HEMME Approach To Neck and Shoulder Pain

HEMME APPROACH TO
NECK AND SHOULDER

PAIN
ii
INSTRUCTIONS FOR THE ANSWER SHEET

Thank you for investing in our HEMME APPROACH TO NECK AND
SHOULDER PAIN COURSE, the third course in the HEMME APPROACH series.
Now that you're ready to start the course, these instructions will make it
easier to complete the quiz on pages 214-223. First, there are no trick
questions. The answers are clearly stated in the book. Second, the questions
are not taken at random, they follow the same sequence as the text. Third,
the questions cover the major points. Reading the table of contents, chapter
headings, section headings, charts, index, and statements following numbers
or bullets (?) will be helpful. Fourth, use the glossary.
This course is not easy. Since 12 hours of continuing education credit

are given for completing the course, you are not expected to read the manual
and complete the quiz in one day.
Feel free to use the manual as you take the quiz. It may be helpful to
look over the questions before reading the manual. Even though 70% or
above (two points per question) is a passing grade, this should not be a
problem for most people. If needed, retakes will be allowed.
Above all else, please follow these three instructions:
X COMPLETE THE TOP OF THE ANSWER SHEET.
Y ANSWER QUESTIONS 1 THROUGH 50.
Z RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED.
When you complete the top of the answer sheet, please print legibly. The
spelling of your name for your diploma will be taken from the answer sheet.
Please be patient. Quizzes are normally graded the same day they arrive. In
addition to a diploma, you will also receive a letter showing that 12 hours of
continuing education credit have been awarded to you for completing this
course. Most state boards recommend holding certificates at least four years
unless otherwise instructed. Good luck with the quiz, and thank you again
for taking the course.
HEMME APPROACH TO NECK AND SHOULDER PAIN

iii
HEMME APPROACH TO NECK
AND SHOULDER PAIN
Copyright, David H. Leflet, 1995

Revised 2005
All rights reserved
Published by HEMME APPROACH PUBLICATIONS

3334 Spring Valley Lane
Bonifay, Florida 32425
(850) 547-9320
The author grants permission to photocopy limited portions of

this manual for personal use. Beyond this consent, no portion
of this manual may be copied or reproduced in any form
without written permission from the author.
Although the author has made every effort to ensure the

accuracy of the information herein, science is progressive and
theories change with time. Practitioners are advised to consult
appropriate information sources if they have any questions
concerning the information presented in this manual.
It is also the responsibility of the practitioner to determine the

appropriateness of any principle or technique in terms of
personal competency and scope of practice. Written medical
opinions are the best way to resolve any questions concerning
conditions that indicate or contraindicate soft-tissue therapy,
and written legal opinions are the best way to resolve any
questions concerning the law.

iv
NECK AND SHOULDER PAIN ANSWER SHEET

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v

EVALUATION FORM
Please give us your comments about the course and return this paper with
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If we have permission to use your comments, please sign below.

vi
PREFACE
The HEMME APPROACH to Neck and Shoulder Pain is the second course
in a trilogy of courses that covers the principles of soft-tissue therapy and
practical applications. As the second course in this trilogy, the HEMME
APPROACH to Neck and Shoulder Pain deals with neck and shoulder pain as
it relates to soft-tissue impairments. Taken together, neck and shoulder pain
are the second leading cause of musculoskeletal pain, after low back pain.
As with the other two courses in the HEMME APPROACH trilogy, the
information included in this course has been carefully selected to give
practitioners the exact amount of background needed to make practical
applications understandable and easy to apply. The real test of any course is
not how much information people can learn, but how much people can
benefit from what they learn. Knowledge alone is not power! Knowledge
becomes power when it solves a problem or satisfies a need.
This course will explore many facets of neck and shoulder pain,
including anatomy, physiology, pathologic conditions, methods of
evaluation, and methods of treatment. Since HEMME APPROACH deals with
soft-tissue therapy, as opposed to medication or surgery, pathologic
conditions treatable by soft-tissue therapy are given much greater focus than
pathologic conditions that are not treatable by soft-tissue therapy. Though
soft-tissue therapy is not a cure-all and some forms of neck and shoulder
pain cannot be treated without surgery, it is equally true that surgery can
sometimes be avoided by early intervention with conservative care.
Though part of this course is based on medical research, the other part is
based on logic, common sense, and clinical experience. Medical research is
no substitute for clinical experience. Despite research studies and huge
volumes of paperwork, many forms of physiotherapy allegedly proven by
experimentation do not work in the real world. Besides problems with
collecting data, calculating statistics, and drawing conclusions, more than a
few studies are strongly influenced by egos, economics, politics, and
tradition.
Historically, classical medicine has pursued medication and surgery to
the exclusion of manual medicine. Even today, some physicians still believe
that trigger points are purely imaginary and chronic pain related to a soft-
tissue injury is purely psychogenic. Fortunately for those afflicted by soft-
tissue impairments, these antiquated beliefs are rapidly changing as more
patients are being successfully treated by soft-tissue therapy.
In today’s changing world, most physicians are willing to accept soft-
tissue therapy as useful, and some of the best books on trigger point therapy

vii
are written by medical doctors. Very few doctors are still willing to label
soft-tissue therapy as nothing more than a palliative or placebo. Not only is
soft-tissue therapy more widely accepted by the health care community now
than it was five years ago, this trend is expected to continue.
HEMME APPROACH is sometimes called eclectic because it collects and
organizes material from many different sources, including physical
medicine, osteopathy, chiropractic, physical therapy, occupational therapy,
massage therapy, athletic training, and nursing. Since all of these specialties
have made tremendous contributions to soft-tissue therapy, ignoring any one
of them would deprive patients of valuable care.
A competent practitioner cannot be expected to work with only one
method of manipulation any more than a master carpenter can be expected to
work with only one tool. HEMME APPROACH uses four methods of
manipulation—trigger point therapy, neuromuscular therapy, connective
tissue therapy, and range-of-motion stretching—and considers each of them
equally important. The power of synergy in soft-tissue therapy comes from
knowing how and when to combine one form of manipulation with another.
More than anything else, the HEMME APPROACH to soft-tissue therapy is
a logical and scientific method for turning thoughts into action and action
into achievements. It is not a cookbook routine or a rigid series of steps that
lead unerringly to miracle cures. What the HEMME APPROACH does promise
is greater therapeutic success when treating patients with soft-tissue
impairments. By using logic and the scientific method, HEMME APPROACH
identifies soft-tissue problems and recommends rational solutions.
The greatest satisfaction from using the HEMME APPROACH is seeing
patients recover after long periods of chronic pain, disability, and
depression, especially when many of them were told: “Learn to live with the
pain” or “It’s all in your mind.” Although not a miracle cure, the results that
soft-tissue therapy produces are sometimes incredible.
The HEMME APPROACH to Neck and Shoulder Pain course is the third
12-hour course in the HEMME APPROACH series. The other three 12-hour
courses are HEMME APPROACH to Soft-Tissue Therapy, HEMME APPROACH
to Low Back Pain, and HEMME APPROACH to Pain. Readers who wish to
fully comprehend the meaning of HEMME APPROACH and soft-tissue therapy
are strongly encouraged to complete the entire series.

viii
TABLE OF CONTENTS
INTRODUCTION ....................................................................................... 1
HEMME APPROACH Concepts ................................................................. 3
HEMME APPROACH Scientific Method .................................................. 3
Anatomy and Physiology........................................................................ 4
Humerus................................................................................................. 4
Scapula................................................................................................... 5
Muscles ................................................................................................... 6
22 Basic Muscles: Description (Table) ........................................... 8
Neck and Shoulder Illustrations ........................................................ 12
Lateral Neck ................................................................................. 13
Anterior Shoulder (Bones) ........................................................... 14
Anterior Shoulder (Muscles)........................................................ 15
Anterior Torso (Superficial)......................................................... 16
Anterior Torso (Deep) .................................................................. 17
Posterior Shoulder (Bones) .......................................................... 18
Posterior Shoulder (Muscles) ....................................................... 19
Posterior Torso (Superficial)........................................................ 20
Posterior Torso (Deep) ................................................................. 21
Muscles by Action (Table) ................................................................ 22
Trapezius................................................................................................ 29
Bones ...................................................................................................... 29
Joints ....................................................................................................... 30
Ligaments ............................................................................................... 30
Muscle-Joint Dysfunction-Disability Cycle ........................................... 31
Glenohumeral Joint................................................................................. 33
Rotator Cuff ............................................................................................ 34
Scapulohumeral Rhythm ........................................................................ 35
Humeral Rotation .................................................................................. 35
Scapular Rotation .................................................................................. 36
Biceps Mechanism.................................................................................. 39
Chapter Summary ........................................................................................ 40
HEMME APPROACH ................................................................................ 42

HEMMEGON (Chart) ....................................................................... 45
Chapter Summary ........................................................................................ 46

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TABLE OF CONTENTS CONTINUED
HISTORY .................................................................................................... 47
Contraindications.................................................................................... 47
Vertebrobasilar Accidents ..................................................................... 48
Medical History Questions ..................................................................... 50
Chapter Summary ........................................................................................ 53
EVALUATION............................................................................................ 54
Observation............................................................................................. 54
Palpation ................................................................................................. 54
Referred Pain .......................................................................................... 57
Postural Pain ........................................................................................... 59
Psychogenic Factors ............................................................................... 62
Soft-Tissue Impairments......................................................................... 62
Pain Cycles ............................................................................................. 64
Rehabilitation Model ......................................................................... 69
TESTING .................................................................................................. 71
Acromion Process Test ........................................................................... 71
Active Range of Motion Testing ............................................................ 71
Muscles by Range of Motion (Table)................................................ 73
Symmetry Test........................................................................................ 75
Passive Range-of-Motion Testing .......................................................... 76
3-Point Touch Test (similar to Apley Scratch Test)............................... 76
Back-to-Wall Test................................................................................... 77
Neurologic Testing ................................................................................. 77
Orthopedic Testing ................................................................................. 78
Muscle Testing........................................................................................ 81
22 Basic Muscles: Muscle Testing (Table) ...................................... 82
HEMME APPROACH Quick Test .............................................................. 87
Cervical Spine........................................................................................ 88
Forearm.................................................................................................. 88
Humerus................................................................................................. 88
Examiner Facing Patient (anterior) ....................................................... 89
Examiner Behind Patient (posterior) ..................................................... 90

x
Pathologic Conditions............................................................................. 91
1. Rotator Cuff Tear.............................................................................. 91
2. Adhesive Capsulitis (frozen shoulder) .............................................. 92
3. Scalene Anticus Syndrome (Thoracic Outlet Syndrome) ................. 96
4. Pectoralis Minor Syndrome.............................................................. 101
Chapter Summary ....................................................................................... 102
MODALITIES ............................................................................................ 104

Cryotherapy ........................................................................................... 104
Thermotherapy....................................................................................... 106
Hot-to-Cold Stretch .............................................................................. 107
Adverse Effects...................................................................................... 108
Effects of Heat and Cold (Table) ..................................................... 109
Vibration ................................................................................................ 110
Chapter Summary ....................................................................................... 111
MANIPULATION...................................................................................... 112
Basic Principles ..................................................................................... 113
Twelve Principles of Soft-Tissue Therapy ........................................... 113
TRIGGER POINT THERAPY ................................................................ 115
Bicipital Groove..................................................................................... 122
Apex of Coracoid Process ..................................................................... 123
Sternal Trigger Points ............................................................................ 123
Sliding-Pressure..................................................................................... 123
Trigger Point Location........................................................................... 125
22 Basic Muscles: Trigger Points (Table)....................................... 126
NEUROMUSCULAR THERAPY .......................................................... 129
Facilitation ............................................................................................. 133
Inhibition................................................................................................ 133
Muscle Spindle Cell Inhibition............................................................. 133
Post-Isometric Relaxation (Inhibition) ................................................. 134
Reciprocal Inhibition ............................................................................ 134
CONNECTIVE TISSUE THERAPY ...................................................... 135
Thixotropy ............................................................................................. 136
Hysteresis............................................................................................... 136
Creep...................................................................................................... 137

xi
Adhesions .............................................................................................. 137

Skin Rolling ........................................................................................... 138
Skin Pulling ........................................................................................... 138
Cross-Fiber Friction............................................................................... 139
RANGE-OF-MOTION STRETCHING .................................................. 144
Mechanics of Stretching ........................................................................ 145
Glenohumeral Stretch ............................................................................ 147
Overhead Stretch ................................................................................... 148
Cross-Over Stretch................................................................................. 149
Force-Couple Stretch ............................................................................. 149
Range-of-Motion Stretching Fundamentals .......................................... 150
Contraindications to Stretching ............................................................ 154
22 Basic Muscles: ROM Stretching (Table) .................................... 155
Chapter Summary ....................................................................................... 168
EXERCISE ................................................................................................. 170

Pendular Exercise (Codman) ................................................................. 172
Three Basic Preliminary Shoulder Exercises ........................................ 173
Five Basic Secondary Shoulder Exercises ............................................ 174
Staff or Walking Cane Exercises........................................................... 177
Table Stretch from Sitting Position (3 to 12 repetitions) ...................... 180
Warm-up Stretching Exercises (10 to 15 repetitions) ........................... 181
The Exercise Challenge ......................................................................... 181
Pain Prevention...................................................................................... 182
Chapter Summary ....................................................................................... 184
CONCLUSION........................................................................................... 185
SELECTED BIBLIOGRAPHY.................................................................. 186
GLOSSARY ............................................................................................... 200
HEMME APPROACH QUIZ..................................................................... 214
INDEX ........................................................................................................ 224

1
INTRODUCTION
Taken together, neck and shoulder pain are the second leading cause of
musculoskeletal pain, after low back pain. Although much has been
published on neck and shoulder pain since the early 1930s, most writers
seem to ignore soft-tissue manipulation as a critical part of therapy. This
reluctance to consider soft-tissue therapy significant could partially explain
why many patients continue to experience neck and shoulder pain long after
the insurance benefits have expired or the treating physician dismisses the
case as purely psychogenic. While psychological factors are consequential
in some cases, personality changes are more likely to result from neck and
shoulder pain than to be the cause of neck and shoulder pain.
What makes neck and shoulder pain difficult to treat is the difficulty in
using standard laboratory procedures such as x-rays and blood testing to
identify the exact cause of pain. Soft-tissue impairments are soft-tissue
lesions or defects that cause disability or loss of function. Most cases of
neck and shoulder pain are caused by soft-tissue impairments that are not
easily identified by x-ray studies or hematologic (blood) testing.
Despite volumes of enthusiastic support for treatments involving
medication and surgery, there appears to be a need for treatments that are
more conservative and less invasive. Not only will soft-tissue therapy
satisfy this need, but it is also clearly the missing link between the onset of
soft-tissue disabilities such as neck and shoulder pain and the final stages of
rehabilitation.
This is not to say that therapy applied to neck and shoulder injuries is
new. Many writers have recommended modalities and exercise as part of a
complex treatment program that frequently involves medication or surgery.
What most writers fail to consider is that passive modalities and therapeutic
exercise as a two-part protocol are not very effective against neck and
shoulder pain caused by soft-tissue impairments.
The most effective protocol for treating soft-tissue impairments has three
parts: (1) modalities, (2) soft-tissue manipulation, and (3) exercise.
Modalities can be used to reduce pain and increase tissue extensibility before
manipulation. Soft-tissue manipulation is used to neutralize trigger points,
control spasm, facilitate weak muscles, and lengthen restricted tissues. Once
patients are capable of nearly painless movement with almost full range of
motion, exercise can be used productively to condition the body by
improving strength, endurance, and flexibility.

2
Beyond helping to control pain, improve neurologic efficiency, and
restore normal tissue length, soft-tissue manipulation improves fluid
dynamics, accelerates healing, and produces a relaxing effect that is
physically and psychologically beneficial. Though soft-tissue therapy can
be used without modalities or exercise, the speed of recovery is greatly
improved when modalities are used to prepare tissues for manipulation and
exercise is used to condition the body and reinforce changes that are made
possible through manipulation.
Though admittedly soft-tissue therapy is not a miracle cure for every
problem that ails the neck or shoulder, it can produce dramatic results that
some patients view as almost miraculous, considering that many of them
were told to live with the pain or get psychiatric help. Regrettably for many
patients, most neck and shoulder problems are not curable by medication or
surgery, and therapy that treats symptoms but not the cause has a tendency
to increase medical bills faster than to increase the quality of life.
For patients with neck or shoulder conditions where surgery is not
required, soft-tissue therapy is a low-cost, conservative, and noninvasive
treatment that offers many victims of neck and shoulder pain realistic hope
for long-term recovery. By early detection and correct treatment, many
patients will avoid chronic pain and loss of function that frequently results
from inappropriate treatment of soft-tissue impairments.
The HEMME APPROACH to Neck and Shoulder Pain course will explore
pain originating in the neck and shoulder. Although shoulder pain alone is a
very broad subject, any discussion of shoulder pain would be incomplete
without considering the close relationship between neck pain and shoulder
pain. In many cases, pain perceived and treated as shoulder pain is actually
pain originating in the neck and referred to the shoulder.
For the purpose of this manual, the term shoulder region refers to
scapulas, clavicles, related joints, and related soft-tissue structures such as
muscles, tendons, ligaments, and joint capsules. The shoulder can also be
defined as the junction between the arms and trunk bounded by the scapulas
in the back. The terms shoulder joint or glenohumeral joint refer to the joint
formed by the humerus and the glenoid cavity of the scapula. The term neck
refers to the part of the body between the head and shoulders and includes
the cervical spine as well as related joints and soft-tissue structures.

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HEMME APPROACH Concepts
Two things that make the HEMME APPROACH different from most other
methods of soft-tissue therapy are (1) the scientific method and (2)
procedural flexibility. Where many approaches present soft-tissue therapy
as a rigid series of cookbook-like steps, the HEMME APPROACH goes beyond
basic routines and presents soft-tissue therapy as a problem-solving process.
Since all patients are unique and each problem is somewhat different, any
approach that fails to include flexibility and freedom of choice is not going
to be equally effective in all cases.
HEMME APPROACH SCIENTIFIC METHOD
1. Identify problem presented by the patient.

2. Determine whether therapy is indicated or contraindicated.
A. Discontinue if contraindicated.
B. Continue if indicated.
3. Investigate problem and form preliminary theories.
4. Collect additional information to verify or deny theories.
5. Begin therapy based on the best possible theories.
6. Use feedback from the patient to see if therapy is successful.
7. Make decision.
A. Complete program if therapy is successful.
B. Repeat earlier steps if therapy is not successful.
C. Discontinue therapy for valid reason.
The HEMME APPROACH is flexible because it uses more than one method
of manipulation to correct soft-tissue impairments. The power of synergy in
soft-tissue therapy comes from knowing how and when to combine one form
of manipulation with another.
Since soft-tissue impairments can affect all four types of tissue found in
the human body—nerve tissue, muscle tissue, connective tissue, and
epithelial tissue—manipulations are needed that affect all four tissues. This
can be done by using three methods of manipulations:
1. neuromuscular therapy: affects nerve and muscle tissue

2. connective tissue therapy: affects connective and epithelial tissue
3. range-of-motion stretching: affects all four categories of tissue

4
Even so, there is still one more problem that is common to most cases of
soft-tissue impairment that is not anatomic in nature. Found mostly in
muscles, fascia, tendons, or ligaments, trigger points are not composed
visibly of tissue. It appears that a large percentage of their composition
involves pain-producing chemicals such as serotonin, bradykinin, substance
P, histamine, and prostaglandins. To address trigger points as well as
problems relating to all four types of human tissue, the HEMME APPROACH
includes a fourth method of manipulation called trigger point therapy.
Since trigger point therapy and neuromuscular therapy are normally the
first and second methods of manipulation used in soft-tissue therapy and
range-of-motion stretching is normally the last, the basic sequence for using
all four methods of manipulation together in HEMME APPROACH would be:
1. trigger point therapy (neutralize trigger points)

2. neuromuscular therapy (inhibit or facilitate muscles)
3. connective tissue therapy (lengthen restrictive tissues)
4. range-of-motion stretching (improve mobility)
Anatomy and Physiology
The key to treating neck and shoulder pain is understanding the anatomy
and physiology. The shoulder region is designed for maximum mobility.
Composed of eighteen major muscles, the shoulder girdle and glenohumeral
joint produce greater mobility than any other part of the body.
To achieve mobility, the shoulder complex sacrifices structural stability.
The sternoclavicular joint is the only attachment between the upper
extremities and the trunk, and the head of the humerus hangs loosely in
place because of soft-tissue attachments while sitting on the inclined plane
that forms the outer surface of the glenoid fossa.
Unlike any other joint in the body, the shoulder is capable of about seven
basic movements relative to the humerus and scapula.
HUMERUS
A. flexion: a forward motion perpendicular to the scapula

B. extension: a backward motion perpendicular to the scapula
C. abduction: an outward movement parallel to the scapula
D. adduction: an inward movement parallel to the scapula

5
E. medial rotation: internal rotation of the humerus
F. lateral rotation: external rotation of the humerus
G. horizontal abduction: abduction of humerus moving away from the
front of the chest starting at 90 degrees abduction at the shoulder
H. horizontal adduction: adduction of humerus moving toward the front
of the chest starting at 90 degrees abduction at the shoulder
I. circumduction: a combination of flexion, extension, abduction, and
adduction performed sequentially in either direction so that the
humerus describes a cone with the glenoid cavity at the apex
Horizontal abduction means about the same as horizontal extension and

horizontal adduction means about the same as horizontal flexion. Though
some definitions describe horizontal abduction or adduction as movements
limited to the horizontal plane, in this text these movements can be within 45
degrees (diagonal) above or below the horizontal plane. Reaching across the
chest and touching the opposite ear, shoulder, or axillary region will be
classified as horizontal adduction. The ranges of motion for horizontal
abduction or adduction are measured by using the humerus abducted to 90
degrees at the shoulder as a starting point.
Medial rotation means the same as internal or inward rotation, and
lateral rotation means the same as external or outward rotation. When using
the right humerus as a reference point, medial rotation is a counterclockwise
movement and lateral rotation is a clockwise movement. Regardless of what
position the humerus is in—flexed, extended, adducted, or abducted—
rotational directions for medial or lateral rotation remain the same.
In addition to humeral movement relative to the scapula, the scapula is
capable of movement relative to the thorax (scapulothoracic rotation).
SCAPULA
A. elevation: upward movement of the scapula relative to the thorax

B. depression: return to normal resting position from elevation
C. abduction: lateral movement of scapula away from spinal column
D. adduction: medial movement of scapula toward spinal column
E. upward rotation: glenoid fossa faces upward and inferior angle of
scapula moves laterally and anteriorly on the thorax (arms overhead)
F. downward rotation: return to normal resting position from upward
rotation (arms at side)

6
To separate humeral adduction or abduction from scapular adduction or
abduction, scapular adduction is sometimes called retraction and scapular
abduction is sometimes called protraction.
For simplicity, some movements are classified by geometric planes. The
three basic planes are sagittal, frontal (coronal), and horizontal (transverse).
From anatomical position, the sagittal plane is a vertical plane that divides
the body into right and left parts, the frontal plane is a vertical plane that
divides the body into anterior (front) and posterior (back) parts, and the
horizontal plane is a transverse plane that divides the body into top and
bottom parts. The median or midsagittal plane is a sagittal plane that divides
the body into equal right and left parts. A diagonal plane is angled at 45
degrees from the sagittal, frontal, or horizontal plane.
Though a complex movement, such as circumduction, can involve
more than one plane, most movements occur basically in one plane.
A. flexion or extension: sagittal plane

B. abduction or adduction: frontal plane
C. horizontal adduction or abduction: horizontal plane (approximate)
Standard directional terms for describing body structures, locating

trigger points, or giving the direction someone is facing:
A. superior (top)
B. inferior (bottom)
C. anterior (front)
D. posterior (back)
E. medial (toward midline or vertebral column)
F. lateral (away from midline or vertebral column)
G. proximal (near)
H. distal (far)
I. cephalad (in direction of head)
J. caudad (in direction of feet)
Muscles
Although soft-tissue structures provide far more restraint in the shoulder

than bony structures, support and stabilization in the shoulder depend more
on muscles and tendons than on ligaments or fascia. Only when muscles are

7
elongated beyond their normal length does fascia become a supporting
tissue. Where muscles are considered dynamic stabilizers, ligaments are
considered static stabilizers. This explains why pain and disability in the
shoulder complex frequently involves muscles and tendons. Muscular
weakness is thought to be one of the main reasons for recurrent dislocations.
The 22 basic muscles that influence the shoulder region are listed below
in alphabetical order. Of the 22 basic muscles, 7 belong to the shoulder
girdle and 11 to the shoulder joint. Because of their close relationship with
the shoulder, 4 additional muscles were added to the list: 3 cervical muscles
and 1 back muscle. The 3 cervical muscles are scalenus anterior, scalenus
medius, and scalenus posterior, and the back muscle is serratus posterior
superior. The scalene muscles refer pain to the shoulder region and serratus
posterior superior refers pain to the scapulas.
It is very important to be familiar with all 22 muscles since they will
appear at least three more times as a group when discussing: (1) muscle
testing, (2) trigger points, and (3) range-of-motion stretching.
The 22 basic muscles are listed first by category and second by
alphabetical order. The first category is “Neck” and the second category is
“Shoulder and Back.” All muscles are described by action, origin, insertion,
and innervation. Though some muscles have multiple actions that can vary
depending on the direction and pull and synergist relationships, only the
most common actions are listed. A similar principle applies to the muscle
testing, trigger point, and range-of-motion stretching charts, where only the
most significant actions, locations, or stretches are listed. Innervation is
shown below as a combination nerve supply and spinal nerve root deviation.
Even though listed separately, most muscles of the shoulder region work
together as a group to produce upper body movement. A tennis serve may
involve latissimus dorsi, pectoralis major, subscapularis, and triceps, while a
baseball pitch may involve the deltoid, latissimus dorsi, subscapularis, and
triceps. A normal push-up uses triceps brachii, pectoralis major, anterior
deltoid, biceps brachii, serratus anterior, and pectoralis minor, whereas a
normal chin-up uses biceps brachii, latissimus dorsi, teres major, posterior
deltoid, pectoralis major, pectoralis minor, and trapezius.
Most muscles work with other muscles to produce movement. As
Beevor’s axiom states: "The brain knows nothing of individual muscles, but
thinks only in terms of movement." Even though muscles working alone
produce an action, muscles working together produce movement.

8
22 BASIC MUSCLES: Description
Neck
1. SCALENUS ANTERIOR (cervical)

Action: forward flexes, laterally flexes, and rotates neck; elevates 1st
rib
Origin: transverse process of 3rd to 6th cervical vertebrae
Insertion: tubercle of 1st rib
Innervation: cervical plexus (C2 through C7)
2. SCALENUS MEDIUS (cervical)

Action: laterally flexes neck and elevates 1st rib
Origin: transverse process of 2nd to 6th cervical vertebrae
Insertion: 1st rib
Innervation: cervical plexus (C2 through C7)
3. SCALENUS POSTERIOR (cervical)

Action: laterally flexes neck and elevates 2nd rib
Origin: transverse process of 4th to 6th cervical vertebrae
Insertion: 2nd rib
Innervation: cervical plexus and brachial plexus (C2 through C7)
Shoulder and Back
4. BICEPS BRACHII (shoulder joint)

Action: flexes arm and forearm, supinates hand
Origin: (1) short head from coracoid process
(2) long head from upper margin of glenoid cavity
Insertion: bicipital tuberosity of radius
Innervation: musculocutaneous nerve (C5 and C6)
5. CORACOBRACHIALIS (shoulder joint)

Action: adducts and flexes arm, forward tilts scapula
Origin: coracoid process of scapula
Insertion: medial surface of humerus
Innervation: musculocutaneous nerve (C5, C6, and C7)

9
6. DELTOID (shoulder joint)
Action: abducts arm (all fibers)
Anterior fibers: flex, medially rotate, and horizontally adduct arm
Middle fibers: flex and abduct arm
Posterior fibers: extend, laterally rotate, horizontally abduct arm
Origin: clavicle, acromion process, and spine of scapula
Insertion: deltoid tuberosity of humerus
Innervation: axillary from brachial plexus (C5 and C6)
7. INFRASPINATUS (shoulder joint)

Action: extends and laterally rotates arm
Origin: infraspinatus fossa of scapula
Insertion: greater tubercle of humerus
Innervation: subscapular from brachial plexus (C5 and C6)
8. LATISSIMUS DORSI (shoulder joint)

Action: adducts, extends, and medially rotates arm
Origin: lower thoracic and lumbar vertebrae, sacrum, and iliac crest
Insertion: intertubercular groove of humerus
Innervation: brachial plexus (C6, C7, and C8)
9. LEVATOR SCAPULAE (shoulder girdle)

Action: elevates and downward rotates scapula
Origin: transverse processes of upper four cervical vertebrae
Insertion: medial border scapula
Innervation: 3rd and 4th cervical nerves (C3 and C4)
10. PECTORALIS MAJOR (shoulder joint)

Action: flexes, adducts, and medially rotates arm, depresses, abducts scapula
Origin: sternum, clavicle, and upper six ribs
Insertion: crest of greater tubercle of humerus
Innervation: anterior thoracic from brachial plexus (C5 and C6)
11. PECTORALIS MINOR (shoulder girdle)

Action: depresses and draws scapula forward; raises ribs
Origin: 3rd to 5th ribs
Insertion: coracoid process of scapula
Innervation: medial and lateral pectoral nerve (C8 and T1)

10
12. RHOMBOID MAJOR (shoulder girdle)
Action: adducts, elevates, and downward rotates scapula
Origin: spinous process of 2nd to 5th thoracic vertebrae
Insertion: medial border of scapula below spine
Innervation: dorsal scapular from brachial plexus (C4 and C5)
13. RHOMBOID MINOR (shoulder girdle)

Action: adducts, elevates, and downward rotates scapula
Origin: spinous process of 7th cervical and 1st thoracic vertebrae
Insertion: medial border of scapula above spine
Innervation: dorsal scapular from brachial plexus (C4 and C5)
14. SERRATUS ANTERIOR (shoulder girdle)

Action:
All fibers together: abducts and upward rotates scapula, elevates ribs
Upper fibers: elevate scapula
Lower fibers: depress scapula
Origin: upper eight or nine ribs
Insertion: angles and medial border of scapula
Innervation: medial and lateral pectoral nerve (C5, C6, and C7)
15. SERRATUS POSTERIOR SUPERIOR (back)

Action: elevates ribs
Origin: nuchal ligament, 7th cervical and upper two thoracic vertebrae
Insertion: 2nd and 5 ribs
Innervation: thoracic nerve (T1 through T4)
16. SUBCLAVIUS (shoulder girdle)

Action: depress lateral end of clavicle, elevates first rib
Origin: first rib and its cartilage
Insertion: lower surface of clavicle
Innervation: subclavian from brachial plexus (C5, C6, and C7)
17. SUBSCAPULARIS (shoulder joint)

Action: medially rotates and adducts arm
Origin: subscapular fossa of scapula
Insertion: lesser tubercle of humerus
Innervation: subscapular nerve (C5 and C6)

11
18. SUPRASPINATUS (shoulder joint)
Action: abducts arm
Origin: supraspinatus fossa of scapula
Innervation: branches of subscapular nerve (C5 and C6)
19. TERES MAJOR (shoulder joint)

Action: adducts, extends, and medially rotates arm
Origin: inferior angle of scapula
Insertion: lesser tubercle of humerus
Innervation: branch of lower subscapular nerve (C5 and C6)
20. TERES MINOR (shoulder joint)

Action: laterally rotates arm
Origin: lateral border of scapula
Innervation: branch of axillary nerve (C5 and C6)
21. TRAPEZIUS (shoulder girdle)

Action:
Upper fibers (head): draws head back or to the side
Upper fibers (scapula): elevates, adducts, and upward rotates scapula
Middle fibers: adducts scapula
Lower fibers: adducts, depresses, and upward rotates scapula
Origin: occipital bone, ligamentum nuchae, spinous process of 7th
cervical, and all thoracic vertebrae
Insertion: clavicle, acromion, and spine of scapula
Innervation: spinal accessory and cervical plexus (C2, C3, and C4)
Additional motor innervation: cranial nerve XI
22. TRICEPS BRACHII (shoulder joint)

Action: extends forearm, adducts and extends arm
Origin: (1) long head from lateral border of scapula
(2) lateral head from lateral and posterior surface of humerus
(3) medial head from humerus below radial groove
Insertion: olecranon process of ulna
Innervation: branches of radial nerve (C7 and C8)

12
NECK AND SHOULDER ILLUSTRATIONS
Lateral Neck Muscles Page

A. scalenus anterior ........................................................................... 13
B. scalenus medius ............................................................................ 13
C. scalenus posterior ......................................................................... 13
Anterior Shoulder Muscles

A. biceps brachii................................................................................ 16
B. coracobrachialis ............................................................................ 16
C. pectoralis major ....................................................................... 16,17
D. pectoralis minor ....................................................................... 16,17
E. serratus anterior ....................................................................... 16,17
F. subclavius ................................................................................ 16,17
G. subscapularis................................................................................. 15
Posterior Shoulder Muscles

A. infraspinatus ................................................................................. 19
B. levator scapulae ............................................................................ 21
C. teres minor .................................................................................... 19
D. rhomboid major ............................................................................ 21
E. rhomboid minor ............................................................................ 21
F. serratus posterior superior ............................................................ 21
G. trapezius........................................................................................ 20
Superior Shoulder Muscles

A. deltoid ...................................................................................... 17,20
B. supraspinatus ................................................................................ 19
Inferior Shoulder Muscles

A. latissimus dorsi ............................................................................. 20
B. teres major ............................................................................... 15,19
C. triceps brachii ............................................................................... 20
Bones of the Shoulder Region

A. clavicle............................................................................ 14,17,18
B. humerus .......................................................................... 14,17,18
C. scapula ................................................................................. 14,18

13
LATERAL NECK (Muscles)
scalenus medius
scalenus anterior
scalenus posterior

14
ANTERIOR SHOULDER (Bones)
acromion process coracoid process superior angle
greater tubercle
clavicle
lesser tubercle
bicipital groove
scapula
lateral border medial border

deltoid tuberosity
inferior angle
humerus

15
ANTERIOR SHOULDER (Muscles)
supraspinatus
subscapularis
teres major
latissimus dorsi

16
ANTERIOR TORSO (Superficial)
subclavius
pectoralis major
pectoralis minor
coracobrachialis
biceps brachii
serratus anterior

17
ANTERIOR TORSO (Deep)
clavicle 1st rib
deltoid subclavius
sternum pectoralis minor
pectoralis major humerus
serratus anterior

18
POSTERIOR SHOULDER (Bones)
clavicle superior angle acromion process
greater tuberosity
glenohumeral joint
spine of scapula
scapula
medial border deltoid tuberosity
inferior angle humerus

19
POSTERIOR SHOULDER (Muscles)
supraspinatus
teres minor
infraspinatus
teres major

20
POSTERIOR TORSO (Superficial)
trapezius
acromion process
deltoid
triceps brachii latissimus dorsi

21
POSTERIOR TORSO (Deep)
levator scapulae
serratus rhomboid minor
posterior
superior rhomboid major

22
MUSCLES BY ACTION
Cervical Spine
1. Extension
A. upper fibers of trapezius
2. Flexion (forward)
A. scalenus anterior
3. Lateral flexion (side-bending)
A. scalenus anterior
B. scalenus medius
C. scalenus posterior
Humerus
1. Flexion (humeral head slides posterior)
A. biceps brachii (short head)

B. coracobrachialis
C. deltoid (anterior)
D. pectoralis major (clavicular attachment)
2. Extension (humeral head slides anterior)
A. deltoid (posterior fibers)

B. latissimus dorsi
C. teres major
D. triceps brachii (long head)
3. Abduction (humeral head slides inferior)
A. deltoid (middle fibers)

B. supraspinatus

23
4. Adduction (humeral head slides superior)
A. coracobrachialis
B. latissimus dorsi
C. pectoralis major (sternal attachment)
D. subscapularis
E. teres major
F. triceps brachii (long head)
5. Medial rotation (humeral head slides posterior)
A. deltoid (anterior fibers)

B. latissimus dorsi
C. pectoralis major (sternal and clavicular attachments)
D. subscapularis
E. teres major
5. Lateral rotation (humeral head slides anterior)

B. infraspinatus
C. teres minor
7. Horizontal abduction (humeral head slides anterior)
8. Horizontal adduction (humeral head slides posterior)
A. deltoid (anterior fibers)

B. pectoralis major (sternal and clavicular attachments)
Forearm
1. Flexion
A. biceps brachii

24
2. Extension
A. triceps brachii
Scapula
1. Stabilization
A. rhomboids
B. serratus anterior
C. trapezius
2. Abduction (protraction)
A. pectoralis major (clavicular attachment)

B. pectoralis minor
C. serratus anterior (upper and lower fibers)
3. Adduction (retraction)
A. rhomboid major
B. rhomboid minor
C. trapezius (upper, middle, and lower fibers)
4. Elevation
A. levator scapulae
B. rhomboid major
C. rhomboid minor
D. serratus anterior (upper fibers)
E. trapezius (upper fibers)
5. Depression
A. pectoralis major (sternal and clavicular attachments)

B. pectoralis minor
C. serratus anterior (lower fibers)
D. trapezius (lower fibers)

25
6. Upward rotation
A. serratus anterior (upper and lower fibers)

B. trapezius (upper and lower fibers)
7. Downward rotation
A. levator scapulae
B. pectoralis minor
C. rhomboid major
D. rhomboid minor
8. Anterior (forward) tilt
A. coracobrachialis
B. pectoralis minor
This listing completes the presentation of muscles by action. On the

following three pages, muscles that work in pairs (page 26) and muscles that
act on specific bones (pages 27-28) are described.

