Shoulder AC/SC.

Name: Shoulder AC/SC.
Uploaded: 2017-07-28T12:19:49+00:00
Duration: PTM35S42
Channel: David Silas Bryan
Description: Shoulder AC/SC.

Shoulder AC/SC

AC & SC Joints Relate to Shoulder & Scapula Motion
Normal motion of the scapula depends on normal motion of both AC & SC joints. Mobility at the AC joint allows the scapula to move in 3 dimensions following the curved contours of the ribcage.

Impingement Testing Hawkins Test Neer’s Test
Examiner exerts internal rotation of humerus (blue arrow) with 90º of forward flexion and 90º of elbow flexion; a positive test is reproduction of pain In this test, the arm is placed thumb down (internal rotation of humerus) in scaption. Examiner stabilizes the scapula border to prevent rotation. The arm is raised in forward flexion in scaption. A positive test is if pain is reproduced.

Sternoclavicular Dysfunctions
Sternoclavicular joint motions: Superior/Inferior glide Movement in the frontal (coronal) plane Also called ADduction/ABduction Anterior/Posterior glide Movement in a horizontal (transverse) plane Also called horizontal extension/horizontal flexion Rotation on its long mechanical axis Anterior (internal)/Posterior (external) Joint motions are coupled ABduction (IG) is coupled with posterior (external) rotation ADduction (SG) is coupled with anterior (internal) rotation Frame of reference for ABd/ADd, horizontal flex/ext is lateral end of clavicle Frame of reference for sup/inf glide, ant/post glide is medial (sternal) end of clavicle Frame of reference for rotation is the superior surface of clavicle

A P A P Posterior Rotation External Rotation Horizontal Flexion
MEDIAL A P LATERAL LATERAL MEDIAL A P Posterior Rotation External Rotation Horizontal Flexion Posterior Glide ABduction Inferior Glide MEDIAL A P LATERAL LATERAL MEDIAL A P As the clavicle ABducts laterally, there is a downward (inferior) glide at sternal end As the clavicle ADducts laterally, there is an upward (superior) glide at the sternal end ABduction/inferior glide and posterior/external rotation are linked ADduction/superior glide and anterior/internal rotation are linked ADduction Superior Glide Anterior Rotation Internal Rotation Horizontal Extension Anterior Glide

Sternoclavicular Dysfunction Assessment
ABduction (IG)/ADduction (SG) Physician stands at head of table Patient is supine Place tips of your fingers on the superior edges of the medial ends of the patient’s clavicle Ask your patient to shrug their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly (inferior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide)

Sternoclavicular Dysfunction Assessment
Horizontal Flex (PG)/Horizontal Ext (AG) Physician stands at head of table Patient is supine Place tips of your fingers on the anterior edges of the medial ends of the patient’s clavicle Ask your patient to reach toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction

Treat elevated SC Joint
Pt is seated and physician stands behind the patient toward the side to be treated Use hand closest to Pt. place the second metacarpophalangeal joint over the distil third of the clavicle to be treated Maintain constant caudad pressure over Pt. clavicle With other hand grasp pt. arm on side to be treated below the elbow. Bring pt. arm toward flexion from adduction with a continuous backstroke motion, the arm is circumducted toward extension until it is at the side of the pt. The arm can be brought forward and placed across the chest if this is comfortable for pt. The release may occur before the barrier is met. The physician reevaluates the dysfunctional (TART) components

Left Clavicle anterior and superior glide (SC Joint)
Both seated. Thumbs under junction of th medial and middle third of clavicle. Fingers over each end of clavicle. Patient rests forearm over D.O.’s forearm. “Lean forward slightly toward me.” “Slightly turn your body away from me.” (gaps SC joint!) D.O. carries sholder posteriorly to gap and balance AC joint. Medial end of clavicle is elevated by rotating clavicle around pivot point formed by thumbs. Clavicle is taken to a point of BLT (balanced ligamentous tension). May need minor movement of the patient’s scapula and clavicle by moving the forearm & body to achieve BLT. Respiratory phases are tested. Pt holds breath in phase giving best ligamentous balance. Recheck. Similar to doing the interosseous membrane in lower leg. Left Clavicle anterior and superior glide (SC Joint)

2. 1. 3. 4. Elevated SC joint-Articulatory

Acromioclavicular Somatic Dysfunction Assessment
Superior/Inferior Glide Physician places fingers on distal clavicle at AC joint. Palpate position of distal clavicle in relation to acromion Spring inferiorly on distal clavicle to assess for motion Assess for restriction of gapping at AC joint. A P External Rotation ADduction AC gapping

