraspinatus

Deltoid

Brachioradialis

Figure 6-56. A. Posterior rotator cuff muscles, the triceps, and radial nerve. B. Muscle attachments tothe posterior shoulder complex.

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Strokes1. Place both thumbs next to each other, and wrap

your hands around the proximal portion of thehumerus (Fig. 6-57). Use the thumbs to penetratethrough the muscle to perform short, back-and-forth strokes transverse to the shaft of the humerusto release the attachments of the infraspinatus,teres minor, and joint capsule on the posterior gle-noid fossa and proximal humerus. For a hypermo-bile shoulder, it is important to stabilize the ante-rior humerus with your fingertips and not allowexcessive forward translation of the head of thehumerus.

2. To palpate the attachment of the long head of thetriceps at the infraglenoid tubercle of the scapula,place the fingertips of one hand on the inferior aspect of the glenoid fossa, and have the client resistas you attempt to press his or her elbow into flexion. U sing a d ouble-thumb t echnique, p erform aseries of back-and-forth, transverse strokes on theattachment site.

3. Release the radial nerve, triceps, posterior deltoid,and the posterior brachialis attachments on theposterior humerus. Use the same double-thumbtechnique described in the first stroke (see Fig. 6-56)Beginning at the proximal humerus, perform a se-ries of short, scooping strokes transverse to theshaft of the humerus. T o release the posterior del-toid with CR MET, have your client lift his or herarm slightly off the table and resist as you press thearm lightly toward the table.

4. Repositioning of the Rotator CuffMuscles and Deltoid in the Seated Position

■ Anatomy: Deltoid, supraspinatus, infraspinatus,teres minor , and subscapularis (Figs. 6-58 A and 6-58B).

■ Dysfunction: The most common dysfunction of theglenohumeral joint is for the humeral head to sithigh in the glenoid fossa. The rotator cuff musclestend to part at the top of the joint and roll inferiorlyas the humeral head is held in this sustained supe-rior position. The technique is performed in thesitting position with the arm at 90 � abduction, asthis is a position of function for eating, reaching,and so on.

Position■ TP: Standing, facing the table at 45� angle. For treat-

ment, place your front foot on the table. If you havea tall client, have the client sit in a chair.

■ CP: Sitting on the table or a chair, a few inches fromthe edge

StrokesThese strokes often follow the passive circumductionassessment (p. 264). Y our assessment findings helyou to determine which of the following strokes to use.

1. Place your foot on the edge of the table or chair ,and rest the client’s forearm on your thigh, with thehumerus in the scapular plane. To help reestablishnormal function and position, perform CR METwith special attention to areas of restriction.a. Abduction—Lift the client’s arm off your thigh,

and have the client resist as you press down onthe elbow.

b. Adduction—Tuck your fingers under the clientselbow, and have the client resist as you attemptto lift the arm off your leg.

c. Internal rotation—Tuck your hand under theclient’s distal forearm. Have the client resist asyou attempt to lift the arm.

d. External rotation—First, lift the wrist a fewinches off your leg. Have the client resist as youattempt to press down on the distal forearm(Fig. 6-59).

e. Horizontal flexion or extension—Have the clienresist as you pull the humerus posteriorly orpress anteriorly into the client’s elbow.

2. After each MET is performed, use either your fingertips on the anterior muscles or your thumbs onthe posterior muscles to scoop the soft tissue supe-riorly and toward the midline of the superiorglenohumeral joint (see Fig. 6-59B). The intentionis to lift the soft tissue toward the highest point ofthe shoulder. You may perform more brisk, back-and-forth strokes if you find areas of fibrosi

3. Stand next to your client, and perform passive cir-cumduction again. The movement should besmooth and pain free. If not, perform this series ofMETs and STMs again.

Chapter 6: The Shoulder | Techniques 287

Figure 6-57. Double-thumb release of the rotator cuff muscles,posterior joint capsule, the triceps, and the radial nerve.

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5. Treatment of the Subdeltoid Bursa

■ Anatomy: The subdeltoid bursa is located deep un-der the deltoid and inferior to the acromial arch. Itacts as a lubricant during shoulder motion, particu-larly abduction, and secretes synovium into thejoint space (Fig. 6-60).