26
Some muscles of the shoulder complex can be listed by pairs. Muscles
are synergistic when they work together and produce the same or opposite
actions. Unlike agonistic-antagonistic muscle pairs, where the agonist
normally contracts while the antagonist relaxes, synergistic muscles can
work as pairs with both muscles contracting at the same time or one muscle
contracting while the other relaxes.
Muscle pairs working synergistically in pairs can produce circular
movements when both muscles contract at the same time, such as upward
rotation of the scapula, or linear movement when one muscle contracts while
the other relaxes, such as abduction or adduction of the scapula.
Helping synergy differs from neutralizing synergy in that helping
synergy produces movement, whereas neutralizing synergy stabilizes a body
part and prevents undesired movement.
Trapezius and Serratus Anterior
Same: upward rotation of the scapula

Opposite: abduction or adduction of the scapula
Trapezius and Rhomboids
Same: adduction of the scapulas

Opposite: upward or downward rotation of the scapula
Trapezius: upper and lower fibers
Same: upward rotation of the scapula

Opposite: elevation and depression of the scapulas
Deltoid: anterior and posterior fibers
Same: abduction of the humerus

Opposite: flexion or extension of the humerus
Subscapularis and Infraspinatus
Same: depress head of humerus in abduction

Opposite: medial or lateral rotation of the humerus

27
The muscles of the shoulder complex can be broken down into five
additional categories. The first three categories are based on whether a
muscle acts on the humerus, scapula, or clavicle. In these three categories,
the muscles shown in italics are not considered shoulder muscles. In the
fourth category, muscles of the shoulder joint are listed by anatomical
position: anterior, posterior, superior, or inferior. In the fifth category, the
rotator cuff muscles are listed by how they occur in the acronym SITS.
(1) Muscles Acting on the Humerus
A. anconeus (origin)
B. brachialis (origin)
C. brachioradialis (origin)
D. coracobrachialis (insertion)
E. deltoid (insertion)
F. extensor carpi radialis longus (origin)
G. flexor carpi ulnaris (origin)
H. infraspinatus (insertion)
I. latissimus dorsi (insertion)
J. pectoralis major (insertion)
K. pronator teres (origin)
L. subscapularis (insertion)
M. supraspinatus (insertion)
N. teres major (insertion)
O. teres minor (insertion)
P. triceps (origin)
(2) Muscles Acting on the Scapula
A. biceps, long head (origin)

B. coracobrachialis (origin)
C. deltoid (origin)
D. infraspinatus (origin)
E. levator scapulae (insertion)
F. omohyoid (origin)
G. pectoralis minor (insertion)
H. rhomboid major (insertion)
I. rhomboid minor (insertion)

28
J. serratus anterior (insertion)
K. subscapularis (origin)
L. supraspinatus (origin)
M. teres major (origin)
N. teres minor (origin)
O. trapezius (insertion)
P. triceps, long head (origin)
(3) Muscles Acting on the Clavicle
A. deltoid (origin)
B. pectoralis major (origin)
C. sternocleidomastoid (origin)
D. sternohyoid (origin)
E. subclavius (insertion)
F. trapezius (insertion)
(4) Muscles of the Shoulder Joint
A. biceps brachii (anterior)

B. coracobrachialis (anterior)
C. deltoid (superior)
D. infraspinatus (posterior)
E. latissimus dorsi (inferior)
F. pectoralis major (anterior)
G. subscapularis (anterior)
H. supraspinatus (superior)
I. teres major (inferior)
J. teres minor (posterior)
K. triceps brachii, long head (inferior)
(5) Rotator Cuff (SITS) Muscles
A. supraspinatus
B. infraspinatus
C. teres minor
D. subscapularis

29
Trapezius
Of all the 22 muscles selected, the trapezius is unique because of its

ability to function either as a single muscle or as three different muscles.
The trapezius has three groups of fibers: upper, middle, and lower fibers.
When working together, all three groups adduct the scapula. When working
separately, the upper fibers elevate the scapula, the middle fibers adduct the
scapula, and the lower fibers depress the scapula. As pointed out above, the
upper and lower fibers can work synergistically to rotate the scapula upward.
The action of the trapezius can change, depending on how the occiput
functions. When the occiput acts as the insertion (moveable) and the
shoulders are fixed, contraction of the upper fibers draws the head back.
When the occiput acts as the origin (stationary) and the shoulders are free to
move, contraction of the upper fibers elevates the shoulders.
The upper part of the trapezius supports the clavicle and the acromion
process only when heavy weight is being carried by hand with the arm in a
downward position along the side. The capsule of the sternoclavicular
articulation is usually adequate to support the arm when lightweights are
being carried with the arm in the same position.
Bones
Muscles combine with bones and joints to form the shoulder complex.
The shoulder girdle (two scapulae and two clavicles) is the only bony
connection between upper extremities and the axial skeleton. The sequence
for attachment is shoulder girdle to thoracic vertebrae via sternum and ribs.
The major bones participating in shoulder movement are:
A. clavicle (collar bone)

B. humerus (arm bone)
C. costae (ribs)
D. scapula (shoulder blade)
E. sternum (breast bone)
As used in this text, arm (humerus) refers to that portion of the upper
extremity or limb between the shoulder and elbow. Forearm (radius and
ulna) refers to that portion of the upper extremity between elbow and wrist.

30
Joints
Muscles exert force by contraction, bones provide the levers for

transmitting force, and joints are the juncture or fulcrum between bones.
The shoulder region has seven basic joints and one mechanism, the biceps
mechanism, which is sometimes classified as a joint.
A. acromioclavicular joint: articulation between clavicle and scapula

B. costovertebral joint: articulation between ribs and vertebral body
C. glenohumeral joint: articulation between glenoid cavity and humerus
D. scapulothoracic joint: articulation between scapula and thorax
E. sternoclavicular joint: articulation between sternum and clavicle
F. sternocostal joint: articulation between sternum and ribs
G. biceps mechanism: gliding articulation of the biceps tendon within
the bicipital groove
The shoulder complex, consisting of three bones—scapula, clavicle, and

humerus—is joined by three anatomical joints and one functional joint. The
anatomical joints are the glenohumeral joint, acromioclavicular joint, and
sternoclavicular joint. The functional joint is the scapulothoracic joint.
The glenohumeral joint (shoulder joint) is a ball-and-socket synovial
joint formed by the head of the humerus and the shallow glenoid fossa.
Normally considered the most important single joint in the shoulder, the
glenohumeral joint has three degrees of freedom: (1) flexion-extension, (2)
abduction-adduction, and (3) medial-lateral rotation.
Although not truly an anatomic joint, the scapulothoracic joint functions
as a joint by allowing the scapula to rotate on the thorax. The
scapulothoracic joint contributes about 60 degrees to humeral abduction and
the glenohumeral joint contributes about 120 degrees.
Ligaments
A. acromioclavicular ligament: connects acromion process and clavicle

B. coracoacromial ligament: connects coracoid and acromion process
C. coracoclavicular ligament: connects coracoid process and clavicle
D. coracohumeral ligament: connects coracoid process and humerus
E. costoclavicular ligament: connects first rib and clavicle
F. glenohumeral ligament: reinforces the glenohumeral joint capsule

31
Muscle-Joint Dysfunction-Disability Cycle
It would be difficult to say that one component of the shoulder

complex—muscle, bone, or joint—is any more important than any other
component. The shoulder cannot function unless all three components work
together with consistency and coordination. What can be suggested is that
soft tissue is more likely to cause pain and disability than osseous tissue.
Muscles are more likely to cause pain and disability than bones, and soft-
tissue defects in a joint are more likely to cause pain and disability than bony
anomalies.
What becomes less clear is deciding which problem came first: a joint
problem that affects muscles or a muscle problem that affects joints.
Although trauma and diseases can affect joints before they affect muscles,
changes in tonus or muscle length affect muscles before they affect joints.
When changes to a muscle affect a joint, hypertonicity or shortness are
normally more damaging to a joint than hypotonicity or increases in length.
Factors that cause hypertonicity (hypertonia) or adaptive shortening include
pain, spasm, or edema, and prolonged periods of limited use or immobility.
Though classical medicine has a tendency to view joint problems as
primary and muscular problems as secondary, this tendency seems to ignore
the fact that muscle shortening can reduce joint space and cause progressive
erosion of the articular cartilage. Without hyaline cartilage protecting the
articular surfaces of a bone, the results may include irritation, swelling,
fibrosis, calcification, immobility (ankylosis), and ultimately dysfunction.
To protect irritated joints from further damage, the body’s normal
reaction is to splint the joint by triggering reflex spasm in the muscles that
cross the joint. Splinting reinforces initial increases in muscle tension and
sets the stage for a muscle-joint dysfunction-disability cycle that started
because of changes in tonus or muscle length. Not only does immobility
have a tendency to shorten connective tissue, but it can also shorten muscles
by decreasing the number of sarcomeres present.
At the same time splinting protects the joint by decreasing mobility, it
also sets the stage for long-term disability. Once a joint becomes immobile,
proliferation of random connective tissue, adhesions, fibrous contractures,
fatty infiltration, ligament atrophy, ossification of soft tissue, and muscle
weakness increase the risk of permanent immobility.
With early recognition and proper treatment, it should be possible to
decrease joint damage by reducing tonus, increasing muscle length, and

32
keeping the joint mobile. Even if hypertonic muscles are not treated before
changes in joint space occur, treating the muscles will help to break the
muscle-joint dysfunction-disability cycle and make treating the joint easier.
If muscles are completely ignored, efforts to increase joint space and
mobility will be offset by muscle tension that decreases joint space and
mobility. When opposing muscles that control a joint are both in spasm or
pathologically shortened, the muscles cannot move the joint because neither
muscle is capable of contracting or relaxing normally. Once joints become
partially immobile, muscle tension, swelling, and pain seem to diminish.
Even after a joint becomes partially immobile, any stress that forces the
joint beyond its new limits can restart the original cycle. If renewed cycles
of muscle tension and joint dysfunction are not treated quickly and properly,
further decreases in joint mobility can be expected.
When loss of mobility becomes extremely severe, muscles may atrophy
because of disuse and circulation decreases because of inactivity. Many
patients report severe chronic pain, difficulty sleeping, and chronic
depression. This may explain why many of these patients are given
medication to reduce pain, improve sleep, and fight depression.
As grim as the muscle-joint dysfunction-disability cycle can be, part of
this sequela could be avoided by understanding that increases in tonus and
decreases in muscle length can be the cause, as well as the consequence, of
joint dysfunction. Unless muscle splinting is caused directly by joint
dysfunction and some degree of immobility is needed to protect the joint
from damage during the acute stage of the injury, muscle tonicity and length
should fall within normal limits.
Since hypertonicity and muscle shortening can decrease joint space and
irritate joints, the best solution is early detection and treatment of any
muscles with abnormal tissue tension or length. Pain and stiffness are two
of the most common indicators of muscle involvement in the shoulder.
Clicking of the biceps tendon during shoulder movement or crepitus may
indicate spasm. Range-of-motion testing, muscle testing, and palpation can
be used to verify spasm.
Most problems involving tonus or muscle length are treated with trigger
point therapy, neuromuscular therapy, and range-of-motion stretching.
Modalities and exercise can be useful. If pain and spasm are severe,
mobilization can be used in place of conventional range-of-motion
stretching. Mobilization moves a tissue through a partial or complete range
of motion with no hold or sustained stretch at the end of the movement.

33
Glenohumeral Joint
The glenohumeral joint is the most complex articulation in the shoulder

and frequently the site of pathologic conditions. Commonly referred to as
the shoulder joint, the glenohumeral joint connects the hemispheric head of
the humerus with the shallow and somewhat pear-shaped glenoid cavity of
the scapula. The glenoid cavity faces upward and to the side with a slight
forward tilt. The cavity (fossa) is slightly deepened by glenoid labrum, a rim
of cartilage that surrounds the periphery.
The glenohumeral joint is a classic synovial joint consisting of a capsule
lined with synovial membrane that attaches proximally to the circumference
of the glenoid cavity and distally to the anatomical neck of the humerus.
The joint is further protected by hyaline cartilage that covers the head of the
humerus and lines the glenoid fossa.
When the arm is hanging freely at the side of the body in a dependent
position, the upper portion of the glenohumeral joint capsule is taut and the
lower portion is slack. When the arms are fully abducted overhead, the
upper portion of the capsule is slack and the lower portion is taut. When the
arm is hanging freely along the side of the body, the joint capsule provides
only secondary support as long as the supraspinatus muscle is functional. In
a dependent (downward) position, the shoulder is not supported by bony
architecture.
If the supraspinatus muscle fails, the joint capsule provides primary
support after the humerus drops downward into subluxation. Factors that
cause supraspinatus failure include trauma, ischemic damage because of
prolonged isometric contractions, stress because of repeated contractions,
muscle fatigue, and tendinitis or rupture of the supraspinatus tendon.
Repetitive or sustained movements involving overhead elevation of the arms
and carrying heavy weights with the arms in a downward position are
frequently implicated as the major causes for supraspinatus failure.
The glenohumeral joint is classified as incongruous because the surfaces
between the head of the humerus and the glenoid cavity are not parallel with
a single axis of rotation. The convex surface of the humeral head is smaller
and steeper than the concave surface of the glenoid cavity. Incongruence
between the head of the humerus and the glenoid cavity increases mobility
by allowing the head of the humerus freedom to glide across the concave
surface of the glenoid cavity and change its angle of rotation. In exchange
for greater mobility, the shoulder joint is less stable than congruent joints.

34
The shoulder joint is stabilized by soft-tissue structures: muscles,
tendons, fascia, ligaments, and the joint capsule. The ligaments that
reinforce the shoulder joint include the coracohumeral ligaments, the three
bands of the glenohumeral ligament, and the coracoacromial ligament. The
eight muscles that reinforce the shoulder joint are supraspinatus, long head
of the biceps brachii, long head of the triceps brachii, subscapularis,
pectoralis major, teres major, teres minor, and infraspinatus.
Rotator Cuff
Four muscles that stabilize the shoulder joint are known collectively as
rotator cuff or SITS muscles: supraspinatus, infraspinatus, teres minor, and
subscapularis. These four muscles, combined with the deltoid, are five of
the most important muscles that act on the shoulder joint. The rotator cuff
muscles rotate the humerus in an arc around a point located in the center of
the head of the humerus. The rotation occurs in the sagittal plane. The
deltoid muscle elevates the humerus away from the body.
Tendons from the supraspinatus, infraspinatus, and teres minor join to
form the common tendon. This common tendon is then joined by the tendon
from the subscapularis, thus creating a single tendon that unites all four
rotator cuff muscles. Tears and calcification are more likely to occur at the
distal end of the common tendon near the greater tuberosity than at the
proximal end of the tendon near the musculotendinous juncture. The distal
end has the greatest tensile strength and is subject to greater stress than other
parts of the tendon.
Depending on which fibers of the deltoid are used, elevation of the
humerus can occur in either the frontal plane or the sagittal plane. The
anterior fibers flex the humerus in the sagittal plane, the middle fibers abduct
the humerus in the frontal plane, and the posterior fibers extend the humerus
in the sagittal plane. Elevation of the humerus is limited by the
coracoacromial ligament. The anterior fibers of the deltoid also participate
in horizontal adduction.
A large percentage of all shoulder disabilities are caused by soft-tissue
impairments in one or more of these muscles. The most common
impairments are tears, lesions, or ruptures that affect the muscle or tendon.
The rotator cuff and deltoid also play a key role in scapulohumeral rhythm.

35
Scapulohumeral Rhythm
Since the shoulder complex is more mobile—and less stable—than any

other joint complex in the body because of the interplay between the
scapula, humerus, and thorax, understanding scapulohumeral rhythm is
critical to treating neck and shoulder pain. Though most people can elevate
the humerus from a downward position to an overhead position without
strenuous effort or conscious thought, the actual movement requires
tremendous coordination between eighteen basic shoulder muscles and the
glenohumeral and scapulothoracic articulations.
The three movements that play a major role in scapulohumeral rhythm
are (1) rotation of the humerus at the glenohumeral joint, (2) upward rotation
of the scapula at the scapulothoracic joint, and (3) elevation and rotation of
the clavicle at the sternoclavicular and acromioclavicular joint.
Starting from a downward position, the first 90 degrees of humeral
abduction (0 to 90 degrees) are about 60 degrees humeral rotation at the
glenohumeral joint and 30 degrees scapular rotation at the scapulothoracic
joint. The last 90 degrees of abduction (90 to 180 degrees) are about the
same: 60 degrees humeral rotation and 30 degrees scapular rotation.
When comparing humeral rotation with scapular rotation, the overall
ratio is about 2:1 (2 degrees of humeral rotation for 1 degree of scapular
rotation). If the humerus rotates 120 degrees, the scapula rotates about 60
degrees. Even though the overall ratio is about 2:1, this ratio is not constant
throughout the entire range of motion. During the first 15 to 30 degrees of
abduction, the scapula tends to remain stationary and serve as a solid base
for humeral rotation. This ratio can also vary from person to person.
Humeral Rotation
The first 0 to 5 degrees of abduction are produced by contraction of the

supraspinatus muscle. Until the humerus reaches about 5 degrees, the
deltoid is mechanically out of position to abduct the humerus. Patients with
weakness or paralysis in the supraspinatus muscle can sometimes abduct the
arm by using body movements to swing (abduct) the arm out beyond 5
degrees to where the deltoid becomes mechanically effective.
Even after the humerus is partially abducted by the supraspinatus, the
deltoid cannot abduct the humerus until the rotator cuff muscles depress the
head of the humerus. Without simultaneous depression and external rotation
of the humerus, the greater tuberosity of the humerus would impinge on the
coracoacromial ligament.

36
With simultaneous depression and rotation of the humerus, the deltoid
can abduct (rotate) the arm at the glenohumeral joint. External rotation of the
humerus begins at about 60 degrees elevation and continues to about 120
degrees elevation. While the supraspinatus, infraspinatus, and teres minor
depress and externally rotate the humerus, the other rotator cuff muscle,
subscapularis (internal rotator) relaxes.
Like most muscles, the deltoid is most efficient at, or slightly beyond, its
normal resting length. The resting length for the deltoid is about midway
between its length while fully stretched (adducted) and its length while fully
contracted (abducted). The deltoid is at resting length when the humerus is
hanging freely at the side and almost fully shortened (contracted) when the
laterally rotated humerus reaches about 120 degrees abduction.
Though not listed as a normal action, the clavicular fibers of pectoralis
major change from adductors of the humerus to abductors of the humerus
after about 110 degrees of elevation. The elevation changes the muscle's
line of pull on the humerus.
Scapular Rotation
A force couple can be defined as two equal, opposite, and parallel forces
separated by distance and applied simultaneously to an object. If two hands
are placed opposite from each other on the steering wheel of a car and one
hand pulls down while the other hand pushes up, the steering wheel rotates
because the hands have created a force couple.
One example of a force couple is the relationship between the deltoid and
the subscapularis. When the arm is by the side, the deltoid pulls the humerus
upward into lateral rotation while the subscapulars pull the humerus downward
into medial rotation. Another example of a force couple is the trapezius and
serratus anterior.
The trapezius and serratus anterior work together as a force couple to
produce the majority of scapular rotation. The upper fibers of the trapezius
pull the scapula inward and up; the middle fibers stabilize the scapula during
abduction of the humerus; and the lower fibers pull the scapula inward and
down. The combination of upward and downward pull causes the scapula to
rotate.
The serratus anterior is the second muscle in a force couple that rotates
the scapula. Located in the scapulocostal joint space between the scapula
and ribs, the serratus anterior pulls the scapula outward and downward. The
upward pull of the upper trapezius combines with the downward pull of the
serratus anterior to produce scapular rotation.

37
The relationship between the trapezius and serratus anterior is
synergistic. Though upper and lower fibers of the trapezius working alone
can produce rotation, working in concert with serratus anterior, rotational
force becomes even greater. The pectoralis major, levator scapulae, and
rhomboids normally relax when the trapezius and serratus anterior contract.
When the scapula begins to rotate upward because of the synergistic
relationship between the trapezius and serratus anterior, the clavicle elevates
about 30 degrees at the sternoclavicular joint. Since the axis of rotation for
the scapula during clavicular elevation is the base of the spine, lateral
movement of the scapula is minimal. Clavicular elevation begins early and
probably peaks by the time the humerus reaches 90 degrees abduction.
After the short, powerful ligament connecting the first rib and clavicle
(costoclavicular ligament) becomes taut at about 90 degrees abduction, the
tension causes the clavicle to rotate on its longitudinal axis from a
downward position to an upward position. The clavicle is shaped somewhat
like a crank handle, and rotating the clavicle is similar to rotating the handle
of a pencil sharpener from a downward position to an upward position.
Rotation elevates the clavicle another 30 degrees and the axis of rotation
becomes the acromioclavicular joint. The total elevation based on scapular
rotation is now about 60 degrees. At maximum overhead abduction (180
degrees), humeral rotation at the glenohumeral joint contributes about 120
degrees and scapular rotation at the scapulothoracic joint contributes about
60 degrees.
Humeral and scapular rotation at 0 to 90 degrees:
1. humeral rotation: 60 degrees

2. scapular rotation with clavicular elevation: 30 degrees
Humeral and scapular rotation at 90 to 180 degrees:
1. humeral rotation: 60 degrees

2. scapular rotation with clavicular rotation: 30 degrees

38
For practical purposes, the inferior angle of the scapula appears to
remain almost stationary during the first 90 degrees of humeral abduction.
This can be partially explained by two factors: (1) the scapula tends to
remain stationary during the first 15 to 30 degrees of abduction, and (2)
lateral movement is minimal during the first 30 degrees of scapular rotation
because the axis of rotation is the spine of the scapula. Limited movement
of the scapula during the first 90 degrees of abduction can be verified by
palpating the inferior angle of the scapula during abduction.
The clinical consequences of scapular movement being minimal during
the first 90 degrees of abduction are twofold. First, if the humerus is
completely frozen (ankylosed) at the glenohumeral joint, the rate of scapular
rotation and humeral elevation will be the same. If the scapula starts visibly
rotating upward during the initial stages of abduction, the glenohumeral joint
is probably dysfunctional. Maximum elevation without humeral rotation at
the glenohumeral joint is about 60 degrees.
Second, even if the scapula is frozen at the scapulothoracic joint,
humeral abduction to 90 degrees or more should still be possible if the
glenohumeral joint is functioning normally. If the humerus cannot be
abducted passively beyond a few degrees, both the scapulothoracic and the
glenohumeral joint are seemingly dysfunctional. Maximum elevation
without scapular rotation is normally about 120 degrees. If the scapula is
frozen for an extended period of time, humeral rotation may exceed 120
degrees by a small amount because of overcompensation.
Even the slightest imbalance in muscular force can totally disrupt the
smoothness of scapulohumeral rhythm and cause serious disability. Without
full range of motion, scapulohumeral rhythm cannot be normal. If tissues
are strong, flexible, and lubricated, shoulder movements should be smooth,
coordinated, and painless.
Evaluation and treatment of the shoulder frequently involves testing
scapulohumeral rhythm for soft-tissue impairment and then treating the
shoulder by correcting the impairment. In terms of HEMME APPROACH:
HISTORY and EVALUATION identify the impairments, while MODALITIES,
MANIPULATION, and EXERCISE correct the impairments.
Testing should include basic movements such as flexion, extension,
abduction, adduction, and rotation as well as combination movements.
Elevating the arms overhead requires a combination of at least two
movements such as abduction and external rotation or flexion and external
rotation.

39
If the scapula rotates without humeral rotation at the glenohumeral joint,
the shoulder will elevate or shrug to about 60 degrees with the arm hanging
downward and partially abducted because of scapular rotation only. Though
it is more common for pain originating in the neck to affect the shoulder
than vice versa, continuous shrugging of the shoulder as a result of
glenohumeral pathology can stress the upper trapezius and cause neck pain.
Biceps Mechanism
The tendinous insertion of the long head of the biceps brachii originates
from the superior lip of the glenoid fossa, passes through the bicipital
groove, and then proceeds downward to the belly of the muscle. The
primary functions of the biceps brachii are forearm supination and elbow
flexion.
When the biceps supinate the forearm or flex the elbow, the biceps
tendon does not move within the bicipital groove if the humerus is hanging
freely at the side. The tendon does move within the groove when the
humerus moves away from the side of the body during flexion, extension,
abduction, adduction, or rotation of the arm.
The transverse humeral ligament prevents the biceps tendon from
slipping out of the groove by crossing over the top of the tendon as it passes
through the groove. Because of traction, compression and friction, the
points of contact between the bicipital tendon, the bicipital groove, and the
transverse humeral ligament are frequent causes of pain and disability in the
shoulder.
If the bicipital tendon is irritated, rolling the tendon under the fingertips
may reveal tenderness, crepitus, or swelling. If the tendon is loose within the
groove, clicking may occur during shoulder movement such as adduction
from an overhead position. Dislocated tendons may cause a popping sound
and occasional locking sensations. Pain is normally most evident when the
arm is abducted to 90 degrees and rotated medially and laterally.

40
CHAPTER SUMMARY
HEMME APPROACH SCIENTIFIC METHOD
• Identify problem presented by the patient.

• Determine whether therapy is indicated or contraindicated.
Discontinue if contraindicated.
Continue if indicated.
• Investigate problem and form preliminary theories.
• Collect additional information to verify or deny theories.
• Begin therapy based on the best possible theories.
• Use feedback from the patient to see if therapy is successful.
• Make decision.
Complete program if therapy is successful.
Repeat earlier steps if therapy is not successful.
Discontinue therapy for valid reason.
FOUR METHODS OF MANIPULATION IN HEMME APPROACH
• Trigger point therapy

• Neuromuscular therapy
• Connective tissue therapy
• Range-of-motion stretching
TWENTY-TWO NECK, SHOULDER, AND BACK MUSCLES
• Cervical muscles: 3
• Shoulder girdle muscles: 7
• Shoulder joint muscles: 11
• Back muscles: 1
ROTATOR CUFF (SITS) MUSCLES
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis

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THREE TYPES OF MOVEMENT IN SCAPULOHUMERAL RHYTHM
• Rotation of the humerus at the glenohumeral joint

• Upward rotation of the scapula at the scapulothoracic joint
• Elevation and rotation of the clavicle at the sternoclavicular and
acromioclavicular joints
HUMERAL AND SCAPULAR ROTATION
• Humeral and scapular rotation at 0 to 90 degrees:

humeral rotation: 60 degrees
scapular rotation with clavicular elevation: 30 degrees
• Humeral and scapular rotation at 90 to 180 degrees:
humeral rotation: 60 degrees
scapular rotation with clavicular rotation: 30 degrees
• Total humeral rotation at glenohumeral joint: 120 degrees
• Total scapular rotation at scapulothoracic joint: 60 degrees

42
HEMME APPROACH
This manual presents a logical, conservative, and comprehensive

approach for treating patients with neck and shoulder pain when soft-tissue
therapy is indicated. The principles and techniques in this approach are
based on scientific research, empirical observation, and clinical experience.
Like most conservative methods, HEMME APPROACH emphasizes modalities
and manipulation over medication and surgery. The HEMME APPROACH
method (pronounced HEM as in “hem” and ME as in “me”) is named after the
acronym "HEMME" that stands for:
HEMME
H HISTORY
E EVALUATION
M MODALITIES
M MANIPULATION
E EXERCISE
More than just a series of steps, the HEMME APPROACH is based on what
system theory refers to as a language model. Language models are used
when complex ideas cannot be formulated mathematically. The purpose of a
language model is to simplify the process of converting knowledge into
action and measuring the results. Language models can be used to (1)
identify problems, (2) collect information, (3) formulate theories, and (4) test
possible solutions by using feedback.
The six connecting steps that hold the model together are:
CONNECTING STEPS
1. ENTER PATIENT 4. OBJECTIVES SATISFIED
2. ALTERNATIVES 5. OBJECTIVES NOT SATISFIED
3. FEEDBACK 6. OUTSIDE INFORMATION
In the HEMME APPROACH model (HEMMEGON), the five basic steps

HISTORY, EVALUATION, MODALITIES, MANIPULATION, and EXERCISE are in
bold letters and the other six steps are in outline letters. The starting point,
the step titled ENTER PATIENT, is boxed.

43
Lines and arrows show which directions of movement are possible
within the model. Therapy begins when the patient enters the system. Step
one is titled ENTER PATIENT. The first two basic steps in the model titled
HISTORY and EVALUATION define the patient's problem. History refers to
medical history and evaluation refers to physical evaluation.
The next step in the model is ALTERNATIVES. This step is a link between
the problem as defined by HISTORY and EVALUATION and possible solutions
as defined by MODALITIES, MANIPULATION, and EXERCISE.
Alternatives should be specifically defined. If modalities, manipulation,
or exercise is needed, practitioners should know specifically which
modalities, manipulations, and exercises. Workable plans for therapy should
include goals, timetables, and measurable results. If therapy involves more
than one practitioner, responsibilities need to be assigned.
The steps MODALITIES, MANIPULATION, and EXERCISE are situated on
one line to emphasize that therapy can include one or more of these three
steps. MANIPULATION was given a central position because the focus of
soft-tissue therapy is manipulation.
The next step is FEEDBACK. Like homeostatic mechanisms that regulate
blood pressure, the HEMME APPROACH uses positive and negative feedback
to regulate the course of therapy. Positive feedback validates the course of
therapy being followed and negative feedback indicates a need for change. If
feedback is positive, it is normally best to continue the same treatment until
all improvements cease. Changes can be made in several ways: (1) repeat
steps (2) change the sequence for using steps, (3) seek new information and
reenter, or (4) exit the system.
The step for entering new information in the upper left-hand corner of
the HEMMEGON is titled OUTSIDE INFORMATION. Like any living system, the
HEMME APPROACH is capable of receiving and processing input from the
outside. This step can be used to enter outside information from sources
such as consultation, research, or laboratory testing. After receiving and
processing the new information, the knowledge can be entered at four points
(1) HISTORY, (2) EVALUATION, (3) ALTERNATIVES, or (4) FEEDBACK.
Practitioners can exit the system by using FEEDBACK to reach the steps
titled OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives
of therapy are not satisfied, the patient may exit the system or reenter at any
of the five basic steps. HISTORY and EVALUATION can be reentered directly,
whereas MODALITIES, MANIPULATION and EXERCISE are reentered by using
the step titled ALTERNATIVES. If the objectives of therapy are satisfied, the
patient exits the system.

44
From the step titled HISTORY you can go directly to OBJECTIVES NOT
SATISFIED or EVALUATION. If contraindications are discovered, the step
titled OBJECTIVES NOT SATISFIED would be used to exit the model. If soft-
tissue therapy is indicated, the next step is EVALUATION.
From EVALUATION you can return to HISTORY if more history is needed
or you can go directly to the steps titled OBJECTIVES NOT SATISFIED or
ALTERNATIVES. OBJECTIVES NOT SATISFIED would be used if therapy is
contraindicated and ALTERNATIVES would be used if therapy is indicated.
Though any combination is possible, a typical sequence for soft-tissue
therapy is (1) modalities, (2) manipulation, and (3) exercise. Another
possibility is to use manipulation without modalities or exercise. Modalities
and exercise, on the other hand, would seldom be used without
manipulation. Regardless of which sequence is used, the next step is
FEEDBACK.
If the patient's problem is solved, OBJECTIVES SATISFIED can be used to
exit the model. If the problem is not solved, OBJECTIVES NOT SATISFIED can
be used to exit the model or continue therapy by repeating any steps
connected by lines and arrows.
There is no limit on the number of times a step can be repeated. Even
after a case is closed, the same patient may reenter the system with a new
problem or recurrences of the old problem. Soft-tissue therapy is an ongoing
process that requires enough flexibility to make changes. To apply the same
routine to all patients ignores the fact that each patient is different and no
two cases are exactly the same.
The HEMME APPROACH provides a powerful way to organize the
elements of therapy into a single working model. Unlike the acronym
“SOAP” (subjective, objective, appraisal, plan), HEMME APPROACH treats
therapy more like an interactive biological system than a series of steps.
The HEMME APPROACH has three basic foundations: (1) scientific
method, (2) systems theory, and (3) medical research. Almost all branches
of medicine recognize and accept the value of medical history, physical
evaluation, modalities, and therapeutic exercise. Though many branches of
medicine would prefer to replace the second “M” in HEMME APPROACH with
an “M” that stands for MEDICATION AND SURGERY instead of
MANIPULATION, soft-tissue therapy is far more recognized and accepted
today than it was five years ago, and this trend can be expected to continue.

45

46
CHAPTER SUMMARY
FIVE BASIC STEPS IN THE HEMME APPROACH
• HISTORY (medical history)

• EVALUATION (physical evaluation)
• MODALITIES (thermotherapy, cryotherapy, vibration)
• MANIPULATION (soft-tissue manipulation)
• EXERCISE (therapeutic exercise)
SIX STEPS THAT LINK THE FIVE BASIC STEPS TOGETHER
• ENTER PATIENT
• ALTERNATIVES
• FEEDBACK
• OUTSIDE INFORMATION
• OBJECTIVES SATISFIED
• OBJECTIVES NOT SATISFIED
FOUR WAYS TO USE A LANGUAGE MODEL
• Identify the problem

• Collect information
• Formulate theories
• Test possible solution by using feedback
BASIC SEQUENCE TO IDENTIFY AND SOLVE PROBLEMS
• HISTORY (identify problem)

• EVALUATION (identify problem)
• MODALITIES (solve problem)
• MANIPULATION (solve problem)
• EXERCISE (solve problem)

47
HISTORY
Soft-tissue therapy begins by defining the problem that needs to be

treated. The first step is taking a medical history (HISTORY) and the second
step is completing physical evaluations (EVALUATION). Therapy cannot be
meaningful and productive unless the purpose for therapy is clearly defined.
To begin treatment without knowing whether soft-tissue therapy is indicated
or contraindicated is morally wrong and dangerous for the patient.
Contraindications
The most general contraindication to soft-tissue therapy is tissue

manipulation during the acute stage of an injury when inflammation and
subcutaneous bleeding are present. Inflammation, as indicated by redness,
swelling, heat, pain, and loss of use, has a tendency to be aggravated by
pressure and interfere with sleep. Even passive mobilization can be harmful
during the acute stage of an injury, when ice and rest are more appropriate
than manipulation. The contraindications listed below apply specifically to
neck and shoulder pain.
• Calcification of a tendon or muscle

• Complete insensitivity to pain or touch
• Complete rupture or tearing away (avulsion) of a tendon or ligament
• Complete tearing of the acromioclavicular capsule (separated shoulder)
• Complete tearing or tearing away (avulsion) of a muscle
• Conditions requiring surgery
• Constant and progressive pain
• Constant, pulsating axillary pain related to mediastinal lesion
• Degenerative osteoarthritis that weakens tendons, cartilage, or bone
• Dislocations or subluxations
• Fractures (open or not completely remodeled)
• Painful, hot, or swollen joints
• Poor general health
• Referred cardiac pain
• Sensations of weakness, numbness, or paresthesia during activity
• Severe deformity of the shoulder
• Sharp, stabbing pain
• Vertebrobasilar insufficiency

48
Vertebrobasilar Accidents
While most contraindications are self-explanatory, the vertebrobasilar

artery contraindication requires special discussion. Though occurrences are
relatively few compared with the total number of cervical manipulations
performed each year, a small number of high-velocity, low-amplitude
cervical manipulations have resulted in serious consequences, including
blurred vision, paralysis, or death, because of vertebrobasilar accidents.
High-velocity, low-amplitude cervical manipulations are moderate- to
heavy-force thrusting movements applied suddenly over a short distance to
improve vertebral alignment. High-velocity manipulations often produce
audible sounds such as cracking or popping because of joint cavitation.
The vertebral arteries run vertically through the transverse foramen of
the upper seven cervical vertebrae, until they enter the foramen magnum
where they merge together and form the basilar artery. The vertebral and
basilar arteries combined are referred to as the vertebrobasilar artery. The
vertebrobasilar arteries carry about 11 percent of the total cerebral blood
flow, and the carotid system carries the remaining 89 percent.
If congenital or degenerative changes decrease the size of the cervical
transverse foramen, there may be some decrease in blood flow with no
symptoms or minor symptoms. Dizziness is by far the most common minor
symptom. What seems to cause the greatest problem is trauma caused by
cervical rotation, with or without extension, at the level of atlantoaxial
complex (1st and 2nd cervical vertebrae). Arterial insult caused by cervical
manipulation involving rotation with or without extension may cause spasm,
arterial wall damage, hemorrhage, brain stem ischemia, and thrombus or
embolism that occludes the vertebrobasilar artery.
Symptoms of vertebrobasilar insufficiency include dizziness, nausea,
vomiting, partial facial paralysis and difficulty with vision, speech, or
swallowing. Involuntary, rapid, and rhythmic oscillating eye movement
(nystagmus) and sensations of spinning around in space (vertigo) have also
been cited as possible symptoms. If rotation, with or without cervical
extension, is planned as part of therapy, it may be advisable to screen
patients for vertebrobasilar insufficiency.
There are three methods of testing for vertebrobasilar insufficiency.
With the patient seated, test one is extending the head back as far as possible
and then holding the head stationary for about 10 seconds. Discontinue
testing immediately if any symptom appears.

49
After pausing for about one minute to allow for latent responses, test two
is rotating the head fully in one direction and then holding the head
stationary for about 10 seconds. If no symptoms appear, repeat the test with
the head rotated in the opposite direction. If no symptoms are present, pause
for about one minute and then begin test three.
Test three is almost identical to test two except the cervical spine is
extended first and then rotated to one side and held stationary for about 10
seconds. If test three is also negative, this would indicate, but not guarantee,
the risk of vertebrobasilar insult is low.
Safety protocol relating to vertebrobasilar insufficiency:
1. Carefully interview patients for symptoms of vertebrobasilar

insufficiency, such as dizziness, before conducting a physical test.
2. Because of the inherent risk, there is no reason to test for

vertebrobasilar insufficiency unless cervical rotation, with or without
extension, is planned as part of therapy.
3. Because of spinal mechanics, the spine rotated from an extended

position will not rotate as far as it would from a neutral position.
4. Since the effects of vertebrobasilar insult can be cumulative,

testing is recommended at the beginning of any session involving
cervical rotation, with or without extension.
5. Any indication of vertebrobasilar insufficiency contraindicates

soft-tissue therapy.
Despite the dangers, the risk of compromising the vertebrobasilar

arteries because of soft-tissue therapy is very small. Historically, most of
the serious complications have resulted from using high-velocity cervical
manipulation. Since soft-tissue therapy uses low-velocity manipulation, the
risk of insulting the arteries is much less. Even so, because of the serious
consequences, practitioners working with neck and shoulder pain should be
aware that vertebrobasilar accidents have occurred and be familiar with
safety protocols when considering the use of cervical manipulation.

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Medical History Questions
1. Where do you feel the pain?
Patients should try to identify the exact locations of pain either by verbal
description or by indicating with a finger. Pain that occurs without
movement is often deep and difficult to localize. Sometimes pain cannot be
localized without muscle contraction against resistance. Contraction stresses
the muscle and related structures. It may be helpful to have the patient
recount the activities that cause pain. Localized or superficial pain is
generally less severe and more manageable than diffuse or deep pain.
Localized pain sometimes follows predictable patterns of distribution.
Dermatomes, sclerotomes, or myotomes are all collections of cells
innervated by a single spinal nerve. Dermatomes are segments of skin,
sclerotomes are segments of bone or other connective tissue (mesenchymal
cells), and myotomes are a group of muscles.
Well-defined pain or paresthesia that follows a dermatome, sclerotome,
or myotome pattern would suggest nerve root involvement. Cervical nerve
roots can be irritated by nerve root entrapment, injuries that cause
compression or traction, and cervical facet synovitis.
The value of using dermatomes, sclerotomes, and myotomes to isolate
the origins of pain is limited because shoulder pain is seldom confined to a
single pattern and trigger points probably radiate more pain than cervical
nerve roots.
2. How and when did the pain arise?
Insidious pain occurs without signs or symptoms to indicate its source.

Pain related to a known cause such as trauma is normally easier to treat than
pain that occurs without the patient being aware of its onset. Insidious pain
may indicate a tumor or growth.
Superficially healed injuries can go for long periods of time without pain
and then suddenly become painful. This frequently happens when a poorly
healed wound is re-injured by stretching or trauma. Re-injury can be more
serious and more painful than the original wound.
Pain arises from stimulating structures that are sensitive to pain. The
structures that are most sensitive to pain are the periosteum and joint
capsule. Muscles, tendon, and ligaments are less sensitive.

