Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

436 CLIN ICAL A PPLICATION OF N EU RO M USCU LAR TECH N I QU ES : TH E UPPER BODY scapular border between the superior angle and the and the site of frequent self-treatment. The anterior surface medial end (root) of the spine of the scapula of the upper angle, while often the source of deep ache, is Innervation: C3-4 spinal nerves and the dorsal scapular usually neglected during treatment unless special accessing nerve (C5) positions are used. These buried fibers may be touched Muscle type: Postural (type I), shortens when stressed directly to address attachment trigger points and for relief Function: Elevation of the scapula, resists downward of the often accompanying enthesitis. movement of the scapula when the arm or shoulder is weighted, rotates the scapula inferior angle medially to ASS ESS M E NT FO R S H O RTN ESS O F LEVATO R face the glenoid fossa downward, assists in rotation of the neck to the same side, bilaterally acts to assist exten­ SCAPU LA sion of the neck and perhaps lateral flexion to the same side (Warfel 1985) • The patient lies supine with the arm of the side to be Synergists: Elevation/medial rotation ofthe scapula: rhomboids tested extended at the elbow, forearm supinated and Neck stabilization: splenius cervicis, scalenus medius with the hand and lower arm tucked under the buttocks Antagonists: To elevation: serratus anterior, lower trapezius, to help restrain movement of the shoulder/scapula. latissimus dorsi To rotation of scapula: serratus anterior, upper and lower • The practitioner's contralateral arm is passed across and trapezius under the neck to cup the shoulder of the side to be tested To neck extension : longus colli, longus capitis, rectus capi­ with the forearm supporting the neck (see p. 421, Fig. tis anterior, scalene muscles (Levangie & Norkin 2001) 13.11). I n d i cations for treatment • The practitioner's other hand supports the head. • Using the supporting forearm, the neck is lifted into full • Neck stiffness or loss of range of cervical rotation • Torticollis pain-free flexion (aided by the other hand) and is turned • Postural distortions including high shoulder and tilted fully toward contralateral flexion and rotation (away from the side to be treated). head • With the shoulder held caudad and the head/neck in the position described, at its resistance barrier there is a Special notes stretch on levator from both ends and if dysfunction exists and /or it is short, discomfort will be reported at The levator scapula usually spirals as it descends the neck the attachment on the upper medial border of the scapula to attach to the upper angle of the scapula. It is known to and /or pain reported near the spinous process of C2. split into two layers, one attaching to the posterior aspect of • The hand on the shoulder should now gently 'spring' it the upper angle while the other merges its fibers anteriorly caudally. onto the scapula and the fascial sheath of serratus anterior • If levator is short there will be a harsh, wooden feel to (Gray's Anatomy 1995, Simons et al 1 999). Between the two this action. If it is normal there will be a soft feel to the layers of the proximal attachment, a bursa is often found springing. and may be the site of considerable tenderness for this region. Other variations include accessory attachments to the mas­ � N MT FO R L EVAT O R SCAPU LA toid process, occipital bone, 1st or 2nd rib, scaleni, trapezius and serratus muscles (Gray's Anatomy 2005). The patient is prone with the arm lying on the table or hang­ ing off the side. The practitioner stands at the level of the The transverse process a ttachments are joined by numer­ shoulder on the side to be treated. ous other tissues attaching nearby, including scalene medius, splenius cervicis and intertransversarii, which may The skin is lightly lubricated superficial to the portion of be addressed at the same time with lateral (unidirectional) trapezius tha t lies directly over the levator scapula. The transverse friction. Medial frictional strokes are avoided practitioner's thumbs glide 6-8 times from the upper angle since they could bruise the tissue against the underlying of the scapula to the transverse processes of C1-4. This glide transverse process. Caution must be exercised to avoid slip­ remains in the most lateral aspect of the lamina groove and page of the treating fingers, which could press the nerve on the posterior aspect of the transverse processes. roots against sharp foraminal gutters. Unidirectional (lateral) crossfiber strumming may be applied to the tendon attachments at the transverse processes using Levator scapula's attachment onto the posterior aspect of non-aggressive pressure due to the vascular structures the upper angle of the scapula is often a site of crepitus, a coursing through the vertebral foramen. Only laterally ori­ sensation felt by the palpating finger when gas or air in the ented strokes are used to avoid bruising the tissue against subcutaneous tissues is encountered. Whether accompa­ the transverse processes (see p. 290) and to avoid intrusion nied by calcific deposits, scar tissue or inflammation, the into the suboccipital triangle where the vertebral artery lies. 'crunchiness' or thickness felt by the finger is often tender The practitioner is repositioned to stand cephalad to the shoulder being treated. Gliding strokes are applied 6-8 times

1 3 Shoulder, a rm and hand 43 7 Figure 1 3.25 Levator sca p u l a's a ttachment at the u pper a n g l e of I the sca pula often has a fi brotic qua lity. Figure 1 3.27 Fingers w ra p com pletely a round tra pezius to touch directly on attachments at the a nterior a spect of the u pper a ngle of the scapula. Figure 1 3.26 Levator sca pula and surrounding muscles. moved aside. Palpating fingers or thumb may isolate leva­ tor scapula and perhaps posterior scalene which lies nearby. caudally superficial to the levator scapula, from the trans­ verse process attachments to the upper angle of the scapula. To address the anterior aspect of the upper angle of the Transverse friction may be applied to the upper angle attach­ scapula, the practitioner uses the most caudad hand to ment (through the trapezius) (Fig. 13.25) if fibrotic fibers are grasp the lower angle of the scapula and press it toward the encow1tered. Frictional tedmiques are avoided if tissue is patient's ear to elevate the upper angle of the scapula off the excessively tender or if inflammation is suspected. top of the shoulder and to secure this elevation while the tis­ sue is addressed. It may be necessary to place the patient's The trapezius may be displaced medially to allow direct hand behind the small of the back to access the scapula but palpation of the central portion of the belly of levator this may be too uncomfortable for a patient with a shoulder scapula (Fig. 13.26) where central trigger points develop. To injury. do so, the upper trapezius must be slackened by passive ele­ vation of the shoulder so its fibers will be loose enough to be The practitioner's cephalad hand fingers are wrapped completely around the anterior fibers of the trapezius and directly contact the anterior surface of the (elevated) upper angle of the scapula while the caudal hand continues to maintain the scapula's displaced position (Fig. 13.27). The fingers should wrap all the way around the anterior fibers of the trapezius since pressing through the trapezius will not achieve the same results and might irritate trigger points located in these fibers. Palpation of the anterior sur­ face of the upper angle will assess fiber a ttachments of the levator scapula, serratus anterior and possibly a small por­ tion of the subscapularis muscles. In some cases, angling the fingers medially and laterally may (rarely) contact the rhomboid minor and omohyoid, respectively. If tenderness is encountered, static pressure or gentle massage may be used to address these v ulnerable tissues.

438 CLI N I CA L A P PL I CATION OF N E U R O M U SCU LAR TECH N I QU ES : T H E U P P E R B O DY I. M ET TREAT M E N T O F L EVATO R S CA P U LA • With the shoulder held caudad and the head/neck in the , (FIG. 1 3.11) position described, the patient is asked to bring the shoul­ der into a light 'shrug' against the practitioner's hand and The position described below is applied, just short of the simultaneously to take the neck and head back toward the easily reached end of range of motion, and should involve table, against the resistance of the practitioner's forearm 20-30% of the patient's strength, not more. The duration of and hand. This is maintained for 7-10 seconds. each contraction should be 7-10 seconds. • On release of the effort, the neck is taken to i ts new resist­ • The patient lies supine with the arm of the side to be ance barrier in flexion, sidebending and rotation before tested relaxed at the side. the patient is asked to slide the hand toward the foot, through the resistance barrier and into stretch. The prac­ • The practitioner stands at the head of the table and titioner maintains this stretch for 20-30 seconds before passes the contralateral (to the side being treated) arm repeating the procedure. across and under the neck to cup the shoulder of the side to be treated while the forearm supports the neck. R H O M B O I D M I NOR AND MAJOR (FIG. 1 3.28) • The practitioner 's other hand supports the head at the Attachments: Minor: From the spinous processes of C7-T1 occiput. to the vertebral (medial) border of the scapula at the root of its spine • The forearm eases the neck intofull pain-free flexion (aided Major: From the spinous processes of T2-5 to the verte­ by the other hand) and the contact hand on the head bral (medial) border of the scapula guides i tfully toward lateral flexion and rotation away from the side to be treated. Trapezius ---� r-- Levator scapula Deltoid ---)f'IH,r/ �-- Rhomboideus minor Latissimus dorsi --h't-�-oeHfc Rhomboideus major __-_ ------- Supraspinatus ���g-r Infraspinatus ;.m�+--jTeres minor ��--rTeres major -nI-lI'--tr*\\':/l Serratus anterior -mtlt-- Triceps __-_ ----Anconeus ;!:'.».:-� Brachioradialis Extensor digitorum Abductor pollicis longus Extensor pollicis brevis Figure 1 3.28 Su perficial and second layer m uscles of the poste rior thorax, shoulder and el bow.

13 Shoulder, arm a nd hand 439 Innervation: Dorsal scapular nerve (C4-5) ASSESS M E f',IT F O R W EA K N ESS OF R H O M B O I D S Muscle type: Phasic (type II) weakens when stressed; how­ • The seated pa tient flexes the elbow to 90° while the prac­ ever, rhomboids can modify their fiber type to postural titioner cups it with one hand and the shoulder with the (type I) under conditions of prolonged misuse (Salmons other. 1985) Function: Adducts and eleva tes the scapula; rota tes the • The patient is asked to maintain the arm at the side as the scapula medially to make the glenoid fossa face down­ practitioner attempts to abduct it using firm, increasing ward; stabilizes the scapula during arm movements force. If the scapula moves away from the spine as the Synergists: Adduction of scapula: middle trapezius arm is forced into abduction, weakness of the rhomboids Elevation ofscapula: levator scapula, upper trapezius on that side can be assumed. Rotation ofscapula: levator scapula, la tissimus dorsi Antagonists: To adduction of scapula: serratus anterior and, • In other words, if the arm abducts easily but the scapula indirectly, pectoralis major remains relatively in place, the weakness demonstrated To elevation of scapula: serratus anterior, lower trapezius, does not involve the rhomboids. latissimus dorsi To rotation ofscapula: upper trapezius, rhomboidii ASSESSM ENT FOR SHORTN ESS O F RHO M BO I D S Ind ications for treatment • Direct palpation i s the only way in which shortness and fibrotic changes can be evaluated (as in the NMT proce­ • Itching or pain in the mid-thoracic region dures described below) . • Posture reflecting retracted (,shoulders b ack') scapular • A useful alternative strategy for increasing localization of position implies possible shortening involving overactiv­ the rhomboids from the trapezius fibers is to have the ity /hypertonicity of rhomboids. Such overactivity may prone patient place the dorsum of her hand onto the paradoxically actually be accompanied by relative weak­ lower back. ness of these muscles. This highlights the fact that hyper­ tonicity should not automatically be taken as a sign of • The practitioner places a fla t hand against the patient's strength. palm and requests the pa tient to push against his contact hand. This will cause rhomboids (and not trapezius) to Special notes stand out for easier palpation. When the middle trapezius and rhomboid muscles are • In this way localized fibrotic, contracted tissues can be placed in strained positions, such as in computer process­ identified and palpated for trigger point activity. ing, painting overhead or abducting and / or flexing the arm for prolonged periods of time, their trigger points may be '\" N MT F O R R H O M B O I DS activated or their fibers shortened to produce excess tension in the muscles. Since many trigger points refer into The patient is prone. The practitioner is standing at the level the area of rhomboid's scapular attachment, other muscles, of the rhomboids and can move as needed to support glid­ includ ing scalenes, serra tus anterior, infraspinatus and ing in all directions. latissimus dorsi, should be examined as well. Other mus­ cles a ttaching deep to the rhomboids, including iliocostalis The broad, flat design of the rhomboids and the fibers of thoracis (erector spinae), serratus posterior superior, multi­ trapezius makes them difficult to lift. Flat palpation and fidi and intercostals, may be the source of immediate as well gliding strips, which press against underlying muscles and as referred pain. Since each of the rhomboid's functions is rib cage, are best used here. The mid-thoracic area is lightly also performed by stronger muscles, testing for their spe­ lubricated and the thumbs are used to glide in all directions cific weakness is difficult (Smith et al 2004). A 'winged between the vertebral border of each scapula and the spin­ scapula' may be an indicator of weakness in either rhom­ ous processes. Superficial glides may soften the overlying boids and / or serratus anterior, as their shared function is to fibers of the trapezius and allow deeper penetration to the flatten the scapula to the torso while they antagonize each rhomboids. Still deeper pressure (through the trapezius and other in adduction (retraction) and abduction (protraction), rhomboids) will influence the serratus posterior superior respectively. and erector spinae attachments. The spinous processes on tender or inflamed tissues are avoided, especially when Deep to the fibers of rhomboid minor lies a hidden trig­ deeper pressure is used. ger point in serratus posterior superior (see pp. 441 and 568). The scapula must be translated laterally (protracted) The following steps may be performed more easily by to reach i t, a position more easily achieved when the patient the practitioner reaching across the body from the opposite is sidelying (see Fig. 1 3.30). side of the table. They may also be performed on the side on which the practitioner is standing or, i f necessary, with the patient in a sitting position. The patient's hand is placed behind the small of the back, if possible without pain in the shoulder, which will elevate the vertebral border of the scapula off the torso and allow

440 C L I N I CAL A PPLICAT I O N O F N E U RO M U SC U LA R T EC H N I Q U E S : T H E U P P E R B O DY AB Figure 1 3.29 ArtB: Applications to the anterior aspect of the medial sca pula a n d the posterior tho rax deep to the scapula. palpation on the scapula's medial edge, medial aspect of its and mildly tender areas in the serratus posterior superior anterior surface and portions of the rib cage deep to its as well as other mid-thoracic muscles. medial border. When the scapula's medial edge will not ele­ • The tissue deep to the medial edge of the scapula is more vate, treatment of serratus anterior and scapular mobiliza­ easily and effectively accessed with the patient placed in tion techniques may allow it to do so. Additionally, a sidelying position (Fig. 13.30). treatment of the infraspinatus and teres minor may be nec­ • The uppermost arm is draped across the pa tient's chest essary to allow the hand to reach behind the back as these and the scapula allowed to translate laterally on the torso. lateral rotators of the humerus, when taut, prevent the • As much as 2-3 inches (5-7.5 cm) of additional access humerus from medial rotation, a movement necessary in may be achieved and the previous steps may be easily order to reach behind the back. performed. • This position is especially convenient to use when the • Lightly lubricated gliding strokes are applied directly to patient is unable to reach behind the back. the vertebral border of the scapula where the rhomboids attach. It M ET F O R R H O M B O I D S • Additionally, the pads of the thumbs or fingertip (with • The patient is supine; the practitioner stands next to the nails cut very short) may be placed under the anterior rhomboids being assessed and faces the table. surface of the vertebral (medial) border of scapula with the pressure applied toward the scapula (Fig. 13.29A). • The patient flexes the elbow and places the arm into hor­ izontal adduction (across chest) as far as is comfortable • Friction or gliding strokes may be used to examine the and assists this position with the opposite hand holding attachments of the serratus anterior and possibly a small the elbow. portion of subscapularis where they attach along the entire anterior vertebral border. • It is important to ensure that the patient's torso does not roll as the arm is brought into adduction. • With the medial edge of the scapula still elevated, the thumbs are placed deep to the vertebral border and pres­ • The practitioner's caudad hand is placed on the dorsal sure is applied down onto the rib cage to address the rib surface of the patient's distal upper arm. attachments of the serratus posterior superior (Fig. 13.29B) and its important 'hidden' trigger point. • The practitioner's cephalad hand is slid under the patient's scapula so that the finger pads can gain a con­ • Static pressure release may be applied to trigger points tact on its medial border. and transverse friction may be applied to ischemic bands

1 3 Shoulder, a rm and hand 441 Lateral (acromial) fibers: abduction of humerus, flexion (later phases) Posterior (spinal) fibers: extension of humerus, stabiliza­ tion of the humeral head during abduction, lateral move­ ments when the humerus is abducted to 90° (horizontal abduction), prevents downward disloca tion when arm is weighted, la teral rotation (unconfirmed) and its most peripheral posterior fibers may adduct the arm Synergists: Abduction of humerus: supraspinatus, upper trapezius, rhomboids Flexion of humerus: supraspinatus, pectoralis major, biceps brachii, coracobrachialis Horizontal adduction ofhumerus: coracobrachialis, clavicu­ lar fibers of pectoralis major Extension of humerus: long head of triceps, latissimus dorsi, teres major Antagonists: To translation upward during abduction (by deltoid): subscapularis, infraspinatus, teres minor. Anterior and posterior fibers of deltoid are antagonistic to each other I n d i cations for treatment • Shoulder pain • Difficulty or pain with most movements of the arm • Pain after an impact trauma to the shoulder region Figure 1 3.30 Adequate scapula mobil ity a l l ows a 'hidden' trigger Specia I notes point for serratus posterior superior to be reached (see p. 439). The anterior and posterior portions of the deltoid have a • The patient is asked to draw the scapula lightly but fusiform arrangement which sacrifices strength while pro­ firmly toward the spine, pressing against the practi­ viding speed. However, the acromial' fibers are a multipen­ tioner's finger pads, without any effort coming from the nate design, which provides tremendous strength but not patient's arm. the speed of the other sections. While trigger points in the anterior and posterior fibers occur primarily in the middle • After 7-1 0 seconds the patient is asked to release the of those fibers, trigger points in the multipennate portion effort. appear to be sprinkled throughout the lateral upper arm due to their fiber arrangement. • The patient then adducts the arm further, assisted by the practitioner applying adduction pressure to the flexed Numerous muscles and a ttachments of muscles underlie arm, while also drawing the scapula away from the spine the deltoid. A portion of infraspinatus may be reached with the fingers, in order to stretch rhomboids. through the posterior (spinal) fibers, while pectoralis major, the tubular tendon of biceps short head and the broad ten­ D E LTO I D (FIG. 1 3.31 ) don of subscapularis may be addressed through the overly­ ing anterior (clavicular) fibers. The lateral (acromial) fibers Attachments: From the lateral third of the clavicle, overlay the synovial sheath of biceps long head and the acromion and lateral third of the spine of the scapula to subdeltoid and subacromial b ursae. the deltoid prominence (tuberosity) of the humerus Barden et al (2005) investigated shoulder muscle activity Innervation: Axillary nerve (C5-6) in subjects with multidirectional instability (MOl) by Muscle type: Phasic (type II), weakens when stressed recording the activity of deltoid, in fraspinatus, supraspina­ Function: Anterior (clavicular) fibers: flexion of humerus, tus, latissimus dorsi and pectoralis major in repetitive movements of shoulder abduction/adduction, flexion/exten­ horizontal adduction of the flexed humerus, stabilization sion and internal /external rotation. They noted significant of the humeral head during abduction, medial rotation of differences in the MOl subjects from the control group: 'The humerus (questionable) and its most peripheral anterior rotator cuff and posterior deltoid muscles demonstrated fibers may adduct the arm abbreviated periods of activity when performing inter­ nal /external rotation, despite activation amplitudes that

442 CLIN ICAL A P PLICAT I O N OF N E U R O M U S C U LAR TECH N I Q U ES : T H E U PP E R B O DY \\ rr+-r-;-,'�;-\"tp:\\ Deltoid middle -/k\".-\"=',t Deltoid anterior Deltoid posterior B Figure 1 3.31 A : Deltoid referra l patterns encompass most of the u pper a rm ; its lateral fibers a re multipennate with an extensive endplate zone. B : The com posite pattern of target zones of synerg istic l atera l rotators. were similar to the controls. In contrast, the activa tion of the a degree of function in situations where, without them, pectoralis major differed from the control group in both the function might be lost or further damage occur. amplitude and time domains when performing shoulder extension.' The authors of this text suggest that the ways Inflammation in these underlying tissues may not be these synergists and antagonists behave in the presence of noticeable on the exterior surface of the thick deltoid until moderate j oint instability, though 'neuromuscularly dys­ the area has been overworked. The underlying tendons function' in the general sense, might very well be adaptive should be palpated prior to the application of friction or or compensatory in the moment toward the more finite deep gliding strokes to evaluate for appropriate pressure. needs of this joint. Muscle substitution and selective recruit­ When moderate or extreme tenderness is found in the ment, with all of the problems they may trigger, may provide underlying tissues, ice and other antiinflammatory treat­ ments should be applied before NMT techniques are used.