■ Dysfunction: Bursae swell when they are inflamedwhether as a result of acute trauma or of cumulativestress, such as repetitive overhead activities. W ithan acute bursitis, the client experiences severe painin the shoulder region and loses all ability to ele-vate t he a rm. C hronic s houlder d ysfunction m ay

lead to a drying out of the bursa, eventually leadingto adhesions, and an inferior migration of the bursa.

Position■ TP: Standing

■ CP: Sitting

StrokesApply some oil or lotion to the client’ s upper arm sothat you can easily slide on the skin. Hold the client’sdistal forearm with one hand, and pull the arm into agentle traction (Fig. 6-61). Place the shaft of yourthumb a few inches distal to the acromion on the

288 Chapter 6: The Shoulder | Techniques

Sternocleidomastoidmuscle

Pectoralisminor

Serratusanterior

Externalabdominal

oblique

Pectoralis major:

Serratusanterior

Deltoid

Trapezius

Sternocostalhead

Abdominalhead

A

B

Supraspinatusmuscle

Infraspinatusmuscle

Deltoid Teresminor

Teresmajor

Figure 6-58. A. Muscles of the anterior shoulder complex. B. Posterior deltoid, supraspinatus, infra-spinatus, and teres minor, and teres major.

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Chapter 6: The Shoulder | Techniques 289

A

B

Figure 6-59. A. Sitting MET and OM. PerformMETs to release hypertonicity in the muscles ofthe glenohumeral joint. B. Next, use fingertips othumbs to reposition the soft tissue toward themost superior part of the joint.

Clavicle

Coracoclavicular ligament (trapezoid)

Subdeltoid bursa

Subscapular bursa

Coracoclavicular ligament (conoid)

Figure 6-60. Subdeltoid (subacromial) bursa.Figure 6-61. Using the web space of the hand, perform slow,gentle strokes on the subdeltoid bursa.

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lateral arm. Using the fleshy portion of the entire shafof your thumb and webspace, perform a slow , gentle,continuous stroke toward the acromion. When youreach the acromion, traction the arm and lift it slightlyinto abduction as you use your thumb to gently pressinto the arm. Coordinate the movements of the armand the stroke so that the arm is lifting as the thumb ispumping the excess fluid from the bursa under theacromion. Repeat this pumping a few times. Then be-gin the stroke again, placing your hand a few inchesbelow the acromion, and perform another long, con-tinuous stroke. In chronic conditions in which thearea has a dry and gristly feel, you may use deeperpressure to rehydrate the bursa. For an acute, swollenbursa, begin your stroke close to the acromion, mov-ing superficiall . Your next stroke begins a little moredistally, milking the excess fluid headward a little biat a time. Repeat the stroke about ten times.

CAUTION: In acute bursitis, use gentlepressure, and do not repeat this strokemore than ten times.

■ Study Guide

Level I1. List the four muscles of the rotator cuff. Describe their

origins, insertions, and actions.2. List which muscles are tight and which are weak in the

shoulder.3. Describe the MET for the pectoralis minor and the

supraspinatus.4. Describe the common positional dysfunction of the an-

terior deltoid. Describe the direction of the massagestrokes to correct it.

5. Describe the signs and symptoms of a supraspinatus, in-fraspinatus, and subscapularis tendinitis.

6. Describe the stroke direction for the teres minor and in-fraspinatus.

7. Describe the MET for the internal and the external rota-tors.

8. List the scapular stabilizing muscles.9. List some common causes of thoracic outlet syndrome.

10. When treating tightness or weakness imbalances, whichmuscles must be treated first

Level II1. Describe how to differentiate rotator cuff symptoms

from a nerve root irritation in the neck.2. Describe the signs and symptoms of bicipital tendinitis,

subacromial bursitis, impingement syndrome, and ad-hesive capsulitis.

3. Describe the empty-can test and Speed’ s test, and de-scribe the significance of a positive test

4. List the muscles and ligaments that attach to the cora-coid process.

5. Describe the scapular stabilization test.6. List the muscle attachments to the anterior humerus

and their relation to the bicipital groove.7. Describe what is indicated when the shoulder hikes up-

ward in active abduction.8. Describe the MET for frozen shoulder.9. Describe the anatomical boundaries of the coracoacro-

mial arch and the contents within the arch.10. Describe the consequences of weak rotator cuff muscles.