51
3. What is the nature of the pain?
Sharp localized pain is more typical of superficial lesions than dull

diffuse pain. Sharp shooting pain may suggest a nerve root lesion or nerve
root involvement. Bilateral pain may implicate the central nervous system at
cord level, and tingling pain in both hands or both feet would indicate spinal
cord involvement. Deep excruciating pain often described as unbearable
may produce autonomic symptoms such as sweating, nausea, and faintness.
4. What changes the nature of the pain?
Musculoskeletal disorders are normally relieved by rest and aggravated

by activity. Muscular pain that is tolerable in the morning may become
worse with activity. The exceptions are night pain caused by sleeping in a
difficult position or musculoskeletal pain caused by muscle spasm. If body
weight stresses sensitive tissues during sleep, getting out of bed may relieve
the pressure and decrease the pain. If muscles are painful because of spasm,
activity may decrease pain by reducing spasm.
Though morning pain and stiffness are sometimes attributed to joint
disease such as arthritis, strenuous exercise may also cause pain, stiffness,
and difficulty getting out of bed. Joint pain tends to get worse with activity.
5. Has this problem occurred before?
If the problem has occurred before, the information could provide

valuable clues regarding the cause of pain and possible treatments.
Treatments that worked in the past may continue to work in the future.
6. Are there any other symptoms associated with the pain?
Two of the most common symptoms associated with pain are weakness
and numbness. Weakness may indicate pain inhibition, spasm,
proprioceptive inhibition, muscle or tendon damage, atrophy, or motor nerve
damage. Pain inhibition is normally the least serious and nerve damage the
most serious. When weakness is caused by pain inhibition, relieving the
pain almost instantly improves strength. Weakness without pain is a
possible sign of nerve damage.

52
Numbness implies nerve involvement that can range from sensory
inhibition because of swelling to complete loss of sensation because of
central or peripheral nerve damage. Crush injuries are less likely to cause
permanent nerve damage than injuries that penetrate or sever tissue.
7. What do you think the problem is?
No one has more personal knowledge of a problem than the person who
has the problem. Whether by past experience, by intuition, by reading and
thinking about the problem, or by discussing the problem with other people,
patients can frequently supply valuable information about their conditions.
The most effective interviews normally begin with general questions and
then narrow the topic to specific questions.
Even though most patients have great personal knowledge of their own
problems, the information they provide should be carefully scrutinized for
correctness. Most patients have difficulty locating the origins of pain and
some patients are influenced by popular beliefs concerning causalities,
remedies, and cures that may or may not be correct.
Careful questioning serves a final purpose that many practitioners do not
consider. It shows respect for the patient’s opinions and a willingness to
work with the patient in the interest of finding a cure. Without cooperation
from the patient, most forms of soft-tissue therapy will not be successful.
Three questions to start a medical history interview are:
1. What is the nature of the problem?

2. Are you presently under a doctor’s care?
3. If treated before, what was the quality of past treatment?
These three question can be summarized by the acronym "PDQ."
PDQ
P Problem
D Doctor's care
Q Quality of past treatment

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CHAPTER SUMMARY
CONTRAINDICATIONS RELATED TO NECK AND SHOULDER PAIN
• Calcification of a tendon or muscle

• Complete insensitivity to pain or touch
• Complete rupture or tearing away (avulsion) of a tendon or ligament
• Complete tearing of the acromioclavicular capsule (separated shoulder)
• Complete tearing or tearing away (avulsion) of a muscle
• Conditions requiring surgery
• Constant and progressive pain
• Constant, pulsating axillary pain related to mediastinal lesion
• Degenerative osteoarthritis that weakens tendons, cartilage, or bone
• Dislocations or subluxations
• Fractures (open or not completely remodeled)
• Painful, hot, or swollen joints
• Poor general health
• Referred cardiac pain
• Sensations of weakness, numbness, or paresthesia during activity
• Severe deformity of the shoulder
• Sharp, stabbing pain
• Vertebrobasilar insufficiency
SIX BASIC MEDICAL HISTORY QUESTIONS
• Where do you feel the pain?

• How and when does the pain arise?
• What is the nature of the pain?
• Has this problem occurred before?
• Are there any other problems associated with the pain?
• What do you think the problem is?
THREE WORDS THAT CORRESPOND WITH THE LETTERS “PDQ”
• Problem
• Doctor’s care
• Quality of past treatment

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EVALUATION
Observation
Observation (inspection) of the patient is normally the starting point for

any evaluation and continues throughout the entire course of therapy. The
greatest danger connected with observation is forming preconceived theories
that filter out relevant information. Even professionals have a tendency to
see what they expect to see or hope to see. During the early stages of
therapy, evaluators should be open to all possibilities until they can focus
more specifically on what the problem appears to be.
During treatment, feedback may occur that invalidates earlier beliefs and
forces practitioners to reevaluate the patient’s condition. Even the most
objective and thorough investigators will sometimes find that problems are
not always what they appeared to be during the initial evaluation. Once new
information appears, the entire course of therapy should be carefully
reviewed and possibly restructured.
Careful observation can detect changes in shape or contour, swelling,
atrophy, abnormal skin color, postural problems, and muscle twitching
(fasciculations). The patient should be observed from several different
angles while sitting, standing, and moving. Simple instruments such as tape
measures, mirrors, or goniometers can sometimes be used as aids to
observation. Significant observations should always be recorded with
special attention to positive or negative changes in the patient’s condition.
Palpation
Palpation is probably the most useful method of physical evaluation used

in soft-tissue therapy. When pain in the shoulder region is reported as
global, systematic palpation can be used to isolate the offending tissues.
Though observation is normally used first, palpation can be used and reused
at any time during the course of therapy. Careful palpation can detect
tenderness, trigger points, tonus, muscle spasm, swelling, atrophy, crepitus,
snapping tendons, abnormal shapes or contours, moisture, and differences in
body temperature. Skin can be palpated for texture, consistency, and
mobility. A secondary use for palpation is locating muscles of bony
landmarks such as the apex of the coracoid process or the bicipital groove.

55
Even though it is more discriminating than most other forms of soft-
tissue evaluation, palpation is not without limitations. Especially in the
shoulder region, the origin of pain and areas where pain is felt are often
different. Pain can also have more than one source. Treating the painful
areas but not the origin of pain is like treating the symptoms of a disease but
not treating the disease. Only by locating and treating all sources of pain can
soft-tissue therapy be effective. Although less useful than palpation, tapping
a tissue (percussion) or listening for sounds (auscultation) can also be used
to identify the origins of pain.
For simplification, the shoulder region can be divided into four basic
zones that are suitable for palpation:
1. rotator cuff
2. prominent muscles of the shoulder girdle
3. subacromial and subdeltoid bursa
4. axilla
Sometimes referred to as a quadrilateral pyramid, the axilla is more

complex than the other three zones. The anterior wall of the pyramid is
formed by pectoralis major and the posterior wall is formed by latissimus
dorsi. The medial wall is formed by serratus anterior and the lateral wall is
defined by the bicipital groove of the humerus. The glenohumeral joint is
the apex and the fleshy skin of the armpit the base.
Evaluators must examine all six sides of the axilla for soft-tissue
impairments. Except for pectoralis major and latissimus dorsi, most
structures of the axilla can be palpated by direct fingertip pressure.
Pectoralis major and latissimus dorsi are best examined by using the thumb
and forefinger in a pincer-like fashion that allows squeezing and pulling at
the same time. Pincer-like palpation can also be used to evaluate other
muscles of the body such as the sternocleidomastoid and the upper fibers of
the trapezius.
Evaluators should develop a sequence for examining the axilla and
follow the same sequence each time to avoid missing any important muscles.
If only one shoulder is involved, bilateral comparison can be used to
differentiate between the involved shoulder and the normal shoulder. If both
shoulders are involved, evaluators must rely on published information and
past experience to establish norms.

56
The main reason for palpation is detection of any tissues that deviate
from normal anatomy or physiology. These deviations can occur because of
abnormal changes in tissue consistency, size, or shape. Excessive tissue
growth can result in lumps or masses, whereas deficiencies in tissue growth
can result in abnormal depressions or muscle atrophy. Changes in tissue
temperature, texture, or moisture can also be significant. Bony anomalies
are less likely to be significant than soft-tissue changes.
Though color change is a factor of observation more than palpation,
color changes that occur during palpation such as abnormal blanching (loss
of color) or flushing (redness) in tissue may indicate abnormal changes in
circulation or the presence of inflammation. Normal tissues lose blanch
when digital pressure is applied (ischemic pressure) and then return to
normal color within about 5 minutes after pressure is released (reactive
hyperemia). Failure to regain normal color within about 5 minutes may
indicate a circulatory deficiency. Tissues that are visibly red before and
after pressure may be irritated or inflamed. The basic symptoms of
inflammation are redness, swelling, heat, pain, and loss of use.
The most important single finding during palpation is normally pain.
The most common causes of pain during palpation are trigger points and
spasm. When digital pressure is applied to painful areas in the shoulder,
pain frequently radiates to other parts of the body such as the arm or hand.
Fasciculation caused by spontaneous, involuntary contracting or twitching of
individual muscles fibers can sometimes be seen or felt when extremely
painful areas are lightly palpated. Pain has a tendency to radiate down the
body as opposed to up the body. Soft-tissue structures in the shoulder that
produce pain include muscles, tendons, ligaments, fascia, joint capsules, and
bursas.
The most common landmarks used when palpating the humerus are:
A. acromion: lateral triangular protection of spine of scapula forming

the highest point on the shoulder (articulates with clavicle)
B. bicipital groove: below inferior anterior edge of acromion process
C. coracoid process: beak-shaped process extending from the neck of
the scapula and located just below the lateral aspect of the clavicle
D. greater tuberosity: below inferior edge of acromion process and
lateral to bicipital groove
E. lesser tuberosity: below inferior edge of acromion process and
medial to bicipital groove

57
Referred Pain
Referred pain makes it difficult to identify the origin of neck and

shoulder pain. By definition, referred pain is any pain experienced at some
point distal from the origin. Except for the acromioclavicular joint, most
structures in the shoulder region refer pain. Supraspinatus pain is often
referred to the mid-deltoid and may be mistaken for subdeltoid bursitis.
Pain originating in the neck is often referred to the shoulder. If shoulder
pain is referred from the neck, cervical movements reproduce the pain,
whereas shoulder movements are painless. Neck pain is often referred to the
chest or shoulder girdle. Pain referred from the scalene group to pectoralis
major can mimic ischemic myocardial pain (angina pectoris).
When pain is referred, the origin of pain and target of pain are often
related by shared nerves or a common spinal segment. Though trigger
points are the major source of referred pain in the shoulder region, pain can
be referred from the heart, diaphragm, or gallbladder. Pain can be referred
from the dome of the diaphragm to the acromioclavicular joint. Referred
visceral pain tends to localize in the scapular region.
Three categories of referred pain affect the shoulder region: (1) visceral
pain from visceral organs, (2) radicular pain from cervical nerve roots, and
(3) somatic pain from musculoskeletal structures in the neck.
Unlike classical projected pain from viscera that follows segmental
distribution patterns, referred pain from visceral organs can be randomly
distributed over multiple segments that are not connected by a single nerve.
Pain referred from the heart to the arm or shoulder can affect more than one
segment, and there appears to be no single nerve connecting the different
segments.
Most referred pain in the shoulder is somatic or radicular pain
originating from the neck. The structures that refer pain from the neck
include muscles, tendons, ligaments, joints, and intervertebral disks. Though
nerve root irritation (radiculitis) is frequently cited as the major cause of
referred pain in the shoulder region, somatic referred pain is possibly more
common.
Somatic structures such as the scalene group frequently refer pain to the
shoulder region by irritating or compressing blood vessels or portions of the
brachial plexus that pass through the muscle. Much of the pain referred
from the neck to the shoulder does not follow distribution patterns
characteristic for nerve root compression.

58
Even when the origin of referred pain involves radiculitis, the cause of
the irritation can be nerve root ischemia. Ischemia caused by compression
of radicular vessels is more likely to cause numbness, prickling, or tingling
(paresthesia) than compression of the nerve root itself. Muscle spasm and
contracture are two of the most common causes for ischemia in the neck
region.
Besides changes to the cervical spine that narrow cervical foramen such
as subluxations, soft-tissue impairments such as spasm can reduce joint
space, irritate cervical nerve roots, and cause referred radicular symptoms.
Because it narrows cervical foramen, manual compression applied vertically
to the top of the head is more likely to cause radicular pain than vertical
traction.
Failure to understand referred pain will make it difficult to identify and
treat the origins of pain. Referred pain can work in two ways: (1)
symptoms originating in the shoulder can be referred to a distal point, or (2)
symptoms originating from a distal point can be referred to the shoulder.
Except for pain originating from the acromioclavicular joint, pain
originating in the shoulder is often referred to distal points along the arm.
On the opposite side, pain originating from the neck is often referred to the
shoulder.
When nerves or vessels in the neck become irritated because of
entrapment, compression, distension, or inflammation, the shoulder can be
affected by pain, impaired sensation, motor weakness, or paralysis (paresis).
Common forms of impaired sensation include paresthesia, increased
sensitivity to pain (hyperalgesia), or decreased sensitivity to pain
(hypoalgesia).
If movement of the neck causes pain, tingling, or numbness in the
shoulder and movement of the shoulder fails to reproduce the same
symptoms, the origin of the symptoms is probably the neck and not the
shoulder. Cervical movements can also refer radicular symptoms to the
arms, forearms, and hands.
Though treating sensitive areas will sometimes reduce pain, therapy will
normally fail if the origin of pain is not treated. One way to identify the
source of pain is to reproduce pain and related symptoms by using digital
pressure along the neck to see if areas in the shoulder become painful.
Radicular pain tends to be sharper and easier to localize than somatic
pain and noxious stimulation from lower cervical levels is more likely to
produce referred shoulder pain than stimulation from the upper levels.

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Pressure applied to posterior and lateral areas along the cervical spine will
frequently refer pain to the shoulders and upper extremities.
The fingers affected by radicular symptoms will sometimes indicate the
level of nerve root involvement: (1) symptoms affecting the thumb
implicate the C6 nerve root, (2) symptoms affecting the first, second, and
lateral portion of the third finger implicate the C7 nerve root, and (3)
symptoms affecting the medial portion of the third finger and the fourth
finger implicate the C8 nerve root. The presence of radicular pain does not
exclude the possibility that somatic or visceral pain are also present.
Postural Pain
The question of posture and shoulder pain is more like a circle than a
cause-and-effect relationship. Though posture may at times cause shoulder
pain, shoulder pain will have a decided effect on posture. Since both posture
and shoulder pain are closely interrelated, worsening of one tends to have a
detrimental effect on the other.
A competent practitioner will avoid alarming the patient by making
observations about shoulder symmetry that have no clinical significance.
When dealing with human bodies, perfection and symmetry are more the
exception than the rule.
Because of handedness, the tendency to favor either the right or left
hand, one shoulder tends to be lower than the other when viewed from the
front or back. For most people who are right handed, the right acromion
process will be lower then the left acromion process and the right anterior
superior iliac crest will be higher than the left anterior superior iliac crest.
When lifting heavy objects with the right hand, most right-handed
people have a tendency to drop the right shoulder and elevate the right hip.
The opposite applies to left-handed people. This could explain how right- or
left-handedness can lead to changes in shoulder symmetry.
Occupation or athletics can also affect shoulder symmetry as well as
muscularity. The decision to treat or not treat will depend on what effect
these changes have on normal function. It is common for occupational stress
and sports activities to cause changes in shoulder symmetry that contribute
to pain.
One postural problem that interferes with shoulder movement is dorsal
kyphosis. When the upper trunk is flexed forward (hunched over), the arms
cannot be fully abducted overhead because the scapula rotates downward

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and causes the greater tuberosity of the humerus to impinge upon the
acromion process. This mechanical problem can be corrected by reducing
dorsal kyphosis and standing more erect. Dorsal kyphosis can be reduced by
using trigger point therapy and range-of-motion stretching to reduce pain,
relieve muscle spasm, and lengthen restricted tissues.
Reducing dorsal kyphosis also relieves stress on the neck caused by
compensatory cervical lordosis and a head-forward posture. When the upper
trunk is flexed forward, the head is pushed forward and posterior neck
muscles are forced into constant contraction to keep the head upright and the
eyes level. When the body is erect, the head remains balanced on top of the
neck and moderate contraction of the neck muscles keep the eyes level.
Since the neck behaves like a lever arm when the centers of gravity for
the head and body are not aligned, the farther forward the head moves, the
longer the lever arm and the greater the amount of force needed to keep the
head upright and the eyes level.
One of the major causes for dorsal kyphosis is muscular imbalance
between opposing muscles because of differences in muscular strength,
tonus, resistance to passive stretch, and length. If daily activities strengthen
anterior muscles such as pectoralis major to a greater extent than posterior
muscles such as the rhomboids are chronically stretched, the shoulders will
have a tendency to be pulled forward (protracted) and become rounded.
This condition becomes progressively worse if the pectoralis major
physiologically or anatomically shortens and chronic stretching of the
rhomboids causes fatigue and stretch weakness. Physiologic shortness is
caused by spasm or contracture, while anatomic shortness is caused by loss
of sarcomeres within the muscles.
Though short muscles are normally strong, chronic shortness in muscles
such as pectoralis major can result in weakness just as chronic stretching in
the rhomboids can result in weakness. Stretch weakness is caused by
prolonged stretching of a muscle that causes proprioceptive inhibition. Short
weakness may be caused by neuromuscular inefficiency.
Sarcomeres within a muscle exert force by decreasing in length. If there
is adequate preexisting tension between the sarcomeres, most of the
shortening translates into muscular force. Like pulling a wagon with a rope,
the rope cannot move the wagon until the slack is gone and the rope is taut.
If muscles are chronically shortened, there may not be enough tension
for some of the sarcomeres to generate normal force. Shortening a muscle
does not mean that tension is uniform throughout the entire muscle. If

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shortening is caused by tense bands of tissue within a muscle, sarcomeres
within the band may be strained and taut, while sarcomeres not within the
band may be too loose or slack to generate tension. Chronic shortening is
normally treated by trigger point therapy and range-of-motion stretching.
Special range-of-motion exercises, such as horizontally stretching a
rubber cable or “chest expander” in front of the body, will stretch the
pectoralis major and strengthen the rhomboids. The combination of
stretching anterior muscles and strengthening posterior muscles should help
to reduce dorsal kyphosis.
Muscular imbalance can also exist between internal and external rotators
or abductors and adductors. If muscle testing determines a serious
difference in relative strength or range-of-motion testing shows an agonist to
be of normal length while the antagonist is abnormally shortened, stretching
and strengthening exercises should be used to correct the problems. The
first step is normally stretching a muscle to achieve normal length and the
second step is normally facilitating a muscle to achieve normal strength. In
other words: “Lengthen first, strengthen second.”
Another problem related to posture is scapulocostal syndrome. Because
of the rounded-back configuration, dorsal kyphosis causes the scapulas to
drop down on the rib cage and rotate outward. This places continuous stress
on the upper fibers of the trapezius, levator scapulae, and rhomboid group.
If there are no physical reasons for poor posture such as connective
tissue restrictions, muscular problems, neurologic defects, or bony
obstructions, the final solution is postural training. Showing patients the
correct way to stand by using mirrors, having them stand against a wall, or
having them walk with a book or sandbag on their head will sometimes be
sufficient to improve postural problems. When patients begin using correct
posture, they sometimes report feeling taller because of pulling the chin
inward and reducing cervical lordosis. Correct posture repeated
continuously for six to eight weeks becomes a habit.
An interesting side effect of improving posture is less depression. For
reasons difficult to give, patients who stand erect with their chins level and
shoulders back seem to be more optimistic about life than patients who are
hunched over with their chins down and heads forward. Many patients
report that pulling their shoulders back and looking up at the sky
dramatically improves the way they feel. Regardless of what the reasons
are, “chin up” and “cheer up” mean nearly the same thing to most people.

62
Psychogenic Factors
Though soft-tissue problems are sometimes incorrectly diagnosed as

psychogenic when physical causes are not found, it would be equally
incorrect to believe that a patient’s mental state has no effect on soft-tissue
impairments. Tension and mental fatigue can adversely affect the patient’s
sensitivity and tolerance for pain. Depression can alter a patient’s posture in
ways that are detrimental to recovery, and patients suffering from depression
are less likely to make beneficial changes in lifestyle or behavior such as
adequate sleep or regular exercise.
A negative mental state can make touching a patient very difficult. If a
patient recoils from even the slightest touch or claims that touching even the
tip of the nose radiates pain, the best alternative is to recommend
psychological evaluation. In some cases, psychological testing helps to
determine if the patient is being completely honest or is simply fabricating
or exaggerating symptoms for personal gain.
Even if the patient is being honest, a problem with being touched may
still exist. Past victims of domestic violence, sexual assaults, or physical
abuse may resist human touch by anyone, including a therapist or doctor. A
clinical psychologist can be a valuable adjunct when dealing with patients
who suffer from psychological problems that make touching or soft-tissue
therapy difficult.
Even if the patient is willing to undergo therapy, deep tissue
manipulation is not recommended if the patient shows a strong aversion to
being touched. Since many patients have a fear of being touched because of
legitimate pain or memories of painful therapy in the past, developing
rapport and gaining the patient’s confidence are very important. If
mechanical vibration or gentle stroking fail to relax the patient, soft-tissue
therapy should be discontinued until the problem is resolved.
Soft-tissue Impairments
Most neck and shoulder conditions that limit range of motion and reduce
muscle strength are directly related to soft-tissue impairments that affect
muscles or joints. Except for trauma and disease, these impairments are
normally caused by overuse, disuse, or improper use of the upper body.
Pain is normally the first indication of soft-tissue impairments, followed by
changes in tissue consistency such as hardness (induration) in muscles or

63
swelling surrounding tendons or joints. Since normal tissue, by definition,
cannot be damaged by normal stress, tissues can be damaged three ways:
1. abnormal stress applied to normal tissues

2. normal stress applied to abnormal tissues
3. abnormal stress applied to abnormal tissues
The most common forms of abnormal stress are caused by trauma,

overuse in terms of repetition, or overuse in terms of effort. All three
varieties of abnormal stress can be seen in tennis players, where injuries are
caused by falls (trauma), multiple repetitions of a single stroke (overuse), or
one repetition of a stroke that requires extreme force (overuse).
Overuse injuries from repetition are frequently classified as insidious
because the onset is gradual and patients cannot relate the pain to a single
incident or trauma. Repetitive overuse injuries occur when the effects of
minor insults accumulate faster than the body can initiate repair. The best
safeguards against repetitive overuse injuries are (1) adequate rest between
exertions, (2) warm-ups before strenuous activity, and (3) proper
conditioning in terms of flexibility, strength, and endurance.
Abnormal stresses can result when body movements are not properly
coordinated. Based on scapulohumeral rhythm, the humerus cannot be fully
abducted overhead without external rotation. If the humerus is forced into
overhead abduction without external rotation, the movement is likely to
create abnormal stresses that damage soft-tissue structures that stabilize,
surround, or cross the glenohumeral joint. Conditions that may interfere
with scapulohumeral rhythm include previous injuries, incoordination,
muscle or tissue weakness, and poor use of body mechanics.
When abnormal stresses exceed the limit of tissue strength, muscles or
joint capsules tear and tendons or ligaments rupture. The point of tearing or
rupture is often referred to as a lesion, injury, or wound.
Normal stresses on abnormal tissues are caused by stressing tissues that
are (1) partially torn or ruptured, (2) contracted or in spasm, (3) ischemic or
edematous, (4) partially desiccated or lacking lubrication, and (5) bound by
adhesions, contractures, or scar tissue. Disuse and immobility decondition
and weaken tissues to the extent that normal or even subnormal stresses
become destructive. Abnormal tissue states are characterized by abnormal
changes in tissue chemistry, circulation, or compliance with pressure.

64
After a wound appears to be healed, repaired tissues are frequently the
site of re-injury because of incomplete or defective healing. One of the best
safeguards against defective healing is continuous passive mobilization
during the healing state to encourage the correct alignment of connective
tissue. A second safeguard is proper exercise to restore normal strength and
coordination. When continued beyond the acute stage, long-term disuse and
immobility increase the risk of chronic pain and disability.
Normal stresses do not injure normal tissues when the tissues are
physiologically prepared to accept normal stress. If a normal muscle is not
properly warmed up or stretched before strenuous activity, injuries can result
even though normal stresses are applied to normal tissues.
An example of abnormal stress applied to an abnormal tissue would be
sudden or excessive force applied to a muscle that is abnormally short
because of a flexion contracture. Instead of stretching elastically and
returning to its original length or stretching plastically and lengthening
permanently without tearing, the shortened muscle or one of its related
structures, such as the musculotendinous insertion on the periosteum of
bone, would probably tear.
Pain Cycles
Pain is normally the first indicator of soft-tissue injuries and the main
reason most people seek medical treatment. What complicates soft-tissue
therapy is the circular nature of pain: (1) conditions that irritate or disrupt
tissues cause tissue changes and pain, and (2) tissue changes and pain cause
conditions that irritate or disrupt tissues. Without therapy, pain cycles often
become self-perpetuating and chronic. Not only are the chances of restoring
normal movement greatly reduced if pain cycles are not broken, most
patients consider therapy a failure if nothing is done to control pain.
If the causes of pain and consequences of tissue damage were always
self-limiting, injuries would heal themselves without treatment within
predictable periods of time. Regrettably, this is not the case for most soft-
tissue injuries. Without treatment, soft-tissue impairments have a tendency
to become chronically painful and disabling because of uncontrolled and
self-perpetuating pain cycles. Though most soft-tissue injuries should
theoretically heal within six to eight weeks, pain cycles can last for years.
Pain begins when internal or external factors irritate or disrupt tissues
and cause inflammation. As stated above, the most common external factors

65
are trauma and disease, while the most common internal factors are overuse,
disuse, or improper body use. Once tissues are damaged, pain results and
psychological factors can increase or decrease the patient’s threshold and
tolerance for pain.
When dealing with pain cycles, two questions need to be answered.
First, what are the initial causes of pain? Second, what are the consequences
of tissue changes related to pain? The initial cause of most pain is tissue
damage and release of pain-producing (algesiogenic) substances that
mediate pain by activating nerves that receive or transmit painful stimulus
(nociceptors).
The pain-producing chemicals most frequently cited are serotonin,
substance P, histamine, prostaglandins, and bradykinin. The breakdown of
blood platelets after an injury releases serotonin and substance P that cause
vasoconstriction and release of mast cells. The granules in mast cells release
histamine that causes vasodilation and edema. Ice counteracts the effects of
histamine and helps to control swelling.
Prostaglandins are potent vasoconstrictors that mediate inflammation
and help to control blood flow in damaged vessels. Nonsteroidal anti-
inflammatory drugs (NSAIDs) such as aspirin (acetylsalicylic acid),
ibuprofen, and ketoprofen reduce pain by slowing production of arachidonic
acid that breaks down to produce prostaglandins. Bradykinin is a pain-
producing substance that irritates nociceptors and directly causes pain. It is
also a powerful vasodilator that encourages edema by increasing capillary
permeability. Bradykinin is released during periods of insufficient blood
supply (ischemia) or oxygen deficiency (hypoxia).
After identifying the initial causes of pain, the next question becomes:
What are the consequences of tissue changes and pain? The first three
consequences of tissue changes and pain are vasoconstriction, edema, and
spasm. These three factors work together to increase metabolite retention.
Working together, vasoconstriction, edema, spasm, and metabolite retention
cause (1) restricted circulation, (2) local ischemia, and (3) restricted
movement.
Muscle spasm not only compresses blood vessels and causes ischemia,
but it also increases the rate of metabolism in muscles, while at the same
time making it more difficult for circulation to remove metabolites, the
byproducts of metabolism. When metabolites, such as lactic acid, are
retained in muscles and body fluids, pain and fatigue result. Agents such as
serotonin, histamine, and bradykinin are also retained.

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Spasm and edema restrict circulation by physically compressing blood
vessels, while metabolite retention reduces blood flow by causing
vasospasm that constricts blood vessels. Besides causing pain and
congestion and slowing the healing process, obstruction and vasoconstriction
restrict circulation and cause local ischemia. Just as myocardial ischemia
damages tissues of the myocardium (ischemic heart disease), ischemia in
skeletal muscles causes similar damage to muscle tissue, connective tissue,
and nerve tissue (ischemic contracture). In addition to affecting muscles,
spasm, edema, and metabolite retention may cause ischemia in tendons.
Even though ischemic damage is secondary damage that results from the
original injury, secondary damage, in turn, can trigger a new round of pain,
spasm, edema, and metabolite retention that causes even more damage. In
some cases, secondary damage is more extensive than damage caused by the
original injury.
Besides causing damage to muscle tissue, ischemia that reduces the
oxygen supply to nerves (hypoxia) may cause weakness, referred pain,
paresthesia, and sensory dysfunction. Ischemia lasting more than six to
eight hours may cause pathologic tissue death (necrosis).
Thus goes the pain cycle: (1) tissue damage from internal or external
sources causes pain, spasm, edema, and metabolite retention; (2) spasm,
edema, and metabolite retention cause, among other things, hypoxia and
local ischemia; (3) hypoxia and local ischemia restart the pain cycle by
causing secondary tissue damage; (4) secondary tissue damage continues the
cycle by generating additional bouts of pain, spasm, edema, and metabolite
retention.
In addition to ischemic damage, the combination of pain, spasm, and
edema restrict movement. Pain restricts movement by causing pain
inhibition and psychological guarding because of pain. Spasm restricts
movement because of muscle guarding that shortens, tightens, and weakens
muscles. Swelling and edema increase resistance to active and passive
movement by increasing internal pressures. The normal outcomes for long-
term restricted movement are contractures, adhesions, atrophy, muscle
weakness, and decreases in range of motion and mobility.
Even if pain, spasm, edema, and metabolite retention appear to be
completely resolved, two factors that sometimes reactivate the original pain
cycle are (1) latent trigger points, and (2) the accidental tearing of fibrous
connective tissue as found in contractures, adhesions, or scar tissue.

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Some trigger points continue to produce low levels of pain between
major flare-ups of a pain cycle, while others remain latent or subliminal
between flare-ups. When physical or psychological conditions are right,
formally quiescent trigger points become active and reactivate the pain
cycle. Trigger points will be discussed more fully under trigger point
therapy.
Contractures, adhesions, and scar tissues can also become latent to the
extent they restrict motion without causing pain. Range-of-motion testing
after the patient claims to be fully recovered will often show significant
reductions in range of motion because of connective tissue restrictions.
These restrictions can remain asymptomatic for indefinite periods of time
until movement or strenuous contraction causes tissue tearing.
Connective tissue structures that result from wound healing are more
prone to tearing than normal tissues for several reasons. First, when torn
muscle fibers are repaired by natural healing, only a small percentage of the
wound is repaired by regeneration of muscle tissue. Most of the wound is
repaired by connective tissue that is very strong but much less elastic than
muscle tissue. Stresses that would not damage normal muscles may be
sufficient to damage a repaired muscle.
Second, if tissues are ischemic and nociceptor metabolites are present
during wound healing, collagen fibers have a tendency to connect or cross-
link with each other instead of remaining separate. The ability of tissues to
stretch without tearing is reduced by each additional connection between
fibers. Collagen fibers that are properly formed can crisscross over the top
of each other without connecting because the fibers are separated by distance
and lubrication.
Glycosaminoglycans (mucopolysaccharides) are polysaccharides that
form chemical bonds with water. Derived from proteoglycans, this protein-
polysaccharide complex forms the ground substance that occupies the
intercellular spaces between fibrous connective tissue. Though ground
substance is normally a low-viscosity fluid or semi-fluid gel, water depletion
caused by ischemia or immobility can reduce the volume of
glycosaminoglycans in ground substance and cause stickiness or hardness.
This decreases lubrication and gliding between connective tissue fibers.
Third, when body parts are not actively or passively moved during the
healing process, collagen fibers have a tendency to be poorly aligned. When
body parts are mobilized during wound healing, collagen fibers form in

68
directions that are parallel to lines of stress. This helps to ensure that
flexibility and length are great enough to allow full range of motion.
Mobilization during wound healing also helps to prevent adhesions, fibrous
bands of tissue that connect structures that are normally separate.
When body parts are injured, pain and protective spasm reduce range of
motion. If the body part is not mobilized after the acute stage of injury has
passed, proliferation of connective tissue and muscle weakness limit range
of motion even more. This tendency can be demonstrated by examining a
body part that was just removed from a rigid cast after six weeks of
inactivity. Immobilization of body parts by casting or splinting encourages
deconditioning, contractures, and atrophy.
Understanding pain cycles and the body’s tendency to reduce range of
motion can make it easier to understand five major therapeutic objectives
based on pain cycles: (1) relieve pain, (2) reduce spasm and edema, (3)
improve circulation and mobility, (4) neutralize all trigger points, and (5)
encourage exercise. Satisfying these five objectives will help to break pain
cycles by altering basic conditions that cause and perpetuate pain.
Pain cycles in the shoulder can lead to adhesive capsulitis (frozen
shoulder). If trauma or microtrauma irritate tissues and cause inflammation,
the short-term effects are pain, spasm, edema, and metabolite retention. In
addition to causing secondary damage, these factors contribute to limited
range of motion because of adhesions and contractures that decrease
mobility. The progressive nature of adhesive capsulitis parallels the
progressive nature of damage caused by pain cycles. Adhesive capsulitis is
discussed more completely at the end of this chapter.
Rehabilitation can be represented by using a seven-step model:
1. Problem: original injury.

2. Results: tissue damage, inflammation, and pain-producing chemicals.
3. Results: pain, spasm, edema, and metabolite retention.
4. Results: restricted circulation, ischemia, hypoxia, and fatigue.
5. Results: restricted motion, inactivity, and fibrosis.
6. Results: adhesions, contractures, trigger points, and atrophy.
7. Solution: Soft-Tissue Therapy. Alternatives: acceptable recovery,
secondary injury, or discontinue therapy.
(Note: Regardless of the step, therapy can be discontinued at any time.)

69
REHABILITATION MODEL
Original Injury
Secondary Injury Tissue damage

Inflammation
Pain-producing chemicals
Pain-spasm
Edema
Metabolite retention
Restricted circulation
Ischemia-hypoxia
Fatigue
Restricted motion
Inactivity
Fibrosis
Adhesions-contractures
Trigger points
Atrophy
Soft Tissue Therapy Discontinue

Therapy
Acceptable Recovery
Eliminate or decrease pain

Increase range of motion
Increase strength and endurance
Improve coordination and mobility

70
Four important sub-cycles should be noted in the model. First, edema
can break out of the main cycle and go directly to secondary injury. Rest,
ice, compression, and elevation (RICE) can be used to break out of this sub-
cycle by reducing edema. Second, ischemia and hypoxia can also produce a
sub-cycle that leads directly to secondary injuries. The effects of ischemia
and hypoxia can be minimized by (1) reducing pain, spasm, edema, and
metabolite retention, and (2) improving circulation.
The third sub-cycle is caused by tearing adhesions or contractures. After
an injury heals, improperly formed connective tissue may not be painful
until some movement stretches the tissue and causes tearing. The best
countermeasure for this problem is passive mobilization during wound
healing. The fourth sub-cycle results from activating trigger points that
cause pain and spasm. The best solution here is trigger point therapy.
Therapy can be started at any point after the acute stage of injury,
normally about step four. Disability is normally reduced by starting therapy
early and continuing therapy until the patient is fully recovered. For various
reasons, many patients are not treated until step seven, when mobility has
already been severely limited by adhesions, contractures, or atrophy.
The Rehabilitation Model demonstrates one problem that many
practitioners seem to ignore: therapy may cause secondary injuries. Though
many patients feel immediate relief after therapy that may continue
indefinitely, some patients will get tremendous relief for about 24 hours after
therapy and then experience several days of pain that resembles muscle
soreness. Even mildest forms of tissue manipulation may cause some degree
of disruption when restricted tissues are therapeutically stretched.
To reduce the effects of therapy-induced (iatrogenic) pain: (1) use the
least amount of force necessary, (2) use progressive stretching spaced out
over several sessions instead of trying to work through all restrictions in one
or two sessions, and (3) use less force if the patient reports several days of
pain after the last session. Even with countermeasures, some degree of
iatrogenic pain may occur. Many soft-tissue impairments cannot be treated
effectively without causing pain both during and after therapy.
One of the most effective countermeasures for dealing with iatrogenic
pain is honesty with the patient. Patients should be advised that therapy may
be painful and pain may occur for several days after therapy. Patients
should be encouraged to seek professional help if they feel the pain they
experience after therapy is too severe. In the vast majority of cases, pain
cycles cannot be broken without periodic pain or discomfort for the patient.

71
TESTING
Acromion Process Test
If pressure applied just below the acromion process produces pain,

abduct the patient’s arm to 90 degrees while still pressing on the same point.
Since the acromion is covered by the deltoid when the arm is abducted to 90
degrees, reduction of pain may indicate subacromial bursitis.
Active Range-of-Motion Testing
Range-of-motion testing for the shoulder measures six basic motions:
1. flexion (forward)
2. extension (backward)
3. abduction (frontal plane and horizontal plane)
4. adduction (frontal plane and horizontal plane)
5. medial rotation (forearm: sagittal plane or horizontal plane)
6. lateral rotation (forearm: sagittal plane or horizontal plane)
Failure to achieve full range of motion can result from (1) pain
inhibition, (2) spasm, (3) contracture, (4) edema, (5) neuromuscular
inhibition or lack of facilitation, (6) muscle atrophy or weakness, (7) mental
or physical fatigue, (8) dysfunctional joints, or (9) lack of effort. A normal
range of motion will be smooth, coordinated, and complete.
Even though abduction of the humerus from 0 to 180 degrees overhead
(frontal plane) starts at the glenohumeral joint, three additional joints are
needed to complete the movement: sternoclavicular joint, acromioclavicular
joint, and scapulothoracic joint. The impaired function of any one joint can
limit range of motion. Pain during the first 90 degrees of abduction may
implicate the glenohumeral joint or the sternoclavicular joint. Pain during
the last 90 degrees of abduction may implicate the acromioclavicular joint or
the scapulothoracic joint. A ruptured rotator cuff muscle may interfere with
abduction by not pulling the head of the humerus down far enough to rotate
under the coracoacromial arch.
The lowering of the humerus from 180 degrees overhead to 0 degrees
(frontal plane) is assisted by gravity when the body is standing erect. The
effects of gravity are partially negated when the arm is lowered slowly and
smoothly along the entire arc because of eccentric contraction by the deltoid.

72
The starting position for measuring adduction is with the arm hanging
freely at the side (dependent position). The primary movers that cause
adduction of the humerus are latissimus dorsi, teres major, and pectoralis
major. Adduction is less likely to be restricted than other movements.
Flexion of the arm brings the humerus 180 degrees forward from the
shoulder (sagittal plane) to an overhead position. The primary muscles
involved are anterior deltoid, pectoralis major, coracobrachialis, and biceps,
and the primary joint involved is the glenohumeral joint. Conditions that
frequently interfere with flexion are adhesive capsulitis and glenohumeral
arthritis.
Extension is a backward movement (sagittal plane) that refers to
swinging the arm behind the body. The primary muscles involved are the
posterior deltoid, latissimus dorsi, teres major, teres minor, infraspinatus,
and triceps. Extension can be hampered by constriction or freezing of the
joint capsule.
Lateral and medial rotation are normally measured with the elbow flexed
to 90 degrees and the arm (1) abducted to 90 degrees at the side or (2) freely
hanging along the side. When the arm is abducted to 90 degrees, the
forearm moves in the sagittal plane. When the arm is hanging freely along
the side, the forearm rotates in the horizontal plane.
When the arm is abducted to 90 degrees at the side, the primary muscles
involved in lateral rotation are supraspinatus, middle deltoid, infraspinatus,
teres minor, and posterior deltoid. When the arm is hanging freely at the
side, the primary muscles involved are infraspinatus, teres minor, and
posterior deltoid. A rupture of rotator cuff muscles can weaken lateral
rotation and prevent the greater tuberosity from rotating under the
coracoacromial arch.
When the arm is abducted to 90 degrees at the side, the primary muscles
involved in medial rotation are supraspinatus, middle deltoid, subscapularis,
pectoralis major, latissimus dorsi, and teres major. When the arm is hanging
freely at the side, the primary muscles involved in medial rotation are
subscapularis, pectoralis major, latissimus dorsi, and teres major.
Adhesive capsulitis can severely limit medial rotation, and the muscle most
commonly involved is subscapularis.