1 3 Shou lder. arm a nd hand 443 Figure 1 3.32 Each head of the deltoid can be compressed as shown Figure 1 3 .33 Pa l pation of the deltoid tuberosity where the three here o n middle fibers. heads of the deltoid merge i nto a common attachment. I N MT FOR D E LTO I D SU PRASPI NATUS • The patient is prone with the arm hanging off the table or Attachments: Medial two-thirds o f the supraspinous fossa the hand is placed next to the face to passively shorten of the scapula to the superior facet of the greater tubercle the deltoid fibers so they may be lifted and grasped. of the humerus • Each of the three heads of the deltoid may be individually Innervation: Suprascapular nerve (C5-6) compressed and manipulated in small increments until Muscle type: Postural (type I), shortens when stressed the full length of the fibers has been treated (Fig. 13.32) . Function: Abducts the humerus (with deltoid), seats the • Broad compression of the tissues will reduce general humeral head in the glenoid fossa, stabilizes the head of ischemia of the fibers, while roUing the fibers between the humerus during arm movements the thumb and fingers more precisely will reveal taut Synergists: Abduction: middle deltoid, upper trapezius, bands and nodules characteristic of trigger points often lower trapezius, serratus anterior (while rhomboids sta­ found there. bilize the scapula during abduction) (Simons et a1 1999) Humeral head stabilization: infraspinatus, teres minor, sub­ • Compression techniques or flat palpation may be applied scapularis (while serratus anterior stabilizes scapula) to trigger points in the deltoid fibers for 1 0-12 seconds Antagonists: To abduction: pectoralis major (lower fibers), while feeling for release of the tau t band. latissimus dorsi, teres major • The position of the arm can be altered to place more or I n d i cations for treatment less stretch on taut bands as they are being assessed and released. • Pain during abduction of the arm or dull ache during rest • Difficulty or pain in reaching overhead or to the head • Friction techniques or gliding strokes with the thumbs • Rotator cuff involvement may be applied along the inferior surface of the spine of the scapula, acromion and clavicle to reveal attachment Specia I notes trigger points. Supraspinatus, infraspinatus, teres minor and subscapu­ • The deltoid tuberosity should be examined for tender­ laris are the four rotator cuff muscles, often called the SITS ness or evidence of inflammation (Fig. 13.33) . tendons, so named from the combined first letters of their names. These four tendons directly overlie the j oint and • Attachment trigger points may need to be addressed as inflamed tissue which can be caused by tension placed on attachment sites; applications of ice may reduce pain and tenderness. • With the deltoid lubricated, gliding strokes may be applied with the thumbs in proximal strokes from the del toid tuberosity to the proximal attachments to further loosen the fibers of the deltoid and soothe the tissues. • Tenderness found in attachments deep to the deltoid should be noted and the associated muscles examined.

444 CLI N ICAL A P PLICAT I O N O F N EU R O M U SCULAR T E C H N I Q U E S : T H E U PP E R B O DY their fibers often blend with the joint capsule. Since the artic­ Supraspinatus assists deltoid in abduction while infra­ ulation surface of the glenohumeral joint is shallow, exces­ spina tus, teres minor and subscapularis counteract the ten­ sive translation in all directions makes it necessary for these dency of the humeral head to upslip when deltoid contracts muscles to constantly check the position of the humeral by pulling the humerus down the glenoid fossa and seating head and stabilize the joint during all arm movements. it into the fossa. Supraspinatus is involved in all phases of A Fig u re 1 3.34 A-C: Pure glenohumera l abduction is i ncreased to fu l l ra nge of 1 800 only with lateral rotation of the h u merus to avoid c im paction of the g reater tu bercle agai nst the a cromion.

13 Shoulder, arm and hand 445 Acromion -----.-,-=--�:-:-__.,. abduction while infraspinatus and teres minor rotate the humerus laterally and subscapularis rotates it med ially. All ----=:- =;��:�iij. ;J!�:I=Subacromial bursa four stabilize the humeral head against the glenoid fossa Supraspinatus and also support the weighted arm so that the head of the biceps brachii, :���;. humerus is not pulled downward by the weight. This posi­ long head \"':.1:;' :;.\";. 0.. tioning role is true for supraspinatus even when the arm is not loaded, as the weight of the arm itself could cause Deltoid downward pull on the humeral head. �l-1L-i�+ Posterior circumfiex In the coronal plane, pure humeral abduction ends at 90° when the greater tubercle impacts the inferior aspect of the humeral artery acromioclavicular joint. Beyond this point, the humerus must be externally (laterally) rotated so that the greater Fig u re 1 3.35 Coronal section through shoulder to show tubercle passes posteriorly to the acromion (Cailliet 1996, subacromial bu rsa (poste rior view). Reproduced with perm ission Hoppenfeld 1976) (Fig. 13.34). When sufficient lateral rota­ from Gray's Anatomy (2005). tion does not occur, especia lly when the lateral rotators are not functioning properly due to ischemia or trigger points, or when the overhanging structures compromise the space in some other manner, such as when luggage or a heavy purse is carried over the shoulder, the tendon of supraspinatus may be compressed or repeatedly abused against the overhanging acromion. This process of abuse, particularly when com­ bined with repetitive overuse, overloading or some other strain, may lead to supraspinatus tendinitis and eventually r--Pectoralis major r--Pectc)ralis minor r-- Coracobrachialis ic vein ��_�I�Ir:-=.: IBliceps brachii, short head First rib --<-4''\" Axillary vein --r\"-�;f.:' �--.t:SlceDs brachii, long head Axillary artery ----.,.--\\.\\-f..r:. -f-l - Serratus anterior --r!';4+-, Brachial plexus -----i-,-Ir-i tf�-1 Long thoracic nerve --:fS�-+. Subscapularis bursa ----HP+.---:F---F----\" Glenoid labrum --I<-\".�:_ir/H7 Subscapularis --�':'-I:-H-�-:i'\"- \"-'\" ­ Scapula ---_,#>\"n';ro:.�Hc. branches of supra­ scapular vessels and nerves Figure 1 3.36 Tra nsverse section through shoulder. Reprod uced with permission from Gray's Anatomy (2005).

446 C L I N ICAL A P PLI CAT I O N OF N E U R O M USCU LAR TEC H N I Q U E S : T H E U P P E R BODY to calcification of the tendon. This process is well explained • Gliding strokes may be applied in both la teral and medial in Shoulder Pain (Cailliet 1991). Simons et al (1999) report directions 7-8 times in the region of the supraspinous that, with inactivation of trigger points in supraspinatus, fossa to reveal thickened or tender areas; however, if early calcific deposits at the insertion site may resolve. inflammation of the tendon or tendon tear is suspected, gliding only in a lateral direction is suggested to reduce Supraspinatus is the most frequently ruptured element potential stress on the tendon. of the musculotendinous cuff (Gray's Anatomy 2005), although portions of the conjoined tendon (infraspinatus • Deeper pressure through the overlying trapezius, if and teres minor), subscapularis or the joint capsule and appropriate, will treat the supraspinatus muscle belly. supporting ligaments may also be damaged. If a partial or complete tear is suspected, range of motion tests or stretch­ • Often the trapezius will need extensive treatment to ing procedures should be delayed until the extent of tearing reduce upper and middle trapezius tension and associ­ is known (Simons et a1 1999) as these steps could lead to fur­ a ted trigger points before deeper pressure can be used. ther tearing of the structures. The trapezius, when softened and its fiber ends approxi­ The supraspinatus fibers lie deep to the trapezius and its mated, may sometimes be displaced posteriorly to allow tendon attachment lies deep to the deltoid. Therefore, access to a small portion of supraspinatus which lies deep supraspinatus is not directly palpable except in some cases to it. This displacement procedure will usually only allow a where displacement of the upper trapezius allows a small small portion of the medial aspect of supraspinatus to be amount of access to the proximal end. However, tenderness compressed directly. However, this procedure is worth­ and trigger points within this muscle may be addressed while in those cases where displacement is possible. through the overlying trapezius if the trapezius fibers are not too tender to be pressed and are not too thick. If trigger points are found in supraspinatus, gliding mas­ sage techniques may be applied from the center of its fibers A S S E SS M E NT F O R S U P R A S P I N AT U S outvvardly toward the ends to elongate central sarcomeres DYS F U N CT I O N and reduce attachment tension from taut fibers. Trigger point pressure release may also be applied through the trapezius. • The practitioner stands behind the seated patient, stabi­ Since this muscle underlies the thick trapezius, which effec­ lizing the shoulder on the side to be assessed with one tively obscures palpa tion, it may be a candidate for trigger hand while the other hand reaches in front of the patient point injections when manual methods of release fail to be to support the flexed elbow and forearm. effective. • The patient's upper arm is adducted to its easy barrier A fingertip or the tip of the beveled pressure bar may be and the patient then attempts to abduct the arm. pressed (caudally) straight into the tissues directly medial to the acromioclavicular joint to treat the tendon of supraspina­ • If pain is noted in the posterior shoulder region, tus through the trapezius fibers. Static pressure is held for supraspinatus dysfunction is suspected and because it is 1 0-12 seconds. This procedure is avoided if a supraspinatus a postural muscle, shortness is implied. tear, subacromial (or subdeltoid) bursitis or bicipital or supraspinatus tendinitis is suspected. ASSESSM E N T F O R SU PRASPI NATUS W EAKN ESS The tendon attachment of supraspina tus is addressed • The patient sits or stands with arm abducted 15°, elbow with the SITS tendons (in a sidelying position) after the ex tended . infraspinatus and teres minor muscles have been treated. See description in the teres minor section of this text on • The practitioner stabilizes the shoulder with one hand pp. 448 and 453. while the other hand offers a resistance contact at the distal humerus which, if forceful, would adduct the arm further. \",� M ET TREATM E N T O F S U P R AS P I N AT U S (see p. 42 1 , FIG. 1 3. 1 3) • The patient a ttempts to resist this and the degree of effort required to overcome the patient's resistance is graded as • The practitioner stands behind the seated patient, stabi­ weak or strong (see grading scale, pp. 39 and 413) . lizing the shoulder on the side to be treated with one hand while the other hand reaches in front of the patient • See also 'drop-arm test' on p. 418. to support the flexed elbow and forearm. � N MT TREATM ENT O F SU PRAS PI NATUS • The patient's upper arm is adducted to its easy barrier and the patient then attempts to abduct the arm using The patient is prone with the arm resting on the table or 20% of strength against practitioner resistance. sidelying with the arm resting on the lateral surface of the body and the practitioner stands cephalad to the shoulder. • After a 10-second isometric contraction the arm is taken gently toward i ts new resistance barrier into greater • The top of the shoulder is lubricated from the acromio­ adduction with the patient's assistance. clavicular joint to the upper angle of the scapula. • Repeat several times, holding each painless stretch for not less than 20 seconds.

1 3 Shoulder, arm and hand 447 Synergists: Lateral rotation: teres minor, posterior deltoid Humeral head stabilization: supraspinatus, teres minor, sub­ scapularis (while serratus anterior stabilizes the scapula) Antagonists: To lateral rotation : pectoralis major, la tissimus dorsi, anterior deltoid Indications for treatment • Pain sleeping on side • Difficulty hooking bra behind back or pu tting hand into back pocket • Scapulohumeral rhythm test positive (see p. 410) / • Identification of shortness (see tests below). Figure 1 3.37 Myofascial release of su praspinatus. Specia l notes f M F R F O R SU PRASPI NATUS (FIG. 1 3.37) Infraspinatus and teres minor have almost identical actions and are so closely related that their tendons are often fused • This procedure is avoided if partial tear or inflamma­ together (Cailliet 199 1, Gray's A natomy 2005, Platzer 2004). tion of the supraspinatus tendon is suspected. Although overlying fascia envelopes the two muscles together as if they a re one, their innerva tions are different. • The practitioner palpates the dysfunctional muscle, seek­ ing an area of local restriction, fibrosis, ' thickening'. When infraspinatus trigger points are active, pa tients find it difficul t to reach behind the back to tuck in a shirt or fasten • This may lie above the spine of the scapula or on the a bra, comb their hair or scratch their back. Trigger points in greater tuberosity of the humerus. infraspinatus often produce deep shoulder pain, suboccipi­ tal pain and referral patterns just medial to the vertebral bor­ • Having located an area of al tered tissue texture which is der of the scapula, an area of common complaint. Trigger sensitive and after the patient has abducted the arm to points in infraspina tus respond favorably to massage appli­ about 30°, a firm thumb contact should be made slightly ca tions and manual release methods (Simons et aI 1999). la teral to the dysfunctional area. The humeral attachment of infraspinatus is addressed • The patient is then asked to slowly but deliberately with the SITS tendons (in a sidelying position) after the adduct the arm as far as possible, while the thumb con­ remaining rotator cuff muscles have been treated. However, tact (reinforced by the other hand, if necessary) is main­ as with supraspinatus, if a partial or complete tear is sus­ tained. pected, range of motion tests and stretching procedures should be delayed until the extent of the injury is known. • This process takes the myofascial tissue from a shortened position to its longest and modifies the tissue's status ASSESS M E N T F O R I N F RAS P I N ATUS under the thumb. S H O RT N E SS/DYS F U N CT I O N • This process should be repeated 3-5 times. • The patient is asked to touch the upper border o f the opposite scapula by reaching with the forearm behind I N F R AS P I N AT U S the head. Attachments: Medial two-thirds o f the infraspinous fossa of • If this effort is painful, infraspinatus shortness should be the scapula to the middle facet of the greater tubercle of suspected. the humerus • Visual evidence of shortness is obtained by having the Innervation: Suprascapular nerve (C5-6) patient supine, the humerus at right angles to the trunk Muscle type: Postural (type I), shortens when stressed with the elbow flexed so that the pronated forearm is par­ Function: Laterally rotates the humerus, stabilizes the head of allel with the trunk pointing caudally. the humerus in the glenoid cavity during arm movements • This brings the arm into internal rotation and places infraspinatus at stretch (see p. 420, Fig. 13. 10). • The practitioner ensures that the shoulder remains in contact with the table during this assessment by apply­ ing light compression onto the anterior shoulder. • If infraspinatus is short the forearm will not be capable of resting parallel with the floor, obliging it to point some­ what toward the ceiling.

448 CLI N I CA L A P P L I CAT I O N O F N EU R O M U S C U LAR T EC H N I Q U E S : T H E U PPER B O DY ASSESS M E NT F O R I N FRASPI NATUS W EAKN ESS Fig u re 1 3.38 Pa lpation of the most latera l fibers of i nfraspina tus. • The patient i s prone with head rotated toward the side \\ being assessed. !\\ • The patient's arm is abducted to 900 at the shoulder and flexed 900 at the elbow. \\ • The forearm hangs over the edge of the table and the dis­ \\ tal humerus is supported on a pad, folded towel or cush­ ion to maintain it in the same plane as the shoulder and Fig u re 1 3.39 M ET treatment of i nfraspinatus. to prevent undue pressure from the edge of the table. ,'� M ET T R EATM E NT OF S H ORT I N FRAS P I N ATUS • The practitioner provides slight stabilizing compression (AN D TERES M INOR) (FIG. 1 3.39) j ust proximal to the elbow to prevent any extension at the shoulder and offers resistance to the lower forearm as the • The patient is supine, upper arm at right angles to the patient a ttempts to bring the forearm from its starting trunk, elbow flexed so that the forearm is parallel with position pointing to the floor to one where i t is parallel the trunk, pointing caudad with the palm downwards. with the floor, palm downwards. • This brings the arm into internal rotation and places • The relative strength of the efforts of each arm is compared. infraspinatus at stretch. • Note that in this, as in other tests for weakness, there may • The practitioner applies light compression to the anterior be a better degree of cooperation if the practitioner applies shoulder to ensure that it does not rise from the table as the force and the patient is asked to resist as much as possi­ rotation is introduced since this would give a false ble. Force should always be built slowly and not suddenly. appearance of stretch in the muscle. f N M T F O R I N F RAS P I N AT U S The patient is prone with the arm resting o n the table or sidelying with the arm resting on the lateral surface of the body. The infraspinous fossa of the scapula is lightly lubri­ cated and gliding strokes are applied (both medially and laterally) under the inferior edge of the spine of the scapula where infraspinatus attaches. The gliding strokes are repeated 7-8 times in each direction to examine the attach­ ment site. The thumbs are moved caudally and the gliding process repeated, in rows, until the entire surface of the scapula has been covered. Gliding strokes are also applied in a diagonal and v ertical pattern as there are many direc­ tions of fibers in this muscle and varying the direction of the glides will reveal taut fibers more clearly. Central trigger points form in the center of the various fibers' bellies. An especially tender trigger point w i th a strong referral pattern may be found in the center of the most lateral fibers. The practitioner's thumbs are placed against the lateral edge of the muscle and pressure gradu­ ally applied into these often very tender fibers (Fig. 13.38). Tender areas or central trigger points are treated with static pressure for 8-12 seconds as thumb pressure meets and matches the tension found within them. Attachment trigger points often form under the inferior aspect of the spine of the scapula. The beveled pressure bar tip is placed parallel to the spine of the scapula and angled at 450 underneath the inferior aspect of the scapula's spine which often has an overhanging ledge. Gentle friction is used to assess the a ttaching fibers for taut bands and tender spots. Static pressure is used to commence treatment of any trigger points found there. If extreme tenderness is found, ice massage may be applied to reduce inflamma tion, which often exists at a ttachment si tes.

