Open Forum for Questions and Answers
February 23, 2009 
25 Comments
Hello everyone, this week I am going to use this post as an open forum for you to discuss topics and ask questions of your choice. We did this last year when this site was fairly new and we had great discussions, but I expect this be even better now that the readership is up!
So take advantage and ask away, anything is open for discussion, question, or debate! I will start it off with a couple of questions to all of you. Considering the upper body cross postural syndrome is so prevalent in our society and all the latest research on the effect of scapula position and thoracic manipulation on function:
What technique/position do you use to manipulate the upper thoracic spine? How do you stretch pec minor?
This is just a question to all of you to kick of this week’s open forum, but by all means lets discuss anything you would like! To ask your question or start a discussion, post a comment to this post by clicking on the comments link next to the date of this post:
Also, if you haven’t noticed yet, there is a widget at the bottom of my webpage in the “interact section” where you can post questions at times other than this week:
Looking forward to it!
Photo by eleaf.
As for the pec minor stretching, I like the use of a 1/2 or full foam roller in supine, combined with stretching in various positions of abduction. I also tend to use the 5-pt postural stretch while on the roller. Manual releases are also an option. At this point I gravitate patients quickly into active exercises to promote posture, such as wall angels, cervical retraction w/ scap retraction in prone, etc.
Thoracic Grade V mobs (I practice in PA-illegal to use the term manipulation) I typically do with my hands in a prayer position with the patient in prone, or I like to use the pistol grip position with my hand under the patient in supine-this is much more aggressive. I have also seen good results with a mulligan technique, in which the patient is in sitting, and the PT directs a PA force to a thoracic vertebra while rotating, extending and lifting the patient’s upper thorax.
Pec minor stretching is really more advanced than most people make it. To effectively stretch the muscle I use sidelying with my body supporting the patient so they do not roll backwards. With one arm/hand under their shoulder on the anterior aspect and one on the posterior scap I elevate the shoulder girdle, then retract the scapula, and finally perform a sustained inferior glide. Alternatively there are great fascial techniques for this area since multiple mm attach onto the coracoid and influence breathing, posture, and upper extremity movements. Sahrman has a great HEP stretch for the pec minor, best performed by a loved one/friend, but also an alternative for self-stretching.
Upper thoracic mob/manips are effective, particularly if you want to induce a parasympathetic response, but I find are short lived if you do not address myofascial restrictions and posture/movement dysfunction. I’m finding that I’m getting more and more removed from the prone PA’s and supine “roll-over” mobs in favor of MET and even visceral manipulations. The French osteopath Jean-Pierre Barral has published some very interesting literature regarding the holistic treatment of the spine, rib cage, and their contents (think of the strength of the spine and ribs without the diaphragm and internal organs- very brittle). Peter Schwind also wrote a very eloquent book entitled Fascial and Membrane Techniques which ties the thoracic region and its contents together better than anybody in my opinion. Worth the read.
Seth Burke, DPT
Hi Mike, to stretch the pecs (minor/major) I have the patient lie supine with a small towel roll between their blades. I stand above and behind them, dig my palms into their deltopectoral grooves bilaterally, and push posteriorly with a slight superior bias. For lower C upper T mobs I use MET with great results. I am curious though since you brought it up, do your athletes get tight in the anterior shoulder musculature? I would think during the late cocking phase of throwing the pecs would be constantly lengthened. Do the pecs become tight in order to accomodate for a hypermobile anterior GH lig/capsule, or are they becoming hyperactive in order to stabilize the humerus during the cocking phase? I have my own ideas on why this happens but I am curious on your opinion.
I tend to go with the supine T2-T10 P/A for thoracic manipulation with more of a pistol grip. It is very comfortable for the patient and effective for both c/s, l/s & shoulder pain that are painful in other positions. I don't do it very often, but placing a foam roll or thick towel roll underneath the patient's crossed arms helps decrease any pressure they may feel over sternum/ribs anteriorly. Seated C7-T1 extension manipulation and prone C7-T1 manipulation with the pt's head rotated is also very effective but not applicable to all patients.
I use a similar technique as Brian of "breaking the pecs" with pressure in A/P and inferior movement inferior to ACJ & on GHJ to address the posture. I don't find stretches very effective but I also don't work on too many athletes. Any good ideas will be helpful.