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MUSCLES BY RANGE OF MOTION
1. Cervical Spine
A. forward flexion: 0-45 degrees (chin touching chest)
B. lateral flexion: 0-45 degrees
C. extension: 0-45 degrees (looking at ceiling)
D. rotation: 0-60 degrees (chin in line with shoulder)
2. Glenohumeral Joint
A. flexion: 0-180 degrees
B. extension: 0-60 degrees
C. abduction: 0-180 degrees (including scapular movement)
D. abduction: 0-120 degrees (excluding scapular movement)
E. adduction: 0-75 degrees (humerus at side of body)
F. lateral rotation (humerus abducted to 90 degrees): 0-90 degrees
G. medial rotation (humerus abducted to 90 degrees): 0-70 degrees
H. lateral rotation (humerus at side of body): 0-60 degrees
I. medial rotation (humerus at side of body): 0-80 degrees
J. horizontal abduction: 0-40 degrees
K. horizontal adduction: 0-135 degrees
L. circumduction: 0-360 degrees
3. Scapular Joint
A. upward rotation: 0-60 degrees (including scapular movement)
B. downward rotation 60-0 degrees (including scapular movement)
C. upward rotation: 0-30 degrees (excluding scapular movement)
D. downward rotation 30-0 degrees (excluding scapular movement)
4. Clavicular Joint
A. elevation: 0-30 degrees
B. depression: 30-0 degrees
C. backward rotation: 0-50 degrees
D. forward rotation: 50-0 degrees
5. Elbow Joint
A. flexion: 0-150 degrees
B. extension: 0 degrees (without hyperextension)

74
Although range of motion is normally represented as the active range of
motion, two additional ranges of motion that may affect the outcome of
therapy: (1) passive range of motion and (2) anatomical range of motion.
The passive range of motion is normally greater than the active range of
motion because movement is not limited by the patient’s ability to contract
or relax muscles. Passive range of motion is reached by applying additional
force after the active range of motion is reached. Stretching to the passive
range of motion will sometimes eliminate restrictions such as contractures or
adhesions that cannot be altered by active range-of-motion stretching.
The difference between active (voluntary) range of motion and passive
(involuntary) range of motion allows for joint play in synovial joints. By
definition, joint play is that small distance between the two opposing
surfaces in a joint. If joint space becomes limited because of hypertonicity
or spasm, passive-range-of motion stretching is needed to restore joint space.
Reduction of joint space is one way soft-tissue impairments cause joint
dysfunction.
The anatomical range of motion defines the limit of movement possible
without tissue damage. This limit is normally defined by joints and
periarticular tissues such as ligaments. Though therapeutic stretching often
exceeds the active range-of-motion limits, care must be taken not to exceed
the anatomical range-of-motion limit. If the anatomic limit is reduced by
joint diseases or bony anomalies, attempts to achieve a normal active range
of motion by passive manipulation may cause tissue damage. The active and
passive limits cannot be greater than the anatomical limit.
Like all ranges of motion, the anatomical range of motion will vary from
patient to patient. The best indicators of this limit are (1) reports of pain by
the patient and (2) a solid resistance or “end-feel” that indicates no further
movement is possible. The fully extended elbow normally presents a solid
resistance that indicates no further movement is anatomically possible
because of the joint.
If the difference between active and passive limits is too great, the active
limit probably needs to be increased. Passive stretches that increase the
passive limit may not have a corresponding effect on the active limit. Since
the risk of injury seems to increase when the difference between active and
passive limits is too great, once the passive range of motion is normal, active
stretching and strengthening exercises should be used to increase the active
range of motion.

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Symmetry Test
The Symmetry Test uses active range of motion to measure bilateral

symmetry. Starting with the arms in a downward position and the hands
facing the body, both arms are elevated to a horizontal position (90 degrees)
with the palms facing forward. After holding this position for 12 seconds,
the arms are elevated to an overhead position (180 degrees) with the arms
vertical and the palms facing each other but not touching. After 12 seconds,
the palms should be brought together and held tightly. After a 12-second
pause, the sequence is reversed.
First, the palms are separated and the arms held overhead (180 degrees)
for 12 seconds with the palms facing each other. Second, the arms are
lowered to a horizontal position (90 degrees) and held for 12 seconds with
the palms facing forward. Third, the arms are lowered to a downward
position with the palms facing the body.
The purpose of the Symmetry Test is to measure bilateral symmetry.
The arcs completed by both arms (zero to 90 degrees and 90 to 180 degrees)
should be smooth, continuous, and painless. The rate of ascent and descent
should be equal for both arms. When motion is stopped at 90 and 180
degrees, the body should be symmetrical and the patient should be able to
hold the position without shaking or moving the body. When the palms are
pressed together, the patient should be able to exert reasonable force.
The Symmetry Test should be repeated at least twice, once viewed from
the front and a second time viewed from the side. Evaluators can measure
the patient’s ability to exert force by placing an open hand between the
patient’s hands when the palms are pressed together.
Some patients will show significant signs of asymmetry without being
aware of the problem. To help patients develop self-awareness, the test can
be repeated with the patient standing in front of a mirror. Using a mirror to
increase self-awareness will give patients a way to exercise the shoulder
with direct supervision and measure their own progress.
Even if no problems are detected during active range-of-motion testing,
passive range of motion testing is still recommended. In some cases, passive
range-of-motion testing will detect crepitus or clicking that was not apparent
during active range-of-motion testing. Crepitus or clicking may or may not
be clinically significant. If crepitus or clicking correspond with pain,
possible causes include abnormal tissue tension, spasm, or contracture.

76
Passive Range-of-Motion Testing
If a patient fails the Symmetry Test, passive range-of-motion testing

helps to isolate the problem by eliminating strength as a variable. If the
Symmetry Test is abnormal, but passive range of motion testing is normal,
the problem may involve strength. If both symmetry and passive range-of-
motion testing are abnormal, the problem may be articular.
Joint blockage occurs in two forms, bony inter-articular blockage and
soft-tissue extra-articular blockage. If a joint movement comes to a solid
stop, the blockage is probably a bone-to-bone contact within the joint. If the
joint movement comes to a soft contact, the blockage is probably a soft-
tissue restriction formed on the outside of the joint.
Passive range-of-motion testing is most reliable when the patient is
relaxed and movements are slow and gentle. The body part on one side of
the joint should be stabilized while the body part on the opposite side of the
joint is tested. When testing the elbow, one hand can be used to stabilize the
upper arm while the other hand is used to move the forearm. Body weight is
normally sufficient to stabilize the shoulder when the arm is tested.
Most passive range-of-motion testing for the shoulder can be broken
down into three categories: (1) cervical spine, (2) humerus, and (3) scapula.
If a patient fails to achieve full range of motion, the approximate angle of
blockage should be noted.
3-Point Touch Test (similar to Apley Scratch Test)
The Touch Test uses three separate maneuvers to measure five basic
shoulder movements: abduction, adduction, horizontal adduction, medial
rotation, and lateral rotation.
1. Patient reaches behind head with one arm and tries to touch the superior
angle of opposite scapula.
Purpose: test abduction and lateral rotation.
2. Patient reaches in front of head with one arm and tries to touch the upper
thoracic spine with fingers (superior surface of arm touches chin).
Purpose: test horizontal adduction and medial rotation.
3. Patient reaches behind back with one arm and tries to touch the inferior
angle of opposite scapula (may require limited humeral extension).
Purpose: test adduction and medial rotation.

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Back-to-Wall Test
The Wall Test is a combination range-of-motion test and symmetry test.

With the patient standing erect and both scapulas lightly touching a wall, the
patient is told to abduct both arms from a downward position to an overhead
position. Once the arms are fully elevated, the patient is told to reach as
high as possible, while at the same time, keeping hands and forearms in
contact with the wall.
Lack of symmetry during abduction or failure to touch the wall with at
least the hands when the arms are completely overhead may indicate a soft-
tissue blockage or a bony blockage. If the blockage is soft-tissue, trigger
point therapy applied to the chest muscles and overhead stretching while the
patient is supine will normally increase the range of motion. The overhead
stretch will be thoroughly discussed later.
Neurologic Testing
Neurologic testing is used to evaluate the integrity of nerves that service

shoulder muscles. Because each motor group is serviced by only one nerve,
damage to that nerve can weaken the motor group and restrict range of
motion.
Injuries and diseases that affect the spinal cord or nerve roots commonly
produce symptoms in the extremities that follow characteristic patterns.
These patterns are determined by changes in motor power, sensation, or
reflex. Since many cases of shoulder pain involve cervical nerve roots C-5
and C-6, these nerves will be considered in terms of motor function,
sensitivity, and reflex action.
The deltoid and biceps muscle are tested for C-5 innervation (C-6
innervation is present, but weak). Abduction of the arm is the easiest way to
test for deltoid strength, while flexion of the elbow is the easiest way to test
for biceps strength . Weakness without pain is more likely to implicate
nerve root involvement than weakness with pain. Weakness without pain
and muscle atrophy would increase the probability of a nerve root deficit.
The probability of having a C-5 innervation deficit increases if both the
deltoid and biceps muscle on the same side of the body are weak without
pain and visibly atrophied.

78
Sensitivity testing for C-5 is best done over the lateral portion of the
deltoid muscle. A cotton swab can be used to measure light touch and the
bristles of a stiff nylon hairbrush to measure pain. In terms of pathogenesis,
a patient normally loses the ability to perceive light touch before losing the
ability to perceive pain.
The biceps reflex is frequently used to evaluate C-5 integrity. When the
elbow joint is flexed and the biceps muscle is contracted, the biceps tendon
will be easy to palpate at the distal end of the biceps. With the patient’s
flexed elbow resting on a padded support such as a table, place your thumb
over the biceps tendon and tap your thumbnail with a reflex hammer. The
biceps tendon should be felt and the wrist should twitch slightly into flexion.
Since a biceps reflex is caused partially by sudden tension on the biceps
muscle as the reflex hammer stretches the biceps tendon, the integrity of the
muscle may have some effect on the reflex. Pain, spasms, or contractures
can diminish the intensity of a reflex.
Orthopedic Testing
1. Painful-Arc Test
Instruct the patient to abduct the right arm from 0 degrees to 180 degrees
and then adduct the same arm from 180 degrees to 0 degrees. If the patient
reports pain between 60 and 120 degrees during elevation and descent, the
problem may be caused by compression of the supraspinatus tendon as the
greater tuberosity passes under the acromion and coracoacromial ligament
during abduction and external rotation or adduction and external rotation.
Since elevation or descent of the humerus should not be painful, the
presence of pain may indicate the supraspinatus tendon is irritated or
partially torn and there is insufficient room in the subacromial joint space for
the tendon to move because of swelling. Degenerative conditions affecting
the acromioclavicular joint may also cause a painful arc.
If painful arc is present, abducting the arms while the upper spine is
flexed forward (dorsal kyphosis) or palpating the area between the acromial
process and humeral head will increase pain. Though movement is painful,
the presence of movement shows the supraspinatus tendon has not been
completely ruptured.

79
Supraspinatus impingement by the acromion and coracoacromial
ligament can lead to pain that interferes with sleep and severe loss of active
movement. In extreme cases, a possible sequela for supraspinatus
impingement syndrome is pain, edema, hemorrhage, fibrosis, tendinitis,
tendon degeneration or calcification, and tendon rupture. The biceps tendon
is another possible site for impingement syndrome.
2. Supraspinatus-Tendinitis Test
Instruct the patient to abduct the right arm to 90 degrees. Place your
right hand on top of the patient’s humerus just proximal to the elbow and tell
the patient to abduct the arm gently against your hand. Apply enough
downward resistance to prevent the patient from elevating the arm. Pain
over the insertion of the supraspinatus tendon indicates a possible tear in the
supraspinatus tendon or muscle. If the supraspinatus tendon is torn, pulling
directly downward on the arm or palpating the tendon should cause pain.
3. Drop-Arm Test
From a seated position, instruct the patient to abduct either arm to 90

degrees, hold the arm level, and then lower the arm slowly. If the arm drops
or the patient is unable to lower the arm slowly, the problem could be a
rotator cuff tear. If active abduction is not possible, passively abduct the
arm to 90 degrees. The patient’s inability to stop the arm from dropping
may indicate complete tearing of a rotator cuff muscle. If downward force
while the arm is abducted to 90 degrees accelerates the drop, complete
tearing is likely.
Even though the deltoid can hold the arm level for a short period of time,
without action from rotator cuff muscles, the head of the humerus cannot be
seated in the glenoid fossa and the arm drops automatically as the humeral
head rotates upward. Muscle testing can be used to isolate the affected
muscles.
The Drop-Arm Test can be modified to test for supraspinatus function by
abducting the arm to 90 degrees and then flexing the elbow to 90 degrees in
a horizontal position. Without force from the supraspinatus resisting the pull
of gravity, the humerus will rotate internally and the forearm will drop.
If external rotators, such as the supraspinatus, can resist the pull of
gravity, complete tearing is unlikely. The patient’s ability to resist
downward force on the wrist while the elbow is flexed to 90 degrees
indicates complete tearing is not present.

80
4. Biceps-Tendon Test
First, with the patient seated, instruct the patient to flex the right elbow
to about 90 degrees and place the elbow on the right upper thigh with the
forearm resting on the thigh and the hand supinated (palm up). Stabilize the
patient’s right elbow with your left hand and hold the patient’s right wrist
with your right hand. While firmly holding the patient’s right wrist, instruct
the patient to externally rotate the humerus against resistance. Localized pain
in the area of C-5 indicates instability of the biceps tendon.
Second, from the same position, instruct the patient to internally rotate
the wrist against resistance. Localized pain indicates instability of the biceps
tendon or possibly tenosynovitis of the long head of the biceps.
Third, stand behind the patient and abduct the patient’s arms to an
overhead position. Hold the forearms just proximal to the wrists and rotate
the forearms externally to create several small circles (right forearm circles
clockwise, left forearm circles counterclockwise). Next, lower the arms to
the patient’s side. An audible click as the arms are being lowered may
indicate subluxation or dislocation of the biceps tendon.
Fifth, if the biceps tendon is completely ruptured, the belly of the muscle
will be rolled up in the distal portion of the arm and elbow flexion weakness
will be apparent.
5. Scapular Rotation and Winging Test
Besides elevating or rotating the scapula, the serratus anterior prevents the
scapula from pulling or winging away from the rib cage because of backward
movement. If the serratus anterior is weak, winging of one or both scapulas
can be demonstrated by having the patient push against a wall with both hands
below the waist, fingers pointing down, and the arms parallel. If scapular
winging is present, evaluate serratus anterior. Modified push-ups that use the
knees as a pivot point instead of the feet or regular push-ups with the back
arched instead of straight can be used to strengthen serratus anterior when
regular push-ups are too difficult.

81
Muscle Testing
Muscle testing normally follows symmetry and passive range-of-motion

testing. In addition to measuring strength, muscle testing can reveal painful
areas that were not recognized during passive range-of-motion testing. This
pain tends to occur in muscles, tendons, joints, or fascia.
Muscle testing covers the 22 basic neck and shoulder muscles. Two
principles will improve the quality of testing. First, if muscles being tested
move the humerus, pressure is applied above the elbow whenever possible.
This helps to avoid erroneous test results because of pathologic elbow
conditions and minimizes the risk of elbow damage. This principle is not
followed when the forearm is used as a lever for testing humeral rotation.
Second, stabilization is used to prevent extraneous movement in body
parts that may interfere with test results by allowing other muscles to
substitute for the muscle being tested. The word “none” is used when body
weight or position provide adequate stabilization.
Four terms are used to explain muscle testing: (1) test, (2) position, (3)
stabilization, and (4) resistance. Test refers to the movement being tested
and position refers to the patient’s position. Examiners can select their own
positions based on personal preference and physical attributes such as body
weight, strength, and reach.
Stabilization (fixation) is the process of stabilizing or holding a body
part in place to prevent unacceptable movement by the patient. Resistance is
isometric force generated by the examiner in a direction opposite to the
movement being tested. The examiner should press only hard enough to
counteract the force being generated by the patient in the opposite direction.
Test both sides for bilateral comparison and look for obvious weakness.
Muscle testing the shoulder is safe and relatively painless if certain
guidelines are followed.
A. Apply isometric resistance slowly (easy on).

B. Do not break the patient’s contraction with suddenly applied force.
C. Do not break the patient’s contraction with too much force.
D. Remove isometric resistance slowly (easy off).
E. Initially test the muscle near midrange whenever possible.
F. Stop the test if resistance causes significant pain.
G. Do not muscle-test during the acute stage of an injury.
H. Advise the patient that muscle testing is not a contest.

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22 BASIC MUSCLES: Muscle Testing
Neck
1. SCALENUS ANTERIOR (difficult to isolate)

Test: lateral neck flexion (side bending)
Patient: supine with neck in neutral position
Stabilization: stabilize shoulder on same side as test
Resistance: press against side of head in direction against lateral flexion
2. SCALENUS MEDIUS (difficult to isolate)

3. SCALENUS POSTERIOR
Shoulder
4. BICEPS BRACHII
Test: forearm flexion and hand supination
Patient: supine with arms along side of body
Stabilization: hold elbow against patient’s side to stabilize shoulder
Resistance: press against distal end of forearm above wrist in direction
of extension and pronation
5. CORACOBRACHIALIS
Test: adduction and flexion of humerus
Patient: sitting with arm flexed to 45 degrees, forearm completely
flexed, and hand supinated
Stabilization: none
Resistance: press against distal portion of humerus in direction of
extension with slight abduction

83
6. DELTOID
Test: abduction of humerus
Patient: sitting with arm abducted to 90 degrees, palm facing down
Stabilization: none
Resistance: press against upper (superior) surface of distal end of
humerus in direction of adduction
7. INFRASPINATUS (same as teres minor)

Test: lateral rotation of humerus
Patient: supine with arm abducted to 90 degrees and elbow flexed to
90 degrees
Stabilization: hold elbow to stabilize the shoulder and prevent
abduction or adduction of humerus
Resistance: press against forearm just above the wrist in direction of
medial rotation
8. LATISSIMUS DORSI
Test: adduction and extension of humerus
Patient: prone with arm extended and medially rotated
Stabilization: none
Resistance: press against humerus slightly above elbow in direction of
abduction and slight flexion
9. LEVATOR SCAPULAE
Test: elevation of scapula
Patient: sitting shoulder relaxed
Stabilization: none
Resistance: press down on top of shoulders with both hands
10. PECTORALIS MAJOR

Test: abduction and medial rotation of humerus
Patient: supine with arm flexed to 90 degrees and medially rotated,
elbow extended
Stabilization: hold opposite shoulder against table
Resistance: press against humerus in direction of horizontal abduction

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11. PECTORALIS MINOR
Test: forward tilt of scapula
Patient: supine with arms parallel to body
Stabilization: none
Resistance: press against anterior aspect of shoulder in downward
direction
12. RHOMBOID MAJOR (same as rhomboid minor)

Test: adduction of scapula
Patient: supine with both arms along side of body, hands pronated
Stabilization: hold opposite scapula against body to prevent movement
Resistance: press against medial border of scapula in direction of
abduction
13. RHOMBOID MINOR (same as rhomboid major)

Patient: supine with both arms along side of body, hands pronated
Stabilization: hold opposite scapula against body to prevent movement
Resistance: press against medial border of scapula in direction of
abduction
14. SERRATUS ANTERIOR

Test: abduction of scapula
Patient: supine with arm flexed to 90 degrees and elbow fully flexed
Stabilization: hold humerus in vertical position
Resistance: press against elbow in direction of adduction
15. SERRATUS POSTERIOR SUPERIOR (no standard test)
16. SUBCLAVIUS (no standard test)
17. SUBSCAPULARIS
Test: medial rotation of humerus
Patient: supine with humerus abducted to 90 degrees and elbow flexed
to 90 degrees
Stabilization: none
Resistance: press against forearm below wrist in direction of lateral
rotation

85
18. SUPRASPINATUS
Test: abduction of humerus
Patient: standing with arm and hand at side
Stabilization: none
Resistance: press against humerus just above elbow in direction of
adduction
19. TERES MAJOR

Test: abduction and flexion of humerus
Patient: prone with humerus extended, adducted, and medially rotated;
hand resting on posterior iliac crest
Stabilization: none
Resistance: press against humerus above elbow in direction of
abduction and flexion
20. TERES MINOR (same as infraspinatus)

Test: lateral rotation of humerus
Patient: supine with arm abducted to 90 degrees and elbow flexed to
90 degrees
Stabilization: hold elbow to stabilize shoulder and prevent abduction or
adduction of humerus
Resistance: press against forearm just above the wrist in direction of
medial rotation
21. TRAPEZIUS
Upper Trapezius (also elevates scapulas—see levator scapulae test)

Test: back and to-the-side movement of head
Patient:
(1) sitting with acromion process of shoulder elevated
(2) head rotated away from elevated shoulder
(3) head extended toward elevated shoulder
Stabilization: none
Resistance: hold shoulder stationary and press head in a direction
midway between flexion and lateral flexion to increase distance
between the head and shoulder

86
Middle Trapezius
Patient: prone with arm abducted to 90 degrees and hand supinated
(thumb pointing up)
Stabilization: none
Resistance: press against humerus above elbow in downward direction
Lower Trapezius
Test: adduction and depression of scapula
Patient: prone with arm abducted to about 150 degrees and elbow
extended
Stabilization: none
Resistance: press against humerus just above elbow in downward
direction
22. TRICEPS BRACHII

Test: forearm extension
Patient: supine with arm along side of body, elbow flexed to
90 degrees, hand supinated
Stabilization: hold elbow against patient’s side to stabilize shoulder
Resistance: press against distal end of forearm above wrist in direction
of flexion

87
HEMME APPROACH Quick Test
The Quick Test is used for quickly muscle-testing the neck and shoulder
muscles with both the patient and examiner standing. To conserve time, the
testing sequence is designed to keep positional changes between each test to
a minimum. The first eight tests are done with the examiner facing the
patient, and the last four are done with the examiner standing behind the
patient. Within five minutes, examiners should be able to check:
A. flexion (forearm)
B. extension (forearm)
C. lateral rotation (humerus)
D. medial rotation (humerus)
E. extension (humerus)
F. flexion (humerus)
G. horizontal abduction (humerus)
H. horizontal adduction (humerus)
I. extension (cervical spine)
J. adduction (humerus from 5 degrees)
K. adduction (humerus from 90 degrees)
L. lateral flexion (cervical spine)
Even though the Quick Test tends to evaluate movements more than
specific muscles, the results are fairly accurate because of bilateral
comparison. Except for testing extension and lateral flexion (side-bending)
of the cervical spine, movements on both sides of the body are tested at the
same time. All testing is done from a standing position with the examiner
facing the patient or standing behind the patient.
Testing is done with isometric resistance. Based on bilateral comparison
and the examiner’s experience, significant findings include obvious
weakness or pain. If more precision is needed, standard muscle testing or
muscle-testing machines can be used to quantify muscle strength.
Whenever possible, if movement of the humerus is being tested,
resistance is applied to the humerus above the elbow. If resistance is applied
to the elbow or forearm, pathologic conditions in either of these structures
may invalidate the test because of pain or weakness. When movement of
the forearm is being tested, resistance is applied to the forearm above the
wrist to avoid complications because of pathologic conditions in the wrist or
hand. Examiners using the Quick Test should follow the same safety
precautions listed above for standard muscle testing.

88
For simplicity, neutral position refers to the hand in a semi-pronated,
semi-supinated position, distal forearm refers to the end of the forearm just
above the wrist, and distal humerus refers to the end of the humerus just
above the elbow. To simplify directions of movement, extension is defined
as the opposite of flexion, adduction as the opposite of abduction, and lateral
rotation as the opposite of medial rotation. The basic prime movers of the
shoulder region involved in each movement include:
CERVICAL SPINE
A. extension: upper fibers of trapezius

B. lateral flexion: anterior, medius, and posterior scalenes
FOREARM
A. flexion: biceps brachii

B. extension: triceps brachii
HUMERUS
A. flexion: coracobrachialis and deltoid (anterior)

B. extension: latissimus dorsi and teres major
C. abduction: deltoid (middle fibers) and supraspinatus
D. adduction: latissimus dorsi, pectoralis major, and teres major
E. medial rotation: pectoralis major and subscapularis
F. lateral rotation: infraspinatus and teres minor
G. horizontal abduction: deltoid (posterior fibers)
H. horizontal adduction: pectoralis major
This list does not include prime movers that are not connected directly
with the shoulder region such as the forearm flexors brachialis and
brachioradialis. The decision as to what constitutes a prime mover varies
from one reference to another. Some authors list latissimus dorsi as a prime
mover in medial rotation. For clarity, the term humeri (plural of humerus)
has been used below to emphasize that reference is being made to the arm as
medically defined (upper extremity between shoulder and elbow).

89
Examiner Facing Patient (anterior)
1. Flexion (forearm)
A. Patient: arms at sides, elbows flexed to 90 degrees, hands supinated
B. Examiner: arms along sides, elbows flexed to 90 degrees, hands
pronated and touching superior surfaces of patient’s distal forearms
C. Resistance: prevent patient from flexing humeri
2. Extension (forearm)
A. Patient: arms at sides, elbows flexed to 90 degrees, hands supinated
B. Examiner: arms at sides, elbows flexed to 90 degrees, hands
supinated and touching inferior surfaces of patient’s distal forearms
C. Resistance: prevent patient from extending humeri
3. Lateral Rotation (humerus)

A. Patient: arms at sides, elbows flexed to 90 degrees, forearms parallel,
hands in a neutral position (vertical)
B. Examiner: arms down at sides, elbows flexed to 90 degrees, hands in
a neutral position (vertical) and touching lateral surfaces of patient’s
distal forearms
C. Resistance: prevent patient from laterally rotating humeri
4. Medial Rotation (humerus)

A. Patient: arms at sides, elbows flexed to 90 degrees, forearms parallel,
hands in neutral position (vertical)
B. Examiner: arms at sides, elbows flexed to 90 degrees, hands in
neutral position (vertical) and touching medial surfaces of patient’s
distal forearms
C. Resistance: prevent patient from medially rotating humeri
D. Option: examiner can draw elbows back (extend arms) and brace
forearms against body for added resistance to internal rotation
5. Extension (humerus)
A. Patient: humeri flexed to 90 degrees, elbows flexed to 90 degrees
B. Examiner: arms and elbows flexed, hands touching inferior surfaces
of patient’s elbows
C. Resistance: prevent patient from extending humeri

90
6. Flexion (humerus)
B. Examiner: hands touching superior surfaces of patient’s distal humeri
C. Resistance: prevent patient from flexing humeri
7. Horizontal Abduction (humerus) (forearms of examiner are parallel)

B. Examiner: hands touching lateral surfaces of patient’s elbows
C. Resistance: prevent patient from horizontally abducting humeri
8. Horizontal Adduction (humerus) (forearms of examiner are crossed)

B. Examiner: hands touching opposite medial surfaces of patient’s elbows
C. Resistance: prevent patient from horizontally adducting humeri
9. Extension (cervical spine)

A. Patient: arms at side and cervical spine flexed slightly forward
B. Examiner: one hand touching parietal region of patient’s head,
opposite hand touching sternal region of patient’s chest
C. Resistance: prevent patient from extending cervical spine
Examiner Behind Patient (posterior)
10. Abduction (humeri from 90 degrees)

A. Patient: arms abducted to 90 degrees
B. Examiner: hands touching superior surfaces of patient’s distal humeri
C. Resistance: prevent patient from abducting humeri
11. Adduction (humeri from 90 degrees)

A. Patient: arms abducted to 90 degrees
B. Examiner: hands touching inferior surfaces of patient’s distal humeri
C. Resistance: prevent patient from adducting humeri
12. Lateral Flexion (cervical spine)

A. Patient: arms at sides,
B. Examiner: one ipsilateral hand on lateral surface of patient head,
opposite hand stabilizing shoulder on same side
C. Resistance: prevent patient from laterally flexing cervical spine

91
Pathologic Conditions
1. Rotator Cuff Tear
The four rotator cuff muscles are supraspinatus, infraspinatus, teres

minor, and subscapularis. Tears in a rotator cuff muscle characteristically
cause pain and weakness. The major causes for rotator cuff tears are trauma,
degenerative changes, overuse, fatigue, and improper body mechanics. The
greater tuberosity is normally tender when palpated and pain is often serious
enough to interfere with sleep.
If a rotator cuff tear is suspect, the muscle should be palpated for trigger
points and atrophy. Resisted abduction is tested with the patient standing
and the arm hanging freely downward along the side of the body. The main
sign of an infraspinatus tear is pain or weakness during resisted abduction.
Resisted lateral or medial rotation can be tested with the patient seated and
the elbow flexed to 90 degrees. Pain or weakness during resisted lateral
rotation indicates an infraspinatus or teres minor tear. Pain or weakness
during resisted medial rotation indicates a subscapularis tear. The involved
side should be compared with the uninvolved side and passive range of
motion may be normal.
If lateral rotation with the arm abducted to 90 degrees is possible, the
supraspinatus muscle or tendon are not completely torn. Most cases
involving the supraspinatus muscle implicate the tendon as well as the
muscle. Inability to abduct the arm 15 to 30 degrees away from the body
without elevating the shoulder indicates a complete tear.
Though pain is not useful in differentiating between a partial or complete
tear, if the supraspinatus contracts strongly without corresponding
movement of the humerus, a complete tear is indicated. See Drop Arm Test
under “Orthopedic Testing” for standard rotator cuff test.
Examiners must not confuse inability to abduct an arm because of
complete muscle tearing with inability to abduct the arm because of pain
inhibition, apprehension of pain, or neurologic inefficiency. Patients with
abduction difficulties will sometimes show remarkable increases in range of
motion after soft-tissue therapy is used to identify and correct soft-tissue
impairments. The most common forms of soft-tissue therapy used for
treating shoulder problems are trigger point therapy, neuromuscular therapy,
and range-of-motion stretching.

92
For many patients with chronic shoulder problems, soft-tissue therapy is
their only hope, when despite continuous pain and limited range of motion,
surgery has been ruled out, medication provides no relief, and standard
methods of therapy based entirely on heating modalities and exercise
prescriptions are not effective. For many of these patients, soft-tissue
therapy is the missing link between suffering and living a normal life. On
the downside, if soft-tissue therapy, which is conservative and noninvasive,
has no effect on the patient’s condition, surgery and medication can always
be reconsidered.
2. Adhesive Capsulitis (frozen shoulder)
Adhesive capsulitis is normally characterized by four stages:
1. pain around the glenohumeral joint during shoulder movement

2. intense pain that interferes with sleep and shoulder stiffness
3. less pain, but more shoulder stiffness
4. limitation of shoulder movement in all directions
Pain is normally more severe during the early stages of frozen shoulder
than during the later stages when the shoulder is stiff and disabled. During
later stages, pain occurs most when efforts are made to increase range of
motion. The final stage is limitation of movement in all directions. The
main goal for therapy is pain-free range of motion.
Though many factors contribute to adhesive capsulitis including trigger
points, muscle tears, inflammation, vasospasm, constriction of glenohumeral
joint capsule, and reflex sympathetic dystrophy, the exact origin is still
debated. Conditions that are sometimes associated with adhesive capsulitis
include coronary disease, pulmonary tuberculosis, diabetes, and lung cancer.
Complete recovery without treatment is rare.
The tendons and bursas that are frequently affected include the biceps
tendon, conjoined tendon, subdeltoid bursa, and subscapularis bursa. The
major sites for pain are the biceps tendon, subdeltoid bursa, and
glenohumeral joint capsule. During the onset, painful areas include the
humeral deltoid insertion and the greater tuberosity. Though active or
passive movements in all directions aggravate the pain, humeral abduction
and external rotation are normally the most painful. If the glenohumeral
joint is frozen, abduction of the humerus depends almost entirely on
clavicular and scapulothoracic motion.

93
As the syndrome progresses, pain becomes severe enough to inhibit
movements and may interfere with daily activities or sleep. Most cases of
adhesive capsulitis occur after 40 years of age unless shoulder trauma is
followed by long periods of inactivity. X-ray findings are normally
inconclusive.
After the initial onset of pain, shoulder motion becomes progressively
restricted in all directions. Loss of motion is apparently caused by (1)
connective tissue adhesions affecting the biceps tendon and glenohumeral
capsule, (2) thickening (hypertrophy) of the glenohumeral joint capsule, and
(3) changes in synovial membrane (synovium) that increase friction by
increasing tissue thickness and reducing lubrication. Also referred to as
frozen shoulder, adhesive capsulitis is characterized by increased vascularity
and fibrosis.
Impaired movement that accompanies adhesive capsulitis because of
spasm or fibrosis tends to implicate certain muscles. Impaired medial
rotation implicates infraspinatus or teres minor, while impaired lateral
rotation implicates subscapularis. When the subscapularis muscle is
implicated because of limited lateral rotation, the concentration of trigger
points in the muscle is normally high. Since the subscapular also adducts
the arm, spasm or fibrosis may also impair abduction. The supraspinatus
(abductor) is frequently a site for trigger points and tendinitis.
Trigger points in the subscapularis seem to encourage trigger points in
other muscles that medially rotate or adduct the arm. The medial rotators
are pectoralis major and latissimus dorsi; the adductor is triceps brachii.
When medial rotation is restricted, lateral rotators have a tendency to
develop trigger points because of overload. The lateral rotators that may be
affected by trigger points in subscapularis are posterior deltoid and teres
major. The subscapularis also refers pain to the posterior deltoid. If the
subscapularis has trigger points, horizontally abducting the arm across the
chest and touching the opposite shoulder will rotate the involved scapula
laterally and may produce pain.
After the acute stage when nothing more aggressive than ice and
pendular exercises are recommended, there are two basic approaches for
treating adhesive capsulitis with soft-tissue therapy. The first approach
focuses on the biceps muscle and tendon, and the second approach focuses
on treating the subscapularis and related muscles. The sequence can be
varied to meet the needs of the patient.

94
The first approach in treating adhesive capsulitis is treating the biceps
muscle with trigger point therapy, neuromuscular therapy, and range-of-
motion stretching. Once pain and spasm in the muscle are reduced, the
biceps tendon should be treated with trigger point therapy, cross fiber
friction, local stretching, and range-of-motion stretching. If the biceps
tendon is irritated, stretching the tendon or contracting the biceps, with or
without resistance, will cause pain. Treating the muscle before the tendon
reduces tension on the tendon that may cause abrasion, irritation, or rupture.
Though treating the muscle first and the tendon second is normally more
effective than treating the tendon first and the muscle second, it can be
shown clinically that pressure applied to a tendon will sometimes release
spasm in the muscle, just as irritation in a tendon will sometimes cause
spasm in a muscle. Regardless of which is treated first, the worst—and all
too common—approach is treating the tendon without treating the muscle.
When applied to the tendon, trigger point therapy helps to relieve pain,
while cross-fiber friction, local stretching, and range-of-motion stretching
help to release any restrictions that are binding the tendon. Local stretching
is accomplished by using the fingers to apply force perpendicular to the
tendon or the proximal portion of the muscle. This will cause limited
stretching of the tendon. In some cases, freeing the biceps tendon leads to
unlocking the entire shoulder.
If trigger point therapy is used first to relieve pain and desensitize
tissues, cross-fiber friction will be less painful. Icing a muscle for about ten
minutes before using cross-fiber friction will also relieve pain and
desensitize tissues. If there is no need to physically release a tendon from
surrounding tissue, trigger point therapy is faster and much less painful than
cross-fiber friction. Most patients dislike cross-fiber friction because of the
pain, and some patients will discontinue therapy if cross-fiber friction is the
only method of treatment used.
Once pain diminishes, fibrous restrictions become more apparent.
Pendular exercises, local stretching, and range-of-motion stretching will
improve mobility by lengthening or breaking fibrous adhesions that restrict
movement. The biceps tendon and glenohumeral joint capsule are both
affected by adhesions. Stretching movements should be slow, gentle, and
progressive. High-velocity, high-force movements should be avoided; the
risk of rupturing the joint capsule or a tendon is too high.

95
Range-of-motion stretching reduces spasm, lengthens contractures, and
neurologically improves proprioceptive function. If several different
methods of manipulation are used in a sequence, range-of-motion stretching
is normally the last method used. Since the movements in range-of-motion
stretching should be slow and gentle, practitioners should be careful not to
use too much leverage or too much force.
Since overhead abduction is not possible without external rotation of the
humerus, a workable sequence for treating humeral range of motion is (1)
external rotation, (2) internal rotation (3) abduction, (4) adduction (5)
flexion, and (6) extension. By combining movements that work in opposite
directions such as flexion and extension, reciprocal inhibition will improve
neurologic efficiency and strengthen the patient's ability to actively move the
arm. If active movements are not used, the sequence for treatment is less
important, provided no attempts are made to abduct the arm overhead before
the humerus can be externally rotated.
The second approach is treating the subscapularis with trigger point
therapy and range-of-motion stretching. The best way to reach the
subscapularis for trigger point therapy is by placing the patient’s forearm
horizontally across the back by extending the humerus and flexing the elbow
to 90 degrees. Placement of the forearm can be done from a sitting or supine
position, though supine is preferred.
If the patient is supine, the subscapularis can be reached by abducting
the humerus to 90 degrees and using a pincer grip to pull the latissimus dorsi
and teres major away from the scapula. This should expose the axillary
border of the subscapularis. The lateral border of the scapula can be used for
reference, and traction on latissimus dorsi and teres major must continue
during palpation or treatment.
With the forearm behind the back, most scapulas can be distracted far
enough away from the patient’s body to give practitioners limited access to
the subscapularis along the medial border of the scapula. Treating the
medial edges of the subscapularis with trigger point therapy is normally
sufficient to relax the entire muscle.
After the subscapularis is treated, all muscles relating to the
subscapularis should also be checked for trigger points. Muscles that are
synergistic or antagonistic to the subscapularis or muscles that act on the
glenohumeral joint are good starting points for evaluation. The eight
muscles, in particular, that should be checked include: (1) supraspinatus, (2)
infraspinatus, (3) teres minor, (4) teres major, (5) latissimus dorsi, (6)
deltoid, (7) pectoralis major, and (8) triceps brachii.

96
The chances of full recovery can be improved by treating adhesive
capsulitis early. Treatment becomes more difficult as range of motion
decreases because of adhesions. The two major goals of therapy are (1)
reduce pain and (2) restore full range of motion by stretching or breaking
fibrous adhesions. After patients regain normal range of motion, shoulder
exercises are needed to maintain full range of motion and strengthen weak
muscles. Though many patients prefer not to exercise, inactivity will
encourage a relapse by giving adhesions a chance to re-form.
3. Scalene Anticus Syndrome (Thoracic Outlet Syndrome)
Though scalene muscles and thoracic outlet syndrome are frequently

overlooked when evaluating shoulder pain, neurovascular entrapment
because of spasm in any of the three major scalenes can radiate or refer pain
to the shoulder region. Constriction of the thoracic outlet causes disabling
symptoms because of the structures within the outlet: brachial plexus,
subclavian artery, and subclavian vein. In addition to pain, sensory changes
(dysesthesia), and motor weakness because of nerve compression,
constriction of the outlet may cause swelling and temperature changes
because of restricted blood flow.
All three of the scalenes can radiate pain anteriorly, laterally, or
posteriorly, and thoracic outlet symptoms can be referred to the shoulder,
arm, forearm, hand, and fingers. If proximal portions of a nerve become
irritated because of compression or stretch, distal portions of the nerve seem
to be more susceptible to pain. Though symptoms of nerve compression
normally occur during activity, they may also occur during rest or sleep.
The scalene muscles originate from the cervical spine and insert on the
first and second ribs. There are three muscles in the scalene group: scalenus
anterior, scalenus medius, and scalenus posterior. The scalene muscles
divide into two parts and surround the brachial plexus and subclavian artery,
with scalenus anterior to the front and scalenus medius to the back. A pulse
can be felt about an inch above the clavicle where the subclavian artery
emerges from behind the scalenes. In rare cases, the subclavian artery
passes directly though scalenus anterior.
The subclavian vein is not surrounded by scalene muscles but lies
between scalenus anterior, the first rib, and the clavicle. Trigger points or
spasm in the scalenus anterior may cause pressure on the vein because of
entrapment between scalenus anterior, the first rib, and clavicle. Obstruction
of the subclavian vein may cause venostasis, loss of circulation, and
swelling.