1 3 Shoulder, arm and hand 449 Figu re 1 3.40 Myofascial release of infraspinatus. I. PRT T R EAT M E N T O F I N F RA S P I NAT U S ( M O ST \" S U ITA B L E F O R A C U T E P R O B L E M S) • The practitioner applies mild resistance just proximal to the dorsum of the wrist for 1 0-12 seconds as the patient • The patient is supine and the practi tioner, while standing attempts to lift it toward the ceiling, so introducing exter­ or seated at waist level and facing the patient's head, nal rotation of the humerus at the shoulder. uses the tableside hand to locate an area of marked ten­ derness in infraspinatus. • On relaxation, the forearm is taken toward the floor (combined patient and practitioner action), which • The patient is asked to grade the applied pressure to this increases internal rotation at the shoulder and stretches dysfunctional region of the muscle as a '10'. infraspinatus (mainly at its humeral attachment). • The practitioner's other hand holds the forearm and I. M FR TREATM E NT O F S H O RT I N F RASPI NAT U S slowly positions the patient's flexed arm in such a way as \" (FIG. 1 3.40) to reduce the score to a '3' or less. • The patient is prone and the practitioner palpa tes and • This will almost always involve the practitioner passively locates areas within the muscle with pronounced tension, taking the muscle into an increased degree of shortness, contraction or fibrosis. involving external rotation together with either abduction or adduction (whichever reduces the 'score' more effi­ • The patient lies with the arm on the affected side flexed at ciently), as well as some degree of shoulder extension. the elbow and close to the side of the body in order to bring the muscle into a shortened state. • When the score is reduced to '3' or less, the position of ease is held for 90 seconds before a slow return to neutral. • The practitioner applies a firm, flat compression contact (thenar eminence or thumb) to an area of the muscle just TRICEPS A N D ANCO N EUS (FIG. 1 3.41 ) superior and lateral to the dysfunctional area. Attachments: Long head: infraglenoid tubercle of scapula • The patient initiates a slow abduction of the shoulder, Medial head: posterior surface of humerus (medial and extension of the elbow followed by flexion of the shoul­ distal to the radial nerve) and intermuscular septum der to its fullest limit, which will bring the distressed soft Lateral head: posterior surface of humerus (lateral and prox­ tissues under the practitioner's pressure contact. imal to the radial nerve) and lateral intermuscular septum All three heads: join together to form a common tendon, • As the movement is performed, a degree of internal rota­ which attaches to the olecranon process of the ulna tion should be included so that at the end of the range, Anconeus: dorsal surface of the lateral epicondyle to the the patient's upper arm should be alongside the head, lateral aspect of the olecranon and proximal one-fourth thumb downwards. of the dorsal surface of the ulna • The arm is then slowly returned to the starting position Innervation: Radial nerve (C6-C8) and the process is repeated (3-5 times). Muscle type: Phasic (type II), inhibited or weakens when stressed (Janda 1983, 1988). Triceps may nevertheless require stretching in order to help normalize trigger points located in its fibers Function: All three heads: extension of the elbow Long head: humeral adduction and extension, counteracts downward pull on head of humerus Anconeus : extension of the elbow, may stabilize ulna dur­ ing pronation of the forearm Synergists: Extension of the elbow: anconeus Humeral adduction and extension: teres major and minor, latissimus dorsi, pectoralis major (adduction) Antagonists: To extension of the elbow: biceps, brachialis To humeral adduction and extension: pectoralis major, biceps brachii, anterior deltoid Counteracts downward pull on head of humerus by pec­ toralis major and latissimus dorsi Ind ications for treatment • Vague shoulder and arm pain • Epicondylitis

Triceps brachii lateral head --fI- 1+Hi..- Triceps brachii medial head \\ Triceps brachii medial head (anterior view) ---+t __._ ..\".\".- Anconeus Figure 1 3.41 Referral patterns for t riceps trigger points. Drawn after Si mons et al ( 1 999).

1 3 Shoulder, arm and hand 451 Supraspinatus Suprascapular notch (foramen) r-- Cut edge of deltoid Cut edge of trapezius ---f: --=:�- __-- Teres minor . Infraspinatus ---1 ..__w>--- - Surgical neck of humerus t- --:I�ITriangular space ---- ----�,- --,.1- -It-- Medial lip of intertubercular sulcus Quadrangular space Triangular interval Teres major Long head of triceps brachii ----1-\" Cut edge of lateral head of triceps brachii Olecranon -�--\\t Fig u re 1 3.42 Right posterior sca p u l a r region. Reprod uced with perm ission from Gray's Anatomy for Students (2005) . • Olecranon bursitis entrapment by taut fibers or scar tissue. Care should be • 'Tennis elbow' or 'golfer 's elbow' taken during deep or frictional massage to avoid irrita tion SpeciaI notes of the radial nerve. The triceps fills the extensor compartment of the upper arm Dellon (1986) noted a significant relationship between with the long and la teral head superficial to the medial head in the upper two-thirds of the a rm. The medial head is the presence of the medial head of the triceps in the cubital directly available on both the medial and lateral aspects of tunnel and ulnar nerve subluxa tion. O'Hara & Stone (1996) the posterior arm just above the elbow. The radial nerve lies 'present a case of clearcut compression of the ulnar nerve at deep to the la tera l head of triceps and is vulnerable to two levels just at and posterior to the epicondyle by a tightly applied prominent head of the triceps, and at a more distal level beneath an anconeus epitrochlearis muscle'. More information on the cubital tunnel is found on p. 489.

452 CLI N I CA L A P P LICAT I O N OF N EU R O M U SCU LAR TECH N I Q U E S : T H E U PP E R BODY The anconeus, a small, triangular muscle positioned on T rieeps long head the posterolateral elbow, is easily addressed when treating the olecranon a ttachment of triceps. It is associated with the Teres minor--f-#/:t<e�,s triceps through their common action of extension of the Teres major -�� elbow and may serve to stabilize the elbow j oint during pronation of the forearm by securing the ulna. The articu­ Fig u re 1 3.43 Pa l pation of triceps attachment to sca pula is laris cubiti (subanconeus muscle) is a small slip of the ach ieved by placing the thumb between teres major and teres m i nor. medial head of the triceps and, when present, may insert into the capsule of the elbow joint. Figure 1 3.44 Finger friction of triceps te ndon at the olecranon process. Avoid pressi n g on the u l nar nerve. ASSESSMENT FOR TRICEPS WEAKNESS teres major and minor before attaching onto the scapula • Patient i s prone with the head resting in a face cradle. (Fig. 13.47) . The olecranon attachment of the triceps is • The patient's arm is flexed at the shoulder, the elbow is treated w ith finger friction or friction which is carefully applied with the beveled pressure bar (Fig. 13.44). Pressure flexed and the hand is resting as close to the same side should be applied directly on the tendon to . avoid com­ scapula as possible, arm close to the side of the head. pressing neural structures on each side of this tendon. • The practi tioner cradles the patient's elbow just proximal to the joint and asks the patient to push the elbow toward M ET T R EATM E NT O F T R I C E PS (TO E N HA N C E the floor. ,� S H O U LD E R FLEXI O N W IT H E LB O W F LE X E D ) • The two sides are compared for relative strength of the \" (FIG. 1 3.45) triceps. • Note that in this, as in other tests for weakness, there may • Patient is prone with the head resting in a face cradle. be a better degree of cooperation if the practitioner applies • The patient's arm is flexed at the shoulder, the elbow is the force and the patient is asked to resist as much as possi­ ble. Force should always be built slowly and not suddenly. flexed and the hand is resting as close to the ipSilateral scapula as possible wi th the arm placed close to the side f N MT F O R T R I C E PS (see a lso p. 494) of the head. The patient is prone with the arm hanging off the side of the table so that the upper arm is supported by the table sur­ face. The posterior aspect of the upper arm is lubricated and proximal gliding strokes are applied in thumb-width rows to cover the entire surface of the posterior upper arm to assess the (superficially positioned) lateral and long heads. The radial nerve lies deep to the lateral head and is vulner­ able to compression with deep pressure. If an electric-like sensation is felt down the arm, the hands are repositioned or lighter pressure used to avoid compression of the nerve. The medial head of triceps lies deep to the other two heads except for just above the elbow, where it lies superfi­ cial on both the medial and lateral sides. The practitioner increases the pressure, if appropriate, and repeats the prox­ imal gliding process to address the medial head through the lateral and long heads. A double-thumb gliding technique may also be used by simultaneously gliding up both medial and lateral aspects of the medial head (deep to the other two heads) wi th pressure from each thumb directed toward the mid-line of the posterior humerus. The attachment of the long head of triceps is isolated on the infraglenoid tuberosity of the scapula and treated with sta tic pressure or mild friction (Fig. 13.43) . The practitioner applies resistance to elbow extension while simultaneously palpating the tendon a ttachment to assure its loca tion. I t may b e advantageous t o muscle test and isolate the two teres muscles as well, since the triceps passes between the

1 3 Shoulder. arm and hand 453 / TERES MINOR f Attachments: Upper two-thirds of the dorsal surface of the most lateral aspect of the scapula to the lowest (third) I facet on the greater tubercle of the humerus Figure 1 3.45 M ET treatment position of triceps. Innervation: Axillary nerve (C5-6) Muscle type: Not established • The practitioner cradles the patient's elbow just proximal Function: Laterally rotates the humerus, stabilizes the head to the joint and asks the patient to push the elbow toward the floor for 10 seconds, using no more than 20% of of the humerus in the glenoid cavity during arm move­ strength as resistance to movement is offered. ments Synergists: Lateral rotation: infraspinatus, posterior deltoid • Following this isometric contraction, the patient is asked Humeral head stabilization: supraspinatus, infraspinatus, to stretch the hand further down the scapula, assisted by subscapularis (while serratus anterior stabilizes the the practitioner. The stretch should be held for not less scapula) than 20 seconds. Antagonists: To lateral rotation: teres major, pectoralis major, latissimus dorsi, anterior deltoid, subscapularis, biceps It N M T FOR A N C O N E U S (see a lso p. 449) brachii (Platzer 2004) The anconeus lies just lateral and distal to the olecranon I nd i cations for treatme nt process. It is easily isolated by placing an index finger on the olecranon process and the middle finger on the lateral • Rotator cuff dysfunction epicondyle while the practitioner 's hand lies flat against the • Teres minor should always be considered as a possible patient's forearm. The anconeus lies between the two fin­ gers. Short gliding strokes are applied between the ulna and contributor to upper arm or elbow pain radius (in the space between what the fingers have out­ lined) to assess this small muscle which is often involved in Specia l notes elbow pain. CAUTION: If rotator cuff tear is suspected, range of NOTE: The following muscles are addressed with the per­ motion testing, stretches and any therapeutic intervention son placed in a sidelying position (see Repose in cervical which could risk further damage to the tissues are not rec­ region, p. 316). The patient's uppermost arm is often ommended until a full diagnosis discloses the extent and placed in a supported position so that the practitioner has exact location of the tear. Only the most gentle assessment both hands free. Alterations can be made in this position, and technique steps may be used until diagnosis is clear. including supporting the arm on the practitioner's shoul­ der, in many cases. Teres minor is the third posterior rotator cuff muscle. Along with infraspinatus and posterior deltoid, it antagonizes medial rotation as well as providing stability of the humeral head during most arm movements. Teres minor and infra­ spinatus also act together to counteract the upward pull of the deltoid during abduction of the humerus to prevent upslip of the humeral head. With their downward tension, the humeral head may then rotate into abduction rather than slide superiorly, which might result in capsular damage but will most certainly result in mechanical dysfunction. The long head of triceps passes between teres minor and teres major and is palpated by placing a thumb between these two muscles to contact the infraglenoid tubercle of the scapula. Muscle testing of teres minor and teres major with resisted lateral and medial rotation of the humerus, respec­ tively, helps to identify these two muscles precisely. ASSESSMENT FOR TERES MINOR WEAKN ESS • Patient is seated, elbow flexed t o 900 with the arm touching the side of the body and the humerus internally rotated. • The practitioner cups and stabilizes the elbow with one hand while the palm of the other hand holds just proximal to the wrist to maintain the humerus in internal rotation.

454 CLI N I CAL A P PL I CAT I O N OF N E U RO M USCU LA R TEC H N I Q U E S : T H E U P P E R B O DY A Figure 1 3.46 The thumb and fi ngers grasp around the teres major and latissimus fibers to precisely compress teres m i nor. • The patient is asked to externally rotate the humerus -- (,Twist your upper arm against my resistance' or 'I am going to try to turn your arm inward and you should --.- resist, against my hand on your wrist, as strongly as you can') and the practitioner grades the relative strength of B the action and compares one side with the other. Figure 1 3.47 The pa l pating thumb feels fi bers of teres m i nor (A) • Note that in this, as in other tests for weakness, there may contract with resisted latera l rotation w h i l e teres major (B) be a better degree of cooperation if the practitioner applies con tracts w ith m edial rotation. Shown here in prone position ; the force and the patient is asked to resist as much as possi­ similar steps can be perfo rmed in sidelyi n g position. ble. Force should always be built slowly and not suddenly. tissue releases and softens, a light stretch may be applied f NMT FOR TERES MINOR until ta ut fibers are again distinctive. A firm nodule (or nest of them) wi thin a ta ut band is often present near the center The patient is placed in a sidelying position with the arm to of the fibers. Pressure that matches the tension in the tissue be treated lying uppermost. The arm is placed in passive and reproduces the patient's pain pattern confirms the pres­ flexion at 90° and is supported there by the patient. This ence of a trigger point, which often can be effectively position is hereafter referred to as the supported arm posi­ released with trigger point pressure release. tion (see sidelying supported arm position, p. 316). Compression, friction or snapping palpa tion is used on The practitioner stands, kneels or sits caudad to the the full length of teres minor and its scapular attachments extended arm and uses both hands (or the caudad hand) to wuess a tear is suspected, which would warrant more cau­ grasp the posterior aspect of the axilla with a pincer compres­ tion. It attaches to the third facet of the greater tubercle of sion as close to the head of the humerus as possible. The fin­ the humerus, which is often tender to palpation. gers are placed on the posterior surface of teres minor while the thwnbs rest on the anterior (axillary) surface (Fig. 13.46). The patient's arm is draped forward to lie passively across the chest. The practitioner assesses the scapular attachment The practitioner 's grasp encompasses the teres major and la tissimus dorsi fibers but does not compress them as the thwnb and fingers are placed precisely on and capture the teres minor. Muscle testing with mildly resisted lateral rotation will produce contraction of teres minor to assure direct palpa­ tion (similar technique shown in Fig. 13.47 with patient prone). The muscle is relaxed before treating it. Pressure is applied with precision and local twitch responses monitored from both sides of the muscle. As the

1 3 Shou lder, arm a nd hand 455 Fig u re 1 3.48 Teres major and teres minor attachments of the Fig u re 1 3.49 The SIT tendons are easily accessed posterior to the lateral (axillary) border of the sca p u l a are often 'su rprising ly' tender. acrom ion when the patient is side lying and the arm is d ra ped across the chest. of teres minor by sliding a thumb along the upper two-thirds of the lateral (axillary) border of the scapula (Fig. 13.48). If ) appropriate, static pressure or light friction is applied to any tender points or trigger points in the a ttachment site or, if ( ------ inflammation is suspected, ice therapy is applied. The teres major attachment is located on the remaining lower one-third Fig u re 1 3.50 Stra i n -cou nterstra in (PRT) for teres m i n o r. of this border and may be ad dressed in a similar manner. the tableside hand to locate an area of marked tenderness To trea t the SITS tendons, the arm remains draped across in teres minor on the lateral border of the scapula close to the patient's chest. When the humerus is so positioned, the the axilla. humeral head is in flexion combined with extreme horizon­ • The patient is asked to grade the applied pressure to this tal adduction and can be further laterally rotated. This posi­ dysfunctional region of the muscle as a '10'. tion rotates the greater tubercle of the humerus posterior to • The practitioner 's other hand holds the forearm and the acromioclavicular joint and makes the facet attachment slowly posi tions the patient's flexed arm in such a way as of supraspinatus available to palpation (through the del­ to reduce the score to a '3' or less. toid). The attachment of supraspinatus faces directly • This will almost always involve the practitioner pas­ toward the practitioner along with the second and third sively taking the muscle into an increased degree of facet attachments of infraspinatus and teres minor, respec­ shortness, involving a degree of shoulder flexion, abduc­ tively (Fig. 13.49). tion and external rotation. • When the score is reduced to '3' or less, the position of Unless contraindicated by extreme tenderness or suspi­ ease is held for 90 seconds before a slow return to neutral. cion of rotator cuff tear, the practitioner cautiously applies friction or static compression directly to the insertion of each of the SITS tendons. The tendon attachment of the fourth rotator cuff muscle, subscapularis, is treated with the anterior su rface of the joint capsule (see Fig. 13.85). MET for teres minor is the same as for infraspinatus described above. \"'6 PRT FOR TERES MINOR (MOST SU ITABLE FOR ACUTE PROB LEMS) (FIG. 1 3.50) • The patient is supine and the practitioner (standing or sitting at waist level and facing the patient's head) uses

456 CLI N I CA L A P P L I CATI O N OF N E U R O M U S C U LAR TECH N I Q U E S : THE U PP E R BODY Figu re 1 3.51 Composite trigger point target zones for medial rotators, Drawn after Simons et al (1 999), ) -f/jf--f'l. Latissimus dorsi T E R E S M AJ O R (FIG, 1 3,51 ) Extension of humerus: latissimus dorsi, posterior deltoid and long head of triceps Attachments: Oval area on the dorsal surface of the scap ula Antagonists: To medial rotation: teres minor, infraspinatus, (near the inferior angle) to the medial lip of the intertu­ posterior deltoid bercular sulcus of the humerus To extension of humerus: pectoralis major, biceps brachii, anterior deltoid, coracobrachialis Innervation: Lower subscapular nerve (C5-7) Muscle type: Phasic (type II), weakens when stressed I n d ications for treatme nt Function: Assists medial rotation and extension of the • Pain upon motion humerus against resistance, adducts the humerus, partic­ • Pain at full overhead stretch, ularly across the back Synergists: Medial rotation : la tissimus dorsi, long head of triceps, pectoralis major, subscapularis

