Description of techniques
| Technique | Description |
|---|---|
| Thoracic extension | The patient is asked to place a finger (typically from the asymptomatic upper limb) on the sternum and while still maintaining contact with the sternum, gently ‘lift’ the finger superiorly, aiming to extend the thoracic kyphosis |
| Scapular elevation | The therapist gently places one hand over the lateral border of the scapular and elevates (ie, upwardly rotates) the scapula ∼1–2 cm using the other hand on top of the shoulder girdle as a guide. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns in the elevated position |
| Scapular depression | The opposite direction to scapular elevation |
| Scapular retraction | The therapist gently places one hand over the lateral border of the scapular and retracts the scapula ∼1–2 cm using the other hand on top of the shoulder girdle as a guide. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns to the new retracted position |
| Scapular posterior tilt | The therapist gently places one hand over the lateral border of the scapular and the thumb over the inferior angle of the scapula. The other hand on top of the shoulder girdle gently displaces the superior aspect of the scapula (and other structures) posteriorly. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns to the new posterior tilted position |
| Combinations | If a number of scapular positions are found to be partially reduce symptoms, they can be combined to determine if further improvement if achieved (eg, elevation and posterior tilt; retraction, depression and posterior tilt) |
| Depression—flexion | In sitting or standing, the patient's shoulder is flexed as close to 90° flexion as possible (maybe in less or more range, depending on symptoms), the elbow is flexed (ie, shortened lever arm). The therapist places his/her hand on the posterior surface of the distal end of the humerus, 2–3 cm proximal to the point of the elbow. The patient is then asked to push the elbow towards the ground with the therapist resisting isometrically for 5–6 s. The contraction is repeated 3–4 times and the arm gently lowered to the side and the provocative movement retested |
| Depression—abduction | The same as for depression—flexion but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
| Depression—flexion (supine) | This technique is the same as depression—flexion but is performed in supine and in addition to the muscle contraction procedure, a series of inferiorly directed gliding pressures are applied to the region of the humeral head. Following the technique, the provocative movement is retested |
| Depression—abduction (supine) | The same as for depression—flexion (supine), but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
| Eccentric flexion | In sitting or standing with the shoulder flexed just before the onset of symptoms, the hand loosely grips an elastic rubber resistance tube, which is firmly suspended from above (ie, over the top of a door). With the arm in the same position, tension is applied to the tube and then the hand firmly holds the tube. Following this, the patient is instructed to extend the shoulder ∼20–30° hold isometrically for 5–6 s and then slowly return to the starting position (ie, concentric, isometric and eccentric contractions). This is repeated 3–4 times, the tube released and the provocative movement retested |
| Eccentric abduction | The same as for eccentric flexion but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
| External rotation | If the provocative movement is shoulder flexion or abduction, the movements are performed with increased shoulder external rotator activity. This could be achieved by using the resistance of an elastic rubber band, the therapists hand or pushing against a wall using a towel, plastic bag or polishing cloth to reduce resistance |
| Internal rotation | The same as for external rotation with resistance aimed at increasing an internal rotation force. In addition to the suggestions above, internal rotation resistance can be achieved by asking the patient to flex the shoulders while applying pressure to a ball the size of a soccer or basketball |
| AP|AP with inclination | Using a mobilisation belt, heavy resistance elastic rubber band, or a neoprene strap placed over the region corresponding to the anatomical location of the humeral head a posteriorly directed force is applied by the therapist with the therapists other hand stabilising the scapula. While the pressure is applied, the provocative movement is retested. This may be shoulder abduction-external rotation as may occur in someone with an anteriorly unstable shoulder. Care needs to be taken. In addition to trialling different amounts of posteriorly directed force, the therapist can apply a posteriorly directed force with a superior inclination to assess if this combination more effectively reduces symptoms |
| PA|PA with inclination | The same as for AP|AP with inclination, but with the pressure applied to produce an anteriorly directed force |
AP, anterior to posterior; PA, posterior to anterior.