Treat elevated AC joint
Pt. seated, physician stands behind the pt. toward the side being treated Physician, using the closest hand to pt., places the second metacarpophalangeal joint over the distal third of clavicle being treated Physician’s other hand grasps the Pt. arm on side to be treated below elbow Pt arm is pulled down and then drawn backward into extension with a continuous motion similar to throwing a ball, circumducting the arm until it is once again in front of patient, finishing with arm across chest in adduction The release may occur before barrier is met The physician reevaluates the dysfunctional (TART) components

Right Clavicle Superior Glide (at Lateral end of clavicle)
Grasp elbow or forearm. Pad of thumb with other hand applies Ant/Inf pressure to the restrictive barrier. Flex elbow. Extend and adduct humerus to gap AC joint. Extend shoulder further and apply a circulatory sweep elbow posterior, then superior, and finally anteromedially must maintain capsular tension through out. Recheck. Right Clavicle Superior Glide (at Lateral end of clavicle) Elevated clavicle on Acromion(elevated AC joint)

Right Clavicle Superior Glide (AC)
Thumbs under middle and medial third portion of clavicle. Patient rests forearm on D.O. forearm. “Lean slightly forward and toward me.” Clavicle needs to be supported by D.O.’s thumbs. “Slightly turn body away from me.” (gaps SC joint.) Carry shoulder posteriorly to gap and balance the AC joint. Elevate lateral end of clavicle by rotating the clavicle around the povot point formed by the DO thumbs. May need minor movement of scapula and body position to obtain BLT. Test resp phase to get best BLT Recheck.

Shoulder (GH)

Range of Motion External and Internal Rotation Flexion and Extension

Strength Testing of Rotator Cuff Supraspinatus-abduction initiator
Test done in “scaption” “Full can” or “Empty can” Doctor pushes down Positive test-when patient has pain or weakness- indicates supraspinatus tendinitis or muscle or tendon tear Supraspinatus Scaption – is the position where the arm is approximately the same plane as the scapula. 45 degrees abduction and 45 degrees to 90 degrees forward flexion. Thumb up or “the full can” test moves the greater tuberosity of the humerus away from the acromion, lessening the contribution of impingement to pain or weakness during the exam. The empty can test or “thumbs down” position places the greater tuberosity closer to the acromion and increases the contribution of imp[ingement to the test. Avoiding impingement is important because you are performing this exam to detect weakness; painful impingement may cause a patient to make less of an effort due to pain, which you would mistakenly interpret as weakness.

Instability Testing Anterior Apprehension Test- doctor gives anterior pressure to humerus and externaly rotates arm Positive=apprehension of patient that shoulder will dislocate indicating anterior glenohumeral instability Posterior apprehension- (opposite) apply posterior force to ant shoulder. Positive= Posterior instability

Instability Testing Anterior Instability
Relocation test Anterior to posterior pressure is place by the examiners right hand to “relocate” shoulder – if symptoms are relieved test is positive indicating anterior instability Anterior release test

What are the “Best” Instability Tests?
Sensitivity Specificity LR (+) LR(-) Apprehension 0.88 0.50 1.8 0.23 Relocation 0.85 0.87 6.5 0.18 Anterior Release 0.92 0.89 8.3 0.09 Luime JAMA (2004) 292:1989

Spencer Technique The seven stages of motions are:
1. Engage GH extension barrier with elbow flexed 2. Engage GH flexion barrier with the elbow flexed 3. Circumduction with compression Start small circles, then gradually increase size Clockwise and counterclockwise May also do ME of IR/ER barriers 1 2 Kimberly Manual, p Direct articulatory/ME 3

4. Circumduction with traction on straight arm
Start small circles, then gradually increase size Clockwise and counterclockwise 5. Engage abduction barrier 6. Adduction/IR with elbow flexed 7. GH pump with distraction and compression along straight arm 4 5 6 7

Cervical Spine (HVLA)

Types of Cervical Vertebrae
Atypical cervical vertebrae Superior division OA joint (occiput on atlas) AA joint (atlas on axis) Typical cervical vertebrae Inferior division C2-C7

Somatic Dysfunction of the Typical Cervical Vertebrae
Segments C2-C7 Sagittal plane Forward and backward bending Triaxial Rotation, sidebending, forward/backward bending

Typical Cervical Vertebrae
Side bending and rotation ALWAYS occur to the SAME side. Fryette’s I & II do not apply to the cervical spine. Fryette’s III does apply! Fryette’s Laws: Thoracic and Lumbar I. In neutral mechanics, sidebending precedes rotation: N SxRy In non-neutral (extreme flexion or extension) rotation precedes sidebending F RxSx or E RxSx

Spurling’s Test Tests for narrowing of neural foramina
Sidebend and backward bend head; add compression Positive if pain radiates to ipsilateral arm

Adson’s Maneuvers Tests for Thoracic Outlet Syndrome
head is placed in extension and side bending while the patient takes a deep breath and holds it, followed by rotation to stretch or tether the plexus and/or artery by the anterior and middle scalenes. The maneuver is held for seconds while the clinician observes for onset of symptoms and obliteration of the pulse. Symptoms have been reported to the side of bending and, more commonly, to the side away from bending