1 3 Shoulder, a rm and hand Special notes Fig u re 1 3.52 Compression of be l ly of teres m ajor. Teres minor, teres major and latissimus dorsi together form border of the scapula. The scapular attachment is often ten­ the posterior axillary fold. Muscle testing with resisted der; therefore a l ighter pressure is used before increased medial rotation causes the fibers of teres major to contract pressure is applied. Trigger points in the attachment sites and distinguishes it from teres minor but not from the fibers require that the associated central trigger points are deacti­ of latissimus dorsi, which 'cradle' teres major as they course va ted . If inflammation is suspected, ice therapy is applied . medially aroWld the humerus to attach anteriorly to it. The teres minor a ttachment is located on the remain ing upper two-thirds of this border and may be addressed in a Teres major and latissimus dorsi fibers can be more easily similar manner (Fig. 13.48). distinguished by separation of their fibers rather than through muscle testing since they perform the same action. ,� PRT F O R T E R ES M AJ O R ( M OST S U I TA B L E F O R Distinction is usually easily made since the fibers of latis­ , ACUTE PROBLEMS) (FIG. 1 3.53) simus dorsi continue past the scapula while the teres major fibers end there. However, occasionally teres major may be • The patient is seated and the practitioner, while standing fused with latissimus dorsi (Platzer 2004), especially near behind, locates an area of marked tenderness in teres the scapular portion (Gray's Anatomy 2005), or a slip of it major close to its attachment on the lower lateral surface may join the long head of triceps or the brachial fascia of the scapula. (Gray's Anatomy 2005). • The patient is instructed to grade the applied pressure to Celli et al (1998) report the substitution of the teres major this dysfunctional region of the muscle as a '10'. muscle for a detached and atrophic infraspinatus muscle in irreparable rotator cuff tears. They suggest this is effective • The practitioner's other hand holds the forearm, bring­ ' to restore continuity of the cuff and to depress the head of ing the arm backwards, internally rotating the humerus the humerus'. Reed ucation of the transferred muscle is nec­ and slowly positioning the patient's extended arm in essary 'because it initially contracts more in adduction and such a way as to reduce the 'score' markedly. internal rotation than in external rotation'. Gerber et al (2006) provide a similar report on the use of latissimus dorsi • The position is a virtual 'hammerlock' position. for a comparable procedure, which they report as successful • This will almost always involve the practitioner pas­ W1less subscapularis function is deficient. Jost et al (2003) report use of pectoralis major transfer for patients with an sively taking the muscle into an increased degree of irreparable subscapularis tear. shortness which involves shoulder extension, adduction and internal rotation. f N MT F O R T E R ES MAJ O R • Long-axis compression toward the shoulder, through the humerus, may provide additional ease to the painful ten­ The patient remains in a sidelying supported arm position der point. (see p. 316). The practitioner stands caudad to the extended • vVhen the score is reduced to '3' or less, the position of arm and uses one or both hands to grasp the posterior aspect ease is held for 90 seconds before a slow return to neutral. of the axilla with a pincer palpation similar to that used for teres minor. The palpating fingers are positioned 1-2 inches (2.5-5 cm) toward the free border of the posterior axillary fold and directly contact teres major (Fig. 13.52) . Muscle test­ ing with resisted medial rotation will help distinguish teres major fibers from those of teres minor, which are relaxed (inhibited) during medial rotation. Latissimus dorsi will also activate during medial rotation along with teres major and should be distinguishable from it (see Fig. 13.47B). The practitioner applies p incer compression, friction or snapping palpation onto the en tire length of teres major. If appropriate, the teres major fibers may be slightly stretched by moving the humerus into further flexion. The fibers of latissimus dorsi are usually distinguished from those of teres major since they continue past the scapula and into the lower back (see Fig. 13.51). The patient's arm is draped forward to lie passively across the chest. The practitioner stands in front of the patient and assesses the scapular attachment of teres major by slid­ ing a thumb along the lower third of the lateral (axillary)

458 CLI N I CAL A P PLICAT I O N OF N EU RO M USCU LAR TECH N I Q U E S : TH E U P P E R B O DY Fig u re 1 3.53 Stra i n-co u n terstra in (PRTj position for teres major. Specia l notes LAT I SS I M U S D O RS I If latissimus dorsi is short it tends to 'crowd' the axillary region, internally rotating the humerus and impeding nor­ Attachments: Spinous processes of T7-12, thoracolumbar mal lymphatic drainage (Schafer 1987). fascia (anchoring it to all lumbar vertebrae and sacrum), posterior third of the iliac crest, 9th-12th ribs and (some­ Portions of latissimus dorsi attach to the lower ribs on its times) inferior angle of scapula to the intertubercular way to the lower back and pelvic attachments. La tissimus groove of the humerus dorsi powerfully depresses the shoulder and therefore can influence shoulder position and neck postures as well as Innervation: Thoracodorsal (long subscapular) nerve (C6-8) influencing pelvic and trunk postures by its extensive Muscle type: Postural (type I), shortens when stressed attachments to the lumbar vertebrae, sacrum and iliac crest Function: Medial rotation when arm is abducted, extension (Simons et aI 1999). of the humerus, adducts the humerus, particularly across La tissimus dorsi can place tension on the brachial plexus the back, humeral depression; influences neck, thoracic by depressing the entire girdle and should always be and pelvic postures and (perhaps) forced exhalation, addressed when the patient presents with a very 'guarded' such as to cough (Platzer 2004) cervical pain associated with rotation of the head or shoul­ Synergists: Medial rotation: teres major, pectoralis major, der movements. This type of pain often feels 'neurological' subscapularis, biceps brachii when the tense nerve plexus is further stretched by neck or Extension ofhumerus: teres major and long head of triceps arm movements. Relief is often immediate and long lasting Adduction of humerus: most anterior and posterior fibers when the latissimus contractures and myofascial restric­ of deltoid, triceps long head, teres major, pectoralis major tions are released, especially if they were 'tying down' the Depression ofshoulder girdle: lower pectoralis major, lower shoulder girdle. trapezius Antagonists: To medial rotation: teres minor, infraspinatus, Latissimus dorsi has been successfu lly harvested to replace posterior deltoid subscapularis in rotator cuff ruptures (Gerber et al 2006), To extension of humerus: pectoralis major, biceps brachii, used in postmastectomy flap reconstruction (Sweetland 2006) anterior deltoid and has even been the host site for the growing of a replace­ To humeral head distraction: stabilized by long head of tri­ ment mandible for a cancer patient (Fricker 2004). While the ceps, coracobrachialis impact on the latissimus dorsi tissues that results from the To depression ofshouldergirdle: scalenes ( thorax elevation), invasive na ture of these surgeries certainly presents a upper trapezius unique set of challenges, the almost certain improvement in the quality of life would likely be worth the consequences. I n d i cations for treatment ASSESSM ENT FOR LATISSI MUS DORSI • Mid-back pain in referred pa ttern not aggravated by S H O RTN ESS/DYS F U N CT I O N movement • The patient lies supine, knees flexed, with the head 1 .5 • Identification of shortness (see tests below). feet (45 cm) from the top edge of the table, and ex tends the arms above the head, resting them on the treatment surface with the palms facing upward. • If la tissimus is normal, the arms should be able to easily lie flat on the table above the shoulder. If the arms are held laterally, elbow(s) pulled away from the body, then latissimus dorsi is probably short on that side. or • The standing patient is asked to flex the torso and allow the arms to hang freely from the shoulders while holding a half-bent position, trunk parallel with the floor. • If the arms are hanging other than perpendicular to the floor, there is some muscular restriction involved and if this involves la tissimus, the arms will be held closer to the legs than perpendicular (if they hang markedly for­ ward of such a position, then trapezius or deltoid short­ ening is possible). • To assess latissimus in this position (one side at a time), the practitioner stands in front of the patient (who

1 3 Shoulder, arm a nd hand 459 ] Fig ure 1 3.54 Fi bers of latissi mus can be easily lifted a n d can be distinguished from teres major and overlying skin. remains in this half-bent position). While stabilizing the Figu re 1 3.55 A broad application of myofascial release to the scapula with one hand, the practitioner grasps the arm axil lary reg ion. just proximal to the elbow and gently draws the (straight) arm forward. • If there is not excessive 'bind' in the tissue being tested, the arm should easily reach a level higher than the back of the head. • If this is not possible, then la tissimus is shortened. � N MT FOR LATI SSI M U S DORSI (FIG. 1 3.54) from the thorax, which makes them easier to grasp. In this position, control of the arm is easily maintained while mov­ The patient remains in a sidelying position with the arm ing it into varying positions to stretch the fibers and define supported as in the treatment of teres major. Myofascial taut bands for loca tion and palpation. Sometimes the fibers release may be easily applied before or immediately follow­ are more defined and respond more quickly in a stretched ing these techniques (Fig. 13.55). position but less pressure is usually needed when the tissue is treated in a stretched position. Once located, the fibers The practitioner sits (or stands) caudal to the supported may be more easily lifted away from the torso (and manu­ arm and grasps the latissimus dorsi, which is the remaining ally stretched) if tension on them is red uced. Hence, varying muscular tissue in the free border of the posterior axillary the position of the humerus will assist the practitioner in fold. Pincer compression is used in a similar manner to that discovering the best position for accessing and also for used for teres major. Beginning near the humerus, the prac­ treating the la tissimus fibers. titioner assesses the latissimus dorsi's long fibers at hand­ width intervals until the rib attachments are reached. These The attachments onto the spinous processes, sacrum and upper fibers ' tie' the humerus to the lower ribs. Ischemic iliac crest may be addressed with friction, glides or static bands are often found in this portion of the muscle and cen­ pressure, depending on tenderness level. The beveled pres­ tral trigger points are found at mid-fiber region of this most sure bar can be used to apply friction or static pressure tech­ lateral portion of the muscle, which is approximately niques throughout the lamina groove and sacrum while halfway between the humerus and the lower ribs. thumbs are best used along the top of the iliac crest. These portions of the latissimus dorsi are discussed more thor­ The practitioner stands with the (sidelying) patient's arm oughly in Volume 2 of this text (lower body) as this muscle placed over the practitioner's upper shoulder to elevate the is very often associated with pelvic distortions. latissimus dorsi and lift i ts lower fibers (somewhat) away

460 C L I N I CA L A P P L I CATI O N OF N E U R O M U S C U LAR TECH N I Q U E S : T H E U P P E R BODY \"1M M ET TREATMENT OF LATISS I M US D O RS I \"1M PRT FOR LATI SSI M U S DORSI ( M OST S U ITA B L E (FI G . 1 3.56) FO R ACUTE PROBLEMS) (FIG. 1 3.57) • The patient lies supine with one leg crossed over the • The patient is supine and lies close to the edge of the other one at the ankle. table. The practitioner is tableside, at waist level, facing cephalad. • The practitioner stands on the side opposite the side to be trea ted at waist level and faces the table. • Using the tableside hand, the practitioner searches for and locates an area of marked localized tenderness on the • The patient slightly sidebends the torso contralaterally upper medial aspect of the humerus, where latissimus (bending toward the practitioner). attaches. • With the legs straight, the patient's feet are placed j ust off • The patient is instructed to grade the applied pressure to the side of the table to help anchor the lower extremities. this dysfunctional region of the muscle as a '10'. • The patient places the ipsilateral arm behind the neck as • The practitioner 's non-tableside hand holds the patient's the practitioner's cephalad hand slides under the forearm close to the elbow and eases the humerus into pa tient's shoulders to grasp the axilla on the treated side, slight extension or compression, ensuring (by 'fine­ while the patient grasps the practitioner 's arm at the tuning' the degree of extension) before the next move­ elbow. ment that the 'score' has reduced somewhat. • The practitioner 's caudad hand is placed lightly on the • The practitioner then internally rotates the humerus anterior superior iliac spine on the side to be treated, in while also applying light traction or compression in such order to offer stability to the pelvis during the subse­ a way as to reduce the pain 'score' more. quent contraction and stretching phases. • When the score is reduced to '3' or less, the position • The patient is instructed to very lightly take the point of of ease is held for 90 seconds before a slow return to neutral. that elbow toward the sacrum while lightly trying to bend backwards and toward the treated side. The practi­ SU B S CAP U LA R I S (FIGS 1 3.58, 1 3.59) tioner resists this effort with the hand at the axilla, as well as the forearm, which lies across the patient's upper back. Attachments: Subscapular fossa (costal surface of scapula) This action produces an isometric contraction in la tis­ to the lesser tubercle of the humerus and the articular simus dorsi. capsule • After 7 seconds the patient is asked to relax completely as the practitioner, utilizing body weight, sidebends the patient further and, at the same time, straightens his own trunk and leans caudad, effectively lifting the patient's thorax from the table surface and so introducing a stretch into latissimus (as well as quadratus lumborum). • This stretch is held for 15-20 seconds, allowing a length­ ening of shortened musculature in the region. • Repeat once or twice more for greatest effect. F i g u re 1 3.56 Body a n d hand positions for M ET treatment of Fig u re 1 3.57 Stra in-cou nterstra in posi tion for treatment of latissimus dorsi. l atissimus dorsi.

1 3 Shoulder, a rm and hand 4 6 1 Innervation: Superior and inferior subscapular nerves Synergists: Medial rotation: latissimus dorsi, pectoralis (CS-6) major, teres major Adduction of humerus: most an terior and posterior fibers Muscle type: Postural (type I), shortens when stressed of deltoid, triceps long head, teres major, pectoralis Function: Medial rotation and adduction of humerus, stabi­ major Humeral head s tabilization: supraspinatus, infraspinatus, lization of humeral head teres minor Transverse humeral ligament Antagonists: To medial rotation: infraspinatus, teres minor Long head of biceps brachii To adduction: deltoid, supraspinatus Short head of biceps brachii --f-+f--+ I nd i cations for treatment Coracobrachialis • Loss of lateral rotation and abduction of the humerus, 'frozen shoulder' syndrome • Difficulty in reaching as if to throw a ball overarm • Identification of shortness (see test below). -ir�jb!f- Tendon of biceps brachii Special notes Figure 1 3.58 The muscles of the anterior shoulder. Reproduced with Subscapularis is a rotator cuff muscle whose job is to stabi­ permission from Gray's Anatomy for Studen ts (2005). lize the humeral head and seat it deeply into the glenoid fossa. It is a powerful medial rotator of the humerus and is responsible for countering downward tension on the head of the humerus when the initial action of abduction forces the humerus upward, toward the overhanging acromion process (Simons et a1 1999). When hypertonicity or trigger points in subscapularis cause excessive tension within the muscle, it holds the humeral head fast to the glenoid fossa, creating a 'pseudo' frozen shoulder (Simons et al 1999). That is, the humeral head appears immobile, as in true frozen shoulder syndrome, but without associated intrajoint adhesions. Ultima tely, how­ ever, long-term reduced mobility and capsular irritation from subscapularis dysfunction may result in adhesive capsulitis Figure 1 3.59 Su bsca p u l a ris referral patterns to the posterior shoulder and i n to the a nterior and posterior wrist. Drawn after Simons et al (1 999). Subscapularis

462 CLI N ICAL APPLI CAT I O N OF N E U RO M U SC U LAR TECH N I Q U E S : T H E U PP E R BODY (Cailliet 1991). Additionally, the subscapularis lies in direct relationship with serratus anterior within the scapulotho­ racie joint space. Myofascial adhesions of these tissues to each other may contribute to full or partial loss of scapular mobili ty. The tendon of subscapularis passes over the anterior joint capsule and lies horizontally between the two a lmost vertical tendons of biceps brachii. It may be injured or torn when the person falls backwards and throws the hands back to bear the body's weight. This impact will force the head of the humerus anteriorly against the joint capsule and the tendon of subscapularis, which overlies the anterior joint capsule (Cailliet 1991). The subscapular bursa lies between the tendon and the joint capsule and commW1i­ cates with the capsule between the superior and middle glenohumeral ligaments while the subcoracoid bursa lies between the subscapularis and the coracoid process. Both bursae communicate with the shoulder joint cavity and therefore may play a role in true frozen shoulder syndrome if they become inflamed (Cailliet 1991, McNab & McCulloch 1994, Simons et al 1999). Ice may be applied if inflammation of the tendon or bursa is suspected or if the region is fOW1d to be excessively tender. ASSESS M E NT O F SU BSCAPU LA R I S Figu re 1 3.60 ARB: Access to su bsca pularis is significantly DYS F U N CT I O N/S H O RTN ESS i ncreased as the scapula tra nslates latera l ly (with assistance) with proper arm positioning. • Direct palpation o f subscapularis i s an excellent means of establishing dysfunction in it, since pain patterns in the O B S E RVAT I O N OF S U B S CAPU LAR I S shoulder, arm, scapula and chest may all derive from it. DYS F U N CT I O N/S H O RTN ESS (see p . 422) • The practitioner's fingernails must be cut very short. • The pa tien t is supine with the arm abducted to 90°, the • With the patient supine, the practitioner stands on the elbow flexed to 90° and the forearm in external rotation, palm upwards. side to be treated and uses the cephalad side hand to position the humerus by grasping it just above the elbow. • The whole arm is resting at the restriction barrier, with The patient's arm is positioned so that the fully flexed gravity as i ts coun terweight. elbow points toward the ceiling and the patient's hand rests on the medial edge of the contralateral shoulder. • If subscapularis is short the forearm will be unable to rest • The practitioner places the fingers of the caudad (treat­ easily, parallel with the floor, but will be somewhat ele­ ing) hand so that they lie between the scapula and the vated, with the hand pointing toward the ceiling. This torso with the finger pads in contact with the anterior position might also implicate pectoralis minor. (inner) surface of the scapula and the dorsum of the hand facing the ribs. The hand will (eventually) slide deeper • Care is needed to prevent the shoulder lifting from the into the subscapular space (Fig. 13.60A). table, so giving a false-nega tive result (i.e. allowing the • Once the fingers are 'prepositioned', the patient is asked forearm to achieve parallel status with the floor by means to slowly reach toward the anterior or lateral surface of of the shoulder lifting) . the contralateral shoulder. While the patient slowly moves the hand, the practitioner gently releases the humerus and slides the cephalad hand under the torso to 'hook' the fingers onto the vertebral border of the scapula. • The scapula is tractioned laterally by the cephalad hand as the caudal hand slides further medially on the ventral surface of the scapula and presses onto the subscapularis (Fig. 13.60B). • There may be a marked reaction from the patient when this muscle is touched, indicating acute sensitivity.