With regards to stretching the pec minor, there was a study in the Journal of Shoulder and Elbow Surgery in May 2006 by Borstad and Ludewig that compared 3 positions for stretching the pec minor and found that a unilateral stretch in standing resulted in the greatest lengthening of the muscle. I tend to use this position as it is easy to reproduce and seems to work well.
thanks
Scott Cameron, PT, MS
I like the MET suggestions Seth and Brian, can you both expand on your techniques?
Scott, please elaborate as well, what were the three stretch positions?
For thoracic MET, I evaluate whether it is a type I or II dysfunction (whether the asymmetry is noticeable in neutral or flexion/extension). This is assessed in sitting and compares transverse processes (static/dynamic). For upper thoracic corrections I treat in sitting. I sidebend down to the apex of the asymmetry, then resist SB at the interbarrier zone, 5-7 seconds x 5-6 reps (utilizing Fryette’s Laws). Occasionally I’ll perform 3-dimensional MET if coronal plane correction doesn’t occur. Lower thoracic dysfxn is treated in sidelying. I use the LE’s as a lever to SB up the kinetic chain (hip/knee flexion). Resistance is then placed through the feet (up or down) x 5-6 reps. I rarely treat the T-spine without addressing the ribs and pectoral girdle musculature/fascia. The pleura, diaphragms, lung tissue, breast tissue, and lymphatics also can contribute to dysfxn.
The 3 positions were as follows:
1. Standing Unilateral Corner stretch- required the subject to abduct the humerus to 90 degrees with the elbow flexed to 90 degrees. The palm was placed on a flat planar surface. The subject then rotated the trunk away from the elevated arm, increasing the horizontal abduction at the shoulder and maximizing the stretch across the chest.
2. Sitting Manual Stretch- persformed with the subject sitting unsupported and with the arm in the dependent position. The subject was instructed to inhale deeply and hold his/her breath while the muscle was fully elongated by the examiner. To stretch the muscle, the examiner applied a posterior force to the corocoid process with 1 hand while stabilizing the inferior angle of the scapula with the other.
After positioning the muscle in the stretch position, the subject was instructed to exhale.
3. Supine Manual Stretch- subject was lying supine with a towel roll running the length of the t-spine. The examiner positioned the subject’s arm to 90 degrees of abd and ER and 90 degrees of elbow flexion. A posterior force was applied to the corocoid process.
The mean change in muscle length for each position was as follows:
Corner: 2.24 cm
Supine Manual: 1.70 cm
Sitting Manual: 0.77 cm
Hope this helps to clarify
thanks
Scott
Article Info:
Comparison of three stretches for the pectoralis
minor muscle
Authors John D. Borstad, PhD, PT, and Paula M. Ludewig, PhD, PT
J Shoulder Elbow Surg May-June 2006
New Question: 15 y/o male pitcher with acromial apophysitis of the throwing arm (right). Initial rehab at another clinic with focus on IR strength and ER ROM, pain free for 20 game pitches then incapacitating. Currently has good ROM and is on pectoral stretch program (I use the unilateral stretch for HEP and towel roll manual stretch in clinic) with core and GH stabelizaion (now good strength) He is pain and crepitus free unless he tries to throw. Even light throws of the tennis ball provoke symptoms at 30 reps. Is there any hope he will be able to return to pitching with managable pain??? and any rehab advice? Thanks Kim Widrick PT
I assess segmental mobility in sitting the same as described by Seth, and treat it it mostly the same manner. I tend to use MET mostly if I can narrow the dysfunction down to 1 or 2 segments, but if it more of a gross poor thoracic extension I do a lot more stretching and global mobs over foam rolls/physioball, etc. And then of course I address the real cause for poor thoracic extension and tight pecs, which is weakened/shortened abs…
Kim, it seems like your athlete is still weak and is fatiguing quickly. What phase of the throwing motion is he getting pain? Has a trainor silled in pitching biomechanics evaluated him? Others may have better advice on this….
Kim… I agree with Brian on this one regarding the weakness and fatigue. Check his ER, supraspinatus, middle and lower traps, etc. Odds are if you put him on a high level cuff and scapular strengthening/stabilization program, he will respond. What is his IR with the arm at the side?
Kim,
not sure if he had a MR-arthrogram, but perhaps along with his apophysitis he has a slap lesion, which would cause pain with throwing. particularly at ball release. something else to consider if he continues to do poorly.