97
Entrapment of the subclavian vein, as well as lymph ducts, may cause
swelling and stiffness in the hands and fingers that is more noticeable after
long periods of inactivity or sleep. Trigger points in the scalene group are
less likely to restrict cervical rotation than trigger points in the splenius
cervicis or levator scapulae.
Prevertebral fascia covers the anterior, middle, and posterior scalenes, as
well at the longus capitis, rectus capitis, and longus cervicis. Before it
travels downward and merges with trapezius muscle fascia, prevertebral
fascia covers all cervical nerve roots and binds down the subclavian artery
and three branches of the brachial plexus.
The neurovascular bundle is a collective term for all the nerves and
vessels exiting through the outlet. Spasm or contracture of the scalene
muscle and thickening of prevertebral fascia are two of the factors most
commonly cited for causing constriction of the outlet and corresponding
irritation of neurovascular elements. If the pain to the shoulder is bilateral,
either the origin is central or structures on both sides of the neck are
involved.
Factors that are thought to cause spasm in the scalene group include
activation of trigger points and irritation of cervical nerve roots (cervical
radiculitis). The combination of trigger points and radiculitis can work
together as a trigger point-radiculitis cycle: (1) trigger points irritate cervical
muscles and cause reflex spasm, (3) reflex spasm decreases joint space and
irritates cervical nerves, and (3) irritated cervical nerves cause reflex spasm
that activates trigger points.
The easiest way to break the trigger point-radiculitis cycle is by
neutralizing trigger points with trigger point therapy and range-of-motion
stretching. Since trigger points in the sternocleidomastoid muscle can
activate trigger points in the scalene group, the sternocleidomastoid muscle
should be treated with trigger point therapy and range-of-motion stretching
along with the scalene group. The sternocleidomastoid is known to produce
referred autonomic disturbances such as vasoconstriction, proprioceptive
dizziness, and disturbed equilibrium.
Constriction of the subclavian artery may cause symptoms of coldness,
weakness, pallor, or cyanosis. Unlike the subclavian artery, the subclavian
and axillary veins are not held in place by prevertebral fascia and
constriction of the fascia will not cause venous congestion.

98
The stellate ganglion is a cervicothoracic sympathetic ganglion formed
by the fusion of the inferior cervical and first thoracic ganglions.
Sympathetic nerves from the stellate ganglia do penetrate the fascia and
thickening of the paravertebral fascia can produce signs or symptoms of
sympathetic nerve irritation such as tenderness, burning pain (causalgia),
coldness, moisture, perspiration, or color changes (bluish or pale).
Reflex sympathetic dystrophy (RSD) is a condition related to the
sympathetic nervous system that produces similar symptoms: diffuse pain,
pallor, sweating, redness, edema, skin atrophy, and vasomotor disturbances.
Other symptoms are excessive sensitivity to pain (hyperalgia) and joint
dysfunction because of synovial edema, inflammation of the synovial
membrane (synovitis), or thickening of articular tissue. Suggested causes
include soft-tissue injuries, trigger points, and vascular accidents such as
heart attacks or strokes.
Although poorly understood, there seems to be an adverse relationship
between pain fibers and sympathetic nerves that perpetuates reflex
sympathetic dystrophy. The best method of prevention is early intervention
with continuous passive mobilization or range-of-motion stretching. The
best conservative treatment is trigger point therapy followed by range-of-
motion stretching.
Using movements or positions to stretch or compress the outlet and
reproduce symptoms is a strong indicator of scalene anticus syndrome.
Having the patient actively and gently extend and rotate the cervical spine
may reproduce symptoms. In most cases, vertical compression applied to
the top of the head will aggravate symptoms and vertical traction applied by
lifting the head alleviates symptoms.
A more direct approach is palpating or manually compressing the
scalenes to reproduce symptoms. If palpating or compressing the scalenes
produces a positive test, using soft-tissue therapy to relieve spasm or
contracture will normally diminish or eliminate the symptoms.
The basic treatments for scalene anticus syndrome are (1) reduce pain,
spasm, and contracture in the scalene muscles, (2) increase flexibility and
range of motion, (3) improve muscular strength and endurance, and (4)
correct any postural problems caused by soft-tissue impairments. The main
postural problem that applies to scalene anticus syndrome, as well as many
shoulder problems, is dorsal kyphosis.

99
Since the basic actions of the scalene group are elevating the first rib and
flexing or rotating the neck, the usual forms of range-of-motion stretching
are extending or rotating the neck. In addition to basic actions, the scalenes
acting unilaterally stabilize the neck against lateral movement and side-bend
(laterally flex) the cervical spine. This means active or passive side-bending
can also be used for range-of-motion stretching.
One test for scalene involvement is to have the patient place the forearm
corresponding with shoulder pain (ipsilateral) on top of the head for several
minutes. By reducing tension of the muscle, elevating the forearm should
relieve pain originating in the scalenes. Placing the opposite (contralateral)
forearm on top of the head should have no effect on pain. Placing either
forearm on top of the head should have no effect on cervical radiculitis.
A second test for scalene involvement is having the patient rotate fully
toward the affected side and press the chin into the depression formed by the
clavicle. Since pressing the chin down requires forceful contraction by the
scalenes, any increase in pain will be a positive sign of scalene involvement.
If the scalenes are painful before the test, pressing the chin down may not be
sufficient to increase pain.
In some patients with scalene involvement, conducting this test will
increase pain and spasm even after the test is discontinued. In addition to
causing pain and spasm by activating trigger point, contracting a muscle
while distal and proximal attachments are not far enough apart to resist
shortening while the muscle contracts seems to encourage spasm.
As a simple test, flex the arm to 90 degrees in front of the body (sagittal
plane) and then flex the elbow until the fingers touch the acromion process.
Very carefully and gently isometrically contract the biceps brachii. As the
muscle starts to shorten, most people will feel the beginning of spasm.
Isometrically contracting the biceps while the elbow is extended or partially
flexed should not cause spasm.
A third test for scalene involvement requires patients to extend the neck,
rotate the chin toward the affected side, and hold their breath after a deep
inspiration. If pulse radial (wrist) pulse is obliterated, the test is positive.
Theoretically, the absence of a radial pulse indicates scalenus anterior is
compressing the neurovascular bundle. This test is not recommended for
two reasons: (1) the test is not reliable, and (2) the possibility of
vertebrobasilar insult.

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Overall, palpation is probably the best way to locate trigger points in the
scalene group. One point that may be tender when trigger points are present
in the scalenes is the middle of the infraclavicular fossa located directly
below the clavicle. This triangular fossa is bordered by the clavicle on the
top, the pectoralis major on the medial side, and deltoid muscle on the lateral
side. Tenderness here may indicate trigger points in the scalenes or pectoral
muscles. Like the apex of the coracoid process that is slightly lateral and
superior, the infraclavicular fossa should always be checked for trigger
points when examining the shoulder.
Though not considered one of the major neck and shoulder muscles, the
omohyoid muscle originates from the upper border of the scapula and inserts
on the hyoid bone. The omohyoid, which has two bellies attached by a
tendon, depresses the hyoid bone. Though trigger points in this muscle can
prevent full stretch of the trapezius and scalene muscles, the proximity of the
omohyoid’s lower belly to scalenus anterior and posterior makes it very
likely that treating the scalenes will also treat the omohyoid. The
omohyoid’s upper belly is proximal to the hyoid bone. Because of the
delicate nature of the hyoid bone and thyroid cartilage, treatment of the
upper belly of the omohyoid is not recommended.
When treating the scalene group for trigger points, the patient can be
prone or supine. Passively rotating or side-bending the head toward the
affected side reduces tension on the scalenes, while passively rotating or
side-bending away from the affected side stretches the scalenes. Elevating
the arm and forearm to a horizontal position with the elbow pointing slightly
forward will slacken the scalenes and make it possible to work closer to the
insertions on the first and second rib by pressing the fingers carefully to the
inside of the clavicle. Resting the hand on top of the head can also be used
to increase the space between the clavicle and scalenes.
Patients can do stretching exercises at home by rotating or side-bending
the head away from the affected side. To increase the stretch, the ipsilateral
hand can rotate or side-bend the head away from the afflicted scalenes by
pushing or the contralateral hand can rotate or side-bend the head away from
the afflicted scalenes by pulling. The movement should be done slowly and
gently from a sitting or supine position. Moist heat and deep abdominal
breathing can be used to facilitate stretching. Even if pain or spasm is
unilateral, these exercises should be done on both sides to help the body
maintain muscular balance.

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4. Pectoralis Minor Syndrome
After treating the scalene muscles, it may be worthwhile to check

pectoralis minor. The two syndromes may coexist. Spasm or contracture in
this muscle are capable of causing neurovascular compression that produces
symptoms similar to scalene anticus syndrome. This condition is sometimes
referred to as pectoralis minor syndrome.
Pectoralis minor originates from the third, fourth, and fifth rib, and
inserts on the coracoid process of the scapula. If pectoralis minor becomes
irritated and swollen, compression could occur where the brachial plexus,
axillary artery, and axillary vein pass between pectoralis minor and the rib
cage. If pectoralis minor is shortened because of spasm or contracture,
lifting the arms overhead could partially compress the neurovascular bundle
against the rib cage.
The pectoralis minor can be treated almost the same way the scalenes are
treated in scalene anticus syndrome. Trigger point therapy along the medial
border of the scapula and passive overhead stretch with the patient supine
are very effective when trying to lengthen the pectoralis minor. The
overhead stretch will be explained later.

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CHAPTER SUMMARY
FOUR BASIC METHODS OF PHYSICAL EVALUATION
• Observation (inspection)
• Palpation (touching)
• Percussion (tapping)
• Auscultation (listening)
FOUR BASIC ZONES FOR PALPATION
• Rotator cuff
• Prominent muscles of the shoulder girdle
• Subacromial and subdeltoid bursa
• Axilla
THREE CONDITIONS THAT CAUSE TISSUE DAMAGE
• Abnormal stress applied to normal tissues

• Normal stress applied to abnormal tissues
• Abnormal stress applied to abnormal tissue
FIVE BASIC PAIN-PRODUCING CHEMICALS
• Bradykinin
• Histamine
• Prostaglandins
• Serotonin
• Substance P
FIVE THERAPEUTIC OBJECTIVES BASED ON PAIN CYCLES
• Relieve pain
• Reduce spasm and edema
• Improve circulation and mobility
• Neutralize trigger points
• Encourage exercise

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SEVEN-STEP REHABILITATION MODEL
1. Problem: original injury.

2. Results: tissue damage, inflammation, and pain-producing chemicals.
3. Results: pain, spasm, edema, and metabolite retention.
4. Results: restricted circulation, ischemia, hypoxia, and fatigue.
5. Results: restricted motion, inactivity, and fibrosis.
6. Results: adhesions, contractures, trigger points, and atrophy.
7. Solution: Soft-Tissue Therapy. Alternatives: acceptable recovery,
secondary injury, or discontinue therapy.
(Note: Regardless of step, therapy can be discontinued at any time.)
3-POINT TOUCH TEST
• Patient reaches behind head with one arm and tries to touch the superior
angle of opposite scapula.
Purpose: test abduction and lateral rotation.
• Patient reaches in front of head with one arm and tries to touch the upper
thoracic spine with fingers (superior surface of arm touches chin).
Purpose: test horizontal adduction and medial rotation.
• Patient reaches behind back with one arm and tries to touch the inferior
angle of opposite scapula (may require limited humeral extension).
Purpose: test adduction and medial rotation.
ORTHOPEDIC TESTING
• Painful-Arc Test
• Supraspinatus Test
• Drop-Arm Test
• Biceps-Tendon Test
• Scapular Rotation and Winging Test
PATHOLOGIC CONDITIONS
• Rotator cuff tear

• Adhesive capsulitis (frozen shoulder)
• Scalene anticus syndrome (thoracic outlet syndrome)
• Pectoralis minor syndrome

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MODALITIES
Modalities are used in soft-tissue therapy to prepare the body for

manipulation. Though seldom curative when used alone, modalities
facilitate manipulation by reducing pain, controlling edema, reducing muscle
spasm, decreasing tissue viscosity, and increasing or decreasing metabolism.
Manipulations are most effective when performed during or shortly after the
application of modalities.
Cryotherapy
During the acute stage of a shoulder injury when stabilization and rest of
an injured body part are advisable, application of an ice pack for 20-minute
periods, three to five times a day, may be helpful. Application of ice for less
than 10 minutes will not affect intramuscular temperatures at a depth greater
than about one inch. Ice therapy should continue for about 48 hours until the
swelling stops.
After swelling because of edema or subcutaneous bleeding stops,
switching to heat will accelerate the rate of healing by increasing tissue
metabolism. The prolonged use of cold during the subacute stage of an
injury can retard wound healing by restricting blood flow and slowing
metabolism.
As a general rule, heat is seldom used during the acute stage, but ice can
be used during the acute or subacute stage. Ice is the therapy of choice for
almost any type of shoulder inflammation such as bursitis or tendinitis.
Ice is an analgesic that relieves pain by (1) decreasing production of
pain-producing chemicals, (2) slowing nerve conduction velocities, and (3)
reducing protective spasm by decreasing spindle cell activity. Ice controls
swelling by decreasing production of inflammatory chemicals such as
histamine and slowing vascular changes such as vasodilation that cause
microscopic bleeding or edema.
There are four basic phases of ice massage: (1) cold, (2) burning, (3)
aching, and (4) numbness. When treating trigger points with ice, cooling
should be continued long enough for numbness to occur. This takes about
five to seven minutes. A standard treatment with block ice held stationary
and pressing downward on a trigger point is normally about 10 minutes.
Applied for less than five minutes, ice massage increases muscle tone by
reflex action and cools the skin. Since ice normally produces a burning

105
sensation or pain before numbing takes effect, ice can be classified as a
counterirritant and may cause the release of endorphins. Based on the gate
control therapy of pain and inhibition, counterirritants reduce pain by
stimulating large fiber proprioceptors that inhibit small fiber nociceptors.
Applied for twenty minutes or more, the effects of ice massage are
vasoconstriction, analgesia, and loss of tonus.
On the positive side, cold-induced analgesia facilitates exercise by
controlling pain and reducing muscle spasm. On the negative side, cold
decreases tissue extensibility by increasing tissue viscosity. Though ice can
be used effectively to facilitate exercise when pain is the limiting factor, heat
can be more effective when the ability to exercise is limited by tissue
extensibility. Ice can also be used to reduce pain and edema after exercise.
Cold is even more effective in controlling edema when combined with
rest, elevation, and compression. The acronym RICE stands for (1) rest, (2)
ice, (3) compression, and (4) elevation. These are the four main steps used
in treating sports injuries. In sports medicine, crushed ice is normally
applied to stabilized body parts for about twenty or thirty minutes with
compression and elevation. Ice treatments are continued for about two days.
Unlike heat, cold tends to decrease bleeding by causing vasoconstriction.
If pain, edema, and subcutaneous bleeding are present, cold is safer to use
than heat. If pain, edema, and subcutaneous bleeding are not present, heat is
preferred over cold. Unlike cold, heat causes vasodilation and stimulates
circulation.
Where time is a factor and subcutaneous bleeding is not present, heat
reduces muscle spasm faster than cold. Heat works by reflex effect on the
gamma system and requires only enough time for shallow penetration. Cold
works by slowing nerve conduction velocities and requires enough time for
deep penetration. Cold applied briefly can trigger a stretch reflex that
aggravates spasm and makes treatment even more difficult.
Contraindications specifically for therapeutic cold are people with cold
sensitivities, heart disease, or signs of general weakness. When people with
sensitivities are exposed to cold, release of histamine causes edema and cold
urticaria. Another contraindication to cold is Raynaud's disease, which
causes abnormal vasoconstriction when extremities are exposed to cold.
A final consideration is whether the patient likes heat or cold. If heat or
cold modalities are both acceptable, let the patient decide.

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Indications for Cold

1 Muscle spasm
2 Pain
3 Edema
4 Trauma
Thermotherapy
After swelling and subcutaneous bleeding have stopped, normally about

48 hours after the acute stages of an injury, heat relieves pain by reducing
protective spasm, dispersing pain-producing chemicals, and producing a
relaxing effect for most patients. The application of heat promotes healing
by stimulating circulation that is needed to supply nutrients and remove
debris or chemical toxins. Both heat and cold can act as a counterirritant to
reduce the feeling of pain.
Heat reduces tissue viscosity, which may discourage collagen fibers
from adhering to each other during the healing process. The intersection
points between normal collagen fibers crisscrossing over the top or bottom
of each other are not attached because of distance and lubrication that
separates the fibers during movement. When collagen fibers adhere to each
other at intersection points or connect tissues that should not be connected,
flexibility is reduced and moderate stress may cause tearing. Moist heat
continues to be the treatment of choice for shoulder pain. Though heat and
cold both relieve pain and spasm, most patients seem to prefer heat over
cold. Unlike cold, heat also reduces joint stiffness and stimulates
circulation.
Common methods for applying therapeutic heat include silicon gel
packs, whirlpools, paraffin baths, and infrared light. Since moist air
conducts heat more rapidly than dry air, moist heat is generally more
penetrating than dry heat. Certain electric heating pads produce moist heat
by trapping vapor that escapes from the body during the heating process.
Heat applications are normally 10 to 20 minutes in length.
Many patients find that soaking in a hot bath (100º-104ºF) produces
feelings of relaxation and well-being. These effects are more psychological
than physical or physiological. Temperatures high enough to increase tissue
extensibility are normally between 105ºF and 110ºF. These temperatures are
very hot and difficult for most people to tolerate. Tissue damage and pain
start when internal tissue temperatures reach 113ºF.

107
For patients who can tolerate temperatures between 105ºF and 110º F,
the benefits beyond general relaxation are (1) reduction of pain and spasm,
and (2) greater tissue extensibility. Therapeutic stretching while patients are
still immersed in hot water is more effective than stretching after they start
to cool off. Except for psychological changes, the benefits of stretching a
patient after tissue temperatures return to normal are minimal.
Soaking in hot water on a continuous basis can produce adverse effects.
On the positive side, by lowering tissue viscosity, heat increases tissue
extensibility and decreases resistance to stretch. This makes it easier for
patients to attain full range of motion with less force. When tissues are
heated, stretched, and then allowed to cool while still extended, tissue
damage is less and increases in length tend to become permanent.
On the negative side, most patients do not stretch after soaking in hot
water, and tissues cooled at or below resting length have a tendency to
remain short and become even more resistant to active or passive stretch.
This tendency relates to a property found in thermoplastics called "set."
Because of thermoplastic set, the long-term effect of using hot water for pain
relief that is not followed by range-of-motion stretching can be an increase
in stiffness and pain.
Some patients report that following the HEMME APPROACH exercise
program directly after soaking in a hot bath produces excellent results. The
HEMME APPROACH eight-step exercise plan for managing neck and shoulder
pain is presented in the chapter titled "EXERCISE."
The contraindications for heat are bleeding, malignancy, inflammation,
vascular insufficiency, edema, burns, fever, tuberculosis, general weakness,
and debilitating diseases such as heart disease. Heat is contraindicated for
patients who are insensitive to pain or unable to communicate pain.
Hot-to-Cold Stretch
Rather than stretch tissues after heating pads or silicon gel packs are
removed, stretch tissues while heating devices are held in place by loosely
wrapped elastic bands. This method prevents tissues from cooling during
the stretching process.
Once stretching is complete, apply ice and hold the stretch at maximum
length until the affected tissues cool. Using heat to decrease viscosity during
stretching and ice to increase viscosity after stretching will encourage tissues
to remain at maximum length.

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In thermoplastics, the tendency for the length during cooling to become
the permanent length is called “set.” Thermoplastics and viscoelastic
materials like muscles often behave in similar ways.
The normal protocol for a hot-to-cold stretch:
1. Apply moist heat for about 15 to 20 minutes.

2. Stretch tissues while heating devices are still in place.
3. Hold stretch and apply ice for about 10 to 15 minutes.
4. Release tension when tissues are cold.
5. Allow patient to rest for about 5 minutes without moving.
Indications for Heat

1 Muscle spasm
2 Pain
3 Contracture
4 Vascular stasis
Adverse Effects
Despite therapeutic effects, heat and cold will sometimes cause neck or
shoulder pain. Overheating can upset the body's electrolyte balance and
make skeletal muscles prone to fatigue, spasm, or cramps. On the opposite
side, some patients report that air conditioning is cold enough to chill
muscles and cause neck or shoulder pain.
Cold produces pain in two ways: (1) by a sequence of vasoconstriction,
ischemia, and pain, and (2) by a sequence of stiffness, abnormal tissue
tension, and pain. For pain to occur, the temperatures must be cold enough
to produce pain but not cold enough to produce analgesia. Some patients
report an increase in both pain and spasm when cold is applied to hypertonic
neck or shoulder muscles.

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EFFECTS OF HEAT AND COLD
The following tables summarize the effects of heat and cold.
NORMAL EFFECTS OF HEAT
1. Vasodilation ---------------------------------------------------- (heat)

2. Increase in local metabolism --------------------------------- (heat)
3. Increase in local circulation ---------------------------------- (heat)
4. Increase in edema ---------------------------------------------- (heat)
5. Increase in inflammation-------------------------------------- (heat)
6. Increase in tissue extensibility ------------------------------- (heat)
NORMAL EFFECTS OF COLD
1. Vasoconstriction ----------------------------------------------- (cold)

2. Decrease in local metabolism -------------------------------- (cold)
3. Decrease in local circulation --------------------------------- (cold)
4. Decrease in edema --------------------------------------------- (cold)
5. Decrease in inflammation------------------------------------- (cold)
6. Decrease in tissue extensibility ------------------------------ (cold)
NORMAL EFFECTS OF HEAT AND COLD
1. Relax muscle spasm -------------------------------- (heat and cold)

2. Reduce pain------------------------------------------ (heat and cold)

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Vibration
Vibration has a relaxing effect on muscles and relieves pain. Other

benefits are better circulation, increased lymphatic flow, and decreases in
sympathetic activity. The most effective way to administer vibration is by
mechanical devices that produce an oscillatory (back-and-forth) movement.
Some vibrators also produce a percussion effect by moving up and down.
Though manual vibration can be useful, it tends to be less effective and more
tiring than mechanical vibration.
When patients cannot tolerate compression or stretching, vibration
prepares the patient for manipulation by desensitizing offending tissues. The
pain-relieving effects of vibration relate to stimulation of A-beta nerve fibers
that block the conduction of electrical impulses that transmit deep pain. It is
also believed that prolonged vibration relaxes muscle spasm by stimulating
proprioceptors to inhibit contraction.
By improving lymphatic flow and circulation, vibration reduces edema
and hastens the resolution of inflammation. Mechanical vibration is
normally more effective and less tiring than manual vibration. To sedate
muscles, relax spasm, relieve pain, and stimulate circulation, vibratory
treatments should be at least three minutes long. Treatments less than three
minutes stimulate more than sedate.
On the negative side, practitioners using electrical hand-held vibrators
for long periods of time may experience musculoskeletal problems. There
are no standards for acceptable levels of exposure, but people using hand-
held vibrators should take frequent breaks and avoid positions that cause
fatigue or discomfort.
The contraindications for vibration are the same as for soft-tissue
therapy in general. Definite contraindications for vibration are heart disease,
hemorrhage, malignancy, open lesions, and overly sensitive skin. Even
though vibration may be used to hasten the resolution of inflammation by
stimulating surrounding tissues, vibration should not be applied directly to
any areas that show signs of acute inflammation.

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CHAPTER SUMMARY
FOUR INDICATIONS FOR HEAT
• Muscle spasm
• Pain
• Contracture
• Vascular stasis
FOUR INDICATIONS FOR COLD
• Muscle spasm
• Pain
• Edema
• Trauma
SIX NORMAL EFFECTS OF HEAT
• Vasodilation
• Increase local metabolism
• Increase local circulation
• Increase edema
• Increase inflammation
• Increase tissue extensibility
SIX NORMAL EFFECTS OF COLD
• Vasoconstriction
• Decrease local metabolism
• Decrease local circulation
• Decrease edema
• Decrease inflammation
• Decrease tissue extensibility
EFFECTS OF BOTH HEAT AND COLD
• Relax muscle spasm and reduce pain

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MANIPULATION
Manipulation implies skilled and dexterous treatment by using the

hands. The manipulations used in the HEMME APPROACH are low-velocity
pushing or pulling movements that correct soft-tissue impairments by
repositioning soft-tissue components of the body. They are not high-
velocity thrusting movements as found in some forms of manual medicine
that seek to adjust or reposition bones. The main goals of soft-tissue
manipulation are (1) correct soft-tissue impairment and (2) restore normal
function in terms of strength, endurance, flexibility, pain-free movement,
coordination, and mobility. These goals should be accomplished with
minimal force and without doing the patient harm.
A good manipulator has a wide variety of techniques to select from and
uses flexibility in selecting the most workable techniques. The four basic
types of therapy used in HEMME APPROACH include (1) trigger point
therapy, (2) neuromuscular therapy, (3) connective tissue therapy and (4)
range-of-motion stretching. Despite hundreds of different names and
techniques, any form of soft-tissue therapy involving physical contact with
the patient can be classified under one of these four basic categories.
Trigger point therapy involves hypersensitive areas of the body known
as trigger points, tender points, or trigger zones. Neuromuscular therapy
involves nerve and muscle tissue, while connective tissue therapy involves
connective tissue and epithelial tissue. Range-of-motion stretching affects
trigger points and all four types of tissue found in the human body: nerve
tissue, muscle tissue, connective tissue, and epithelial tissue. Modalities and
exercise are supplements or adjuncts to soft-tissue therapy, but not
substitutes. Neither is fully effective in treating soft-tissue impairments
without manipulation.
Practitioners are responsible for sequencing manipulations to produce
the best possible outcomes. The normal sequence for treating soft-tissue
impairments is (1) trigger point therapy to control pain, (2) neuromuscular
therapy to inhibit spasm or facilitate weak muscles, (3) connective tissue
therapy to lengthen adaptively shortened tissues or break adhesions, and (4)
range-of-motion stretching to normalize muscle tonus, lengthen connective
tissue, and maximize range of motion. A competent practitioner should be
skilled in all four methods of manipulation and flexible enough to alter the
normal sequence based on feedback from the patient (symptoms), physical
evidence (signs), and clinical experience.

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Basic Principles
Soft-tissue therapy is based on a series of scientific principles that are

sometimes called axioms or laws. Though principles can make it easier to
simplify complex ideas, they do change. Pflüger's laws of Unilaterality,
Symmetry, Intensity, and Radiation are classical examples.
Written in 1853 by the German physiologist Edward Pflüger, these laws
were widely accepted for more than 50 years. Pflüger developed these laws
by observing frogs and reading clinical cases of spinal lesions in man.
When all four laws were shown to be invalid by Dr. Charles Sherrington in
1915, the laws became scientific history. This explains why none of these
laws are found in current medical textbooks or dictionaries.
The following principles, on the other hand, are still widely accepted by
medical science. These principles explain why forces applied to the human
body produce physical and physiological changes that are beneficial.
Twelve Principles of Soft-Tissue Therapy
(1) Arndt-Schultz law: Weak stimulus causes activity, moderate stimulus

increases activity, strong stimulus retards activity, and very strong
stimulus stops activity.
(2) Beevor's axiom: The brain knows nothing of individual muscles, but
thinks only in terms of movement.
(3) Creep: Deformation of viscoelastic materials when exposed to a slow,

constant, low-level force for a long time.
(4) Facilitation-Inhibition:
A. When a nerve impulse passes once through a set of neurons to the

exclusion of other neurons, it usually takes the same path in the future
and resistance to the impulse becomes less.
B. As opposites, facilitation encourages a process and inhibition restrains

a process (e.g., moderate tension quickly applied to a muscle facilitates
contraction; heavy tension slowly applied to a tendon inhibits
contraction).

114
(5) Head's law: If painful stimulus is applied to areas of low sensibility in
close central connection with areas of high sensibility, the pain may be
felt where sensibility is high.
(6) Hilton's law: The nerve trunk that supplies a joint also supplies the
muscles that move the joint and supplies the skin covering the insertions
of the muscles that move the joint.
(7) Hysteresis: The capacity of viscoelastic properties to lose energy when

subjected to stress or cyclic loading.
(8) Meltzer's law (Contrary Innervation): All living functions are

continually controlled by two opposing forces (e.g., inhibition and
facilitation).
(9) Sherrington's laws:
A. Every posterior spinal root nerve supplies one particular region on the
skin, though fibers from segments above and below can invade this
region.
B. Reciprocal Inhibition: when the agonist receives an impulse to

contract, the antagonist relaxes.
C. Irradiation: nerve impulses spread from a common center and

disperse beyond the normal path of conduction. Dispersion tends to
increase as the intensity of stimulus becomes greater.
(10) Sherrington's reflex: A muscle contracts in response to passive

longitudinal stretch (also called stretch reflex or myotatic reflex).
(11) Thixotropy: Certain gels liquefy when agitated and revert to gel
upon standing.
(12) Wolff's law: Bone and collagen fibers develop a structure most
suited to resist the forces acting upon them.

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TRIGGER POINT THERAPY
Trigger point therapy is a progression from one trigger point to another

until all remaining trigger points are neutralized. Though muscles normally
become progressively less sensitive with each treatment, trigger point
therapy should be continued until all trigger points are neutralized. When
myofascial trigger points are present, most of the following signs or
symptoms will be present:
• Points or zones that are tender when pressure is properly applied

• Distinct patterns of referred pain or radiated pain
• The presence of taut, indurated, or ropy bands within a muscle
• Tremors or fasciculations when pressure is properly applied
• Jump signs or local twitch responses when pressure is properly applied
• Abnormal weakness, shortness, tightness, or spasm within a muscle
As in most conditions treated by soft-tissue therapy, trigger points can be

identified in most cases of neck and shoulder pain. By definition, trigger
points are hyperirritable spots or zones that produce pain when stimulated by
pressure or compression. The basic cause for trigger points appears to be
mechanical stress that causes macroscopic or microscopic trauma to the
body. Trigger points can appear as nodules or palpable bands of tense,
indurated tissue. Though trigger points can occur in cutaneous, ligamentous,
or periosteal tissue, the majority of trigger points occur in muscle or fascia
(myofascial trigger points).
Trigger points can be palpated but not biopsied. From all indications
they are physiological or molecular, but not cellular. In many respects they
appear to be a collection of fluids and pain-producing chemicals such as
histamine, prostaglandins, and bradykinin.
The hardness of trigger points is probably caused by spasm, edema, or
changes in tissue viscosity. This would explain the rapid change from hard
to soft when trigger points are treated with digital pressure. Digital pressure
inhibits spasm by dispersing pain-producing chemicals and reduces edema
by compressing tissues with excessive fluid. The fact that trigger points
become soft and pliable directly after treatment makes it unlikely that
contracture, fibrous connective tissue, or fatty infiltration are the main
causes for palpable hardness.

116
Spasm and edema partially explain why trigger points are painful.
Spasm produces pain by causing ischemic damage and allowing noxious
metabolites such as lactic acid or adenosine diphosphate to accumulate,
while edema causes pain by causing secondary tissue damage because of
swelling and lowering the threshold to pain. By reducing spasm and edema,
trigger point therapy helps to reduce pain.
Though commonly called points, trigger points are more likely to occur
as zones than discrete points. Sometimes a large portion of a muscle or even
the entire muscle responds as a single trigger point. Treating several points
within a hypersensitive muscle will sometimes neutralize or relax the entire
muscle.
Trigger points normally produce deep aching pain as opposed to
superficial pain. When pressure stimulates trigger points, the patient may
recoil or experience autonomic responses such as vasoconstriction,
perspiration, or dizziness. Activation of trigger points can also cause severe
spasm, muscular weakness in surrounding muscles, involuntary tremors, and
difficult breathing (dyspnea).
Trigger points can produce changes in skin temperature as evidenced by
palpation or shown by thermograms. Temperatures higher than normal may
indicate active inflammation or rapid metabolism. Temperatures lower than
normal may indicate circulatory insufficiency or sluggish metabolism.
Spasm and edema are two of the main causes for circulatory failure in
soft tissue. High rates of metabolism and low rates of circulation produce
ischemic damage that corresponds with pain and weakness. When trigger
points are properly treated, temperatures normalize, circulation improves,
pain diminishes, and muscles become stronger. Though trigger points are
sometimes inactive for long periods of time, trigger points are not self-
limiting and complete neutralization without treatment is rare.
Locating trigger points depends on the identification of certain
characteristic signs. The most common signs are (1) pain when pressure is
correctly applied, (2) referred pain, (3) a jump response, (4) a local twitch
response, and (5) hardness or ropiness within a muscle.
The simplest test for trigger points is the appearance of pain when
pressure is correctly applied to sensitive tissues. Light pressure is normally
more discriminating than heavy pressure when locating trigger points. Light
pressure can be applied by using the fingers or thumb to compress or pinch
suspect tissues.

117
Trigger points are sometimes easier to locate when muscles are
stretched. If stretching a body part produces a dull pain, palpate the
stretched muscle for trigger points. If trigger points cannot be found, the
origin of pain is possibly the joint or joint capsule. Trigger points normally
produce intermittent pain as opposed to joint or capsular involvement that is
normally present day and night.
If a patient recoils while pressure is being applied, the jump sign is
positive. If the trigger point is in a muscle, slight pressure will sometimes
cause spontaneous contraction of the entire muscle. This contraction may or
may not be strong enough to move the affected body part. A positive jump
sign combined with simultaneous radiation of pain to other parts of the body
is strong evidence of trigger point involvement.
Cutaneous tissue responses and a positive twitch response can be used
for additional verification. If skin that is pinched and pulled away from the
body feels coarse, granular, and inelastic, the cutaneous tissue response is
positive. If taut bands of indurated tissue within the muscle respond
elastically by snapping back into place after plucking the tissues like a guitar
string, the twitch response is positive. The twitch response is caused by
muscle fibers contracting in response to transverse stretching.
The amount of pressure used during palpation is critical because too
much pressure can obscure physical signs. Responses produced by light
pressure are sometimes canceled by heavy pressure that restricts tissue
movement and deadens pain. Light pressure is also more sensitive to
differences in tissue consistency than heavy pressure. In some cases, heavy
pressure will change tissue consistency before differences in tissue
compliance can be felt. In trigger point therapy, it is not uncommon for
evaluation and treatment to occur simultaneously. Even light palpation will
at times neutralize trigger points.
Muscular weakness and resistance to passive stretch are consistent with
trigger point activity, but not definitive because spasm, contracture, and
various neurologic conditions produce similar conditions. If taut bands of
muscular tissue caused by trigger point involvement compress a nerve, the
physical signs are similar to those caused by fibrous or osseofibrous
entrapment. In both cases, nerve conductivity may be reduced and the
patient may experience weakness, aching pain, or paresthesia. If trigger
points are indirectly causing the entrapment, trigger point therapy and
stretching should eliminate the signs and symptoms of entrapment.

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Satellite trigger points are trigger points activated by another trigger
point in the same reference zone. When left untreated, satellite trigger
points can become primary trigger points and develop their own satellite
patterns of distribution. Untreated satellite trigger points can also reactivate
primary trigger points that became clinically quiescent after treatment.
Secondary trigger points develop in synergistic or antagonistic muscles
because of overload. When active trigger points weaken the agonist and
make it more resistant to passive stretch, synergistic muscles compensate for
weakness in the agonist by substitution, while antagonistic muscles work
harder than normal to stretch the agonist because of passive resistance. This
creates an overload that encourages secondary trigger points to form in
synergistic or antagonistic muscles. Primary, secondary, and satellite trigger
points should always be treated together.
Three factors seem to explain why trigger point therapy reduces pain:
X Digital pressure disperses pain-producing chemicals.
Y Digital pressure stimulates production of endogenous opioids.
Z Trigger points activated by pressure act as a counterirritant.
First, when digital pressure disperses blood and pain-producing

chemicals away from trigger points, surrounding tissues become ischemic,
as indicated by blanching or whiteness of the skin. A decrease in electrical
conductivity after treatment indicates that pressure has dissipated pain-
producing electrolytes such as potassium ions. Immediately upon release of
pressure, blood reacts to a lowered hydrostatic pressure by reentering
ischemic areas, as indicated by flushing or redness of the skin. The redness
itself is caused by hyperemia. The net effect of ischemic pressure and
reactive hyperemia is a lower concentration of pain-producing chemicals
such as histamine, bradykinin, and prostaglandins. Since pain-producing
chemicals stimulate nociceptors and cause pain, lowering their concentration
reduces pain.

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Second, trigger point therapy relieves pain by stimulating the body to
produce endogenous opioids such as endorphins that affect the limbic
system and brain stem, enkephalins that affect the central nervous system,
and dynorphins that are active in the brain and pituitary. Endogenous
opioids produce analgesia by binding to opiate receptor sites involved in
pain perception. Not only do opioids produce a type of analgesia similar to
that produced by opiates, but also the effects of both substances are canceled
by a drug called naloxone that prevents or reverses the effects of morphine
and other opioid drugs. When patients receive naloxone, the pain-relieving
effects of trigger point therapy and acupuncture are reduced.
Third, trigger point therapy relieves pain by acting as a counterirritant.