13 Shoulder, arm and hand 463 Figure 1 3.61 A small portion of subsca pularis may be reached i n the sidelying position. ASSESSM ENT OF WEAKNESS I N Figu re 1 3.62 MET treatment of subscapularis. SU BSCAPU LAR I S Since this muscle is often ex tremely tender, mild pressure • The patient i s prone with humerus abducted to 90°, the is initially used and increased only if appropriate. The elbow flexed to 90° and the humerus internally rotated so practitioner applies static pressure for 1 0-12 seconds a t that the forearm is parallel with the torso and the palm thumb-wid th intervals onto a l l accessible portions o f sub­ faces toward ceiling. scapularis. If not too tender, repea t the process while increasing the static pressure or by applying a snapping • The practitioner stabilizes the scapula with one hand and (unidirectional) transverse friction. Repeat the entire with the other applies pressure (toward the floor) to the process 3-4 times during the session while allowing short pa tient's distal forearm to externally rotate the humerus breaks in between applications of pressure. against the patient's resistance. The humeral attachment and a portion of the tendon of • The strength of the two sides should be compared. subscapularis may be treated between the two bicipital ten­ dons on the anterior surface of the humeral head; this is dis­ f NMT FOR SUBSCAPULARIS cussed with biceps brachii (p. 482). Recurrent bicipital tendinitis and frozen shoulder may both improve consider­ The patient is placed in a sidelying position (see p . 316) with ably after the (horizontal) subscapularis tendon is treated the arm supported by the patient or placed on top of the between the two (vertical) biceps tendons. practitioner's shoulder when the practitioner is seated in front of the patient at the level of the pa tient's chest. The Note: The palpation exercise described previously as pa tient's arm is tractioned directly forward as far as possible 'Assessment of subscapularis dysfunction / shortness' is to translate the scapula la terally and allow maximum palpa­ also an excellent position for treatment of this muscle as i t ble space on the ventral (anterior) surface of the scapula. allows for substantially greater access to the fibers o f this 'hidden' muscle. The practitioner 's cephalad hand lies on the posterolat­ eral portion of the shoulder and can be used to support the It M ET F O R S U BSCAPU LA R I S (FIG. 1 3.62) shoulder 's position. The bellies of teres major and latissimus dorsi comprise the posterior axjJjary fold. Subscapularis • The pa tient is supine with the arm abducted to 90°, the resides medial to both of these muscles and fills the sub­ elbow flexed to 90° and the forearm in external rotation, scapular fossa on the ventral surface of the scapula. The palm upward. practitioner locates the lateral edge of the scapula (medial to teres major and la tissimus dorsi) with the thumb of the cau­ • The whole arm is resting a t the restriction barrier, wi th dal hand and slides the thumb medially onto the anterior gravity as i ts counterweight. surface of the scapula where subscapularis resides. The elbow of the practitioner 's treating arm must remain low to assure the proper angle of the thumb (Fig. 13.61).

464 CLIN ICAL APPLI CATION OF N E U RO M USCU LAR TECH N I QUES: THE UPPER BODY • Care is needed to prevent the anterior shoulder from SERRATUS ANTE R I O R (FIG. 1 3.63) becoming elevated in this position (moving toward the ceiling) and so giving a false-normal picture. Attachments: Superior part: outer and superior surface of ribs 1 and 2 and intercostal fascia to the costal and dorsal • The patient raises the forearm slightly, rotating the shoul­ surfaces of the superior angle of the scapula der internally, pivoting at the elbow against light resist­ Intermediate part: outer and superior surface of ribs 2, 3 ance offered by the practitioner on the lower forearm, and (perhaps) 4 and intercostal fascia to the costal surface and holds the resistance for 7-1 0 seconds. along almost the entire medial border of the scapula Inferior part: outer and superior surface of ribs 4 or 5 • Following relaxation, gravity or slight assistance from through 8 or 9 and intercostal fascia to the costal and dor­ the practitioner takes the arm into external rotation and sal surfaces of the inferior angle of the scapula through the soft tissue resistance barrier, where it is held for at least 20 seconds. Innervation: Long thoracic nerve (CS-7), which lies on the external surface of the muscle I. PRT F O R S U B S CA P U LA R I S ( M OST S U ITA B L E \" F O R A C U TE P R O B L E M S) Muscle type: Phasic (type II), weakens when stressed Function: Stabilization of the scapula during flexion and • The patient is supine and lying so that the arm being treated is close to the edge of the table. abduction of the arm; rotates the scapula laterally to make the glenOid fossa face upward; abducts the scapula • The practitioner locates a n area of marked tenderness on and therefore protracts the shoulder girdle; assists in ele­ the anterior border of the scapula, using the procedure vating the scapula; presses the scapula to the thorax, outlined above for direct palpa tion assessment. counteracting 'winging' of the scapula; may be an acces­ sory muscle of inspiration during abnormal or demand­ • The patient is instructed to grade the applied pressure to ing breathing patterns this dysfunctional region of the muscle as a '10'. Synergists: Protraction of scapula: pectoralis minor and upper fibers of pectoralis major • The practitioner's other hand holds the arm above the Upward rotation of the glenoidfossa: trapezius elbow and eases it into slight extension and asks the Elevation of scapula: levator scapula, upper trapezius, patient for a score. If no reduction is reported, 'fine-tuning' rhomboids of the degree of extension is carried out to achieve this. Fixation ofscapula during arm movements: rhomboids, mid­ dle trapezius • Once a reduction in the score is reported, the practitioner Antagonists: To protraction: rhomboids, latissimus dorsi, then internally rotates the humerus in such a way as to middle trapezius reduce the 'score' further. To upward rotation of theglenoidfossa: la tissimus dorsi, pec­ toral muscles, levator scapula, rhomboids • When the score is reduced to '3' or less, the position of ease is held for 90 seconds before the arm is slowly returned to neutra!' Serratus anterior Figure 1 3.63 Serratus anterior trigger poi nts include one that prod uces a 'short of breath' condition as well as an often fa miliar intersca pular pa in. D rawn a fter Simons et a l ( 1 999).

1 3 Shoulder. a rm and hand 465 Ind ications for treatment perpetuate myofascial trigger points as well (Simons et al 1999). • Shortness of breath due to trigger points • 'Winging' of the scapula (reflexive, inhibited weakness) CAUTION: Caution must be exercised in the deep axil­ • Scapula fixation flat to the thorax (tense fibers) lary regions as lymph nodes are present and should be • Loss of expansion of rib cage during inhalation avoided, especially if enlarged. If enlarged lymph nodes • Disrupted scapulohumeral rhythm or other masses are found, the patient should immedi­ • Restriction of adduction of the scapula ately be referred to the proper healthcare professional to confirm or rule out breast cancer, thoracic or systemic Special notes infection or other serious pathology. Serra tus anterior is synergistic with pectoralis minor to pro­ Trigger points in serratus anterior, as well as the diaphragm tract the scapula in practically all reaching and pushing and external oblique, may produce a 'stitch in the side' com­ movements. It serves to stabilize the scapula (pressing in plaint, especially when a high demand is placed on it for onto the thorax to counteract 'winging'), rotate and abduct excessive breathing. The pain may be accompanied by the it, and assists in elevating it. Without the stabilization that inability to take a full breath as serratus anterior and sur­ serratus anterior offers, the function of many other muscles rounding tissues restrict movement of the ribs. Injection of that pull on the scapula will be affected. these trigger points should only be attempted when manual methods of release have failed and then only by the most Serratus anterior is also an accessory breathing muscle, highly skilled practitioner, due to the risk of thoracic punc­ recruited during demanding situations rather than normal ture (Simons et aI 1999). breathing patterns. Y\\'hether its fibers are activated and how much they are activated will vary depending upon the con­ ASS ESS M E NT F O R W EA K N ESS O F S E R RATU S ditions. When it is inhibited, unusual demand may be ANTERIOR placed on other respiratory muscles, such as the scalenes and sternocleidomastoid, when the serratus would nor­ • The patient adopts a position on all fours with weight mally be used. This overload may lead to associated trigger placed mainly onto the arms rather than knees. point formation in these and other respiratory muscles, although it is not always clear which comes first - the • On slightly flexing the elbows, the scapulae are observed abnormal respiratory pattern or the trigger points (Simons to see whether they wing or deviate laterally, which indi­ et aI 1999). cates weakness of serratus anterior (there is some influ­ ence from lower trapezius in this assessment but it The long thoracic nerve, which innervates serratus ante­ focuses mainly on serratus). rior, lies vertically on the surface of the muscle in the line of the axillary fold and is therefore vulnerable during palpa­ • The implication, according to Lewit (1985) and Janda tion. Additionally, portions of this nerve supply may pass (1996), is that excessive tone in the upper fixators of the through the scalenus medius muscle, where it may be shoulder and accessory breathing muscles is probably entrapped. Damage to or compression of this nerve would inhibiting these lower fixators. produce excessive 'winging' of the scapula in which the medial border of the scapula stands out away from the tho­ � N MT F O R S E R RATU S A NT E R I O R rax. However, since 'winging' can sometimes be relieved when trigger points in this muscle are inactivated (Simons The patient remains in a sidelying position with the arm rest­ et aI 1999), the condition may be a result of a combination of ing in the supported arm position without forward pull on the activation of antagonists (reflex facilitation) and weakness arm. The practitioner stands caudad to the extended arm and induced within the serratus since it is a phasic muscle and uses the thwnb of the most caudal hand to perform the ther­ weakens when stressed (Janda 1996, Simons et al 1999). apy. The patient's arm may be placed on the practitioner 's Weakness in the serratus anterior would affect the patient's shoulder for support and elevation, which will also allow bet­ ability to raise the arm as well as push away with the arm. ter access to portions of the serratus anterior that lie deep to the scapula, or can be supported by the patient (Fig. 13.64). Herpes zoster lesions often run the course of intercostals nerves, forming on the skin surface superficial to the serra­ The practitioner palpates the fibers of serratus anterior tus anterior. These lesions are extremely painful, have a on the lateral chest wall to determine the level of tenderness long recovery process and often recur. Care should be taken and whether friction or gliding strokes are appropriate to to avoid stimulating them through examination of tills mus­ apply. Treatment begins illgh in the axilla and progresses cle, particularly during the early stages of this condition down the lateral surface of the thorax. when they are the most tender and prone to spread into fur­ ther eruptions. During the early stages of eruption, herpes Each palpable segment of serratus anterior is wider than zoster pain may mimic that of serratus or intercostal trigger the one before, forming a triangular treatment area with the points and herpes viruses are likely to aggravate and vertex of the triangle in the axilla. As the treatment pro­ gresses down the lateral thorax, the vertical (often extremely tender) fibers of the pectoralis minor are encountered on the

466 C L I N ICAL A P PLICAT I O N OF N E U R O M U SC U LAR T EC H N I Q U E S : THE U PP E R BODY Fig u re 1 3.64 When serratus a n terior is exqu isitely tender, gentle Box 1 3. 1 0 MFR lubricated gliding strokes may be substituted for frictional MFR stands for myofascial release. A number of different techniques, w hich (u n l ike the g l iding strokes) can be performed approaches a re clustered u nder this heading. t h rough a cover sheet. 1. John Barnes (1 996) describes MFR as the application of pas­ sive (practitioner active, patient passive) gentle pressure to restricted myofascial structures, in the direction that will stretch the tissues as far as 'their col lagenous barrier'. Sustained pressure results in the 'creep' phenomenon (see Cha pter 1 ) , a g radual elongation and ultimately 'freedom from restriction'. 2. Mark Barnes ( 1 997) states: 'Myofascial release is a ha nds-on soft tissue technique that facilitates a stretch into the restricted fascia. A sustained pressure is applied into the restricted tissue barrier; after 90- 1 20 seconds the tissue will undergo h istological l ength changes a l lowing the first release to be felt. The therapist follows the release into a new tissue barrier and holds. After a few releases the tissue will become softer and more pliable'. 3. Mock (1 997) offers a different, more active (both practitioner and patient) form of myofascial release methodology. 'Ad hesions' (described as 'ropy', 'leathery', 'fibrous', 'nodular', etc.) are identified in soft tissues by means of pa l pation. Various release methods are described, the most active involv­ ing compression of the dysfu nctional tissue as the muscle in which it is found is taken, four or five times at one treatment session, either passively or actively, through a ra nge of move­ ment from its shortest to its longest length. This effectively 'drags' the 'adhesion' u nder the compressive contact and ' releases' it. most anterior aspect. The scapula forms the posterior bor­ I. FACI LITATI O N O F TO N E I N S E R RAT U S der of the palpable region and may be lifted away from the , ANTE R I O R U S I N G PU LSED M ET (Ruddy 1 962) thorax so as to reach as much of the muscle as possible by sliding the treating thumb under the lateral aspect of the This technique is used for rehabilitation and proprioceptive scapula to apply friction or gliding strokes onto the rib cage. reeducation of a weak serratus anterior. If the muscle fibers are not excessively tender, light fric­ • The patient is seated or standing and the practi tioner tion is applied in between and on the ribs to assess and treat places a single-digit contact very lightly against the the serratus anterior. If extremely tender, light-pressure lower medial scapula border, on the side of the upper gliding strokes (anterior to posterior) are applied to an area trapezius being treated. The patient is asked to a ttemp t to tha t begins at the top of the lateral chest (in the axilla) and ease the scapula (at the point of d igital contact) toward ends at the bottom of the rib cage. The more tender the mus­ the spine. cle, the lighter the pressure should be. If the lightest pres­ sure is still too much, cryotherapy (ice applications) may be • The request is made, 'Press against my finger with your substituted and the treatment attempted again at a future shoulder blade, toward your spine, just as hard (i.e. very session. Progressively more pressure may be applied as the lightly) as I am pressing against your shoulder blade, for tenderness subsides with treatment, unless osteoporosis or less than a second'. recent rib fractures contraindicate pressure techniques. • Once the patient has managed to establish control over The friction or gliding techniques may be repeated at the particular muscular action required to achieve this thumb-width intervals, from the pectoralis minor to as far subtle movement (wruch can take a significant number of posteriorly as possible and from the axilla to the 9 th rib. attempts) and can do so for 1 second at a time, repeti­ Allowing the tissue to rest between applications of gliding tively, the sequence based on Ruddy'S methodology (see strokes or friction will often produce dramatic reduction of Chapter 10) can be commenced. tenderness. • The patient is instructed, 'Now that you know how to Myofascial release techniques may also be used on the activate the muscles which push your shoulder blade lateral surface of the body. lightly against my finger, I want you to do this 20 times in Note: MET applied to the upper fixators of the shoulder (if 10 seconds, starting and stopping, so that no actual they test as short), notably upper trapezius, to release movement takes place, just a contraction and a stopping, hypertonicity would automatically increase tone in serra tus repetitively'. an terior.

1 3 Shoulder, arm and hand 467 Cephalic vein Subclavius Pectoral branch of thoracoacromial artery Lateral pectoral nerve ---+­�_f Pectoralis minor --'.-r+t,f Clavipectoral fascia --Tt-:'­fd Pectoralis major --:r-;� Medial pectoral nerve --/-'r,.tiF Attachment of fascia to fioor of axilla --'+-f�I: Pectoralis major Figu re 1 3.65 With pectora lis major removed, pectora l i s m i nor, subcl avi us and clavi pecto ra l fascia a re revea led, as well as the neurovascular bundle cou rsing deep to them. Reprod u ced with permission from Gray's Anatomy for Students (2005). • This repetitive contraction will activate the rhomboids, Costal portion: costal cartilage of ribs 2-6 (or 7) middle and lower trapezii and serratus an terior, all of Abdominal portion: superficial fascia of external obligue and which are probably inhibited if upper trapezius is hyper­ (sometimes) upper part of rectus abdominis; all portions tonic. The repetitive contractions also produce an a uto­ converge into a tendon a ttaching to the lateral lip of the matic reciprocal inhibition of upper trapezius. intertubercular sulcus of the humerus at its greater tubercle • The patient should be taught to place a light finger or In nervation: Medial and l a teral pectoral nerves (C5-Tl) thumb contact against the medial scapula (opposite arm Muscle type: Postural (type 1), shortens when stressed behind back) so that home application of this method can Function: Adduction (and horizontal adduction), medial be performed several times daily. rotation of the humerus, flexion of the humerus (clavicu­ PECTO RALIS MAJ O R (FIGS 1 3.65, 1 3.66) lar), extension of the flexed shoulder (sternal, costal), brings the trunk toward the humerus when the h umerus Attachments: Clavicular portion: sternal half of the anterior surface of the clavicle is fixed (such as in pull-ups), lowers the raised arm (ster­ Sternal portion: sternum nal, costal, abdominal), pulls the shoulder girdle down and forward (sternaL costal) or up and forward (clavicu­ lar), accessory in deep (forced) respiration

468 CLI N ICAL A P P LICAT I O N OF N E U R O M USCULAR TECH N I Q U E S : T H E U PP E R B O DY Pectoratis major Pectoralis major Subclavius Figure 1 3. 6 6 Trigger point patterns of pectora lis major and subclavius. Drawn after Si mons et al (1 999).

1 3 Shoulder, arm and hand 469 Synergists: Adduction: teres major (and perhaps minor), a somatovisceral referral that causes irregular heart beats. anterior and posterior deltoid, subscapularis, triceps The associated trigger points are found between the 5th and (long head), latissimus dorsi 6th ribs on the right side while trigger points in a similar Medial rotation: latissimus dorsi, teres major, subscapularis position on the left side mimic ischemic heart disease. Flexion ofhumerus: supraspina tus, an terior deltoid, biceps brachii, coracobrachialis In the condition of thoracic outlet syndrome, pectoralis Protraction of shoulder: subscapularis, pectoralis minor, major and subclavius should be trea ted due to their down­ serratus anterior, subclavius ward pull on the clavicle. This tension, coupled with Depression of shoulder: la tissimus dorsi, lower trapezius, upward pull of the 1st and 2nd ribs by the scalene muscles, serratus anterior can close the subclavicular space, leading to impingement of Assist clavicular section: anterior deltoid, coracobrachialis, the neurovascular and /or lymphatic structures serving the subclavius, scalenus anterior, sternocleidomastoid upper extremity, which by definition is thoracic outlet syn­ Assist lowerfibers: subclavius, pectoralis minor drome (Simons et al 1999). Additionally, pectoralis minor may produce a similar result a few inches further inferolat­ Antagonists: To sternal section: rhomboidii, middle trapezius erally along the neurovascular course and the scalene mus­ To adduction: supraspinatus, deltoid cles may entrap the cervical nerves as they exit the vertebral To medial rotation: teres minor, infraspinatus, posterior column (especially when brea thing patterns are abnorma l). deltoid; the clavicular and costal fibers antagonize each other in raising and lowering the arm to horizontal Chronic shortening of pectoralis major and minor pro­ duces a rounded shoulder, slumping posture, which is usu­ Indications for treatment ally accompanied by a forward head position. Treahnent of the pectoral muscles, diaphragm, upper rectus abdominis and • Back pain between the scapulae other muscles that influence this dysfunctional posture is • Pain in front of the shoulder, in the chest and /or down important in an effort to regain proper aligrunent. Further, the rhomboids and lower trapezius are often inhibited and weak, the arm which allows the forward slumping. A postural retraining • Intense chest pain program should be implemented which incorporates length­ • Breast pain ening, strengthening and awareness exercises to avoid recur­ • Symptoms of vascular thoracic outlet syndrome ring dysfunctional postural patterns which are often induced by chronic work positions and recreational habits. Special notes Overlying the pectoralis major are mammary tissues and The pectoralis major is one of the most complex muscles of the nipple of the breast. In both genders, but significantly in the shoulder region, having four sections, a spiraling twist a higher percentage of females, breast cancer is a condition to its lamina ted layers and crossing three joints (sternoclav­ for which surgical removal, various types of reconstruction icular, acromioclavicular, glenohumeral) to influence sev­ and significant tissue damage may be presented; 99% of eral movements of the upper extremity. The complex breast cancer cases occur in women. Fifty years ago a arrangement of its layers of laminae is best viewed from woman's chance of developing breast cancer was 1 in 20 behind (as shown exquisitely by Simons et al (1999) in while today's chances are 1 in 8 (DeLany 1999, Fitzgerald Figure 42.5) as an anterior view primarily encompasses 1998, National Cancer Institute 2006). It is the second leading only the superficial layers. To form the anterior axillary cause of cancer dea ths in women and is the leading cause of fold, the dorsal layers fold under the ventral layers in a spi­ all death in women aged 40-55. Poshnastectomy care is a ral so that the lowest fibers attach highest on the humerus. condition often presented to the manual practitioner for rehabilitation of the upper extremity and chest muscles. Pectoralis major is one of many muscles whose trigger points can refer pain that mimics true cardiac pain. While it Since breast cancer is a life-threa tening condition, it is criti­ is important to rule out these trigger points as the source of cally important that a comprehensive treatment plan with a false angina, it is even more important to rule out ischemic qualified healthcare professional be initiated as soon as a heart disease as the source of viscerosomatic chest pain. If breast cancer diagnosis has been made. Traditional treatments trigger points are a source of a mimicking angina pattern include surgery, radiation, chemotherapy and hormonal and the pattern is abolished, an underlying true cardiac drugs (DeLany 1999, Fitzgerald 1998, National Cancer condition may still exist even though the external pain pat­ Institute 2006). Each of these treatments has its own posttreat­ tern has been eliminated. Similarly, once a cardiac condition ment side effects and special precautions must be taken in is stabilized and chest pain still exists, trigger points may each case. Consulta tion with the patient's physician(s) and a be found to be the source of the long-lasting (and fear­ clear understanding of her particular condition and trea tment provoking) pain (Simons et al 1999), long after the source of plan is recommended before beginning myofascial therapy. the pain has been removed. Great care must be used when addressing poshnastec­ Pectoralis major or underlying intercostal fibers may tomy tissues, especially w i th reconstruction efforts or contain trigger pOints associated with cardiac arrhythmias, lymph node removal (Chikly 1999). The myofascial tissues of the area may be extremely tender and the site of incision