Forward bending stretching
Objective: Stretch posterior cervical tissues 1) doctor at head of table; patient supine. Cross forearms and place them behind pt’s head with fingertips on pt’s shoulders. Exert slow forward bending stretch until a restrictive barrier is engaged, slowly increase to next barrier

Longitudinal Stretching
Objective: Relax the paravertebral muscles (PVM). 1) doctor at head of table; patient supine. 2) palmar surfaces of fingers of both hands under the neck near spinous processes 3) lift PVM with fingers and draw it toward you (cephalad = toward head) 4) release and carry tissue away from you (caudally = toward tail)

Kneading Objective: Relax the cervical paravertebral muscles (PVM).
1) doctor standing on patient’s side; patient supine. 2) With caudad hand, reach across patient and cup PVM; Place cephalad hand on pt’s forehead 4) Push head away from you, then pull up and laterally on PVM tissue letting head roll back toward you.

Trapezius Stretch Objective: Relax the trapezius muscle
1) Patient supine, doctor at head of table 2) Stabilize one shoulder with opposite hand 3) With free hand contact same side of head as stabilized shoulder and introduce GENTLE stretch

HVLA for Cervical Spine
C2 – C3 Supine – Direct Method – HVLA Rotation emphasis, Kimberly manual, A-1, pg 78 Supine – Direct Method – HVLA sidebending emphasis, Kimberly manual, A-2, pg 79 C4 – C7 Supine – Direct Method – HVLA, Kimberly manual, B-1, pg 81

For C2 – C3: Supine – Direct Method – HVLA Rotation emphasis, Kimberly manual, pg 78
Backward Bend Rotate into the barrier Sidebend away from barrier (slightly) HVLA Rotation Thrust

Supine-Direct-HVLA Rot Emphasis C3 RLSL
Bilateral contact at articular pillars at inferior portion of C3

Backward Bend at C3/C4 joint by lifting anterior Do not hyperextend entire cervical spine, only the ONE segment.

Maintain tight contact at Left articular pillar!! Rotate to the Right to the restrictive barrier

Sidebend slightly to the LEFT over your THRUST POINT (SB left) Note: This SB motion to the left is only meant to tighten the restrictive barrier. It does not reverse the coronal plane

HVLA thrust in rotation Both hands must rotate!

For C2 – C3: Supine – Direct Method – HVLA sidebending emphasis, Kimberly manual, 4421.11A-2, pg 79
Key Points Contact lower vertebra of the segment Forward bend Sidebend over fulcrum Rotate away Thrust to opposite orbit

Supine-Direct-HVLA The Segment (C3-C4)
C3 RLSL C3 is the upper vertebra of the segment C4 is the lower vertebra of the segment

Supine-Direct-HVLA C3 RLSL
Support head in LEFT hand

Will need to change C3 RLSL
Contact RIGHT articular pillar at inferior border of C3 with thrust contact of RIGHT hand use lateral margin of index finger intent is to close facet joint C3 on C4 3 4

Contact RIGHT articullar pillar of C4 with thrust contact of RIGHT hand use lateral margin of index finger intent is to close facet joint C3 on C4

Forward bend with a tight contact at the RIGHT articular pillar of C3/C4

Maintain tight contact in FB Sidebend RIGHT over your thrusting fulcrum at C3/C4

Rotate to the LEFT to tighten the barrier Do not lose previous localization!!

HVLA thrust toward opposite orbit of eye glide C3 into C4 to close facet counterforce must be maintained with Right hand

C4 – C7 Supine – Direct Method – HVLA, Kimberly manual, 4221
C4 – C7 Supine – Direct Method – HVLA, Kimberly manual, B-1, pg 81 Key Points Contact upper vertebra of the segment Forward bend Sidebend over fulcrum Rotate away Thrust to opposite scapula

Supine-Direct-HVLA The Segment (C4-C5)
C4 RLSL C4 is the upper vertebra of the segment C5 is the lower vertebra of the segment

Support head in LEFT hand

Contact RIGHT articular pillar of C4 with thrust contact of RIGHT hand use lateral margin of index finger or MP joint intent is to force C4 down onto C5 4 5

Contact RIGHT articullar pillar of C4 with thrust contact of RIGHT hand use lateral margin of index finger intent is to force C4 down onto C5

Forward bend with a tight contact at the RIGHT articular pillar of C4

Maintain tight contact in FB Sidebend RIGHT over your thrusting

Rotate to the LEFT to tighten the barrier Do not lose previous localization!! Final adjustment of flexion/extension in sagittal plane

HVLA thrust toward opposite inferior angle of the scapula force C4 down onto C5

Cervical Spine (ME)