Brian Chad and Trevor thanks for the advice. He had a MRI and xray only. His ER, Supraspinatus and traps are now strong and fatique is decreasing. His IR at 90 abd is 45. His pecs are very weak. He came in with only a 3 month LE strength program, a weak core and NO thoracic rotation so his mechanics were mostly shoulder based throwing. His ant shoulder was tight and ant delt dominate strength. His inital complaint was pain with ball release and now with the initiation of light throwing it is with full ER. Has anyone been able to return althetes to pitching, without pain, with apophysitis. Thanks
Kim
Kim, this sounds like a heck of a case. I think he may have something more going on than we realize. Maybe he needs an arthrogram? Agree with the recommendations, really emphasize ER and lower trap strength. I would de-emphasize pec strength. Pain at ball release is different than pain in ER. Maybe he can take up another hobby, chess?!?
Love all the comments guys on the t-spine and pec stretching. All great ideas! anyone else have anything they want to discuss?
Kim,
have returned a lot of kids to throwing with apophysitis, without pain. Your case sounds like there is more than meets the eye, however. sounds like labrum to me and as suggested before and by mike-arthrogram may be indicated. not a fun test for a young kid though!
Had my first ever case of an infected shoulder arthroscopy/rc repair this week. MRSA developed on the shoulder and within a week of being untreated burrowed into the subacromial space and has now infiltrated his cuff and joint. anyone else ever see a mrsa infection in a post op scope shoulder????pretty rare i believe. The guy went back in for a scope today with I&D and will be admitted for IV antibiotics. Just wondering if anyone else has ever dealt with this issue in a shoulder before????
Have had MRSA with a few knee scopes, tough ones, I bet they are going to get really tight! Ouch…
Video Motion analysis. I know Mike you showed us your little hand held device. What does everyone else use? Any special software?
Most popular and decent software is Dartfish. You can use it with any camera, I even use a small webcam with my laptop.
I have a pt. 1.25 years after whiplash injury with chronic neck pain, considering prolotherapy. Literature seems inconclusive. Anyone know anything about it? Good results?
Brian, I dont have a lot of experience with prolotherapy but I do know that it is becoming more popular, along with platelet rich plasma therapy. These are new areas that are being explored to help stimulate healing. Part of me thinks there is limited downside, so why not? Hope we are not being too naiver about that. Would love to hear from others that have tried these therapies or have patients that have had these procedures…
Brian, as I’ve understood more about whiplash and fascial continuities throughout the body (think Anatomy Trains), I’ve changed my treatment paradigm. I would consider examining their breathing pattern in a very in-depth manner to see if they are transmitting forces through their soft tissue. Correction may need to be made all the way at S2 if there are altered tissue dynamics of the dura. MFR there may be helpful as well as on the scalenes (almost always involved), UT, and SCM Bilat. Also check the mobility of the clavipectoral fascia, especially where it envelops the coracoid and pec minor. Prolotherapy is promising but do they still have their “glide” when they are locked down at the segment in question? Alar/apical OA/AA jt instabilities are no joking matter!! Peter Schwind’s Fascial and Membrane Techniques is a great book that has the most thorough respiratory analysis I’ve read to date. Good compliment to the “traditional” PT info I’m sure we’ll all received.
Dr Seth, thanks for the advice. How do I asses his breathing pattern? Do you think these pts develop a compensatory breathing pattern in the acute phase of injury that never resolves? His segmental mobility was restricted but has normalized with mobs…
Oops… Kim I was reading through the comments again and noticed I asked IR at side instead of ER for potential subscap restriction. Anyhow, hope he’s continued to progress well with your program.
Brian,
I assess breathing in sitting most often. Sit behind the patient on a stool and broadly contact the tissues below the costal arch. Assess that the ribs on both sides are rising equally, that a rotational motion is present and equal bilat, and that equal separation is occurring between ribs. Next move up to the transition between the upper chest cavity and the neck while to the side of the patient. Assess the mobility of both pleural cupulas and the connection between the two clavicles and the first rib (subclavius muscle). Differentiate between bucket handle and pump handle movement of the ribs. Also don’t rule out some pelvic changes. Depending on where the feet were when they were hit will possibly create a pelvic torsion, upslip, etc. This will definitely affect the entire spine all the way up to the cervical region. Working into the ribs, endothoracic fascia, and especially the pectoral girdle and scalenes/SCM/UT will help immensely. Once things are tensioned equally like a tent, neuromuscular re-ed and stabilization techniques are more appropriate. I often recommend a Theracane and Clair Davies Trigger Point Therapy Workbook to patients with immense soft-tissue dysfunction. Hope that helps!!
Seth