470 CLIN ICAL APPLICATION OF N EU R O M U SCULAR TECH N I QUES: T H E UPPER BODY Figure 1 3.67 Test for strength of pectora lis major. A : I ncorrect procedu re. B : Correct procedure (because shoulder is stabil ized). may not have healed completely. In the case of radiation • If pectoralis major is normal the arms should be able to therapy, extreme cau tion must be taken with any tissue that easily reach horizontal (parallel with the floor) while was irradiated as i ts capillaries are often more fragile. being directly in contact with the surface of the table for Aggressive therapies, such as friction, skin rolling or even the entire length of the upper arms. There should be no myofascial release, may result in permanent injury to the arching of the back or twisting of the thorax. capillary vessels. This would include all muscles of the region that was irradiated and potentially those that lie on • If an arm cannot rest with the dorsum of the upper arm in the posterior surface of the body through which the radia­ contact with the table surface, withou t effort, then pec­ tion would also pass. toral fibers (major and /or minor) are almost certainly short. Special care is advised with postmastectomy cases to avoid increasing lymph congestion within the extremity (Chikly • Assessment of the sternal portion of pectoralis major 1999), to avoid stretching the incision tissue until well healed involves abduction of the arm to 90° (Lewit 1985). In this and to avoid working with certain techniques when edema or position the tendon of pectoralis major at the sternum inflammation already exists. Unless otherwise contraindi­ should not be found to be unduly tense even with maxi­ cated, lymph drainage and antiinflammatory techniques (e.g. mum abduction of the arm, unless the muscle is short. cryotherapy) may be applied to these tissues until the tissue conditions change to allow massage applications. Special • For assessment of costal and abdominal attachments the training may be needed to safely apply lymphatic drainage arm is brought into elevation and abduction as the mus­ and other techniques in cancer recovery therapy. cle as well as the tendon on the greater tubercle of the humerus is palpated. Other less aggressive techniques, such as myofascial release or mild stretching techniques, may be applied to • Tautness will be visible and tenderness of the tissues associated muscles until the questionable tissues can be under palpation will be reported, if the sternal fibers safely treated with NMT. Ex treme tenderness to even mild have shortened. touch, redness, swelling and heat within the tissues all indi­ cate an inflammatory response, which could be in tensified ASS ESSM E NT F O R STR E N GTH O F PECTORALIS or spread with NMT applica tions. Consultation with the MAJOR [FIG. 1 3.67) patient's phYSician is strongly advised and special training in postmastectomy care is suggested, especially if the prac­ • Patient is supine with arm in abduction at the shoulder titioner 's experience is limited in this area . joint and medially rotated (palm is facing down) with the elbow extended. ASSESS M E NT FOR S H O RTN ESS I N PECTORALIS MAJ O R • The practitioner stands at the head and secures the oppo­ site shoulder wi th one hand to prevent any trunk torsion • The patient lies supine with the head several feet from and contacts the dorsum of the distal humerus with the the top edge of the table and is asked to ex tend the a rms other hand. above the head and rest them on the treatment surface with palms facing up. • The patient a ttempts to lift the arm and to bring it across the chest, against resistance, as strength is assessed in the sternal fibers. • Different arm positions can be used to assess clavicular and costal fibers.

1 3 Shoulder, arm and hand 47 1 !\\ Figu re 1 3.68 Trigger point referral for the axi l lary portion of Figure 1 3.69 The b reast tissue self-displaces toward the treatment pectora lis major is i nto the b reast tissue. Referral pattern d ra w n table, w h ich al lows excellent access to pectoralis major's lateral after Simons et al ( 1 999). portions. • For example, with an angle of abduction with elevation of 135°, costal and abdominal fibers will be involved; with abduction with eleva tion of 45°, the clavicular fibers wil l be assessed. • The practitioner should palpate to ensure that the 'cor­ rect' fibers contract when assessments are being made. It N MT F O R PECTO RALIS MAJ O R Figure 1 3.70 The arm is tractioned forward to pull the clavicle away from the underlying neurovascular structures. The patient remains in a sidelying position. The arm to be treated is uppermost and rests in the supported arm position pectoralis major. Thickness usually associa ted with trigger without forward pull on it. The practitioner is seated caudad points is often found in the mid-fiber region. When nodules, to the extended arm at the level of the pa tient's waist and exquisitely tender spots or taut fibers are found, the practi­ grasps the fibers of the axillary portion of pectoralis major tioner locates and isolates the trigger points and applies with the cephalad (treating) hand. The pa tient's arm may be static compression for 8-1 2 seconds which may provoke placed on the practitioner's shoulder for support and eleva­ classic referral patterns into the breast tissues, onto the chest tion, which may a lso allow better access to the area, or it can and down the arm. Addi tionally, a ligh t stretch placed on be supported by the patient. The arm is pulled forward until the fibers may make the ta ut fibers more palpable and may the pectoralis major 'pulls away' from the chest wall. The also augment the release. breast tissues will displace themselves toward the therapy table and away from the mid-belly region of the pectoralis To treat the clavicular a ttachment of pectoralis major and major where the central trigger points can be fOLmd (Fig. subclavius (see p. 477) which lies deep to i t, the patient 13.68) . Although the practitioner could be standing to per­ remains in a sidelying position and the practitioner stands form this technique, a seated posi tion is recommended to cephalad to the pa tient's head. The patient's supported arm decrease wrist stress and avoid bending at the waist (which is pulled as far forward as possible to distract the clavicle may produce low back strain). If the wrist does feel strained, from the chest. The fingers of the 'face-side' (treating) hand the practitioner should change position in such a way that are 'curled' onto the inferior surface of the clavicle and fric­ the wrist rests in a neutral position, which usually involves tion is applied to the entire length of the inferior aspect of moving toward the patient's feet. the clavicle to treat the clavicular a ttachment of pectoralis major and subclavius (Fig. 13.70). The supraclavicular fossa Pincer palpation is used to isolate and assess each section of the muscle (in small portions) while avoiding intrusion onto breast tissues. If not too tender and unless otherwise contraindicated, each of the three sections of pectoralis major is manipulated by rolling the fibers between the thumb and fingers of the examining hand . Taut bands tha t are adhered to one another may separate and can then be addressed more independently. The practitioner continues to examine the fibers i n thumb-width segments while moving toward the hwneral insertion (Fig. 13.69) . Repeat the process for all divisions of

472 CLI N ICAL A P P LI CAT I O N OF N E U RO M U SCU LAR TECH N I Q U E S : T H E U P P E R B O DY is avoided as the brachial plexus and blood vessels lie here --- - - \\..' and may be damaged by excessive pressure. Pectoralis major /1 is usually thick and pressure may need to be increased to influence subclavius, which lies deep to it. However, the \\ pressure should be d irected onto the inferior surface of the clavicle and not deeply into the torso as the neurovascular Figure 1 3.71 The stern a l i s has a frighten i n g 'cardiac-type' pa i n bundle serving the upper extremity also courses through pattern i ndependent o f m ovement while the 'cardiac a rrhythmia' the subclavicular area. When addressing subclavius in this trigger point (see fingerti p) contributes to distu rbances i n normal position, the arm should be pulled so far forward that the hea rt rhyth m without pa i n referra l . Drawn after Simons et al ( 1 999). patient almost rolls forward, which will pull the clavicle even further away from the chest wall and help to protect • Between these two extremes lies the position which influ­ the neurovascular structures. ences the sternal fibers most directly. Following the trea tment of pectoralis minor in the sidely­ • The patient lies as close to the side of the table as possible ing posi tion (see pp. 316 and 476), the patient moves to a so that the abducted arm can be brought below the hori­ s upine position. The sternal and costal attachments of pec­ zontal level in order to apply gravitational pull and pas­ toralis major and sternalis are assessed by the practitioner sive s tretch to the fibers, as appropria te. who stands at the level of the chest on the side being treated. Lubrica ted gliding strokes, friction or myofascial • The practi tioner stands on the side to be treated and release may be applied to the remaining portions of pec­ grasps the humerus while the other hand contacts the toralis major while care is taken not to intrude on breast tis­ insertion of the shortened fibers (on a rib or near the ster­ sue. The pa tient's hand may be used to displace and protect num or clavicle, depending upon which fibers are being the breast while the practitioner examines the attachments treated and which arm position has been adopted). along the sternum and the portion of the muscle that lies caudal to the breast. • The thenar and hypothenar eminence of the contact hand stabilizes the area during the contraction and stretch, Slow, transverse friction is applied to the sternum to preventing movement of it but not exerting any pressure examine for a sternalis muscle or trigger points within the to stretch it. fascia covering the sternal area. These trigger points may refer a deep ache to the chest and pain down the upper arm • The patient's hand should be placed on the contact area (details regarding sternalis are found on p. 479). so tha t the practitioner's hand can be placed over i t, allowing i t to act as a 'cushion'. This hand placement is The practitioner locates the top of the xiphoid process or for physical comfort and also prevents physical contact where the two sides of the ribs meet if the xiphoid is not pal­ with emotionally sensitive areas, such as breast tissue. pable. The practitioner's palpating finger moves laterally onto the right side (approximately 2 inches (S cm), depend­ • All stretch is achieved via the positioning and leverage of ing upon body size) and into the rib space between the 5th the arm; the contact hand on the thorax (whether directly and 6th ribs. The practitioner palpates on the ribs and in or 'through' the patient's hand) acts as a stabilizing con­ between the ribs on pectoralis major and intercostal muscle tact only. fibers for tenderness and trigger points. These 'cardiac arrhythmia' trigger points may refer into the heart and • As a rule, the long axis of the pa tient's upper arm should cause disturbances in i ts normal rhythm (Simons et a1 1999) be in a straight line with the fibers being trea ted. (Fig. 13.71). Though the trigger point is located on the right side, the corresponding points on the left side should a lso • A useful hold, which depends upon the relative sizes of be treated to eliminate contralateral referrals, which may the patient and the practitioner, involves the practitioner perpetuate these volatile trigger points. grasping the anterior aspect of the patient's flexed upper arm just above the elbow, while the patient cups the It M ET F O R P E CTO R A L I S M AJ O R • The pa tient lies supine with the arm abducted in a direc­ tion which produces the most marked evidence of pec­ toral shortness (assessed by palpation and visual evidence of the particu lar fibers involved). • The more elevated the a rm (i.e. the closer to the head), the more focus there will be on costal and abdominal fibers. • With a lesser degree of abduction, to around 45°, the focus is more on the clavicular fibers.

1 3 Shou lder, arm and hand 473 ,-�- Figure 1 3.72 M ET trea tment of pectora l i s major, supine position. Figu re 1 3.73 M ET treatment of pectora l i s m ajor, prone position. practitioner's elbow and holds this contact throughout �� A LT E R N ATIVE M ET F O R P E CTO R A L I S M AJ O R the procedure (Fig. 13.72). , (FIG. 1 3.73) • Starting with the patient's a rm in a position which takes the affected fibers to just short of their restriction barrier, • Patient is prone with face in a face hole or cradle. the patient introduces a light contraction (20% of • The patient's right arm is abducted to 90° and the elbow strength) involving adduction against resistance from the practitioner, for 7-1 0 seconds. flexed to 90°, palm toward the floor, with upper arm sup­ • If a trigger point has previously been identified in pec­ ported by the table. toralis major, the practitioner should ensure, by means of • The practitioner stands at waist level facing cephalad palpation if necessary or by observation, that the fibers and places the non-tableside hand palm to palm with the housing the triggers are involved in the contraction. patient's so that the patient's forearm is in contact with • As the patient exhales following complete relaxation of the ventral surface of the practi tioner 's forearm. the area, a stretch through the new barrier is activated by • The practitioner's tableside hand rests on the patient's the patient and maintained by the practitioner. right scapula area, ensuring that no trunk rotation occurs. • The stretch needs to be one in which the arm is first • The practitioner eases the patient's arm into extension a t pulled away (distracted) from the thorax before the the shoulder until the first sign of resistance from pec­ stretch is introduced which involves the humerus being toralis is sensed. It is important when extending the arm taken below the horizontal. in this way to ensure that no trunk rotation occurs and • During the stretching phase it is important for the entire that the anterior surface of the shoulder remains in con­ thorax to be stabilized . No rolling or twisting of the tho­ tact with the table throughout. rax in the direction of the stretch should be permitted. • The patient is asked, using no more than 20% of strength, • The stretching procedure should be thought of as having to bring the arm toward the floor and across the chest, two phases: with the elbow taking the lead in this attempted move­ 1. the slack being removed by distracting the arm away ment, which is completely resisted by the practitioner. • The practitioner ensures that the patient's arm remains par­ from the contact/ stabilizing hand on the thorax allel with the floor throughout the isometric contraction. 2. movement of the arm toward the floor, initiated by the • Following release of the contraction effort and on an exhalation, the arm is taken into greater extension, with practitioner bending the knees. the patient's assistance, and held at stretch for not less • Stretching should be repeated 2-3 times in each position. than 20 seconds. • All attachments should be treated, which calls for the use • This procedure is repeated 2-3 times, slackening the muscle slightly from i ts end-range before each subse­ of different arm positions, as discussed above, as well as quent contraction, to reduce discomfort and for ease of different stabilizing ('cushion') contacts as the various application of the contraction. fiber directions and attachments are stretched.

474 CLI N ICAL APPLICATION OF N E U RO M USCULAR TECH N I QUES: THE U PPER BODY Figure 1 3 .74 Pa l pation of pectora lis major fo r M FR appl ication. Muscle type: Not determined Function: Draws the shoulder down and forward, rotates • Varia tions in pectoralis fiber involvement can be achieved by altering the angle of abduction: with a more superior the scapula (depressing the glenoid), accessory in deep angle (around 140°), the lower sternal and costal fibers; (forced) respiration, lifts the inferior angle and medial with a lesser angle (around 45°), the clavicular fibers will border of the scapula away from the ribs be committed. Synergists: Deep respiration: diaphragm, scalenes, inter­ costa Is, levator scapula, sternocleidomastoid, upper \" M FR F O R P E CTORA L I S M AJ O R (FIG. 1 3.74) trapezius Shoulder depression: pectoralis major, latissimus dorsi, • Patient is supine with arm in abduction at the shoulder lower trapezius joint and medially rotated so that the palm is facing Forward pull and rotation of scapula: pectoralis major down and the elbow is extended. Downward rotation: rhomboids, levator scapula Antagonists: To protraction and rotation of scapula: lower • The practitioner palpates and assesses pectoralis major trapezius until areas of restriction, congestion or fibrosis are To shoulder depression: upper trapezius, levator scapula discovered. I n d i cations for treatment • The arm is then brought into adduction to slacken the muscle fibers. • Chest pain similar to cardiac pain • Restricted humeral movements (particularly in reaching • The slackening process is further encouraged by means of light compression from the upper humerus toward the overhead) lower sternum. • Constriction of nerve or blood flow when reaching over­ • A broad flat (finger pads or thumb) digital contact is then head or sleeping with the arms resting overhead (neu­ made just d istal to the dysfunctional tissues. rovascular entrapment syndrome) • The patient is then asked to move the arm to its fullest Specia l notes abduction and then back into adduction, lengthening and shortening the m uscle, and so intermittently drag­ Postural implications of pectoralis minor have been dis­ ging the dysfunctional tissues under the compressive cussed previously with the overlying pectoralis major. force of the practitioner 's fingers or thumb. Widely prevailing slumping postures created by tightness in pectoralis minor are readily noticeable (along with forward • 3-5 repetitions are normally adequate for each contact head position) when viewing the body from the side (coro­ area. nal plane). Kyphosis often accompanies the 'depressed' look of this postural position, as do repressed breathing patterns. • Different arm positions can be used to trea t the various pectoral fibers in the same manner. Impingement of neurovascular structures that course deep to pectoralis minor may create duplication of symp­ PECTORAL I S M I N O R toms of thoracic outlet syndrome. In such a case, the patient will report loss of feeling in the hand or a tendency to drop Attachments: O uter and upper surfaces of 3rd through 5th objects, particularly when reaching up to a shelf to retrieve ribs (sometimes 2nd through 4th) and fascia of a djoining them. Additionally, the radial pulse (which is being simul­ in tercostals to the medial aspect of the coracoid process taneously palpated) will d isappear as the axillary artery becomes occluded when the practitioner administers the Innervation: Medial and lateral pectoral nerves (C5-T1) Wright maneuver, a positioning which places the arm in hyperabduction or, in some cases, by merely abducting the humerus to 90° with lateral rotation (see Simons et al 1999, p. 350, Fig. 43.4). Trigger points in pectoralis minor can refer into the breast, creating pain and hypersensitivity of the breast and nipple, into the chest and anterior shoulder, down the ulnar side of the arm and into the last three fingers and palmar hand. Whereas scalenus anticus is more likely to produce hand edema and finger stiffness by entrapment of the subclavian vein, the authors' cl inical experience indica tes that fascial restrictions and scar tissue, due to surgery or other traumas, near the coracoid process may also occlude lymph drainage of the upper extremi ty. This consideration is especially