According to Melzack and Wall's gate-control theory of pain, the large
diameter A-beta nerve fibers that transmit superficial pain can inhibit the
small diameter A-delta and C nerve fibers that transmit deep pain. Since
most people find the superficial pain more tolerable than deep aching pain,
counterirritants such as trigger point therapy and chemical irritants are
sometimes useful. The most common chemical irritants are those that feel
hot or cold when applied to the skin. Some people refer to superficial pain
as a "good hurt."
Though digital pressure is normally effective in treating trigger points,

the amount of pressure needed varies from case to case. Moderate to heavy
pressure is normally more effective than light pressure. Trigger points in
large deep muscles or muscles that overlay soft-tissue often require more
pressure than trigger points in small superficial muscles or muscles that
overlay bone.
Compared with moderate to heavy pressure, light pressure is more likely
to cause facilitation than inhibition. When trigger points in muscles are
stimulated by light pressure, hypertonia and spasm increase as the muscle
attempts to guard itself against the insult. With light pressure, pain tends to
increase and then remain constant. This differs from moderate to heavy
pressure that normally causes the pain to intensify and then diminish as the
pressure continues and the muscles relax.
When moderate to heavy pressure is used, pressure should be applied
slowly and released slowly. Slowly applied pressure causes less trauma
because tissues have more time to absorb force and accommodate the
changes caused by pressure. Slowly released pressure lessens the recoil

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effect that normally occurs after pressure is removed. Both measures will
increase the patient's comfort and improve the probabilities that treatments
will have a longer-lasting effect. The principle of "easy on, easy off" applies
to both muscle testing and trigger point therapy.
The best method for gauging time is continuing pressure until the tissue
changes in consistency and softens or melts down. Feedback from the tissue
and the patient is a better way to estimate treatment time than arbitrary
numbers such as 20 or 60 seconds. In a large, indurated muscle such as the
gluteus maximus, changes in tissue consistency may take several minutes.
Regardless of duration, digital pressure should not be used in the presence of
inflammation as indicated by heat, redness, swelling, and pain.
The normal sequence is a sharp increase in pain followed by a gradual
decrease in pain. If the patient reports no reduction in pain after one minute
of pressure, stop the pressure and look for signs or symptoms that indicate
the trigger point being treated is not causing the pain. If the pain is being
referred from another trigger point, find and treat the origin of the pain. If
the pain is being caused by inflammation, acute trauma, or nerve
entrapment, trigger point therapy will not be effective.
If pain continues to decrease as pressure is being applied, continue the
pressure until the affected tissues become less resistant to pressure. Changes
in tissue consistency normally coincide with pain relief. If trigger point
therapy is successful, the patient will experience less pain and greater
mobility within minutes after treatment.
If patients cannot tolerate digital pressure, it may be possible to pinch the
skin directly over the trigger point and partially desensitize the area by reflex
effect. Once the skin is desensitized, trigger points are normally less
sensitive to pressure. It is not uncommon to find that skin pinching will
sometimes neutralize trigger points in a muscle without further treatment.
Trigger points can be treated with tissues stretched, at normal resting length,
or slack.
The final phase of trigger point therapy is stretching. If tissues are not
stretched to normal length, trigger points are likely to recur. Low-velocity
stretching helps to restore normal length without causing a stretch reflex or
tearing tissues. Though stretching will in some cases eliminate trigger
points without digital pressure, it can also irritate trigger points and cause
spasm. Stretching is normally safer and much less painful if trigger points
are neutralized first.

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It is not uncommon to treat identifiable trigger points during one session
and have the patient return for the next session with entirely different trigger
points. It is possible that elimination of primary points during the first
session makes secondary trigger points more discernible during the second
session. In any event, treatment should be continued until all trigger points
are eliminated as completely as possible. It is common to find great
improvement after one treatment.
When trigger points and spasm are widespread, the origin of pain is
difficult to localize. The origins of pain can be obscured by trigger point
zones that represent areas of referred pain. Autonomic, sensory, or motor
responses caused by trigger point activity can be observed anywhere within
the zone.
As spasm recedes, the origins of pain will be more apparent. Tissues
that caused the original involvement are often the last tissues that respond to
therapy. Though most soft-tissue impairments cannot be resolved until all
trigger points are neutralized, in many cases, comprehensive trigger point
therapy followed by range-of-motion stretching will give the patient
complete pain relief.
Summary of trigger point classifications:
• active trigger point: symptomatic with characteristic behavior

• associated trigger point: developed in response to another trigger point
• latent trigger point: symptomatic only when palpated or compressed
• primary trigger point: caused directly by dysfunction in a muscle
• satellite trigger point: caused by trigger points in a different structure
• secondary trigger point: caused by compensatory overload
Even if a tender point does not meet all of the above criteria, this is not
to say that trigger point techniques cannot be used to reduce pain or spasm.
It could be argued that any tender point that responds to trigger point therapy
deserves to be called a trigger point. Miscellaneous points that may respond
to trigger point therapy include: acupuncture points, acupressure points,
reflex points, motor points, stimulation points, neurovascular points, tender
points, and wobble points (osteopathy). It is not uncommon for two or more
different points to occupy the same space at the same time, such as trigger
points overlapping acupuncture points.

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Palpation is the most reliable way to identify the exact location of trigger
points within a zone. Though charts are sometimes useful when trying to
approximate where trigger points should occur, there is no substitute for
palpating the entire muscle, especially in the shoulder region where muscles
are relatively small compared with muscles in the lower extremity. To save
time, feedback from the patient, range-of-motion testing, and muscle testing
can be used to narrow the search parameters.
Palpation can be used to locate trigger points when a muscle, tendon, or
ligament is stationary, stretched or in motion. Any muscle that tests short,
weak, or swollen is a good candidate for trigger points. Most muscles that
are painful when stretched have trigger points.
The patient’s pathologic condition may also indicate where trigger points
can be found. In adhesive capsulitis (frozen shoulder), trigger points are
characteristically found in the subscapularis muscle. In scalenus anticus
syndrome (thoracic outlet syndrome), they are found in the scalene muscles.
Common sites for trigger point involvement in the shoulder:
• acromioclavicular joint
• bicipital tendon
• glenohumeral joint
• insertion of subscapularis at lesser tuberosity
• insertion of supraspinatus tendon at greater tuberosity
• sternoclavicular joint
• subdeltoid bursa
Bicipital Groove
A critical portion of the biceps tendon lies within the bicipital groove.
To locate the groove, use the first or second finger to palpate directly under
the inferior, anterior edge of the acromial process. If finger position is
correct, examiners will feel the bicipital groove move as the humerus is
internally or externally rotated.
For reference, the supraspinatus muscle inserts on the greater tuberosity,
which is lateral to the bicipital groove, and the subscapularis muscle inserts
on the lesser tuberosity, which is medial to the groove. For a quick bilateral
comparison, face the patient and use the thumbs to palpate bicipital grooves
and tendons on both sides of the body at the same time.

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Apex of Coracoid Process
The coracoid process on the upper anterior surface of the scapula

resembles a crow's beak. The apex of the coracoid process is often tender
when palpated because of the tendons that originate or insert on the coracoid
process. The coracobrachialis originates from the coracoid process and the
short head of the biceps and pectoralis minor insert on the apex.
Treating the apex of the coracoid process in the same way you would
treat a trigger point will often relax the coracobrachialis, biceps brachii, and
pectoralis minor and give patients tremendous relief. As a general rule,
digital pressure applied to a tendon produces a reflex effect that tends to
inhibit contraction and relax a muscle. Pressure on a tendon that inhibits
contraction and relaxes the attached muscle is called inhibitory pressure.
Sternal Trigger Points
Tender areas are frequently found in the intercostal spaces along the
sternum near the costosternal junctures. Although sternal trigger points may
in some way be related to neurovascular reflexes, treating these points with
trigger point therapy seems to relieve spasm in the pectoralis major and may
improve respiration. The origins for the pectoralis are sternum, upper six
ribs, and clavicle.
When sternal trigger points are present, a corresponding set of trigger
points may be present along the lateral borders of the thoracic spine. These
points should also be treated.
Sliding-Pressure
Sliding-pressure is used for treating taut, indurated zones or bands within

a muscle. Sliding movements can be linear, curved, circular, or spiral,
depending on where the zones or bands are located. Sliding-pressure starts
by treating a single point within a zone or band until the tissues “melt down”
or soften. Once this change occurs, the next step is sliding over to another
point within the zone or band without releasing pressure. Even though
patients may experience an increase in pain, the sliding movements are so
slow and gradual that some patients will not realize new points are being
treated. Sliding will be easier if lubrication is used to reduce friction.

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The key to using sliding-pressure is to move very slowly and wait for
tissues to soften slightly before moving in a new direction. This requires
much less force than pushing through hard or indurated tissue without
waiting for tissues in the direction of movement to melt down and become
more compliant to pressure. Though areas being treated will be blanched
(white) because of ischemic pressure, once pressure is released, these same
areas become flushed (red) because of reactive hyperemia.
When used properly without too much force or velocity, sliding-pressure
is more effective and less painful than treating zone or bands point by point.
If the first sweep through a zone or band fails to release tension, several
more sweeps can be made. Sliding-pressure is very effective when treating
the supraspinatus or infraspinatus muscle.
Sliding-pressure can be used for treating the upper fibers of the trapezius
by slowly pinching the fibers together at opposite ends of the ridge created
by the upper fibers and then working slowly toward the center. The fibers
can be pinched together using the first finger and thumb or the first and
second fingers and thumb. Using sliding-pressure that converges on the
belly of the muscle will also have a tendency to relax the muscle because of
proprioceptive inhibition.
Several sweeps are normally needed to relax the upper fibers. After
treating one side, use palpation to compare the treated side with the
untreated side. Differences in tissue consistency should be apparent if both
sides were equally hard before treatment. Because of reductions in tissue
tension or pain, patients will normally notice an immediate difference
between the treated and untreated side. Sliding-pressure should always be
followed by range-of-motion stretching.
One alternative to using sliding-pressure along the upper fibers of the
trapezius is using a pincer-like grip to apply digital pressure. With the
patient supine, place the fingers on the posterior surface of the upper fibers
and wrap the thumb around until it touches the anterior surface. Pressure is
applied by approximating the fingers and thumb to create a pincer-like
movement. Once the tissues between the fingers and thumb soften, pressure
can be reapplied somewhere else along the upper fibers if needed. It is
normally less painful to start with lateral fibers near the acromioclavicular
joint and work in a medial direction toward the neck. By standing over the
patient, body weight can be used to increase downward pressure. To reduce
mechanical tension on the upper fibers, horizontally adduct the patient’s
ipsilateral arm while digital pressure is being applied.

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When sliding pressure is used between the medial borders of the
paravertebrals and the lateral borders of the thoracic spine, the pressure
sometimes produces a state of sedation that resembles a drug-like state.
Some patients fall into deep sleep, while others report general relaxation and
feelings of well-being. Some patients become slightly incoherent when
aroused. One possible explanation is that sliding pressure along the spine
stimulates the release of endorphins or enkephalins.
This technique can be applied with the patient sitting and upper spine
flexed forward over a padded table or prone on a table with the arms down at
the sides. The direction for sliding-pressure is normally toward the head
(cephalad), although movement in the opposite direction also seems to work.
Lubricant is especially important when working along the spine to reduce
friction, and both sides of the spine can be treated at the same time. Sliding-
pressure applied between the lateral borders of the paravertebrals and the
medial (vertebral) border of the scapula neutralizes trigger points, but fails to
produce sedation.
When applied to a tendon, sliding-pressure produces inhibitory pressure
that encourages a muscle to relax. Sliding-pressure should start at the
musculotendinous juncture and move toward the bony attachment (away
from the belly of the muscle). Vibration applied to a tendon sometimes
produces a similar effect.
Trigger Point Locations
The following table shows trigger point locations within a muscle. Even
though the concentration of trigger points tends to be higher in some areas
than others, trigger points can occur almost anywhere in the muscle. Tables
and charts are no substitute for palpating the entire muscle. Though several
of the muscles listed refer pain past the shoulders and down the arms, the
focus will be on pain referred to the chest and shoulders. When trigger
points in the chest or shoulder are neutralized, pain-referral patterns that
extend below the chest or shoulder are neutralized.
Though trigger points can be activated by countless different movements
that cause the body to reach, lift, hold, push, pull, throw, or swing, the three
basic mechanical factors that activate trigger points are (1) stretching, (2)
compression, and (3) muscular contraction. Trigger points can also be
activated by changes in temperature (normally hot to cold), chemical
irritants, and psychological stress.

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22 BASIC MUSCLES: Trigger Points
Neck
1. SCALENUS ANTERIOR
A. Location: central portion of muscle
B. Referred pain: chest and shoulder girdle
2. SCALENUS MEDIUS
A. Location: inferior portion of muscle
3. SCALENUS POSTERIOR
A. Location: central portion of muscle
Shoulder and Back
4. BICEPS BRACHII
A. Location: bicipital tendon and proximal to insertion on elbow
B. Referred pain: scapula
5. CORACOBRACHIALIS
A. Location: proximal to apex of coracoid process
B. Referred pain: anterior of shoulder
6. DELTOID
A. Location: anterior and posterior borders
B. Referred pain: locally within the muscle
7. INFRASPINATUS
A. Location: superior and medial border
B. Referred pain: anterior deltoid and shoulder joint
8. LATISSIMUS DORSI
A. Location: proximal to humeral insertion and lower lateral border
B. Referred pain: posterior shoulder

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9. LEVATOR SCAPULAE
A. Location: inferior portion of muscle
B. Referred pain: medial border of scapula and posterior shoulder joint

A. Location: central portion and medial or lateral borders
B. Referred pain: chest

A. Location: lateral border
B. Referred pain: front of chest and shoulder
12. RHOMBOID MAJOR

B. Referred pain: superior and medial border of scapula
13. RHOMBOID MINOR

B. Referred pain: superior and medial border of scapula

A. Location: anterior border over 5th and 6th ribs
B. Referred pain: lateral and anterior chest
15. SERRATUS POSTERIOR SUPERIOR

A. Location: lateral border of muscle
B. Referred pain: upper portion of scapula and back of shoulder
16. SUBCLAVIUS
A. Location: medial border
B. Referred pain: front of shoulder and down front of arm
17. SUBSCAPULARIS
A. Location: axillary border and superior angle
B. Referred pain: posterior deltoid and scapula

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18. SUPRASPINATUS
A. Location: insertion on humerus and medial or lateral borders
B. Referred pain: mid-deltoid region of shoulder
19. TERES MAJOR

A. Location: medial and lateral border
B. Referred pain: posterior deltoid
20. TERES MINOR

A. Location: central portion
B. Referred pain: inferior border of deltoid
21. TRAPEZIUS
A. Location: superior and lateral border
B. Referred pain: interscapular region
22. TRICEPS BRACHII

A. Location: central portion
B. Referred pain: suprascapular region

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NEUROMUSCULAR THERAPY
Since joints without muscle spasm are normally painless, one of the first
objectives of soft-tissue therapy is reducing spasm. After muscles have been
treated for trigger points, neuromuscular therapy is the most effective way to
relieve spasm.
Neuromuscular therapy is characterized by manual techniques that
inhibit or facilitate muscle fibers. The primary tissues acted upon are nerve
and muscle tissue. Inhibition encourages elongation and facilitation
encourages shortening. Extensibility is the ability of muscle fibers to
lengthen and contractility is the ability of muscle fibers to shorten. Muscles
can lengthen to 50 percent more than resting length and shorten to 50
percent less than resting length. Inhibition lengthens hypertonic muscles by
relaxation and facilitation shortens hypotonic muscles by contraction.
Neuromuscular techniques strengthen a muscle by eliminating factors
that cause weakness. This allows the patient to attain the greatest amount of
strength possible without using exercise to increase potential strength. By
using inhibition and facilitation to balance opposing muscles in terms of
length and strength, neuromuscular therapy restores function and prepares
the patient for the next stage of therapy, which is normally exercise.
Inhibition encourages relaxation by decreasing reflex activity. The two
basic principles are (1) deactivating any facilitating mechanism tends to
inhibit facilitated muscles, and (2) deactivating any inhibitory mechanism
tends to facilitate inhibited muscles. It should be noted however, that even if
inhibitory mechanisms are deactivated, a muscle will not contract unless the
existing level of stimulation is greater than the absolute threshold. By
definition, the absolute threshold is the least amount of stimulus that causes
a muscle to contract.
As the opposite of inhibition, facilitation stimulates reflex activity that
causes contraction. When stimulation exceeds the absolute threshold,
muscles contract and produce force. If the force of contraction is greater
than resistance, muscles contract isotonically and body parts move. If the
force of contraction is not greater than resistance, muscles contract
isometrically and body parts remain stationary.
The immediate goal of neuromuscular therapy is muscular balance. This
means balancing and normalizing opposing muscles or muscle groups in
terms of length and strength. The effects of muscular imbalance are pain
and limited range of motion. Pain results when muscles and joints are
abnormally stressed by asymmetrical forces. Limited range of motion is

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caused by agonistic muscles that are too weak to initiate movement or
antagonistic muscles that are too short to allow movement.
Although pathologic joints can produce pain and limit range of motion,
dislocations, loose bodies, and menisci tears are less common than muscular
imbalance. Even when joints are implicated, muscular imbalance may have
caused the joint to become dysfunctional.
First, asymmetrical forces acting on the joint may cause one side of the
joint to wear more rapidly than the other and become irritated. Second,
when both muscle pairs are too short, excessive tension reduces joint space
and limits range of motion. If restoring muscular balance normalizes the
joint, muscles are more likely than joints to be the cause of disability.
Meltzer's law of contrary innervation states that all living functions are
controlled by two opposing forces. This law relates to the Chinese concept
of yin-yang, which states that opposing and complementary forces control
all of nature. In neuromuscular therapy the opposing forces are inhibition
and facilitation. Inhibition restricts and facilitation promotes.
Muscles move joints by facilitating the agonist and inhibiting the
antagonist. They restrict joint movement by facilitating the agonist and
partially facilitating the antagonist. Muscles stabilize a joint or maintain
posture by facilitating both the agonist and the antagonist (cocontraction).
Facilitating both the agonist and the antagonist prevents movement.
When using neuromuscular techniques to balance muscles, inhibition
and facilitation have the following uses:
X Inhibition:
• Lengthen hypertonic muscles.

• Strengthen weak muscles.
Y Facilitation:
• Shorten stretched muscles.

• Strengthen weak muscles.
The standard protocol for using neuromuscular therapy to balance

muscles or muscle groups is:

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• Evaluate length by range-of-motion testing
• Use inhibition to lengthen restricted tissues
• Evaluate strength by muscle testing
• Use facilitation to strengthen weak muscles
• Evaluate length first and then strength
• If needed, treat again with inhibition or facilitation
The underlying principle that applies to almost any method of soft-tissue

therapy is lengthen first, strengthen second. Rarely would it be advisable to
strengthen a muscle with limited range of motion. Even if the muscle
becomes stronger, any rapid movement that encourages the muscle to
achieve its normal length could result in tearing.
If one muscle is too short, the opposing muscle is too long, and both
muscles are weak, lengthen the short muscle first. This will decrease tension
on the longer muscle and help it assume normal length.
If opposing muscles both test long and weak, which is not likely,
strengthen both muscles first and monitor length to ensure that all muscles
shorten at the same rate.
If a muscle has limited range of motion but correcting the problem
requires lengthy treatment, lengthening and strengthening can be combined
to avoid deconditioning the muscle and possible atrophy. The first half of
the treatment should focus on lengthening restricted muscles and the second
half of the treatment on strengthening weak muscles.
KEY POINT: LENGTHEN FIRST, STRENGTHEN SECOND
Neuromuscular therapy deals with muscle function more than trigger

point therapy, connective tissue therapy, or range-of-motion stretching. The
three main neurologic conditions that contribute to loss of muscle function
are (1) hypotonia or loss of tone, (2) decrease of contractile strength, and (3)
changes in the activation or recruitment patterns. All three of these
conditions relate directly to proprioceptors referred to as muscle spindles and
Golgi tendon organs.
Tone is caused by continuous partial contractions of a muscle when a
person is conscious. Tonic contractions will increase a muscle's resistance
to passive elongation or stretch and allow the body to maintain posture.
Without tonus, muscles become flaccid and the body cannot maintain
posture. With too much tonus, the body becomes spastic and movements are

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stiff and awkward. Muscle spindles and Golgi tendon organs regulate
muscle tone at the reflex level.
The contractile strength of a muscle is determined by the number of
muscle fibers contracting within the muscle. The number of muscle fibers
contracting depends on the intensity and frequency of stimulation. Factors
that prevent stimulation from developing or that inhibit existing stimulation
decrease contractile force. Activation of muscle spindles facilitates
contraction while activation of Golgi tendon organs inhibits contraction.
When a body part moves normally in terms of strength, range of motion,
or coordination, muscles appear to follow the same sequence of activation or
recruitment each time the body part moves. Synergists and stabilizers
contract to enhance the agonist, and opposing muscles relax to free the
agonist. The common factors that often change recruitment patterns and
cause faulty movement because of weakness, tightness, or incoordination
include: (1) pain or proprioceptive inhibition that weakens a synergist or
stabilizer, and (2) proprioceptive facilitation that prevents opposing muscles
from relaxing normally or causes abnormal contractions.
Changes in activation or recruitment patterns can occur with or without
pain. Even though pain inhibition is a common cause for limited mobility in
neck and shoulder patients, pain does not always precede proprioceptive
inhibition. Stretch weakness, caused by long-term stretching and continuous
activation of the Golgi tendon organs, can weaken a muscle without causing
pain. This principle can be applied to static stretching.
Inhibition caused by changes in joint space may or may not be painful.
If muscle tension decreases joint space enough to irritate the joint, weakness
may occur without significant pain because of proprioceptive inhibition from
mechanoreceptors. In other cases, decreasing joint space will cause pain and
swelling in addition to weakness and loss of function.
Proprioceptors respond to stimulus such as pressure, equilibrium, or
stretch and give information concerning movements or positions of the body.
In terms of neuromuscular therapy, the single most important proprioceptor
is the muscle spindle, which measures how rapidly and to what extent
muscles change in length.
The highest concentration of muscle spindle cells is found in the belly of
the muscle. Depending on which way the belly of the muscle is compressed,
muscle spindle cells can either facilitate or inhibit contraction. Facilitation
can be used without inhibition if muscles test weak but are able to achieve
full range of motion when tested passively.

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Facilitation
Activation of Stretch Reflex: Muscle spindles react to sudden

stretching by a reflex contraction called stretch reflex, myotatic reflex, or
Sherrington’s reflex. What is commonly called a tendon reflex is actually
caused by activating a stretch reflex. Sharply striking the patellar tendon
rapidly stretches the quadriceps muscle and causes a "knee jerk."
Muscle Spindle Cell Facilitation: The safest way to facilitate a skeletal
muscle is by grasping the belly of a muscle near the center and using
divergent force to stretch the muscle in opposite directions away from the
belly. The direction of pull is parallel to the muscle and the rate of pull is
faster than pulling to lengthen a muscle, but not fast enough to cause pain.
Weak muscles will normally test stronger after facilitation. Other ways to
facilitate a muscle include plucking, tapping, or rapidly shaking the muscle.
Repeated Contractions: If a muscle is capable of reaching full range of
motion, repeated contractions against progressive resistance will facilitate
and strengthen the muscle. Facilitation reverses the effects of inhibition and
helps muscles achieve their normal strength. Only exercise can strengthen a
muscle beyond its normal strength.
Inhibition
Spindle cell inhibition, post-isometric relaxation, and reciprocal

inhibition are three ways to inhibit a muscle. Since most new patients begin
with limited range of motion, inhibition is normally used before facilitation.
Muscle Spindle Cell Inhibition
Compressing the belly of a muscle toward the center relaxes intrafusal

fibers in the muscle spindle cells and causes reflex inhibition. This can be
done by grasping the muscle near the musculotendinous junctures and using
convergent force to compress the belly of the muscle until both hands meet
near the center.
The direction of push is parallel to the muscle and the rate of push is
slow enough for tissues to thin out, melt down, or dissolve as the fingers
move toward the center of the belly. The need for anything more than
moderate force indicates that movements are too fast. Hypertonic muscle
will normally relax and test weak after spindle cell inhibition.

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Post-Isometric Relaxation (Inhibition)
Fatigue can be used to inhibit contraction. If hypertonic muscles

contract isometrically for about ten seconds and then relax, the refractory
period that follows contraction decreases neurologic efficiency and the
muscle becomes more relaxed. During the refractory period, muscles
become hypotonic and easier to stretch. The technique of stretching a
muscle after isometric contraction is called post-isometric relaxation.
The degree of contraction used in post-isometric relaxation should not be
excessive. If the contraction is too strong, accessory muscles may come into
play and possibly irritate the muscles that need to relax. Moderate force will
discourage other muscles from being recruited.
If post-isometric relaxation is used, breathing cycles should correspond
correctly with periods of exertion and relaxation. The best method is having
the patient exhale during exertion, inhale during the first stage of relaxation,
and exhale during the second stage of relaxation as muscles are being
stretched. The muscle sequence is contract, relax, and be stretched.
1. Patient exhales and contracts (practitioner applies counterforce).

2. Patient inhales and relaxes (practitioner stops counterforce).
3. Patient exhales and deepens relaxation (practitioner stretches muscle).
Reciprocal Inhibition
When muscles work in pairs, facilitation of the agonist causes reciprocal

inhibition of the antagonist. As the agonist contracts, the antagonist relaxes
to allow stretching by the agonist. If the antagonist fails to relax, the agonist
may test weak despite normal strength. Coordinated movement is possible
because one muscle relaxes when the opposing muscle contracts. Anything
less than total relaxation of the antagonist restricts shortening of the agonist.
If a flexor muscle is hypertonic, contracting the extensor muscles will
cause the flexor muscles to relax. If a flexor muscle such as the biceps
brachii is in spasm, contracting the opposing extensor muscle, the triceps
brachii, should cause the biceps brachii to relax. The more completely the
extensor muscles relax, the easier it is for the flexor muscle to generate
movement. After relaxing a muscle using reciprocal inhibition, the final step
is stretching the muscle to prolong the effects.

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CONNECTIVE TISSUE THERAPY

Connective tissues support and connect other tissues. Compared with
most other types of tissue, connective tissues have very few cells. The bulk
of connective tissue is composed of intercellular substance or matrix that
gives each type of connective tissue its own particular properties. With the
exception of cartilage, most connective tissues are highly vascular.
Examples of dense fibrous connective tissue are tendons, ligaments,
aponeuroses, deep fascia, and dermis. Other forms of connective tissue are
bone, adipose tissue, and cartilage.
Connective tissues have three main components: cells, fibers, and
matrix or ground substance. The most common mechanical properties of all
connective tissues except bone are elasticity and plasticity. Elastic materials
yield to stress and then resume normal shape. Plastic materials yield to
stress and remain permanently deformed.
Immobilization after an injury increases the density of collagen and the
frequency of cross-bridging between fibers. The cross-bridging makes
collagen fibers more resistant to passive stretch and less mobile. Stretching
and exercise increase flexibility by reducing the number of cross-links.
The ability of ground substance to hold water allows for diffusion of
metabolites between capillaries and cells. The presence of hyaluronic acid
in ground substance reduces friction by increasing water retention.
Hyaluronic acid molecules form large random chains that are filled with
water. Proteoglycans such as hyaluronic acid give tissues elasticity and
resistance to compression.
Excessive water retention produces higher tissue tension and greater
resistance to pressure. Tissue tension is a palpable sign that frequently
occurs during inflammation or after trauma. High degrees of edema reduce
mobility by increasing tissue tension and causing spasm.
Reduced water retention, on the other hand, increases friction between
fibers and causes cross-bridging. Friction and cross-bridging irritate tissues
and reduce mobility. Without water retention, tissues lose elasticity.
Three principles explain the mechanics behind connective tissue therapy:
1 Thixotropy
2 Hysteresis
3 Creep

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Thixotropy
The "gel-sol" theory proposes that aqueous solutions within connective

tissues become highly viscous and produce a sticky gelatinous or glue-like
substance that limits tissue mobility. Because of thixotropy, connective
tissue manipulation is thought to restore free movement by liquefying and
dispersing viscous gel.
According to the concept of thixotropy, gels liquefy when agitated by
any force that puts energy into the system. The energy input from
connective tissue manipulation (compression, tension, or shear) is friction
and heat. Changing the ground substance in connective tissue from gel to
liquid increases tissue mobility by decreasing viscosity and tissue tension.
Viscosity is a stickiness that causes tissues to bind with each other and
tissue tension stimulates reflex activity that facilitates muscle contraction.
Reducing viscosity allows tissues to slide freely over each other and
decreasing tissue tension causes reflex inhibition and relaxation of
underlying muscles. Because of thixotropy, tissue may give the appearance
of thinning out or melting down after manipulation.
Hysteresis
Collagen is considered viscoelastic because of two main properties:

viscosity and elasticity. According to the concept of hysteresis, cyclic
loading and stress cause viscoelastic materials to soften and change shape
when energy is lost in the form of internal friction or heat. Cyclic loading
refers to cycles of loading and unloading such as pull-and-release or stretch-
and-release. Even with low magnitudes of tension, viscoelastic materials
will lengthen progressively because cyclical loading and unloading reduce
the energy that binds tissues together.
Hysteresis plays the greatest role when the same connective tissues are
treated multiple times by a sequence of slow stretch and slow release. After
repeated bouts of stretch-and-release, the tissues will deform plastically or
rupture. Applied carefully, the principle of hysteresis can be used to stretch
tissues and break adhesions without causing excessive tissue damage.
Because of hysteresis, cyclic loading can relieve tissue congestion by
improving vascular flow and lymphatic drainage.

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Creep
Creep is defined as deformation of viscoelastic materials when exposed

to a slow, constant, low-level force for long periods of time. When
individuals stand on their feet all day long, they become shorter by the end
of the day because of creep. Even though body weight does not change, the
steady load from body weight causes deformation of intervertebral disks and
subsequent loss of height. The principle of creep applies directly to
myofascial release as found in osteopathy. The application of heat tends to
accelerate lengthening because of creep in muscles and tendons.
After the patient is properly positioned for access and comfort, tissues
are stretched carefully until solid resistance is felt. Small degrees of
constant tension are then applied steadily until the tissues start to relax and
lengthen. The point at which tissues start to lengthen is sometimes referred
to as a meltdown or release. Constant tension is continued until the tissues
are fully elongated or no further stretching is needed. The keys to using
creep effectively are (1) minimize force and (2) maximize time.
Once a tissue is fully elongated, the body part should be held in this
position long enough for the tissue to fully relax. This can be done without
using additional force. According to biomechanics, when deformation is
held constant, internal stresses within a structure will decrease with time.
Holding tissues in position long enough for total relaxation to occur will
increase the probability that changes in tissue length will be permanent.
Adhesions
Range-of-motion stretching and topical stretching will sometimes break

the adhesions that form during wound healing. Adhesions are abnormal
fibrous bands that connect tissues that are normally separate.
Adhesions that form between the dermis and superficial fascia in
response to inflammation or trauma are fairly common. Depending on how
the attachments form, adhesions may or may not be symptomatic.
Adhesions that irritate nerves or restrict mobility are symptomatic.
Adhesion and skin restrictions frequently occur over the scapulas. If
adhesions prevent the dermis from sliding freely over the top of underlying
structures, limited loss of mobility and pain are possible. When adhesions
break, relief from pain is almost immediate and the skin starts to move freely
again.

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Skin Rolling
Skin rolling is a particular sequence of forces (tension, compression, and

then bending) applied to skin and subcutaneous fascia. The reasons for
using skin rolling are threefold: (1) Break adhesion, (2) Increase tissue
mobility, and (3) Improve fluid dynamics. Skin rolling can be used very
effectively over the scapulas because superficial tissues tend to be loose
when the arms are horizontally adducted with the elbows flexed.
Using both hands together, the balls of each thumb and forefingers of
each hand are used to pull skin away from the patient's body. A single skin
fold is then created by using the tips of each forefinger to bend the patient's
skin over the tips of each thumb.
Once created, the skin fold is rolled forward in a wave-like motion by
using the tips of each thumb to push the skin fold forward while the finger
tips of each hand pull new skin over the top of the fold. If adhesions are
detected in areas of the body where the skin is normally loose, skin rolling
will normally generate enough tension to break the adhesion. If the adhesion
is not released by normal skin rolling, use tension with additional bending to
pull the skin farther away from the body.
Skin rolling is used to release fibrous adhesions that connect skin and
superficial fascia to deep fascia. If the skin is too sensitive for this
technique, gently pinching the skin until the thickness of the skin fold
decreases will often reduce tenderness enough to allow skin rolling. Skin
rolling should be followed by long stroking movements to disperse fluids
and sedate muscles.
Skin Pulling
Even though the low back region seems to be more sensitive to skin
rolling than the shoulder region, some patients will find skin rolling painful
and difficult to tolerate. For these patients, pulling loose skin directly away
from the body can be used in place of skin rolling. Adducting the arm and
flexing the elbow behind the back will loosen the skin by creating ripples
and skin folds.
The process of skin pulling begins by using minimum force to pull loose
tissue away from the body and holding the position long enough for tissues
to relax (creep). The pressure generated by holding the tissues in place will
cause some degree of tissue thinning (thixotropy). The process is repeated
several times to maximize tissue mobility (hysteresis). For breaking
adhesions, parallel stretching techniques are not as effective as skin rolling.

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Once tissue mobility is restored, local and range-of-motion stretching
will help to preserve mobility. Adhesions and restrictions are less likely to
re-form if shoulder tissues are mobilized on a regular basis. Without
continuous passive mobilization, adhesions and restrictions have a tendency
to recur in the same place.
Cross-Fiber Friction
Cross-fiber friction combines digital pressure with perpendicular force to

produce local friction as fingers or thumbs move back-and-forth across a
tissue such as a tendon or ligament. Normal treatments are 10 to 20 minutes,
twice a week. Because of the need for deep friction, lubricants are not used.
Another name for cross-fiber friction is transverse friction.
Linear force can be produced in two ways: digital stroking over the top
of a stationary body part or stationary digital pressure over the top of a
moving body part. Cross-fiber friction is applied to the subscapularis tendon
by stroking back and forth with the thumb, whereas cross-fiber friction is
applied to the biceps tendon along the bicipital groove by holding the fingers
stationary and rotating the humerus back and forth.
The justifications for cross-fiber friction are (1) breaks adhesions, (2)
reduces cross-links between connective tissue fibers, and (3) aligns scar
tissue parallel to lines of stress in accordance to Wolff’s law. Cross-fiber
friction produces hyperemia that promotes healing and reduces pain by
dispersing pain-producing chemicals, acting as a counterirritant, and
stimulating the body to produce endorphins.
With the exception of breaking adhesions or helping to align scar tissue,
the effects produced by trigger point therapy and cross-fiber friction are very
similar. Since trigger point therapy is faster and less painful than cross-fiber
friction, the main justification for using cross-fiber friction relates to
adhesions and scar tissues.
What cross fiber-friction does more effectively than trigger point therapy
is shear the cross-links between collagen fibers that form during the early
stages of wound healing. Where trigger point therapy tends to focus on
muscles and fascia, cross-fiber friction is normally applied to tendons or
ligaments.

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Since trigger point therapy combined with range-of-motion stretching
seems to be more effective in preventing adhesions and helping to align scar
tissue than cross-fiber friction, the best time for using cross-fiber friction is
during the early stages of an injury, when even passive mobilization is not
recommended because of pain, spasm, or tissue disruption.
During the early stages of wound healing, friction should be light and
superficial to avoid disrupting properly placed scar tissue. Though some
degree of passive mobilization should begin as early as possible, applying
cross-fiber friction directly over a lesion may improve wound healing.
Trigger point therapy can also be used in combination with cross-fiber
friction. When used together, trigger point therapy desensitizes hyperesthetic
(sensitive) tissues and cross-fiber friction moves and stretches connective
tissue. Ice can be used before trigger-point therapy or cross-fiber friction to
induce analgesia.
Though cross-fiber friction can produce some degree of anesthesia, the
process is normally more painful than trigger point therapy. To induce
anesthesia, the treatment should begin with light pressure and limited
movement and progress to stronger pressure and deeper movement. Instead of
anesthesia, many patients report pain intensifies during the initial minutes of
treatment and continues without abatement until cross-friction is stopped.
The recommended frequency for cross-fiber friction, like most forms of
soft-tissue manipulation, is twice a week. This allows enough time for tissues
to recover between treatments. Cross-fiber friction should not be used for
more than about two weeks. After two weeks, other forms of manipulation
such as trigger point therapy and neuromuscular therapy are normally more
effective.
Cross-fiber friction tends to be ineffective when used alone. Before
treating a tendon, the muscle attached to the tendon should be treated with
trigger point therapy or neuromuscular therapy to reduce pain and spasm.
Cross-fiber friction is not recommended for the belly of a muscle. After cross-
fiber friction, partial or complete range-of-motion stretching will help to
relieve muscle tension on the tendon if tissues are stable enough to permit
stretching. Icing contact points for about 20 minutes after manipulation
reduces the possibility of therapy-induced (iatrogenic) pain or swelling.
To avoid digital fatigue when using cross-fiber friction, practitioners can
use fingers from the same or opposite hand to reinforce the fingers that are
doing the actual stroking. (Finger is defined as any one of five digits on the
hand, including the thumb.)

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To avoid excessive joint compression, digits should not be elevated more
than about 30 degrees above the surface of the patient’s skin. Below 45
degrees, more force is directed horizontally than vertically. At 45 degrees,
vertical and horizontal forces are equal. At angles greater than 45 degrees, but
less than 90 degrees, vertical force is greater than horizontal force. At 90
degrees, all force is directed downward with no horizontal component. The
higher the angle, the greater the downward pressure on the patient and the
greater the pressure on digital joints.
Whether finger-shaped objects made of wood, metal, plastic, or rubber
with various types of handles can be used in place of fingers or thumbs when
administering cross-fiber friction or trigger point therapy is a matter of
personal choice. The advantage of using devices such as a “T-bar” is being
able to deliver high degrees of pressure without causing digital stress. The
disadvantage is losing the sensitivity of human touch.
Since the need for high degrees of force in soft-tissue therapy are minimal
if pressure is applied slowly and correctly, the disadvantages of using special
devices to administer cross-fiber friction or trigger point therapy may outweigh
the advantages. Despite the popular trend in therapy that favors replacing
manual medicine with machines, there is still no substitute for the sensitivity
of human touch.
The four main tendons treatable by cross-fiber friction are
1. supraspinatus tendon
2. infraspinatus tendon
3. subscapularis tendon
4. biceps tendon
Supraspinatus tendon: Lesions on the supraspinatus tendons cause pain

during the first 0 to 5 degrees of resisted abduction. If resisted abduction is
painful and passive abduction produces a painful arc, the tear is probably at the
distal end of the tendon and lesions can be exposed by adducting the arm and
placing the forearm behind the back. The supraspinatus tendon will be just
lateral to the bicipital groove.
Pain present during resisted abduction and full overhead abduction would
also indicate the lesion is at the distal end of the tendon. Unlike a painful arc,
which is caused by pressure on the supraspinatus tendon as the greater
tuberosity and acromion process approximate during abduction, pain during
overhead abduction is caused by pressure on the supraspinatus tendon as the
greater tuberosity and glenoid rim approximate.

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If resisted abduction is painful and passive abduction does not produce a
painful arc or painful overhead abduction, the tear is probably at the proximal
end of the tendon and the lesion can be exposed by abducting the arm to 90
degrees. At 90 degrees, the origin and insertion approximate and allow the
supraspinatus to shorten because of natural elasticity. As the muscle shortens,
the supraspinatus tendon is pulled to the proximal side of the acromion
process, where it can be reached between the spine of the scapula and the
clavicle.
Because of limited space, instead of applying cross-fiber friction by
moving the fingers back and forth across the tendon, the fingers are held
stationary and the forearm is rotated back and forth to produce cross-fiber
friction.
Infraspinatus tendon: Lesions on the infraspinatus tendon cause pain

during resisted lateral rotation. Painful resisted lateral rotation with a painful
arc or pain during overhead elevation indicates the lesion is in the distal end of
the tendon. Painful resisted lateral rotation without a painful arc or painful
overhead abduction indicates the lesion is in the proximal end of the tendon.
Either way, the treatment position is identical: from a sitting position, flex the
arms and elbows to 90 degrees, press the forearms together, lean slightly
forward, and place the elbows on the thighs. The tension created by this
position will force the infraspinatus insertion (greater tubercle) out from under
the acromion process.
Subscapularis tendon: Lesions on the subscapularis tendon cause pain

during resisted medial rotation. The most common site for lesions is where the
subscapularis tendon inserts on the lesser tubercle of the humerus. The
subscapularis insertion is just medial to the bicipital groove and feels hard
because it lies directly over bone. The easiest way to apply cross-fiber friction
on the subscapularis tendon is (1) place the thumb directly over the lesion, (2)
wrap the fingers around the upper arm, (3) apply counterforce with the fingers
to increase pressure on the tendon, and (4) move the thumb vertically up and
down along the insertion.