■ References

1. Boissonnault W, Janos S. Dysfunction, evaluation, andtreatment of the shoulder . In Donatelli R, W ooden M(eds): Orthopedic Physical Therapy . New Y ork:Churchill Livingstone, 1994, pp 169–201.

2. Porterfield J, DeRosa C. Mechanical Shoulder DisordersSt. Louis: Saunders, 2004.

3. Garrick J, Webb D. Sports Injuries: Diagnosis and Man-agement, 2nd ed. Philadelphia: WB Saunders, 1999.

4. Cailliet R. Shoulder Pain, 3rd ed. Philadelphia: F ADavis, 1991.

5. Levangie P, Norkin C. Joint Structure and Function, 3rded. Philadelphia: FA Davis, 2001.

6. Hertling D, Kessler R. Shoulder and Shoulder Girdle.Management of Common Musculoskeletal Disorders,4th ed. Baltimore: Lippincott Williams & Wilkins, 2006,pp 281–355.

7. Hammer W. The Shoulder . In Hammer W (ed): Func-tional Soft Tissue Examination and Treatment by Man-ual Methods. Gaithersburg, MD: Aspen, 1999, pp36–135.

8. Corrigan B, Maitland GD. Practical Orthopaedic Medi-cine. London: Butterworths, 1983.

9. Kendall F, McCreary E, Provance P , Rodgers, M, Ro-mani, W. Muscles: Testing and Function, 5th ed. Balti-more: Lippincott Williams & Wilkins, 2005.

10. Janda V. Evaluation of muscular imbalance. In Lieben-son C. Rehabilitation of the Spine, 2nd ed. Baltimore:Lippincott Williams & Wilkins, 2007, pp 203–225.

11. Halbach J, Tank R. The shoulder. In Gould J (ed): Ortho-pedic and Sports Physical Therapy . St. Louis: CVMosby, 1990, pp 483–521.

12. Greenman PE. Principles of Manual Medicine, 2nd ed.Baltimore: Williams & Wilkins, 1996.

13. Faber K, Singleton S, Hawkins R. Rotator cuff disease:Diagnosing a common cause of shoulder pain. J Muscu-loskeletal Med 1998;15:15–25.

14. Neer OS. Impingement lesions. Clin Orthop 1983;173:70–77.

15. Wilk K. The Shoulder . In Malone T , McPoil T , Nitz A(eds): Orthopedic and Sports Physical Therapy, 3rd ed.St. Louis: Mosby, 1997, pp 410–458.

16. Brukner P, Khan K, Kibler WB, Murrel G. Shoulder pain.Clinical Sports Medicine, 3rd ed. Sydney: McGraw-Hill,2006, pp 243–288.

17. Oatis CA. Kinesiology: The Mechanics and Pathome-chanics of Human Movement. Philadelphia: LippincottWilliams & Wilkins, 2004.

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■ Suggested Readings

Chaitow L. Muscle Energy T echniques, 3rd ed. New Y ork:Churchill Livingstone, 2006.

Corrigan B, Maitland GD. Practical Orthopaedic Medicine.London: Butterworths, 1983.

Cyriax J, Cyriax P. Illustrated Manual of Orthopedic Medi-cine. London: Butterworths, 1983.

Garrick J, Webb D. Sports Injuries, 2nd ed. Philadelphia: WBSaunders, 1999.

Greenman PE. Principles of Manual Medicine, 2nd ed.Baltimore: Williams & Wilkins, 1996.

Hoppenfeld S. Physical Examination of the Spine and Ex-tremities. New York: Appleton-Century-Crofts, 1976.

Kendall F, McCreary E, Provance P , M Rogers, W Romani.Muscles: T esting and Function, 5th ed. Baltimore:Williams & Wilkins, 2005.

Magee D. Orthopedic Physical Assessment, 3rd ed.Philadelphia: WB Saunders, 1997.

Levangie P, Norkin C. Joint Structure and Function, 3nd ed.Philadelphia: FA Davis, 2001.

Platzer W. Locomotor System, vol. 1, 5th ed. New Y ork:Thieme Medical, 2004.

Reid DC. Sports Injury and Assessment. New Y ork:Churchill Livingstone, 1992.

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