1 3 Shoulder, arm and hand 47 5 • Tissues which su rround neura l structu res, and which move • Additional tests to assess for shortened muscle structures and independently of the nervous system, are cal led the mechanical joint restrictions wou ld a lso be appropriate, as these may be the interface (MI) (e.g. supinator muscle is the MI to the radial nerve, cause of adverse tension i n the nervous system. as it passes through the radial tunnel). Upper limb tension tests (ULTI) • Any pathology in the MI may produce tension on the neura l Both versions of the ULT test described below should be used in structure, with unpredictable results (e.g. disc protrusion, cases i nvolving thoracic, cervical and u pper limb symptoms, even if osteophyte contact, carpal tunnel constriction). this i nvolves only local finger pai n . • Symptoms are more easily provoked in active movement rather U LTI 1 than passive tests. 1 . Patient is supine and the practitioner places the tested a rm into • Pathophysiolog ical changes resu lting from i nflammation or from abduction, extension and lateral rotation of the glenohumeral joint. chemica l damage (i.e. toxic) a re noted as commonly leading on to 2. Once these positions a re establ ished, supination of the forearm is internal mechanical restrictions of neural structures in a different man ner from mechanical causes, such as those imposed by a disc introduced together with el bow extension. lesion, for example. 3 . This is followed by addition of passive wrist and finger extension. • Adverse mechanical tension (AMT) changes do not necessarily affect If pain or sensations of tingling or numbness are experienced at any nerve conduction (Butler Et Gifford 1 989) but Korr's ( 1 981) research stage during the positioning into the test position or during addition shows it to be likely that axonal transport wou ld be affected. of sensitization maneuvers (below), particularly reproduction of neck, shoulder or arm symptoms previously reported, the test is positive; • Maitland (1 986) suggests that treatment (placing the neura l this confirms a deg ree of mechanical in terference affecting neural structures at tension, i n the test positions) involves 'mobilization' structu res. of the neural structures, rather than simply stretching them, and recommends that these tests be reserved for conditions which fa il Additional sensitization is performed by: to respond adequately to normal mobil ization of soft and osseous structures (muscles, joints and so on), for example by use of • adding cervical lateral flexion away from the side being tested, or tech niq ues such as NMT or MET. • introduction of U LTI 1 on the other arm simultaneously, or • the simu ltaneous use of straight leg raising, bi- or u n ilateral ly, or Notes • introduction of pronation rather than supination of the wrist. 1 , When a tension test is positive (i.e. pain is produced by one or ULTI 2 another element of the test - initial position alone or with ' Butler maintains that ULTI 2 replicates the working posture i nvolved sensitizing' additions) it only indicates that AMT exists some­ in many instances of u pper limb repetition disorders. where in the nervous system. 2. The restriction is not, however, necessa rily at the site of reported 1 , To perform right-side ULTI 2, the patient l ies close to right side of pain. the table, i.e. sca pula is free of the su rface. 3. When tissues housing myofascial trigger poi nts a re stretched, pain and other sensations may result. This can add a degree of 2. Trunk and legs are angled toward the left foot of the table. confusion when evidence derived from use of the tension tests is 3, The practitioner stands to right side of the patient's head facing the being eva luated. feet with the left thigh depressing the patient's right shoulder g irdle. GEN ERAL PRECAUTIONS AND CONTRAINDICATIONS 4. The patient's fu lly flexed rig ht a rm is supported at both elbow • Care shou ld be taken when introducing sideflexion of the neck and wrist. during the u pper limb tension test. 5. Variations in the degree and angle of shou l der depression ('l ifted' • If any a rea is sensitive, care should be taken not to aggravate toward ceiling, held toward floor) may be used. existing cond itions d uring the performance of tests. 6. Holding the shoulder depressed, the practitioner's right hand • If obvious neurological problems exist special care shou l d be grasps the patient's right wrist while the elbow is held by the taken not to exacerbate the condition by vigorous or strong practitioner's left hand. stretc h i n g . • Similar precautions apply to d iabetic, MS or recent surgica l Sensitization options include: patients or where the area being tested is much affected by circulatory deficit. • shoulder internal or external rota tion • The tests should not be used if there has been recent onset or • elbow flexion or extension worsening of neu rological signs or if there is any cauda equina • forearm supination or pronation. or cord lesion. A combination of shoulder internal rotation, elbow extension and General advice regarding use of these methods forearm pronation is the most sensitive. • Usually treatment positions that encourage release of mechanical The practitioner then slides the right hand down onto the restrictions impinging on neura l structures involve rep lication of patient's open hand, with the thumb between the patient's thumb the test positions. and i ndex fi nger and i ntroduces supi nation or pronation, ulnar or • Butler ( 1 99 1 ) suggests that initial stretching should commence well radial deviations or stretching of fi ngers/th umb. away from the site of pain in sensitive individuals and conditions. • Retesting regularly during treatment is useful, in order to see Further sensitization may involve: whether there are gains in range of motion or lessening of pain provoked during testing. • neck movement (e.g. sidebend away from tested side) or • Any sensitivity provoked by treatment should subside im mediately • altered shoulder position, such as increased a bduction or extension. fol lowing application of a test position/stretch. If it does not, the technique/test should be stopped to avoid i rritation of the neura l Notes tissues involved. • Butler ( 1 991) reports that where mechan ical interface restrictions are present, cervical lateral flexion away from the tested side increases arm symptoms in 93% of people a nd cervical lateral flex­ ion towards the tested side increases symptoms in 70% of cases. • ULTI mobil izes the cervical dural theca in a tra nsverse d i rection.

476 C LI N I CA L APPLICATION OF N E U ROM USCU LAR TECHN IQUES : T H E UPPER BODY important if lymph node removal was necessary, particu­ Fig u re 1 3.75 When pectora lis m i nor is extremely tender, m i l d static larly from the subclavicular area. (See additional informa­ pressure is substituted for frictional techniques. tion regarding the lymphatic system on pp. 29-31.) Simons et al ( 1999) note that pectoralis major can occlude lymphatic drainage of the breast and that trigger points which form in posttraumatic scar tissue in the regions of pectoralis minor's coracoid attachment are relieved by trigger point injection. However, extreme caution is advised when injecting tho­ racic muscles to avoid penetration into the thoracic cavity. Additional slips of the muscle are sometimes noted, vary­ ing in number and level (Gray's Anatomy 2005, Platzer 2004, Simons et al 1999), including fibers extending to the greater tuberosity of the humerus (Simons et al 1999). More rare variations include pectoralis minimus (coracoid process to the first rib) (Gray's A natomy 2005) and pectoralis inter­ medius (from rib cartilages to the fascia covering biceps brachii and coracobrachialis) (Simons et al 1999). Though rarely absent, pectoralis minor may be present or absent when pectoralis major is missing (Gray's A natomy 2005). � N M T F O R P E CTO R A LI S M I N O R t � '/�'l) ), The patient i s placed in a sidelying position with the arm - - --''-'- -- supported by the patient or placed on top of the practi­ tioner's shoulder when the practitioner is seated at the level Figure 1 3.76 Trigger point ta rget zones for pectora l is m i nor. Draw n of the patient's chest. The arm is pulled forward sufficiently after Si mons et al ( 1 999). to allow the thumb of the practitioner's caudal hand to be placed posterior to pectoralis major and directly on the cau­ Gentle friction may also be applied through pectoralis dal end of pectoralis minor. The practitioner presses onto major while transversing the fibers of pectoralis minor, the lateral head of pectoralis minor a t its 5th rib attachment coracobrachialis and short head tendon attachment of to assess for tenderness. Static pressure may be used for biceps brachii as long as the supporting structures of the 8-12 seconds or, if not too tender, light-pressure transverse breast mentioned above and neurovascular structures deep friction may be applied. This muscle, when non-tender or to the coracoid are respected. Biceps tendon and coraco­ only mildly tender, responds well to a unidirectional snap­ brachialis lie laterally and perpendicularly oriented to pec­ ping friction which transverses i ts fibers. toralis minor in this arm position. The practitioner's treating thumb is moved up the muscle The muscle fibers are all stretched when the arm is in this at thumb-width intervals and applies static pressure and/ position of extreme lateral rotation and less pressure is used or crossfiber friction to the entire length of pectoralis minor to avoid tearing the fibers or provoking a reflexive spasm. (Fig. 13.75). This muscle may become significantly wider at the 4th and then a t the 3rd rib a ttachments. The treatment MET and MFR treatments of pectoralis major (pp. 472-474) techniques are stopped approximately 2 inches (5 cm) caudal would a lso involve (to an extent) pectoralis minor. to the coracoid process to avoid compressing the neurovas­ cular blmdle that supplies the arm. If pectoralis minor is not too tender, these steps are repeated (gently) 2-3 times. Often, static compression will release the fibers more readily, espe­ cially after the light friction has been applied at least once. With the patient in the supine position, pectoralis minor may be further addressed through pectoralis major. With the elbow flexed to 90°, the arm is placed in an abducted, exter­ nally rotated ('Hi') position (Fig. 13.76). Myofascial release may be used superficial to pectoralis minor (through pec­ toralis major). The pressure should be toward the clavicle rather than toward the breast to avoid stretching the fascia and ligaments that support the breast tissue. This step may also help to bring the shoulders back into coronal alignment.

1 3 Shoulder, arm and hand 477 S U B C LAVI U S Attachments: From the first rib at its j unction with its costal cartilage to the middle third of the clavicle on its caudad surface Innervation: Subclavian nerve (C5-6) Muscle type: Not determined Function: Assists in bringing the shoulder down and for­ ward, seats the clavicle onto an articular disc at the stern­ oclavicular joint Synergists: Protraction of the shoulder: pectoralis major, sub­ scapularis, pectoralis minor, serra tus anterior Antagonists: Trapezius, rhomboidii I n d ication for treatment • Pain under clavicle and down the arm Figu re 1 3.77 Di rect myofascial stretch for pectora lis m i nor. Specia l notes D I R ECT ( B I LAT E RAL) MYO FAS C I A L STRETCH This muscle has a short, thick tendon and is difficult to pal­ �� O F S H O RT E N E D P E CTO R A L I S M I N O R pate or access for electromyography. It may be absent but , (FIG. 1 3.77) that would be difficult to determine manually since it underlies the thick clavicular head of pectoralis major. • The patient is supine with the arms comfortably at the side. Some of its fibers may be influenced through pectoralis • The practitioner, while standing at the head of the table, major if care is taken to avoid intruding on the neurovascu­ lar complex that lies deep to a portion of it. internally rotates the arms and places the palms of the hands (having ensured nails are well clipped) into the The pain pattern for subclavius is significant as it is one axilla, palms touching the medial humerus, thumb side of numerous muscles referring a pattern that mimics of index fingers touching the axilla . ischemic cardiac disease. As discussed in other areas of this • At this stage the dorsum of the finger pads are located book, referral to a phYSician is advised to rule out cardiac under the lateral border of each pectoralis minor. involvement. • The practitioner now slowly externally rotates the arms and, using gentle pressure, insinuates the fingertips (index, Sanders & Hammond (2005) report potential occlusion of middle and ring - the small finger and thumb play no part the subclavian vein by subclavius and surrounding tissues. in this method) under the lateral border of the muscle. • The hands, the palms of which are now facing medially, Unilateral arm sweLLing without thrombosis, when not are then drawn lightly toward each other (medially) until caused by lymphatic obstruction, may be due to subclavian all the slack in pectoralis minor has been removed. vein compression at the costoclavicular Ligament because of • The practitioner 's hands then slowly, deliberately and compression either by that ligament or the subclavius tendon painlessly lift the tissues toward the ceiling, easing the most often because of congenital close proximity of the vein muscle away from its attachments until a ll slack has been to the Ligament. Arm symptoms ofneurogenic TOS [thoracic removed (i.e. no actual s tretching is taking place at this outlet syndrome), pain, and paresthesia often accompany stage, merely a removal of all slack). venous TOS while neck pain and headache, other common • The practitioner should then transfer body weight back­ symptoms ofneurogenic TOS, are infrequent. wards to introduce a lean which removes the slack further, by tractioning in a superior direction (toward the head). NMT techniques for subclavius are presented with pec­ • The muscle fibers will now have been eased medially, toralis major (p. 471). anteriorly and superiorly and should be held at these combined barriers as they slowly release over the next It M FR FOR S U B C LAVI US few minutes. • If correctly applied, this should not be painful or prove • The muscle lies deep to pectoralis major, between the 1st invasive to breast tissue. The procedure is normally both rib and the clavicle. well accepted and effective in releasing tensions at the lower end of the thoracic inlet. • The patient abducts and internally rotates the arm. • The practitioner makes digital contact with the muscle by applying broad flat finger pad pressure as far under the clavicle as possible, without causing undue discomfort.

478 CLIN ICAL APPLICATION OF N EU RO M USCU LAR TECH N IQUES: TH E U PPER BODY Proprioceptive neuromuscular fac i litation (PNF) methods have been • On complete relaxation, the practitioner, with the patient's incorporated into useful assessment and treatment seq uences assistance, takes the arm further into flexion, adduction and (McAtee Et Charland 1 999). These ideas have been modified to take external rotation, stretching these m uscles to a new barrier. account of MET principles (Chai tow 2003). • The sa me procedure is repeated 2-3 ti mes. 1 Stretch i nto extension • To i ncrease the ra nge of motion i n flexion, adduction and 2 Stretch i nto flexion • To i ncrease the ra nge of motion in extension, abduction and external rotation. • The patient lies supine with the head turned to the left and internal rotation. • The patient l ies supine and ensu res that the shoulders remain in ensures that the shoulders remai n i n contact with the table throughout the procedure. contact with the table throughout the procedure. • The patient flexes, adducts and externally rotates the (right) • The patient extends, abducts and internally rotates the (right) a rm ful ly, maintaining the elbow in extension (pa l m facing the ceiling). arm fu l ly, maintaining the elbow in extension (wrist pronated). • The practitioner sta nds a t the head of the table and supports the • The practitioner stands at the head of the table and supports the patient's a rm a t proximal forearm and hand. • The patient is asked to beg i n the process of returning the patient's arm at distal forearm and elbow. arm to the side, in stages, against resistance offered by the • The patient is asked to begin the process of retu rning the arm to p r a c t i t i o n e r. • The amount of force used by the patient should not exceed 250/0 the side, in stages, against resistance. of available strength. • The amount of force used by the patient should not exceed 25% • The first instruction is to pronate and internally rotate the arm ('Turn you r arm inwardly so that your pa l m faces the other way'), of available strength. followed by abduction and then extension ('Bring your arm back • The first instruction is to supinate and externally rotate the arm outwards and to your side'). • All these efforts are combined by the patient into a sustained ('Turn your arm outwardly so that your palm faces the other effort wh ich is resisted by the practitioner so that a 'compound' way'), followed by adduction and then flexion ('Bring your arm isometric contraction occurs involvi ng i nfraspina tus, m iddle back toward the table and then u p to your side'). trapezius, rhomboids, teres m inor, posterior deltoid and pronator • All these efforts are combined by the patient into a sustained teres. effort which is resisted by the practitioner, so that a 'compound' isometric contraction occurs i nvolving the clavicular head of pectora lis major, anterior deltoid, coracobrachial is, biceps brachii, infraspinatus a nd supinator. • On complete relaxation, the practitioner with the patient's assistance takes the arm further into extension, abduction and i nternal rotation, stretching these m uscles to a new barrier. • The sa me procedure is repeated 2-3 times. Fig u re 1 3.78 Spira l M ET a pp lication to increase range of Fig u re 1 3.79 Spiral M ET a p p l ication to increase ra nge of flexion, add uction a n d externa l rotation of shoulder. extension, a b d u ction and i nternal rotation of shou lder.

1 3 Shoulder, arm a nd hand 479 Box 1 3. 1 3 Sterna lis \",d chest pam ofa ventraL longitudinaL coLumn muscle Layer arising at the ventral tip of the hypomeres (Sadler, 1995). Sadler claimed Chest pain referred from this muscle [sternal is) has a terrifying that this muscle is represented by rectus abdominis in the quality that is remarkably i ndependent of body movement. abdominaL region and by the injrahyoid muscuLature in the (Simons et a1 1 999) cervicaL region; in the thorax, this Layer usuaLLy disappears but occasionally remains as a sternalis muscle. Kitamura et • The patient is then asked to adduct and externally rotate aL (1985) reported a case of congenitaL partiaL deficiency of the shoulder slowly and deliberately while firm digital pectoralis major accompanied by an enormous sternalis. pressure is maintained. BarLow (1934), on the other ha.nd, claimed that sternaLis represents the remains ofa panniculus carnosus. • This should be repeated 3-5 times. NMT techniques for sternalis are presented with pectoralis ST E R N A L I S major (pp. 471-472). Attachments: A vertical slip ascending from the sheath of CORACOBRAC H IALIS (FIG. 1 3.80) rectus abdominis, fascia of the chest or costal cartilages of the lower ribs to merge with the fascia of upper chest, Attachments: From the coracoid process to mid-way a long attach to the sternum or blend with sternocleidomastoid the medial border of the humeral shaft (between the tri­ ceps and brachialis muscle) Innervation: Varies considerably, but usually intercostal nerves or the medial pectoral nerve Innervation: Musculocu taneous nerve (C6-7) Muscle type: Postural (type I), shortens when stressed Muscle type: Not determined Function: Flexes the arm forward and adducts it, seats the Function: Unknown Synergists: Not applicable humeral head into the glenOid fossa during abduction, Antagonists: Not applicable may assist in returning the arm to neutral position Synergists: FLexion of humerus: anterior deltoid, biceps Ind ications for treatment brachii (short head), pectoraliS major Antagonists: To flexion: latissimus dorsi, posterior deltoid, • Soreness on surface of the sternum teres major, triceps (long head) • Deep, intense pain internally deep to the sternum I nd i catio ns for treatment Special notes • Pain in front of shoulder and down the posterior arm Sternalis remains one of the great mysteries of modern • Pain when reaching across the lower back anatomy. Since function is unknown and no apparent movement has been determined, the evolu tion of this mus­ Special notes cle continues to intrigue those who study the locomotor sys­ tem. To add to the mysterious nature of this anomalous This muscle's position allows it to be stretched with both muscle, i ts presence is highly variable: it may be unilateral medial and lateral rotation of the humerus. It assists in or, if bilateral, may not be symmetrical in length or size and adduction and may (uniquely) also assist in hyperabduc­ its attachments as well as innervation are unpredictable. tion by pulling the arm toward the mid-line in both of these vertical positions. It is present on average 4.4% of the time but cadaver stud­ ies range from 1.7 to 14.3% (Simons et al 1999). It is half as Approximately half of i ts belly can be touched directly likely to be bilateral as unilateral; however, when present, it is beneath the skin before it courses deep to pectoralis major likely to develop trigger points following acute myocardial on its way to the coracoid process. The practitioner 's thumb infarction or angina pectoralis and needlessly prolong the fear may slide under pectoralis major to touch an additional associated with the pain of heart a ttack (Simons et aI 1999). small portion of this muscle. The practitioner must exercise caution on the inen r surface of the upper humerus to avoid Trastour et al (2006) note that sternalis is present in 5-8% pressing on the neurovascular bundle which courses poste­ of people. They note that since physicians are usually not rior to (musculocutaneous nerve usually pierces) coraco­ familiar with it this might lead to misdiagnosis as it 'may be brachialis by palpating for the arterial pulse and remaining misinterpreted as a breast mass on mammogram'. anterior to the pulse. In a published correspondence, Jeng & Su (1998) offer a ASSESSM ENT FOR STRENGTH OF few more ideas regarding sternalis. C O RAC O B RAC H I A LI S (Ja nda 1 983) Although the importance of this muscle is still a mystery, • Patient is seated, arm alongside trunk, in ternally rotated, various difef rent interpretations have been made. CLemente elbow flexed. (1985) considered sternaLis to be a mispLaced pectoraLis major, although some embryoLogists have viewed it as part

1 Coracobrachialis Biceps brachii Brachialis Fig u re 1 3 .80 B i ceps a n d b rachial is both refer simi lar patterns to the a n teri o r upper arm w h ile brach ialis a lso extends to the thumb. Drawn after Simons et al (1 999).