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Biceps tendon: Lesions on the biceps tendon cause pain during resisted
elbow flexion and resisted supination of the hand. Though lesions can occur
anywhere along the tendons biceps brachii, cross-fiber friction is most
effective where the tendon from the long head emerges from the bicipital
groove. Once the lesion is located, cross-fiber friction is applied by medially
and laterally rotating the humerus back and forth, using the forearm flexed to
90 degrees as a lever.
Cross-fiber friction is not recommended for the short head insertion of the
biceps tendon on the coracoid process. Trigger point therapy applied to the
apex of the coracoid process would be more effective than cross fiber friction.
Before cross-fiber friction is used on the biceps tendon, the muscle should be
carefully checked for spasm. If spasm is present, trigger point therapy or
neuromuscular therapy should be used to relieve tension on the muscle.
Chronic tension in biceps brachii will increase the risk of lesions by increasing
pressure where tendons cross bony structures.
Ligaments
In addition to the tendons, cross-fiber friction can be applied to ligaments

such as the acromioclavicular ligament and the coracoacromial ligament.
Ligaments are normally treated by deep stroking perpendicular to the ligament
while body parts connected by the ligament remain stationary.

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RANGE-OF-MOTION STRETCHING
Manual stretching is the fourth and final method of manipulation. The

soft tissues affected by range-of-motion (ROM) stretching include muscles,
fascia, tendons, ligaments, and joint capsules. Besides improving range of
motion, stretching improves muscle response by stimulating proprioceptors
in muscle and mechanoreceptors in joints.
The reason for therapeutic range-of-motion stretching is to help joints
achieve or maintain a normal range of motion by lengthening pathologically
shortened tissues. A joint is biomechanically most efficient when a joint is
neither too stable nor too mobile. Increasing a joint's range of motion
beyond normal decreases stability, while decreasing a joint's range of motion
to less than normal decreases mobility.
Because of human touch and the ability to measure the direction and
magnitude of resistance, manual stretching is normally safer and more
effective than mechanical stretching by machine. Patients have the option of
verbally or physically resisting a stretch when stretching is done by the
dexterous use of the hands and not by machine.
Although range of motion stretching is normally safe because patients
have the ability to stop the tension at any time, caution must be used not to
overstress healing tissues. Stress applied early during the wound-healing
process (1) promotes remodeling and proper alignment of scar tissue, (2)
increases lubrication that allows glide between fibers, and (3) improves
flexibility by reducing cross-links and breaking adhesions. Excessive stress,
on the other hand, can disrupt tissues and slow the healing process.
As a rule, stretching is not beneficial until the acute stage of an injury is
clearly over, as indicated by the absence of swelling or subcutaneous
bleeding. Since production of scar tissue is greatest during the first three
weeks of wound healing, stretching to improve mobility should begin
shortly after the acute stage is over. Restriction patterns in the shoulder can
begin within 24 hours after immobility.
Low-force, long-duration stretching is normally more effective during
the wound-healing process than high-force, short-duration stretching. Since
high-force, long-lever techniques are seldom needed, hand placement is
normally close to the tissue being stretched. Care should be taken to avoid
triggering reflex spasm, a stretch reflex, or inflammation.

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Mechanics of Stretching
There are many varieties of stretching and each method seems to have its
own merits. A competent practitioner should be familiar with at least three
types of preliminary manipulation and two types of basic stretching.
Preliminary manipulations prepare tissue for stretching by reducing pain
or spasm. The first manipulation uses trigger point therapy to relieve pain,
while the second and third manipulations use neuromuscular therapy to
reduce spasm.
X Trigger point therapy can be used to relieve pain that limits range of
motion by physically or psychologically inhibiting movement. If
trigger points are located that appear to be causing limited range of
motion, ice or ischemic pressure can be used to neutralize the trigger
points in preparation for stretching.
Y Muscle spindle cell inhibition is most effective when spasm in a limb

such as an arm or leg restricts movement. By using convergent force
toward the belly of the muscle, muscle spindle cells inhibit contraction
and make the muscle less resistant to stretch.
Z Post-isometric relaxation, as discussed under neuromuscular therapy,

is a second way to inhibit contraction. Though post-isometric
relaxation is sometimes presented as a stretching technique, it is
technically a neuromuscular technique that prepares the muscle for
stretching by inhibiting contraction.
In severe cases of pain or spasm, heating or cooling modalities should be

used in conjunction with soft-tissue manipulation to relieve pain or relax
spasm. Beside reciprocal inhibition or counterstrain inhibition, other
methods of neuromuscular therapy that relax muscles and reduce spasm are
(1) rocking motions applied slowly and rhythmically to the body, (2)
mechanical or manual vibration, and (3) gently stroking, pinching, or
tapping skin that overlies irritated muscles.

146
Before discussing the different methods of stretching, there are five
principles that are common to both methods:
1. Stretching should not be attempted until the patient is physically and

psychologically relaxed. Techniques for relaxation include music, light
massage, supportive conversation, and deep breathing.
2. Therapeutic stretching should be slow and progressive. Rapid or

ballistic stretching increases the risk of tissue damage and may trigger a
stretch reflex.
3. Stretching applied with low force and a long duration is more likely to
produce permanent increases in length than stretching applied with high
force and a short duration.
4. High-velocity, low-amplitude stretching produces a less permanent

increase in tissue length than low-velocity, high-amplitude stretching.
5. Heat increases tissue extensibility; cold decreases tissue extensibility.
The two basic methods of stretching are based on two different

principles: (1) multiple-repetition stretching is based on hysteresis and (2)
single-repetition stretching is based on creep.
Multiple-Repetition Stretching: This method is based on hysteresis

and uses multiple repetitions of low-force and short-duration stretching to
produce permanent changes in tissue length. Viscoelastic materials such as
connective tissue lose energy and become more pliable when subjected to
multiple cycles of stress and relaxation. The tissues are stretched slowly at
the beginning of each movement and released slowly at the end of each
movement. The average number of repetitions is normally three to twelve
and the average duration for each repetition is five to fifteen seconds.
Single-Repetition Stretching: This method is based on creep and uses

low and continuous force with long duration to permanently lengthen tissue.
The tension is held constant until the internal stresses dissipate and the
tissues relax. The average duration for single-repetition stretching is fifteen
seconds to several minutes. Since the body part is stationary for a longer
period of time, heat is more effective with single-repetition stretching than
with multiple-repetition stretching.

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Single-repetition stretching can be used to stretch two body parts at the
same time. With patients supine and their knees extended, practitioners can
lift one ankle with each hand and then step back until the arms are fully
extended. Traction is then applied to both legs at the same time by stepping
away from the patient. This stretch can also be done with the patient on the
floor. Practitioners should be careful not to hyperextend their own backs
when stepping away from the patient to apply traction.
This technique helps to realign soft tissues and bring the iliac crest on
the high side into alignment with the iliac crest on the low side. It also
stretches soft-tissue structures surrounding the head of the femur, which at
times become tight enough to reduce joint space and irritate the hip joint.
As with all stretches, caution should be taken not to injure any joints that
are located within the line of pull. Though traction, in general, seems to
improve mobility of joints, any complaints of ankle, knee, or hip joint
weakness would contraindicate leg traction.
Glenohumeral Joint Stretch
The most basic form of stretching used in shoulder therapy is

manipulation of the head of the humerus against the glenoid fossa. The
purpose of stretching is to increase joint space and freedom of movement.
The head of the humerus is moved in five directions: superior, inferior,
posterior, anterior, and lateral. The up, down, backward, and forward
movements are accomplished by facing the patient and holding the right
scapula down with your left hand on top of the acromioclavicular joint while
the right hand holds the upper shaft of the right humerus and mobilizes the
arm. Hand positions are reversed when dealing with the opposite shoulder.
Standing close to the patient will make it easier to stabilize the shoulder and
manipulate the humerus.
To combine all four motions into a single movement, follow a diamond
pattern and go from superior to posterior, posterior to inferior, inferior to
anterior, and anterior back to superior. The top position should be the
starting and ending point for each pattern.
The lateral movement requires distracting or pulling the head of the
humerus away from the glenoid fossa. This can be done most easily by
standing behind the patient and placing your left forearm under the patient’s
right arm pit and then using the right hand to adduct the distal shaft of the
patient’s right humerus. By using the left forearm as a fulcrum and the shaft
of the humerus as a lever, small degrees of gentle force can be used to pull
the head of the humerus slightly away from the glenoid fossa.

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After excluding pain and spasm, pathologically shortened connective
tissue is the main cause for immobility in the shoulder joint, whereas
pathologically lengthened connective tissue is the main cause of instability.
Movements to lengthen short tissues and strengthen muscles that stretch the
tissues are used to improve mobility. Movements to strengthen muscles that
prevent excessive movement in the joint are used to improve stability.
Overhead Stretch
To execute an overhead stretch, the arms of the patient should be fully

extended overhead and parallel. If the patient is on a table, the angle
between the arms and table should be about 30 degrees or less, depending on
the patient’s comfort.
With the palms of the patient facing each other, practitioners should use
a wrist hold on the patient in the same way someone would hold the handles
of a wheelbarrow: firmly but not too tight. Practitioners can apply tension
by leaning back slowly until there is no slack and then holding the stretch for
several minutes. Even with low, steady tension, most practitioners will feel
restricted tissues release and lengthen as the stretch continues. To avoid
using arm strength, practitioners should keep their elbows fully extended and
their arms parallel to those of the patient.
This stretch can also be done from a sitting position with patients on a
mat. The sitting position has two advantages. First, most practitioners find
it easier to apply tension from a sitting position than from a standing
position. If a standing position is used, care should be taken to keep the
back straight or slightly flexed while tension is being applied. Second, when
the patient is on a table, there is always a danger of falling. In terms of
safety, working from a mat is much safer.
If therapy is successful, the patient will be able to stand more erect and
will find that touching the wall with both hands from an overhead position is
less difficult. Many patients find the overhead stretch extremely relaxing
and pleasant. If the blockage is bony or joint disease is present, patients may
find that overhead stretching is painful. Overhead stretching should be
discontinued if patients report serious pain in the wrist, elbow, or shoulder
joint. Some patients will feel the effects of overhead stretching all the way
down to the lower back.

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Cross-Over Stretch
Though cross-over stretching is normally used as a local stretch to

improve tissue mobility, it can also be used for range-of-motion stretching
when applied between the neck and shoulder. To apply the cross-over
stretch with practitioner standing and patient seated, cross the forearms
several inches above the wrists and simultaneously push on: (1) the lateral
surface of the neck and (2) the superior surface of the shoulder. This push-
push movement will increase the distance between the neck and shoulder.
When the forearms are crossed, the contact point becomes a pivot point
or fulcrum between the forearms. Leaning down, while keeping the
forearms crossed, will increase the distance between neck and shoulder by
causing the hands to move apart. As the hands separate, the pivot point will
have a tendency to slide upward toward the elbows.
The cross-over stretch can be used to separate (abduct) the scapulas.
With the patient prone, stand at the patient’s head (cephalic) and lean over
the scapulas to apply the cross-over stretch. The hands will be pushing
against the medial (vertebral) borders of the scapulas.
Force-Couple Stretch
A force couple can be defined as two equal, opposite, and parallel forces
separated by distance and applied simultaneously to an object to produce
rotation. If hands are placed on opposite sides of a steering wheel and one
hand pushes up while the other hand pulls down, the steering wheel rotates
because the hands have created a force couple. The same push-up-and pull-
down principle applies to force-couple stretching.
If hands are separated by distance and placed on the body with one hand
pushing up while the other hand pulls down, tissues, and possibly underlying
structures, will twist or rotate. In physics, forces that produce rotary motion
are called torque and the process of twisting or rotating is called torsion.
In scapulohumeral rhythm, the scapula rotates upward when the upper
trapezius pulls up and serratus anterior pulls down. Since muscles can pull
(contract) but not push, force couples created by internal forces are based on
pulling movements only (pull-pull). When force couples are created by
external forces, push-pull or push-push movements may be easier to use and
biomechanically more efficient than pull-pull movements.

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By placing one hand on the scapula where the upper trapezius attaches and
the other hand on the scapula where serratus anterior attaches, a force couple
can be used to mobilize the shoulder and tissues above the scapula by pushing
up with one hand and pulling down with the other. This technique works best
when the patient is prone and the arms are touching the sides of the body.
Force-couple stretching applied to loose tissues over the scapulas will
sometimes break adhesions or release scar tissue faster than skin rolling.
Once the tissues are mobilized, the scapula can be rotated by abducting the
arm directly overhead and then returning the arm to its original position along
the side of the body. While the arm is overhead, the shoulder joint can be
stretched by gently pulling the arm. The patient’s hand should be palm down
and the elbow fully extended.
Just as all muscles that cross a joint should be treated when movement
around the joint is deficient, all muscles involved in a force couple should be
treated when rotation of a bone is deficient. Force-couple stretches are
normally followed by range-of-motion stretches.
Range-of-Motion Stretching Fundamentals
The following table at the end of this section covers range-of-motion

stretching for the 22 basic muscles of the neck and shoulder region. Since
range-of-motion stretching is normally done in a direction opposite to the
muscle’s normal action, opposing action is listed in place of normal action.
For a muscle such as triceps brachii, if the normal action is extension of
the elbow, the opposing action is flexion of the elbow. The most basic form
of stretching is moving a muscle in a direction opposite its normal action.
To stretch the triceps brachii, whose normal action is forearm extension, the
elbow should be flexed, not extended.
To achieve even greater stretch, some muscles must be positioned in
ways that take up the slack before the opposing action is used to stretch the
muscle. Even though the biceps brachii are stretched to their normal range
of motion when the elbow is fully extended, extending the humerus at the
same time the elbow is fully extended will stretch the biceps brachii even
more.
This principle of taking up slack to "over-stretch" a muscle can be
demonstrated by following a three-step procedure. While step one is a
normal stretch, steps two and three increase intermuscular tension on the
biceps brachii by progressively taking up slack.

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(1) Abduct the arm to 90 degrees, fully extend the elbow, and supinate the
hand (thumb pointing up). At this point the biceps brachii are fully stretched
in terms of elbow extension. Palpating the biceps brachii will indicate the
amount of tension on the muscle. (Palpation can frequently be used to
indicate intramuscular tension during stretching.)
(2) Starting with the arm in a downward position, abduct the humerus to
90 degrees, fully extend the humerus, and then fully extend the elbow with
the hand supinated. Palpation should reveal that using humeral extension to
take up slack before extending the elbow increases intramuscular tension on
biceps brachii.
(3) Repeat step two above, but this time stand perpendicular to a door and
place the supinated hand on the inside surface of the doorway. Keeping the
hand in place, it should be possible to increase humeral extension by rotating
the body away from the doorway. This should increase intramuscular
tension of the biceps brachii even more.
Regarding terminology, target muscle refers to the muscle being

stretched and target side refers to the same side of the body (ipsilateral) as
the target muscle. Since most of the stretches affect muscles on only one
side of the body (unilateral), as opposed to affecting muscles on both sides
of the body (bilateral), all but a few stretches will have two sides: the target
side and the opposite side. Horizontal adduction refers to any movement
that crosses in front of the chest, even if the movement deviates as much as
45 degrees from the horizontal plane.
All forces will be expressed as either push or pull in a given direction.
Range-of-motion stretching is normally most effective when the patient’s
body is relaxed and manual forces used are slow, progressive, and gentle. In
static stretching, tissues are stretched to a certain length and then held in
position for a given period of time before release. The time for holding a
muscle in place can range from 5 seconds to several minutes, depending on
the method of stretching being used. For stretching neck and shoulder
muscles, 12 seconds is a good starting point for static stretching.
In ballistic stretching, muscles are stretched by bouncing movements
with no hold at the end of the movement. Because of the stretch reflex that
causes muscles to contract when suddenly stretched, ballistic stretching has a
tendency to increase resistance to active stretch and cause muscle soreness.

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When bouncing movements force muscles to contract and lengthen at
almost the same time, the end result can be tissue damage and pain. Because
static stretching is easier to control, less likely to trigger a stretch reflex, and
safer than ballistic stretching, static stretching is preferred over ballistic
stretching for increasing range of motion.
Though most forms of range-of-motion stretching rely on manual force,
different ways to supplement manual force include (1) mechanical stretching
devices, (2) passive or active assistance by the patient, and (3) gravity.
Mechanical stretching devices that are sometimes used by athletes to
increase range of motion are not recommended for therapy because
machines, unlike human touch, cannot measure changes in tissue tension or
respond to complaints of pain by the patient.
One variant of mechanical stretching that can be useful is having the
patient actively stretch a muscle as far as possible and then use a wall, table,
chair, or some other device to hold the body part in place until the muscle
being stretched relaxes. The patient must have the ability to safely
discontinue the stretch at any time if pain becomes too severe. This
approach works well when stretching exercises are done at home.
Passive or active assisted stretching by the patient can be useful when
spasm, contracture, or pain inhibition are too severe. In passive-assisted
stretching, outside manual force stretches the muscle to the greatest length
possible within safe and normal limits and then the patient uses active
contraction by opposing muscles to hold the stretch for about 12 seconds.
This helps to strengthen antagonistic muscles that may be weak because of
chronic stretching (stretch weakness).
Passive-assisted stretching is very effective when the active stretch
follows a passive post-isometric relaxation stretch. The sequence would be
(1) the patient contracts and then relaxes the target muscle, (2) the
practitioner stretches the target muscle, and (3) the patient uses antagonistic
muscles to stretch the target muscle.
When active-assisted stretching is used, the patient actively contracts
antagonistic muscles during the entire stretch. This not only strengthens
antagonistic muscles, but also helps to improve neurologic efficiency and
coordination.
Gravity is an excellent way to supplement manual force when the body
part can be positioned is such a way that gravity works to stretch the target
muscle. Light manual force working with gravity, or gravity alone, are

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excellent ways to produce a slow, progressive stretch. Adding weights to
supplement gravity is normally not recommended. Joints that tolerate the
normal weight of a body part may not tolerate the weight of a body part with
added weight.
On rare occasions, stretching a muscle against active resistance by the
patient can be used to lengthen a muscle severely shortened by contracture.
To perform isolytic stretching, the patient actively contracts the muscle
being stretched while the practitioner uses sufficient force to overcome the
patient’s resistance and lengthen the muscle. On the positive side, isolytic
stretching increases muscle length by breaking down and stretching fibrotic
tissues. On the negative side, the risk of tearing a muscle, rupturing a
tendon, or pulling a tendon away from its bony insertion makes isolytic
stretching far more dangerous than other forms of stretching that are
normally just as effective.
Though most directions of movement will be standard for the shoulder
region, such as flexion or extension, push forward or pull back may be used
to clarify the meaning. In addition to supinated, pronated, or neutral (semi-
supinated and semi-pronated) position for the hand, a thumb direction may
also be given. The directions used for a thumb are up, down, forward
(anterior), back (posterior), in (medial), and out (lateral).
When distal and proximal arm or forearm are used: (1) proximal arm
refers to the arm just below the glenohumeral joint, (2) distal arm refers to
the arm just above the elbow, (3) proximal forearm refers to the forearm just
below the elbow, and (4) distal forearm refers to the forearm just above the
wrist. These locations are based on anatomic position.
The practitioner’s position is given in general terms such as in front of
patient, behind patient, or to side of patient (shoulders perpendicular or
parallel to patient) on the target (affected) side or the opposite side. These
positions can be varied to meet the needs of the practitioner if slightly
different positions are more comfortable. The same applies to patient
positions. Many stretches done from a sitting position can also be done from
a prone or supine position, and vice versa. Practitioners who understand the
principles behind range-of-motion stretching should be flexible enough to
understand that body positions can be changed if needed.
Stabilization indicates a need to keep a body part stationary such as the
shoulder. Although stationary implies no movement in any direction,
shoulders are normally held stationary to prevent elevation or depression. If
body weight is sufficient to hold the patient in place during stretching,
stabilization may not be required.

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Although not stabilization in the classical sense of fixation, a second
type of stabilization involves keeping a body part horizontal or vertical even
though the body part is being moved in one or more directions. The body
part involved is normally the arm or forearm.
Like muscle testing where any single test normally activates more than
one muscle, in range-of-motion stretching, any single stretch normally
lengthens more than one muscle. Even though the pectoralis minor stretch
focuses more on pectoralis minor than pectoralis major, pectoral major is
also stretched. In several cases, the same stretch can be used for two
different muscles with about equal effectiveness.
When used properly, breathing can effectively facilitate stretching.
Deep abdominal breathing produces general relaxation, and the normal
sequence for breathing and stretching is (1) apply tension (stretch) when the
patient exhales and (2) hold or release tension when the patient inhales.
In addition to this pattern, there are two special cases where breathing
can be used specifically to stretch certain muscles: the patient can (1) breath
in during a rhomboid stretch to expand the chest or (2) breath out during the
serratus posterior superior test to depress the ribs.
Barring special cases, breathing should be slow, smooth, rhythmic, and
regular. The tendency some patients have to hold their breath in response to
pain or apprehension of pain should be strongly discouraged. Several
practice stretches that incorporate stretching with proper breathing are
normally more effective than verbal instruction alone.
Contraindications to Stretching
• severe pain or discomfort

• acute tissue damage or hemorrhage
• inflammation, infection, or swelling around joints
• instability or hypermobility
• recent fractures or dislocations
• degenerative bone or joint disease

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22 BASIC MUSCLES: ROM Stretching
Neck
1. SCALENUS ANTERIOR (difficult to isolate)
RANGE OF MOTION
Normal Action: lateral neck flexion

Normal Range: 45 degrees (angle of mandible may touch shoulder)
Opposing Action: lateral neck flexion (opposite direction)
Opposing Range: 45 degrees (angle of mandible may touch shoulder)
STRETCH
Patient: supine with arms at sides and head rotated toward target muscle
Practitioner: standing at head and facing feet
Stabilization: hold shoulder stationary on target side
Force: push lateral neck in direction of lateral flexion (away from target
muscle)
2. SCALENUS MEDIUS (difficult to isolate)
RANGE OF MOTION

STRETCH
Patient: supine with arms at side, head in neutral position

Practitioner: at head and facing feet
muscle)

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3. SCALENUS POSTERIOR (difficult to isolate)
RANGE OF MOTION

STRETCH
Patient: supine with arms at side, head rotated away from target muscle
Practitioner: at head and facing feet
muscle)
Shoulder and Back
4. BICEPS BRACHII
RANGE OF MOTION
Normal Action: flexion (forearm)

Normal Range: 0-150 degrees
Opposing Action: extension (forearm)
Opposing Range: 0 degrees (without hyperextension)
STRETCH
Patient: sitting with humerus abducted to 90 degrees, elbow fully

extended, and the hand supinated (thumb up)
Practitioner: standing behind patient
Stabilization: hold elbow on target side vertically in place
Force: pull distal end of forearm in direction of extension
Option for practitioner: once the elbow is fully extended, extend the
arm at the shoulder for greater stretch

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5. CORACOBRACHIALIS (same as stretch for anterior deltoid)
RANGE OF MOTION
Normal Action: flexion

Opposing Action: extension (humerus)
Opposing Range: 0-60 degrees
STRETCH
Patient: sitting with arm abducted to 90 degrees and laterally rotated as

far as possible
Practitioner: standing behind patient and off to side
Stabilization: none
Force: simultaneously pull against elbow with one hand and distal end
of forearm with the other hand in direction of humeral extension
6. DELTOID
Anterior fibers (same as stretch for coracobrachialis)
RANGE OF MOTION
Normal Action: flexion

Opposing Action: extension (humerus)
STRETCH

far as possible
Stabilization: none
Force: simultaneously pull against elbow with one hand and distal end
of forearm with the other hand in direction of humeral extension

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Middle fibers
RANGE OF MOTION
Normal Action: abduction (humerus)

Opposing Action: adduction (humerus)
STRETCH
Patient: prone with arm fully adducted behind back and elbow fully
flexed
Practitioner: standing on side of target muscle
Stabilization: none
Force: push against distal end of arm (above elbow) with one hand and
pull up on proximal end of forearm (below elbow) with other hand in
direction of humeral adduction
Posterior fibers
RANGE OF MOTION
Normal Action: horizontal abduction (humerus)

Opposing Action: horizontal adduction (humerus)
STRETCH
Patient: sitting with arm horizontally abducted across the chest, forearm
flexed around neck, and hand pronated (palm down)
Practitioner: standing almost directly behind patient
Stabilization: none
Force: pull back on patient’s distal forearm with one hand while
pushing forward on patient’s shoulder with opposite hand in the
direction of horizontal adduction

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7. INFRASPINATUS
RANGE OF MOTION
Normal Action: lateral rotation (humerus)

Opposing Action: medial rotation (humerus)
STRETCH
Patient: sitting with arm horizontally adducted across chest, elbow

flexed with forearm crossing over ribs below axilla, and hand
pronated (palm down)
Stabilization: none
Force: simultaneously pull on distal forearm with one hand and push on
posterior surface of target shoulder with other hand to move humerus
in direction of horizontal adduction and internal rotation
8. LATISSIMUS DORSI (same as for teres major)
RANGE OF MOTION
Normal Action: adduction (humerus)

Opposing Action: abduction (humerus)
STRETCH
Patient: sitting with arm fully abducted overhead, elbow flexed to 90

degrees, and hand pronated (thumb down)
Stabilization: hold shoulder on opposite side stationary, keep forearm
on target side horizontal
Force: pull distal end of forearm with one hand and push elbow with
other hand in direction of humeral abduction

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9. LEVATOR SCAPULAE (same as trapezius, upper fibers)
RANGE OF MOTION
Normal Action: draws head back

Opposing Action: draws head forward
STRETCH
Patient: sitting with arms hanging down at sides and head flexed
forward and rotated away from target side about 45 to 50 degrees
(head should be rotated, but comfortable)
Practitioner: standing perpendicular to patient on target side
Stabilization: hold shoulder on target side stationary
Force: push head forward in the direction of the patient’s nose (rostral)
RANGE OF MOTION
Normal Action: flexion and medial rotation (humerus)

Normal Range: A. flexion: 0-180 degrees
B. medial rotation: 0-70 degrees
Opposing Action: extension and lateral rotation (humerus)
Normal Range: A. extension: 0-60 degrees
B. lateral rotation: 0-90 degrees
STRETCH
Patient: sitting with arm abducted to 90 degrees, elbow flexed to 90

degrees, and hand pronated (thumb pointing in)
Practitioner: standing parallel to side of patient facing target muscle
Stabilization: hold opposite shoulder stationary
Force: push elbow in direction of horizontal abduction (horizontal
extension) and lateral rotation

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RANGE OF MOTION
Normal Action: depresses and draws scapula forward

Normal Range: no accepted standard
Opposing Action: elevates and retracts scapula
STRETCH

far as possible
Stabilization: none
Force: pull elbow and wrist in direction of humeral abduction and
horizontal abduction to elevate and retract scapula
12. RHOMBOID MAJOR (same as rhomboid minor)
RANGE OF MOTION
Normal Action: adducts scapulas

Opposing Action: abducts scapulas
STRETCH
Patient: seated with arms horizontally abducted and crossed in front of

chest, forearms slightly flexed, hands pronated (thumbs pointing
back), and upper spine flexed forward
Practitioner: standing in front of patient
Stabilization: none
Force: simultaneously push patient’s elbows in direction of horizontal
abduction, thus causing scapular abduction
Option for patient: breathe in during the stretch to expand the chest and
increase scapular abduction

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13. RHOMBOID MINOR (same as rhomboid major)
RANGE OF MOTION

STRETCH
Patient: seated with arms horizontally abducted and crossed in front of

chest, forearms slightly flexed, hands pronated (thumbs pointing
back), and upper spine flexed forward
Stabilization: none
RANGE OF MOTION
Normal Action: abducts scapulas

Opposing Action: adducts scapulas
STRETCH
Patient: sitting with arms horizontally adducted and forearms vertical

Stabilization: none
Force: pull the patient’s distal arms in the direction of horizontal
adduction

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15. SERRATUS POSTERIOR SUPERIOR
RANGE OF MOTION
Normal Action: elevate ribs

Opposing Action: depress ribs
STRETCH
Patient: sitting with arm along side, elbow slightly flexed, supinated
hand (thumb pointing forward) grasping posterior surface of the distal
thigh, and upper spine flexed forward
Stabilization: practitioner holds shoulder on target side stationary,
patient uses grasp on distal thigh to reinforce stabilization of shoulder
Force: press lateral neck forward and away from target side as the
patient exhales deeply
16. SUBCLAVIUS
RANGE OF MOTION
Normal Action: depresses lateral end of clavicle

Opposing Action: elevates lateral end of clavicle
Normal range: 0-30 degrees
STRETCH
Patient: supine with target shoulder at edge of table, arm abducted

overhead, elbow fully extended, and hand pronated (thumb pointing
in)
Practitioner: standing at head of patient
Stabilization: none
Force: simultaneously pull elbow and distal forearm in direction of
humeral abduction and extension to elevate lateral end of clavicle
Option for practitioner: gravity can be used to assist with extension and
lateral rotation of humerus

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17. SUBSCAPULARIS
RANGE OF MOTION
Normal Action: medial rotation (humerus)

Opposing Action: lateral rotation (humerus)
STRETCH
Patient: supine with target shoulder at edge of table, arm abducted to 90

degrees, elbow flexed to 90 degrees, and hand pronated (thumb
pointing in)
Practitioner: standing parallel to side of patient facing target muscle
Stabilization: none
Force: simultaneously push distal forearm and elbow in direction of
humeral extension and lateral rotation
Option for practitioner: gravity can be used to assist with extension and
lateral rotation of humerus
18. SUPRASPINATUS
RANGE OF MOTION
Normal Action: abduction and lateral rotation (humerus)

Normal Range: A. abduction 180 degrees
B. lateral rotation: 0-90 degrees
Opposing Action: adduction and medial rotation (humerus)

Normal Range: A: adduction: 0-75 degrees
B. medial rotation: 0-70 degrees
STRETCH
Patient: sitting with arm extended and adducted; forearm flexed to 90

degrees, and hand supinated (thumb up)
Stabilization: keep forearm on target side horizontal

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Force: pull distal forearm with one hand and elbow with other hand in
direction of humeral adduction and medial rotation
19. TERES MAJOR (same as for latissimus dorsi)
RANGE OF MOTION
Normal Action: adduction (humerus)

Opposing Action: abduction (humerus)
STRETCH
Patient: sitting with arm fully abducted overhead, elbow flexed to 90

degrees, and hand pronated (thumb down)
Stabilization: hold shoulder on opposite side stationary, keep forearm
on target side horizontal
Force: pull distal end of forearm with one hand and push elbow with
other hand in direction of humeral abduction
20. TERES MINOR
RANGE OF MOTION
Normal Action: lateral rotation (humerus)

Opposing Action: medial rotation (humerus)
STRETCH
Patient: sitting with arm fully abducted overhead and medially rotated
with elbow flexed and forearm behind the head
Stabilization: hold distal end of forearm on target side stationary

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Force: pull distal end of arm (below elbow) slightly back with one hand
while at the same time pushing the distal end of the forearm slightly
forward in direction of medial rotation
21. TRAPEZIUS
Upper Fibers (same as levator scapulae)
RANGE OF MOTION
Normal Action: draws head back

Opposing Action: draws head forward
STRETCH
Patient: sitting with arms hanging down at sides and head flexed
forward and rotated away from target side about 45 to 50 degrees
(head should be rotated, but comfortable)
Practitioner: standing perpendicular to patient on target side
Force: push head forward in the direction of the patient’s nose (rostral)
Middle and Lower Fibers
RANGE OF MOTION


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STRETCH
Patient: sitting with arms crossed over in front of chest, elbows slightly
flexed, and the upper spine flexed forward
Stabilization: keep the forearms approximately horizontal
22. TRICEPS BRACHII
RANGE OF MOTION
Normal Action: extension (forearm)

Normal Range: 0 degrees (without hyperextension)
Opposing Action: flexion (forearm)
STRETCH
Patient: sitting with arm flexed to 90 degrees, elbow fully flexed, and
hand supinated (thumb pointing out)
Practitioner: standing perpendicular to target side
Force: push patient's elbow in direction of humeral flexion

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CHAPTER SUMMARY
TWELVE PRINCIPLES OF SOFT-TISSUE THERAPY
• Arndt-Schultz law
• Beevor's axiom
• Creep
• Facilitation-Inhibition
• Head's law
• Hilton's law
• Hysteresis
• Meltzer's law
• Sherrington's law
• Sherrington's reflex
• Thixotropy
• Wolff's law
SIX SIGNS OR SYMPTOMS OF TRIGGER POINTS
• Points or zones that are tender when pressure is properly applied

• Distinct patterns of referred pain or radiated pain
• The presence of taut, indurated, or ropy bands within a muscle
• Tremors or fasciculations when pressure is properly applied
• Jump signs or local twitch responses when pressure is properly applied
• Abnormal weakness, shortness, tightness, or spasm within a muscle
THREE WAYS TRIGGER POINT THERAPY REDUCES PAIN
• Digital pressure disperses pain-producing chemicals

• Digital pressure stimulates production of endogenous opioids
• Trigger points activated by pressure act as counterirritants
BASIC GOALS OF NEUROMUSCULAR THERAPY
• Inhibition: lengthen hypertonic muscles and strengthen weak muscles

• Facilitation: shorten stretched muscles and strengthen weak muscles

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STANDARD PROTOCOL FOR NEUROMUSCULAR THERAPY
• Evaluate range of motion

• Use inhibition to lengthen short tissues
• Evaluate strength
• Use facilitation to strengthen weak muscles
• Test for length and strength
• Treat again if necessary
THREE WAYS TO FACILITATE A MUSCLE
• Activation of stretch reflex

• Muscle spindle cell facilitation
• Repeated contractions
THREE WAYS TO INHIBIT A MUSCLE
• Muscle spindle cell inhibition

• Post-isometric relaxation
• Reciprocal inhibition
THREE PRINCIPLES OF CONNECTIVE TISSUE THERAPY
• Thixotropy
• Hysteresis
• Creep
TWO BASIC METHODS OF STRETCHING
• Multiple-repetition stretching based on hysteresis

• Single-repetition stretching based on creep
CONTRAINDICATIONS TO STRETCHING
• Bony obstructions that limit the range of motion

• Inflammation, infection, hemorrhage, or swelling around joints
• Instability or hypermobility
• Recent fractures or dislocations

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EXERCISE
Adequate range of motion is a prerequisite for active exercise. If range

of motion is severely limited, modalities and manipulation should be used to
improve range of motion before starting an exercise program. Once range of
motion is complete, or nearly complete, active exercises can be used to
preserve, or slightly improve, the existing range of motion. Controlled
progressive exercise strengthen tendons and ligaments as well as muscles.
The exercises presented below are designed for home use by patients
with a history of soft-tissue impairments. The home exercises can be used
between treatments or after therapy has been discontinued. Long-term
supervised exercise programs are seldom required unless patients lack the
ability or self-discipline to be responsible for their health. Patients who are
able to exercise at home without direct supervision should be encouraged to
do so, the advantage being long-term independence as opposed to long-term
dependency. If problems do arise, patients should be advised to discontinue
the exercise program immediately and seek professional help.
Most home exercise programs are a combination of stretching and
strengthening movements. The stretching movements increase tissue length
and the strengthening movements increase strength and endurance.
Stretching and strengthening exercises together seem to produce greater
gains in flexibility than stretching exercises alone. Exercises, in general,
improve circulation and stop the deconditioning process caused by
inactivity.
Though stretching exercises can be done four to eight times per day,
seven days per week, if pain is tolerable, once or twice a day, three to four
times per week, is normally sufficient. These numbers can be reduced if too
much stretching is aggravating the patient’s condition. For rehabilitation
stretching, 3 to 12 repetitions of the same movement are normally sufficient.
Patients should be warned not to continue any movement that causes
extreme pain, stiffness, perspiration, or fatigue.
Strengthening exercises should be done once a day, two or three times
per week. Once again, extreme pain, stiffness, perspiration or fatigue may
indicate the frequency is too high. The recommended frequency for
strengthening exercises is lower than for stretching exercises because more
time is needed between sessions for tissue repair and growth.

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Where stretching exercises can be used to increase mobility in
hypomobile joints, strengthening exercises can be used to increase stability
in hypermobile joints. Strengthening exercises can be very important since
the shoulder favors mobility over stability and most support structures are
soft tissue as opposed to bony tissue. If a muscle is weak because of
proprioceptive inhibition or pain inhibition, neuromuscular therapy that
facilitates the muscle or trigger point therapy that relieves pain will help to
restore normal strength. If the muscle is hypotonic and stretched because of
proprioceptive inhibition, neuromuscular therapy that facilitates the muscle
will increase tonus and help to restore normal length.
Contrary to popular belief, strengthening a muscle does not necessarily
shorten a muscle, as sometimes implied by the term “muscle bound.”
Preventing a muscle from achieving its normal range of motion over an
extended period of time, with or without strengthening exercise, will have a
tendency to shorten a muscle. The reasons for decreases in muscle length
include contractures, adhesions, and reductions in the number of sarcomeres.
Only in rare cases would increases in muscle size because of exercise
(adaptive hypertrophy) reduce muscle length or range of motion.
Since most therapeutic exercise programs combine stretching and
strengthening into a single program, once a day, two or three times per week
is normally adequate to maintain shoulder fitness. The purpose of
therapeutic exercise is to restore normal function; programs for aerobic
conditioning, athletic competition, or weight loss are much different.
The exercises here are designed to improve movement by stretching or
strengthening groups of muscles, not individual movements. Very few
movements in the body occur because of single muscles acting alone. Most
movements in the shoulder involve a complex interaction between prime
movers, secondary movers, antagonists, and synergists.
This is not to say that therapeutic exercise programs cannot be strenuous.
Competitive athletes suffering from a shoulder disability may find the
shoulder exercises presented below even more strenuous than normal
workouts because of pain, spasm, weakness, contractures, and psychological
stress.
When following a therapeutic exercise program, patients need to be clear
on two points. First, more is not always better. Exercise during the acute
stages of an injury or too much exercise while tissues are healing may cause
more damage to the body than not exercising at all. Second, though
platitudes such as “no pain, no gain” are potentially dangerous, avoiding

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pain can also be dangerous. Therapeutic exercises are often painful and
patients must learn to tolerate at least some degree of pain. Patients with
sub-acute injuries who stop exercising completely because of pain can
expect short-term immobility and long-term disability.
Since moderation is just as difficult for some patients as motivation is
for others, patients exercising at home should be given a list of warning
signs that may indicate problems. In addition to excessive pain, stiffness,
perspiration, or fatigue, other possible warning signs include difficulty
sleeping, headaches, vertigo, dizziness, swelling, unusual feelings of being
hot or cold, nausea, vomiting, shortness of breath, chest pains, abdominal
pain, blurred vision, tingling, weakness, or numbness. Patients should be
advised to seek professional help if any of the above listed warning signs are
present. If any of the signs or symptoms relating to congestive heart failure
are present, such as shortness of breath or chest pain, patients should be
advised to seek emergency medical help.
If painful arc is present, active movements are more likely than passive
movements to irritate or inflame tissues and cause degenerative changes.
Patients should normally avoid active exercise until passive movements are
nearly painless. Passive movements cannot be done without pain unless
tissue inflammation is greatly subsided.
Pendular Exercise (Codman)
The Pendular Exercise is normally the first step in a progressive exercise

program just after the acute stage of a glenohumeral joint injury. This
exercise is done by patients to prevent adhesive reactions between adjacent
synovial layers of the joint capsule surrounding the glenohumeral joint.
From a sitting position, the patient flexes the trunk forward until the affected
arm is hanging freely from the shoulder. The elbow of the opposite arm can
be rested on the patient’s ipsilateral knee. The patient then uses the shoulder
to swing the hanging arm back and forth or in small circles.
Even though shoulder movement is active, the arm itself swings
passively without muscular effort. The weight of the arm separates the
glenohumeral surfaces and stretches the joint capsule slightly. During the
later stages of rehabilitation, the arm can be moved actively and small
weights can be held in the hand to increase muscular activity. The pendular
exercise is more specifically a stretching exercise than a strengthening
exercise.