1 3 Shoulder, arm and hand 48 1 Fig u re 1 3.82 Myofascial release of coracobrachial is. Fig u re 1 3.81 The neurovascular structures located nea rby a re posterior to the muscle. Palpation of the pulse and then avoided by muscle testing for loca tion of coraco brachia l is. positioning the hands to avoid the pulse is required to safely trea t this muscle. • The practitioner offers a stabilizing contact to the shoul­ der from above, hand resting directly over the joint. The coracoid attachment of coracobrachialis has been discussed with pectoralis minor in the supine position • The practitioner 's o ther hand is placed on the distal (p. 476). In that procedure, friction is applied through pec­ aspect of the humerus, just above the elbow, offering toralis major while transversing the fibers of pectoralis counterforce/resistance as the patient attempts to flex minor, coracobrachialis and short head tendon attachment the upper arm to 90°. of biceps brachii while avoiding the neurovascular struc­ tures deep to these tissues. • Both sides should be tested and compared for relative strength. This procedure also tests the anterior fibers of f M FR FOR CO RACO BRACH IALIS (FIG. 1 3.82) deltoid. • An area of restriction or fibrotic change is palpated for and It N MT FOR CO RACO BRAC H I A L I S identified in the accessible part of the muscle, i.e. in its dis­ tal third mid-way along the medial border of the humeral With the patient resting supine, the arm i s abducted to 90° shaft (between the triceps and brachialis muscles). with the forearm supinated and the upper arm supported by the table. This position will allow access to the medial • A flat thumb contact is made by the practitioner slightly aspect of the upper portion of the arm and allow room for distal to the dysfunctional tissues. the practitioner's hands to glide proximally when they are correctly positioned. • The patient lies close to the edge of the table with the elbow flexed and the shoulder externa lly rotated. To assess coracobrachialis, the thumbs are placed on the medial surface of the upper arm at mid-level and posterior • The practitioner's thumb introduces slight but firm com­ to the biceps brachii while avoiding the neurovascular bun­ pression, as the patient slowly and deliberately extends dle mentioned previously (Fig. 13.81). A muscle test of hor­ both the elbow and the humerus at the shoulder, before izontal adduction (resisted above the elbow as the arm is returning to the commencement position. raised toward the ceiling) will help define the lower fibers of coracobrachialis for palpation. The practitioner applies • The lengthening of the muscle during the extension proximal gliding strokes 7-8 times directly on the portion of aspect of this movement will draw the dysfunctional tis­ coracobrachialis that is available. As pectoralis major is sue under the compressive thumb contact. encountered, the thumbs slide deep to it to continue gliding as high as possible on coracobrachialis. • The procedure is repeated 3-5 times. Trigger point pressure release methods may be used by It PRT F O R CO RACO B RAC H IA L I S pressing the muscle against the humeral shaft. However, care must be taken to avoid the artery and nerves coursing • Patient is seated with the practitioner standing behind. • The practitioner identifies a point of tenderness on the anteromedial aspect of the coracoid process.

482 CLI N I CA L A P PLICA T I O N O F N E U R O M USCULAR TEC H N I Q U E S : TH E UPPER B O DY • The palpating hand cups the shoulder while a finger of Antagonists: To supination: pronator teres, prona tor quadratus tha t hand makes contac t on the tender point and applies To elbowflexion: triceps brachii pressure to i t, sufficient to have the pa tient ascribe a To flexion of shoulder: posterior del toid, triceps brachii value of '10' to the discomfort. (long head) To adduction of the arm: middle deltoid, supraspinatus • With the other hand the practitioner eases the ipsilateral To abduction of the arm: pectoralis major (clavicular por­ arm into extension and introduces internal rotation at the tion), coracobrachialis shoulder, with the dorsum of the patient's hand being placed fla t against the back. Indications for treatment • The patient is asked to report the pain score and fine­ • Shoulder pain (superficial anterior) tuning of the a rm position is carried out to achieve a • Pain when supinating or when forearm flexion is reduction in the pain score of at least 50%. overloaded • Fine-tuning is then increased; for example the pa tient's • Snapping or crackling sounds as the arm is abducted flexed elbow may be eased anteriorly, increasing internal • Pain or weakness when eleva ting the hand higher than rotation at the shoulder, to further reduce the reported score. the head • Add itional fine-tuning methods to reduce pain scores Special notes further might include: 1. the hand on the shoulder applying light (l Ib (0.5 kg) The biceps brachii is discussed here with the shoulder and maximum) inferomedial 'crowding' of the shoulder is followed by a full discussion of the elbow joint since it contact towards the painful point, or crosses both of these joints. Additionally, note that the tri­ 2. crowding of the acromioclavicular joint by long-axis ceps also crosses both joints and is discussed briefly with compression of the humerus in a cephalad direction the elbow (supine position). The reader is referred to p. 449 (l Ib (0.5 kg) force at most). for a full discussion of the triceps brachii. • Once pain is reduced by 70%, the position is held for not The biceps brachii is a complex shoulder muscle as it less than 90 seconds, before a slow return of the arm to a crosses three joints (glenohumeral, humeroulnar, humerora­ neu tral position and a reassessment of function and ten­ dial) and consists of two heads (sometimes three) whose derness is performed . shape and length a re different from each other. A third head anomaly is noted by some authors as present in 1-10% of BICEPS BRACHI I cases (Gray's Anatomy 2005, Platzer 2004, Simons et aI 1999) . Attachments: Short head: Apex of the coracoid process \"The long, narrow tendon of the lateral head lies in the Long head: supraglenoid tubercle of the scapula at the intertubercular groove and courses through the joint cap­ apex of the glenoid cavity to a common tendon merging sule enclosed in a double tubular sheath, which is continu­ the two heads and attaching to the posterior surface of ous with the joint capsule. It is held in the groove by the transverse humeral ligament. When this ligament is torn the ra d i a l tuberosi ty w i t h a d d itional expansions (bicipi­ free, the long head tendon may 'pop' as it dislocates from the groove during lateral and medial rotation. When the tal aponeurosis) blending into the deep fascia of the fore­ tendon ruptures completely, the humeral head rises con­ arm on the ulnar side spicuously and the muscle belly bulks on the anterior sur­ Innervation: Musculocuta neous nerve (C5-6) face of the arm. Research by Warner & McMahon (1995) Muscle type: Postural (type I), shortens when stressed confirms biceps brachii long head as a stabilizer of the Function: Supination of the forearm (when elbow is at least humeral head in the glenoid d uring abduc tion of the shoul­ slightly flexed), elbow flexion (strongest with the fore­ der in the scapular plane. arm supinated), assists flexion of the shoulder joint The short head tendon is thick and f1attened. It does not (when medially rotated), stabilizes the h umeral head attach to or pierce the jOint capsule but instead runs slightly d iagonally (anterior to the subscapularis tendon) to a ttach against upward translation when deltoid contracts and at the coracoid process with the coracobrachialis and pec­ against downward translation when the dependent arm toralis minor. It lies deep to the deltoid and pectoralis is weigh ted, assists abduction of the arm (when laterally major's usually thick mass. rotated), horizontal adduction of the arm, eccentric (lengthening) contractions when ex tending the weighted Passive supination of the forearm and slight lateral rota­ forearm, brings the humerus toward the forearm when tion of the humerus places biceps brachii in the most ideal the forearm is fixed (such as in pull-ups) position for palpation. The long head tendon may be more Synergists: Supination: supinator easily felt with full lateral rotation of the humerus. Elbowflexion: brachialis and brachioradialis Additionally, strumming laterally across the medial tendon Flexion of shoulder: anterior deltoid, pectoralis major (short head) and medially across the lateral tendon (long Abduction of the arm: middle deltoid, supraspina tus Adduction of the arm: pectoralis major (clavicular portion), coracobrachia Iis

1 3 Shoulder, arm and hand 483 head) will help the practitioner to more consistently feel them through the often thick mass of overlying deltoid muscle. A portion of the tendon of subscapularis may be addressed between the two proximal bicipital tendons and can be a source of pain when recurren t bicipital tendinitis has been diagnosed. A bursa lies horizontally between the tendon and t he joint capsule and communicates with the capsule between the superior and middle glenohumeral ligaments. Ice applications may be needed on the anterior shoulder if inflammation of the subscapular or bicipital tendons is sus­ pected . Subscapularis is further discussed on p. 421 . ASS ESSM E NT FOR STRENGTH OF BICEPS BRACH I I F i g u re 1 3.83 The biceps and brac h i a l is may be grasped i ndivi d u a l l y and compressed between the thumb and fingers. • Janda (1983) reports: f N MT FOR BICEPS BRACHI I It must be remembered that biceps brachii is the most impor­ tant [elbow}flexor. Difef rentiation . . . is a means ofdeciding The patient is lying supine with the arm resting on the table on future treatment and the arm should therefore be posi­ for support and the forearm passively supinated. The ante­ tioned so that biceps brachii can act as the principal flexor rior humerus is lightly lubricated and the thumbs are used · . . A slight weakness ofbiceps brachii only shows on testing to glide proximally, in thumb-width segments, from the if the movement startsfrom maximal extension. crease of the elbow to the head of the humerus to address the entire belly of the biceps brachii. Medially placed glid­ • Patient is supine with elbow extended, arm abducted and ing strokes address the short head while laterally placed externally rotated from the shoulder to 90°, palm facing s trokes assess long head fibers and are repeated 7-8 times upward. on each segment while evidence of tenderness, thickness or taut fibers is assessed within the bellies of the biceps brachii. • The practitioner places one hand, palm upward, on the If ischemia is found, these gliding steps are repeated several posterior surface of the distal upper arm, above the elbow times with a short break in between, possibly incorporating so that the hand supports the patient's arm. hot packs to encourage additional blood flow. • The other hand is placed palm downward on the distal Gently applied transverse friction can be used on both forearm, above the wrist. bicipital bellies to assess for muscular nodules and taut bands, both characteristic of trigger points. When thickness, taut • The practitioner introduces light hyperextension of the fibers or trigger point nodules are located, pincer compression patient's elbow, utilizing the contact on the lower armfor can be used to lift and differentiate the biceps brachii from the leverage. brachialis, which lies deep to it (Fig. 13.83). Trigger points found within its bellies may be treated with compression • The patient is asked to introduce flexion at the elbow techniques, either by lifting and compressing the fibers or by against this resistance. pressing them against the deeper belly of brachialis. • Relative strength ofbiceps brachii is compared on each side. With the forearm passively supinated, the groove between the ulna and radius is located and the patient is ASSESSM ENT FOR SHORTN ESS AND M ET asked to mildly flex the elbow against resistance while the T R EAT M E N T O F B I C E PS B RAC H I I practitioner contacts the tendon area with a thumb or finger (Fig. 13.84) . Contraction of the radial attachment of the • The patient sits on the treatment table with legs hanging biceps brachii and the ulnar attachment of brachialis will off the side, with the practitioner seated alongside, on the make their location obvious. The patient should relax the side of the dysfunctional arm. arm before the tendon is treated with static pressure or mild • The practitioner supports the elbow with the hand near­ est the patient while the other hand holds the patient's proximal wrist area (patient's forearm supinated), intro­ ducing slight elbow extension (the slack is removed; this is not a forced extension). • If there is biceps brachii shortness, elbow extension will be limited and possibly painful. • To treat this shortness using MET, the patient is asked to attempt to flex the elbow for 7-1 0 seconds, using mini­ mal effort, resisted by the practitioner. • Following the contraction the degree of extension is increased with patient assistance and the stretch held for not less than 20 seconds. • The process is repeated 2-3 times more.

484 C LI N I CAL APPLICAT I O N OF N E U R O M U SC U LAR TECH N I Q U E S : T H E U P P E R B O DY Fig u re 1 3 .84 Lightly resisted flexion with the forea rm supi nated w i l l contract the tendon of biceps to identify i ts specific a ttach ment so as to avoid the neurovascular structu res nea rby. Figure 1 3.86 M ET treatment fo r biceps tendon dysfu nction. the tissue is not inflamed . Additionally, gliding strokes are applied proximally to soothe the tissues following the fric­ tional techniques. Short gliding strokes are applied (through the deltoid) between the bicipital tendons to address the subscapularis tendon, which lies between the two bicipital tendons and deep to the deltoid. Biceps brachii and triceps brachii cross both the shoulder and the elbow j oints. Triceps brachii is discussed on p. 449 and an additional supine approach is given (see p . 494) after the discussion of the elbow joint. Figure 1 3.85 The short a n d long tendons of b i ceps a re iden tified �. M ET F O R PA I N F U L B I C E PS B RACH I I T E N D O N w ith tra nsverse pa l pation. Su bsca pu laris tendon fi l l s the space , ( LO N G H EA D ) (FIG. 1 3.86) between the two. • Patient is seated with practitioner behind. friction. A bicipitoradiai bursa protects the tendon from the • The patient is asked to take the hand behind the back and radial tuberosity (see discussion of the elbow joints next). to place the dorsum of that hand against the contralateral To address the proximal tendons of the biceps brachii buttock. (through the deltoid), the short head tendon on the anterior • The practitioner holds the patient's hand and gen tly upper humerus and the long head tendon on the lateral takes i t into pronation (palm toward floor), taking out the upper humerus are both located (Fig. 13.85). These tendons slack. feel very tubular and are slightly larger in diameter than the • The patient is asked to a ttempt to lightly turn the hand shaft of a pencil. The strumming techniques ].l. sed to locate into a supina ted position against resistance offered by the the tendons (mentioned above) may also be used as a treat­ practitioner. ment step or transverse (snapping) friction may be used if • After 7-1 0 seconds the patient ceases the effort and the practitioner (assisted by the patient) increases the degree of pronation at the same time as extending the elbow and further adducting the arm. • This stretch is held for a t least 20 seconds. • The process is repeated 2-3 times.

1 3 Shoulder. arm and hand 485 It PRT FOR B I C E PS B RAC H I I I NTRO D U CT I O N TO E L B O W T R EATM E NT There are two tender points associated with biceps brachii: Before beginning treatment of the elbow, postural distor­ in the bicipital groove (long head) and on the inferola teral tions of the body's framework should be observed and a surface of the coracoid process (short head). distinction made between struc tural and muscular causes. Inability of the arm to hang straight at the side, loss of range Long head of motion at the elbow joint, functional arm length differ­ ences and vertical plane devia tions of the torso all suggest • The practi tioner loca tes an area of tenderness in the biomechanical challenges for which the elbow (and other bicipital groove and applies sufficient pressure to have joints) may be compensating. For instance, when shoulder the patient ascribe a value of '10' to the discomfort. motion is restricted, compensations might involve more distal portions of the extremity, placing undue stress on the • The practitioner eases the patient's arm into a position in elbow, wrist or hand. which it rests, elbow flexed, with the dorsum of the lower arm against the patient's forehead. The patient should be asked to demonstrate to the practi­ tioner the sort(s) of work activities and positions, seated and • The practitioner fine tunes this position until the standing, which are performed on a daily basis. Long hours reported tenderness score is reduced by at least 70%. without breaks are often spent at office and home office desks with little a ttention given to ergonomic (postural) design of • A greater degree of 'score' reduction is usually possible the workspace. The postural and use ca uses of repetitive by the addition of a small degree of pressure (l Ib (0.5 kg) stress disorders involving the forearm muscles and strains of maximum) appl ied from the elbow through the long axis the arm, wrist, shoulder, neck and torso need to be addressed of the humerus to 'crowd' the shoulder joint. if long-lasting relief is to be achieved. Frequent breaks, cou­ pled with stretches and movement therapy, should be part of Short head both recovery and preventive programs. • The practitioner loca tes an area of tenderness on the When addressing pain in the elbow, forearm and hand, it inferola teral surface of the coracoid process and applies is important to treat trigger points in the torso and shoulder sufficient pressure to have the patient ascribe a value of girdle muscles as well as nerve compression possibilities at '10' to the discomfort. the spinal level and potential entrapment sites along the nerve's path. The cervical region should be assessed in all • The position of ease which reduces the pain score in this hand, arm or shoulder pain patterns, including the thoracic tender point is found by the practitioner taking the ou tlet and subclavicular area (such as pectoralis minor, patient's interna lly rotated arm, flexed at the elbow, into which should be tested for potential encroachment upon adduction. neurovascular space). • Once pain is reduced by 70% in either of these pOSi tions, STR U CTU R E A N D F U N CT I O N it is held for not less than 90 seconds, before a slow return of the arm to a neutral pOSition and a reassessment of function and tenderness is performed. ELBOW The elbow joint is the intermediate joint o f the arm, which links the forearm to the upper arm and allows the upper The mechanical advantages that the shoulder joint offers extremity to bend and the forearm to rotate. The proximal include the ability to achieve an amazing range of positions. radioulnar joint, the humeroradial joint and the humeroul­ The elbow has a more limited ability but its use is absolutely nar joint together form the compound jOint usually referred critical to normal daily functioning. Its bending action to as the elbow. These three joints work in combina tion allows food to be brought to the mouth, the upper body to together to provide: be scratched and many other daily activi ties which are per­ formed literally without thought. This joint's design also • flexion / extension - by the humeroradial and humeroul­ permits the hand and forearm to be rota ted, which allows nar joints us to turn doorknobs, use screwdrivers and open jar lids. • prona tion/supination - by the humeroradial and radioul­ The two distinct functions of the elbow joint - flexion/ nar joints. extension and supination/pronation - are discussed indi­ vidually though they are often used in combina tion during Stability of these joints is provided by bony support of the real movement. For instance, for food to be placed in the apposition of the trochlea of the humerus and the trochlear mouth, the arm begins in ex tension with pronation and notch of the ulna, together with the ligamentous support of ends in flexion with supination. Eating would indeed look the annular and colla teral ligaments. Additionctlly, a joint different if either of these actions were not possible. capsule encloses the structure, housing all three joints within the capsule.