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Ice can be used during the acute stage of injury and heat during the
subacute or chronic stages of injury. If pain is more of a problem than tissue
extensibility or range of motion, ice can be used during the subacute or
chronic stages. Trigger point therapy can be used to relieve pain in muscles
surrounding the glenohumeral joint. Where the early stages of this exercise
focus on flexibility and range of motion, the later stages focus on muscular
strength and endurance. The Pendular Exercise is frequently used to prevent
or treat adhesive capsulitis (frozen shoulder).
Three Basic Preliminary Shoulder Exercises
Even though the ultimate goal is being able to complete all eight basic
shoulder exercises correctly, patients should not continue with the last five
exercises until they complete the first three exercises listed below. The first
three exercises parallel the 3-point Touch Test that was used to evaluate the
five basic shoulder movements: abduction, adduction, horizontal adduction,
medial rotation, and lateral rotation.
Using similar movements for evaluation and therapeutic exercise helps
practitioners and patients work together in the interest of achieving common
goals: increase range of motion and restore normal pain-free movement.
The first three exercises can be done from a sitting or standing position.
Movements should be slow and pain should not be excessive.
The 3-Point Touch Test can be enhanced by allowing patients to use
their free hand to assist with body movements that are doing the actual
stretching or prepare the body for stretching Assistance involves pushing an
elbow to increase humeral abduction or horizontal adduction. Optional
preparation for the last movement requires pulling the wrist to increase
humeral adduction before attempting the exercise or between repetitions.
1. Shoulder Touch: Patient reaches over and behind head with one arm
and tries to touch the opposite posterior shoulder (or superior angle of
scapula) with fingers. When the exercise is completed, the elbow of the
reaching arm is pointing upward.
Assistance: pull down on elbow to increase abduction of reaching arm.
Optional: Patients can use fingers of reaching arm to pull or “walk” the
hand closer to the lateral border of shoulder.

174
2. Thoracic Touch: Patient reaches over and in front of head with one
arm and tries to touch upper thoracic spine with fingers. When the
exercise is completed, the reaching arm will be touching the chin.
Assistance: push back on elbow of reaching arm to increase horizontal

adduction.
Optional: Patients can use the fingers of the reaching arm to pull or
“walk” the hand closer to the upper thoracic spine.
3. Scapula Touch: Patient reaches down behind back and tries to touch
inferior angle of opposite scapula. When the exercise is completed, the
reaching arm will be touching the side of the body with the elbow
pointed downward.
Assistance: none.
Optional: If humeral adduction is limited, patients can use their free

hand to increase adduction by pulling the wrist of the reaching arm
horizontally across the back.
Even if only one shoulder is impaired, patients should exercise both

shoulders. Movements done correctly on the healthy side provide a model
for the opposite side. All movements should be done slowly and gently and
a mirror can be used to monitor symmetry, velocity, and smoothness. Once
the reaching arm achieves the greatest range of motion possible, patients
should hold the position for about 12 seconds and then slowly release the
arm. If patients experience severe pain during or after exercise, the program
should be discontinued and the patient should seek professional help. Once
the first three exercises are completed with at least moderate success,
patients should continue on with secondary exercises one through five.
Five Basic Secondary Shoulder Exercises
1. Back-to-Wall Exercise
Start: Back up to wall with heels about six inches from wall and stand
erect with arms in a downward (dependent) position.

175
One: Lean back until the scapulas touch the wall and slowly abduct the
arms directly overhead until the forearms and hands touch the wall
with fingers pointing up and thumbs pointing in. Hold position for
about 12 seconds.
Two: Return to starting position.
Three: Extend arms and place elbows and palms firmly against the wall
with forearms parallel, fingers pointing down and thumbs pointing in.
Lean slightly forward and hold position for about 12 seconds.
Finish: Return to starting position.
Repetitions: 3 to 12 per session.
2. Face-to-Wall Exercise
Start: Face wall with toes and chest touching wall and arms in a downward
(dependent) position.
One: With elbows fully extended, place palms on wall and simultaneously
abduct the hands from 0 degrees to 180 degrees (overhead) at the same
slow rate. During abduction, the palms should be in constant contact
with the wall. If needed, fingers can be used to pull or “walk” the hands
up the wall. Hold overhead position for about 12 seconds.
Two: Once the hands are directly overhead (fingers pointing up, thumbs
pointing in, and palms on wall), slide the palms vertically down the
wall until the hands are about level with the shoulders (fingers
pointing up, thumbs pointing in, and palms on wall).
Three: Step back from wall about 12 inches and lean in until chest touches
wall (resembles push-up position). Hold position for about 12 seconds.
Finish: Push away from wall and return to starting position

176
3. Overhead Floor Exercise
Start: Lie supine on padded floor (mat or carpet) with arms directly
overhead and hands supinated (palms up and thumbs pointing in).
Hold overhead position for about 12 seconds.
One: Adduct arms to 90 degrees and flex elbows to 90 degrees with hands
supinated (palms up and thumbs pointing in)
Two: Medially rotate humerus until palms touch floor (thumbs pointing in).
Three: Laterally rotate humerus until backs of each hand (dorsum) touch
floor (palms up and thumbs pointing in)
Repetitions: 6 to 12 per session
4. Doorway Exercise
Start: Stand facing doorway with elbows flexed to about 90 degrees,

forearms about horizontal, and palms on anterior surface of doorway
(thumbs pointing up).
One: Keeping both hands in about the same place, step into doorway until
the elbows are about fully extended.
Two: Lean slightly forward to gently extend the arm and adduct (retract)
the scapulas. Sliding the hands slowly up the doorway will increase
the stretch. Hold position for about 12 seconds
Three: Keeping both hands in place, rotate the body slightly in one
direction to stretch one shoulder and then in the opposite direction to
stretch the other shoulder. Hold each stretch for about 12 seconds.

177
5. Corner Exercise
Start: Stand facing a corner with feet about 18 to 24 inches from corner.
First: Starting with arms in a downward position, flex elbows and place one
palm on each wall at about shoulder level with fingers pointing up
and thumbs pointing in (resembles push-up position).
Two: Keeping both hands in about the same place, lean in and touch head
to corner of wall. Hold position for about 12 seconds.
Repetitions: 3 to 12.
Staff or Walking Cane Exercises
Using a staff or walking cane for exercise has one major advantage: if
only one side of the body is impaired, the stronger side of the body can
mobilize and stretch the weaker side. When both sides of the body are doing
the same movement simultaneously, movement by the strong side reinforces
movement by the weak side.
Staff or walking-cane exercises done in front of a mirror will make
coordinating movements easier and more enjoyable for most patients. Since
many shoulder problems allegedly have a psychological component related
to tension, anxiety or stress, background music will help some patients relax
and develop a rhythm while doing exercises.
1. Overhead Staff to Side
Start: With arms abducted to about 135 degrees and elbows fully extended,
hold staff horizontally overhead.
One: Tilt staff about 45 degrees to one side (frontal plane). Hold position
for about 12 seconds.

178
Three: Tilt staff about 45 degrees to opposite side (frontal plane). Hold
position for about 12 seconds.
2. Overhead Staff Behind Neck
Start: With arms abducted to about 135 degrees and elbows fully
extended, hold staff horizontally overhead.
One: Adduct arms and place staff behind neck. Hold position for about
12 seconds.
Repetitions: 3 to 12 repetitions.
3. Overhead Staff in Front of Neck
One: Adduct arms and place staff in front of neck. Hold position for about
12 seconds.
4. Vertical Staff Behind Back
Start: Hold proximal end of staff behind head (palm facing forward and
thumb pointing down) and allow body of staff to hang vertically
downward behind center of back. With opposite hand, grasp distal
end of staff (palm facing back and thumb pointing up).

179
One: While holding the staff with both hands, slowly elevate upper hand
to pull lower hand up. Hold position for about 12 seconds.
Three: While holding the staff with both hands, slowly depress lower hand
to pull upper hand down. Hold position for about 12 seconds.
5. Front Staff Shoulder Shrug
Start: The arms abducted to about 45 degrees and elbows fully extended,
hold staff horizontally below waist in front of body.
One: Elevate scapulas and fully shrug shoulders. No hold required.
6. Rear Staff Shoulder Shrug
Start: With arms abducted to about 45 degrees and elbows fully extended,
hold staff horizontally below waist behind back.
One: Elevate scapulas and fully shrug shoulders. No hold required.
7. Diagonal Overhead Staff

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One: Adduct arms and place staff behind neck. No hold required.
Two: Holding one hand in place, tilt the staff to about 45 degrees by
elevating the opposite hand directly overhead. Hold for about 12
seconds.
Three: Return to starting position.
Four: Reverse hands and use the same procedure to tilt the staff about 45
degrees to the other side. Hold for about 12 seconds.
Table Stretch from Sitting Position (3 to 12 repetitions)
Table stretches are done sitting at a chair and directly facing a table with the
arm flexed in front of the body and the elbow flexed to about 90 degrees.
The arm position resembles an arm-wrestling position. A pad that is soft
enough to cushion the elbow, but smooth enough to slide, should be placed
under the elbow for protection. All moving is done slowly and gently.
1. With arm in arm-wrestling position, push elbow forward, drop shoulder.
2. With arm in arm-wrestling position, internally and externally rotate

humerus until the hand touches the table on both sides of the arm.
The following movements are designed as a warm-up and stretching

sequence for athletes. All exercises are done with the feet slightly more than
shoulder-width apart. Since many of these movements are somewhat more
ballistic than static, these exercises are not recommended for therapy.
Even though static stretches with low force and long duration are
normally more effective in therapy than ballistic stretches with high force
and short duration, athletes who engage in sports activities that require
ballistic movements would be unwise to warm up and stretch with exercises
that failed to include at least some degree of mild ballistic stretching.

181
Warm-up Stretching Exercises (10 to 15 repetitions)
1. Shrug shoulders up; roll shoulders forward and down.
2. Shrug shoulders up; roll shoulders back and down.
3. Place palms together in steeple position with the fingers pointing down
and the thumbs pointing forward. Swing the arms overhead until the hands
are behind the back with the fingers pointing down and the thumbs pointing
forward. Hold the position for about 12 seconds as a stretch and return to
starting position.
4. Rotate trunk with forearms horizontal, hands open, and palms down. The
hands should give the appearance of moving over the top of a flat, smooth
surface.
5. With arms flexed about 45 degrees, elbows extended, fingers pointing

down, and thumbs pointing up, touch palms in front of body, swing arms
behind back, and touch palms behind back (fingers and thumbs pointing
down).
6. Abduct both arms to 90 degrees with elbows extended, hands open,

palms facing down, and thumbs pointing forward. Draw 6 imaginary 6-inch
circles with the hands in one direction, stop and hold the abducted position
for about 6 seconds, draw 6 imaginary 6-inch circles in the opposite
direction, and then stop and hold the position for about 6 seconds.
(Dropping the arm from the abducted position may indicate a rotator cuff
tear or weakness in the deltoids. See Drop Arm Test.)
The Exercise Challenge
One way to encourage patients to exercise is offer a challenge: If we do

our part, are you willing to do your part? After evaluating the patient using
the 3-Point Touch Test, give the patient the results and explain how the
patient can practice similar movements at home. If patients are motivated to
improve, they should be willing to practice at home.
During the next evaluation, compare the new results with the old results.
If the patient shows improvement as a result of exercising at home, praise
the patient for the improvement. For most patients who are motivated to
improve, seeing measurable progress will be reward enough in itself.

182
If patients fail to show progress, try to determine if they are doing their
exercises at home. If patients say they are doing their exercises, have them
demonstrate the movements. If they are doing the exercise incorrectly, show
them the correct way to exercise. If they cannot demonstrate the
movements, they are not doing the exercises at home, regardless of what
they claim. Either way, give them the results of the evaluation and restate
the challenge.
For patients who are not willing to exercise at home, consider the
possible reasons. In some cases, patients are not motivated to improve
because of psychological, social, or economic gain that results from
disability. If you continue to treat patients of this nature, offer the best
treatment possible but realize that improvement may not occur. Even if
progress does occur, some patients will try to conceal the progress.
Another option is to refer the patient to an expert who may be able to
diagnose the problem, such as a psychologist or psychiatrist. Some patients
need psychological help in addition to soft-tissue therapy. If a patient is
willing to exercise but lacks motivation to exercise at home, refer them to an
exercise specialist who is qualified to supervise patients during
rehabilitation. Though learning to exercise at home is normally the best
solution for most patients, some patients will not exercise without direct
supervision.
Pain Prevention
Since neck and shoulder pain are difficult to prevent, any activities that
are known to cause neck or shoulder pain should be discontinued. Many of
these activities involve overuse, repetitive strain, fatigue, trauma, poor
posture, improper use of body mechanics, high degrees of sudden force, and
failure to warm up or stretch before vigorous activity.
Over-stretching when turning and reaching sideways or backward to
pick up an object seems to be a common cause for rotator cuff injuries.
Many patients report working or sleeping with the arms overhead causes
neck and shoulder pain. Athletes with “I’ll do it if it kills me” attitudes are
always good candidates for neck and shoulder pain. That “just one more
time” is all too often “one time too many.”

183
Some shoulder injuries can be avoided by changing body positions to
face an object before moving it as opposed to reaching for an object by
twisting the trunk or shoulders and then moving it. Because of leverage,
lifting with the arms close to the body places less strain on the shoulders
than reaching out to lift an object. Overhead movement should be avoided,
and working with the arms at or below 90 degrees elevation is normally
safer than working with the arms above 90 degrees. Frequent breaks can be
helpful, especially when neck or shoulder movements are causing pain,
fatigue, or discomfort.
For athletes especially, learning to fall correctly is one of the best ways
to prevent neck and shoulder injuries. Falling on outstretched arms, a hard
surface, or the point of the shoulder are three ways to increase the risk of
shoulder injuries. Developing the larger shoulder muscles such as the
deltoid and trapezius will add integrity to the neck and shoulder and help to
cushion a fall. Isometric exercises are good for strengthening the scalenes,
and shoulder shrugs can be used for strengthening the upper trapezius.
Athletes should be encouraged to use properly fitted protective equipment
and report neck or shoulder injuries as soon as possible.
For most people, not putting yourself in a high-risk situation is the best
way to avoid shoulder injuries. Know the limits of your strength, endurance,
and flexibility, and work within those limits. Avoid situations that expose
the shoulder to sudden force, such as falling into hard objects or being struck
by hard objects. Moving heavy patients or reaching for falling objects can
put the neck and shoulders at serious risk. Most of all, think of the many
factors that cause neck and shoulder injuries and then think before you act.
The best form of treatment is always prevention.
Suggestions for Preventing Neck and Shoulder Pain
• Discontinue activities that cause neck or shoulder pain.

• Avoid conditions that cause fatigue because of overuse or repetition.
• Warm up before vigorous neck or shoulder movements.
• Face objects and stand close before moving or lifting the object.
• Avoid working with the arms while stooped over.
• Avoid working with the arms above the shoulders.
• Do neck and shoulder stretching to improve flexibility.
• Do neck and shoulder exercises to improve strength and endurance.
• Use common sense and good judgment.

184
CHAPTER SUMMARY
EIGHT BASIC SHOULDER EXERCISES
THREE PRELIMINARY EXERCISES
• Shoulder touch
• Thoracic touch
• Scapula touch
FIVE SECONDARY EXERCISES
• Back-to-wall exercise
• Face-to-wall exercise
• Overhead exercise
• Doorway exercise
• Corner exercise
SUGGESTIONS FOR PREVENTING NECK AND SHOULDER PAIN
• Discontinue activities that cause neck or shoulder pain.

• Avoid conditions that cause fatigue because of overuse or repetition.
• Warm up before vigorous neck or shoulder movements.
• Face objects and stand close before moving or lifting the object.
• Avoid working with the arms while stooped over.
• Avoid working with the arms above the shoulders.
• Do neck and shoulder stretching to improve flexibility.
• Do neck and shoulder exercises to improve strength and endurance.
• Use common sense and good judgment.

185
CONCLUSION
Considering the psychological, social, and economic consequences of

neck and shoulder pain and soft-tissue impairments in general, there
continues to be a pressing need for new approaches that are both
conservative and cost-effective. In all but a few cases, surgery is not the
answer, and medication treats only the symptoms of a disability without
treating the cause. Classical approaches to therapy that rely totally on
modalities or exercise without manipulation often leave the patient more
demoralized, sometimes even more disabled, than before therapy. Most of
these patients receive little comfort in hearing they must learn to live with
the pain or the problem is purely psychogenic.
What the HEMME APPROACH trilogy has tried to offer is a logical and
scientific approach for treating soft-tissue impairments that relies on a
collection of principles and techniques found in physical medicine,
osteopathy, chiropractic, physical therapy, occupational therapy, massage
therapy, athletic training, and nursing. Though the art and science of manual
medicine has been carefully developed by many different professions,
politics, economics, and ego have made it difficult for one profession to
openly share information with another profession. The HEMME APPROACH
tries to remedy this problem by incorporating the best principles and
techniques from a number of different professions into a single, unified
approach.
Should HEMME APPROACH and soft-tissue therapy be given a chance?
The people who ultimately benefit from HEMME APPROACH are those
patients who escape from chronic pain, disability, and depression because of
soft-tissue therapy. When it comes to their own health, patients care most
about two things: “Can I be helped?” and “Will I be harmed?”
Based on medical research, clinical experience, and feedback from
patients, soft-tissue therapy can help many patients recover from serious
disabilities caused by soft-tissue impairments. Based on medical statistics,
the dangers and side effects from using soft-tissue therapy are almost too
small to calculate when compared with the risks posed by medication or
surgery. If soft-tissue therapy can help patients without causing them harm,
it would appear that soft-tissue therapy deserves to be given a chance in the
interest of providing patients with the best care possible. To believe
otherwise would not be acting in the best interest of the patient.

186
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GLOSSARY
action Anatomical movements produced by the normal contraction of a

muscle.
active trigger point Hyperirritable spots or zones that actively produce pain
and may cause autonomic responses.
acute Short duration, rapid onset, severe, not chronic.
adhesion A tissue structure holding together parts that are normally

separated.
agonist Muscle or muscle group primarily responsible for performing some

movement (prime mover).
algesic: painful or causing pain.
algesiogenic: Pain-producing, algogenic.
anabolism The constructive phase of metabolism.
analgesia Loss of sensitivity to pain.
anesthesia Partial or complete loss of feeling, with or without loss of

consciousness.
ankylosis Fixation of a joint.
anoxia Without oxygen.
antagonist Muscle or muscle group that opposes the movement of the

agonist and produces the opposite movement.
aponeurosis A flat fibrous sheet of connective tissue that attaches muscles

to bone.
approximate To bring close together.

201
apraxia Loss of ability to perform purposeful movement in the absence of
paralysis.
asthenia Loss of strength or energy.
ataxia Loss of motor coordination.
athetosis Snakelike movements.
atonia Lack of tension or tone, flaccid.
atrophy Decrease in size of an organ or tissue.
auscultation Listening for sounds made by various body structures.
ballistics A study of motion and trajectory.
barrier An obstruction that tends to restrict free movement.
blanch To become pale, white, or lose color.
capsulitis Inflammation of a capsule.
catabolism Destructive phase of metabolism.
caudad In direction toward the feet, tail, or distal end, opposite cephalad.
causalgia Burning pain.
cephalad In direction toward the head, opposite caudad.
chronic Long duration, normally more than six months.
claudication Lameness resulting from inadequate circulation.
clonus Uncontrolled spasmodic muscle jerking.

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cocontraction Mutual contraction of antagonistic muscles for the purpose
of stabilizing a body part.
Codman, Ernest Amory US surgeon, 1869-1940, developed pendular

exercise for shoulder.
collagen A fibrous protein found in connective tissue.
concentric contraction A muscle shortens during contraction.
contractility Having the ability to contract or shorten in response to

stimulus.
contraction Increased tension caused by physiologic shortening of a

muscle.
contracture A pathologic shortening of a muscle due to spasm or fibrosis

that increases resistance to active or passive stretch.
contralateral Affecting opposite side or on opposite sides of the body.
convergence The moving of two or more forces toward the same point.
conversion Changing emotions such as hysteria into physical

manifestations.
counterirritation Superficial irritation that relieves another irritation or

deep pain.
cramp Strong and painful spasm.
creep Deformation of viscoelastic materials when exposed to a slow,

constant, low-level force for long periods of time.
crepitus The sound of bone rubbing against bone.
cryotherapy Therapeutic application of cold.

203
cyanosis Bluish or gray discoloration of skin because of reduced
hemoglobin in blood.
Cyriax, James British orthopedist; author of books relating to manual

medicine, physical evaluation, and cross-fiber friction.
cyst A closed sac or pouch containing fluid, semisolid, or solid material.
diaphoresis Profuse sweating or perspiration.
discography X-ray taken after injecting an absorbable contrast medium into

an intervertebral disk.
disease A morbid or pathologic condition that deviates from normal

function where the agent, signs, and symptoms are identifiable.
distract To separate.
divergence The moving of two or more forces away from a common center.
dysesthesia Unpleasant sensations produced by ordinary stimulus.
eccentric contraction A muscle lengthens during partial contraction.
EMG Acronym for electromyogram, the graphic record of muscle

contraction that results from electrical stimulation.
EMT Acronym for Evaluate, Manipulate, and Test again.
encephalitis Inflammation of the brain.
endogenous Produced or developed from within the organism.
entrapment syndrome Entrapment of a nerve by hard or soft tissue.
etiology Scientific study involving the causes of disease.

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exacerbation Aggravating symptoms or increasing the severity of a disease.
exostosis Bony growth arising from surface of bone.
extensibility The ability to lengthen.
exteroceptor A sense organ receiving stimuli from outside the body.
extracellular Outside the cell.
extravasation Fluids escaping from vessels into surrounding tissue.
fascia A fibrous connective tissue membrane covering, supporting, and

separating a muscle.
fasciculation Spontaneous contraction or twitch of a group of muscle

fibers.
fascitis Inflammation of any fascia.
fibrinolytic Dissolution or splitting up of fibrin.
fibroblast A cell that produces connective tissue.
fibroma A fibrous, connective tissue tumor.
fibroplasia Development of fibrous tissue during wound healing.
fibrosis Inflammation of fibrous tissue.
flaccid Soft, relaxed, flabby, or without muscular tone.
flush Sudden or transient redness of skin.
force That which changes or tends to change a body's motion or shape.

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gamma motor neuron An efferent nerve cell that innervates the ends of
intrafusal muscle fibers.
ganglion Benign cystic tumors developing on a tendon or aponeurosis.
GTO Acronym for Golgi tendon organ.
guarding Involuntary muscle contractions that limit range of motion to

avoid pain.
handedness Preferential use of right or left hand when performing

voluntary motor acts.
HEMME Acronym for History, Evaluation, Modalities, Manipulation, and

Exercise.
hypalgesia Decreased sensitivity to pain, opposite hyperalgesia.
hyper- Prefix meaning more than, excessive, above.
hyperalgesia Increased sensitivity to pain, opposite hypalgesia.
hyperemia Increased amount of blood in a body part, shown by skin redness.
hyperesthesia Increased sensitivity to touch or pain.
hyperirritable Increased response to stimulus.
hypermobility Excessive mobility of any joint.
hypertonia Excessive tone of skeletal muscles that increases resistance to

passive stretch.
hypertonic A state of greater than normal tension in muscles.
hypertrophy Increase in size of an organ or tissue.
hypo- A prefix meaning less than, deficient, beneath.

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hypoesthesia Decreased sensitivity to touch or pain.
hypokinetic Decreased motor function.
hypomobility Decreased mobility of a joint or range of motion.
hypotonia Diminished tone in skeletal muscles and decreased resistance to

passive stretch.
hypotonic A state of less than normal tension in muscles.
hypoxia Deficiency of oxygen.
hysteresis Energy loss in viscoelastic materials subjected to stress or cycles

of loading and unloading.
hysteria A neurotic condition presenting somatic symptoms in the absence

of organic disease.
iatrogenic An adverse state or condition induced by treatment.
idiopathic A disease of spontaneous origin with unknown cause.
impulse Suddenly applied force or rapid loading because of changes in

momentum that occur over a short time interval.
induration Hardening of soft tissue caused by extravasation of fluids.
insidious A disease that appears slowly and progresses with few or no

symptoms indicating the illness.
inspection Examination by the eye.
ipsilateral Affecting same side or on same side of the body.
ischemia Insufficient blood supply to a tissue or organ.
isometric contraction Contraction of a muscle with no change in length.

207
isotonic contraction Contraction of a muscle with a decrease in length.
joint mice Bits of bone or cartilage that are present in joint space.
jump sign A general, involuntary response caused by withdrawal from pain

when pressure is applied to a trigger point.
keloid scar A raised, red, smooth scar that is often painful.
kinetics A study of forces acting on a system.
kyphosis Backward convexity, prominence, or hump on the spine caused by

flexion.
latent trigger point Trigger points that lie dormant except when palpated.
lesion Pathologically altered tissue, injury, or wound.
ligament A band of fibrous connective tissue connecting the articular ends

of bones.
lipoma A fatty tumor which is not metastatic.
lordosis Forward convexity in the curvature of the lumbar or cervical spine

as viewed from the side.
lumbar-pelvic-rhythm A combination of lumbar and pelvic movements

that occur during maximum trunk flexion.
malingering Pretending to be ill.
manipulation Therapeutic use of hands with or without impulse.
matrix The intercellular substance of a tissue.
mechanism of injury The forces that caused the injury.
meralgia A pain in the thigh.

208
metastasis Spread of malignant cells.
mobilization Making a joint movable.
modality A therapeutic or physical agent such as thermotherapy (heat),

cryotherapy (cold), or hydrotherapy (water).
MRI Acronym for magnetic resonance imaging.
MSC Acronym for muscle spindle cell.
muscle atrophy A decrease in the size of a muscle.
muscle hypertrophy An increase in the size of a muscle because of

activity.
myalgia Muscular pain.
myelography X-ray of spinal column after injection of contrast medium

into the spinal subarachnoid space.
myofascial Involving muscles and fascia.
myofascial release An osteopathic technique that follows the principle of

creep.
myofibrosis Replacement of muscle tissue by fibrous connective tissue.
myositis Inflammation of a voluntary muscle.
myotenositis Inflammation of a muscle and its tendon.
necrosis Death of a tissue.
neoplasm A new and abnormal formation of tissue with uncontrolled and

progressive cell growth which may be malignant or benign.
neuralgia Pain along the course of a nerve.

209
neuritis Inflammation of a nerve.
neuropraxia A traumatized nerve that no longer conducts even though

anatomic structure appears to be intact.
nociceptor A nerve for receiving and transmitting injurious or painful

stimuli.
NSAID Acronym for nonsteroidal anti-inflammatory drug.
opioid An opiate-like synthetic narcotic not derived from opium.
osteoarthritis Chronic disease involving degeneration of joints.
osteoblast A cell that produces bone.
palliative Relieving symptoms but not a cure.
pallor Lack of color or paleness of skin.
palpation Examining the body by application of hands or fingers to the

surface of the body.
paralysis Loss or impairment of voluntary muscle function.
paresis Incomplete loss of voluntary muscle function.
paresthesia Abnormal sensation of burning, tickling, or tingling sometimes

referred to as a feeling of “pins and needles.”
pathology Condition or manifestation produced by disease.
PDQ Acronym for Problem, Doctor’s care, and Quality of past treatment.
percussion Tapping sharply on the body to determine position, size, and

consistency of underlying structures.
periosteum A fibrous connective tissue membrane that covers bone.

210
physiatrist A doctor specializing in physical medicine.
pilomotor Pertaining to the arrector muscles that cause hairs to move or

stand erect (goose flesh).
PNF Acronym for Proprioceptive Neuromuscular Facilitation.
prone Lying horizontal with face down.
proprioceptor A receptor within the body that responds to pressure,

position, or stretch.
proteoglycans The extracellular matrix of connective tissue composed of

glycosaminoglycans (GAG) bound to protein chains.
psychogenic Created by the mind.
radiculitis Inflammation of a spinal nerve root, especially the portion of the

root that lies between the spinal cord and spinal canal, accompanied by pain
and increased sensitivity to touch.
range of motion The maximal span of a joint as measured by angular

displacement between two adjacent segments.
Raynaud's disease A peripheral vascular disorder characterized by

abnormal vasoconstriction of the extremities when exposed to cold.
rebound tenderness Pain or discomfort when pressure is released.
recruitment Activating additional motor units to produce greater activity as

the intensity of stimulus remains constant and the duration of stimulus
increases.
reflex An involuntary response to stimulus.
rheumatoid arthritis A form of arthritis involving inflammation of joints,

stiffness, and swelling.

211
RICE Acronym for rest, ice, compression, and elevation.
ROM Acronym for range of motion.
salicylate Any salt of salicylic acid which is used in drugs such as aspirin to
reduce pain and temperature.
satellite trigger point A trigger point activated by another trigger point in

the same reference zone.
sciatica Severe pain along the sciatic nerve.
scoliosis A lateral curvature of the spine normally consisting of a primary

curve and a secondary compensatory curve.
secondary trigger points Trigger points that develop in a synergist or

antagonist because of overload.
self-limiting A condition that runs a definite course and then stops without
treatment.
sentient Capable of feeling sensation.
servomechanism A control mechanism that operates by positive or

negative feedback.
sign Objective evidence of an illness.
SITS Acronym for rotator cuff muscles: supraspinatus, infraspinatus, teres

minor, subscapularis.
soft-tissue impairment Soft-tissue lesion or defect that causes disability or

loss of function.
somatic dysfunction Altered or impaired function related to components of

the body and treatable by manipulation.
spasm Involuntary contraction of a muscle beyond physiologic needs.

212
spastic Inflicted by spasm.
spinal segment The functional unit of a spine consisting of two contiguous

vertebrae with an intervening disk, two facet joints, intrinsic muscles, and
interconnecting ligaments.
splinting Rigidity or fixation of a body part because of reflex spasm.
spondylosis Vertebral ankylosis, which may involve osteoarthritis.
sprain Trauma to a joint causing injury to ligaments.
stasis Stagnation of blood or other body fluids.
stenosis Constriction or narrowing of a passage.
strain Trauma to a muscle or musculotendinous unit.
strength The ability to exert muscular force briefly.
stress The results produced when a structure is acted upon by force.
subluxation A partial or incomplete dislocation.
supine Lying horizontal with face up.
symptom Subjective evidence of an illness.
syncope Loss of consciousness caused by inadequate blood flow to the

brain, fainting.
syndrome A group of signs and symptoms characterizing a disease.
synergist A muscle functioning in cooperation with another muscle.
tendinitis Inflammation of a tendon.
tendon A fibrous connective tissue attaching muscles to bones.

213
thermography The process of taking a thermograph with an infrared
camera to show distribution of the body's surface temperature.
thermotherapy Therapeutic application of heat.
thixotropy A property of certain gels that liquefy when agitated and

become semisolid again when left standing.
tonus Partial, steady contraction in skeletal muscle that helps to maintain

posture or firmness.
torque A turning caused by rotary force acting about a pivot point.
traction Process of pulling apart.
trigger point A tender point or spot on the body that produces sudden pain
when stimulated by pressure or compression.
trigger zone A tender zone or area on the body that produces sudden pain
when stimulated by pressure or compression.
tumor A swelling or enlargement, one of the four cardinal signs of

inflammation.
twitch response Transient contraction of a muscle fiber group when

pressure is applied to a trigger point.
urticaria Eruption of skin characterized by severe itching.
vasoconstriction Decrease in the caliber of a blood vessel.
vasodilation Increase in the caliber of a blood vessel.
viscoelastic A viscous material that is also elastic (e.g., connective tissue).
viscosity Resistance to flow or shear caused by stickiness or cohesion.

214
HEMME APPROACH QUIZ
1. What is the first step in the HEMME APPROACH scientific method?
a. identify problem presented by patient

b. determine if therapy is indicated or contraindicated
c. investigate problem and form preliminary theories
d. collect additional information to verify or deny theories
2. Which method of manipulation is not used in HEMME APPROACH?
a. trigger point therapy

b. neuromuscular therapy
c. connective tissue therapy
d. rotation therapy
3. Of the 22 basic muscles listed under neck and shoulder muscles, how
many belong to the shoulder girdle?
a. 3
b. 7
c. 11
d. 18
4. What is the back muscle that refers pain to the scapulas?
a. scalenus anterior
b. serratus anterior
c. serratus posterior superior
d. subscapularis
5. What muscle can flex, abduct, or extend the humerus?
a. biceps brachii
b. deltoid
c. supraspinatus
d. triceps brachii

215
6. What muscle can elevate, adduct, upward rotate, or depress the scapula?
a. deltoid
b. trapezius
c. rhomboid major
d. rhomboid minor
7. What are the four rotator cuff (SITS) muscles?
a. supraspinatus, infraspinatus, teres major, subscapularis

b. supraspinatus, infraspinatus, teres minor, serratus anterior
c. supraspinatus, infraspinatus, teres minor, subscapularis
d. supraspinatus, infraspinatus, trapezius, subclavius
8. Which articulation joins the glenoid cavity and humerus?
a. acromioclavicular joint
b. costovertebral joint
c. glenohumeral joint
d. scapulothoracic joint
9. Which movement does not play one of the three major roles in
scapulohumeral rhythm?
a. rotation of the humerus at the glenohumeral joint

b. rotation of the humerus at the scapulothoracic joint
c. upward rotation of the scapula at the scapulothoracic joint
d. elevation and rotation of the clavicle at the sternoclavicular and
acromioclavicular joints
10. Based on scapulohumeral rhythm, what muscle contributes the most to

the first 5 degrees of humeral abduction?
a. deltoid
b. supraspinatus
c. infraspinatus
d. subscapularis

216
11. At maximum overhead abduction (180 degrees), how many degrees of
rotation are contributed by humeral rotation at the glenohumeral joint?
a. 30 degrees
b. 60 degrees
c. 90 degrees
d. 120 degrees
12. At maximum overhead abduction (180 degrees), how many degrees of

rotation are contributed by scapular rotation at the scapulothoracic joint?
a. 30 degrees
b. 60 degrees
c. 90 degrees
d. 120 degrees
13. Which sequence defines the acronym HEMME?
a. History, Examination, Modalities, Manipulation, Exercise

b. History, Evaluation, Modalities, Movement, Exercise
c. History, Examination, Modalities, Methods, Exercise
d. History, Evaluation, Modalities, Manipulation, Exercise
14. Which contraindication relating to cervical manipulation may cause

blurred vision, paralysis, or death?
a. complete tearing of the acromioclavicular capsule

b. complete tearing or avulsion of a muscle
c. referred cardiac pain
d. vertebrobasilar insufficiency
15. The "P" in the acronym "PDQ" stands for:
a. prognosis
b. problem
c. pathology
d. parameters

217
16. Which method of physical evaluation is normally the starting point?
a. observation
b. palpation
c. percussion
d. auscultation
17. Of the four basic zones in the shoulder region used for palpation, which
one is called a quadrilateral pyramid?
a. rotator cuff
b. prominent muscles of the shoulder girdle
c. subacromial and subdeltoid bursa
d. axilla
18. Which structure in the neck or shoulder region does not refer pain?
a. cervical spine
b. scalene muscles
c. acromioclavicular joint
d. coracoid process
19. Which condition does not explain tissue damage and soft-tissue
impairments?
a. normal stress applied to normal tissue

b. abnormal stress applied to normal tissues
c. normal stress applied to abnormal tissues
d. abnormal stress applied to abnormal tissue
20. Which substance is not considered a pain-producing chemical?
a. serotonin
b. histamine
c. prostaglandins
d. acetylsalicylic acid

218
21. What is the second step in the Rehabilitation Model?
a. Results: tissue damage, inflammation, and pain-producing chemicals.

b. Results: pain, spasm, edema, metabolite retention.
c. Results: restricted circulation, hypoxia, ischemia, and fatigue.
d. Results: restricted movement, inactivity, fibrosis.
22. What is glenohumeral joint range of motion for horizontal adduction?
a. 0-180 degrees
b. 0-135 degrees
c. 0-90 degrees
d. 0-70 degrees
23. What does the first maneuver in the 3-Point Touch Test (touch superior
angle of opposite scapula) measure?
a. abduction and lateral rotation

b. adduction and flexion
c. abduction and medial rotation
d. adduction and medial rotation
24. Which orthopedic test measures pain between 60 degrees and about 120
degrees?
a. Painful-Arc Test
b. Supraspinatus-Tendinitis Test
c. Drop-Arm Test
d. Biceps-Tendon Test
25. What pathologic condition is tested by using the Drop-Arm Test?
a. rotator cuff tear

b. adhesive capsulitis
c. scalene anticus syndrome
d. pectoralis minor syndrome

219
26. The HEMME APPROACH Quick Test is used for:
a. active range-of-motion testing

b. passive range-of-motion testing
c. muscle testing
d. neurologic testing
27. Which pathologic condition limits shoulder movement in all directions?

28. Which pathologic condition constricts the thoracic outlet?

29. What pathologic condition has symptoms similar to scalene anticus

syndrome?

c. frozen shoulder
30. In cryotherapy, what is the third phase of ice massage?
a. numbness
b. aching
c. burning
d. cold

220
31. Which modality decreases tissue extensibility, relaxes muscle spasm,
and reduces pain?
a. thermotherapy
b. cryotherapy
c. vibration
d. all of the above
32. Bleeding, malignancy, inflammation, vascular insufficiency, and edema

are all listed as contraindications for:
a. thermotherapy
b. cryotherapy
c. vibration
d. none of the above
33. Which effects are produced by heat and cold?
a. vasodilation and increase in edema

b. vasoconstriction and decrease in edema
c. relax muscle spasm and reduce pain
d. vasoconstriction and decrease in tissue extensibility
34. When following the normal sequence for treatment, what are the first
and last methods of manipulation used in the HEMME APPROACH?
a. trigger point therapy and neuromuscular therapy

b. neuromuscular therapy and range-of-motion stretching
c. trigger point therapy and range-of-motion stretching
d. neuromuscular therapy and trigger point therapy
35. What principle is being described: Deformation of viscoelastic materials

when exposed to a slow, constant, low-level force for long periods of time?
a. Arndt-Schultz law
b. Beevor’s axiom
c. Creep
d. Facilitation-inhibition

221
36. What principle is being described: When the agonist receives an
impulse to contract, the antagonist relaxes?
a. Head's law
b. Hilton’s law
c. Meltzer’s law (Contrary Innervation)
d. Sherrington’s law of Reciprocal Inhibition
37. Which signs or symptoms indicate the presence of trigger points?
a. Points or zones that are tender when pressure is properly applied

b. Distinct patterns of referred pain or radiated pain
c. The presence of taut, indurated, or ropy bands within a muscle
d. All of the above
38. What factor(s) explain why trigger point therapy reduces pain?
a. Digital pressure disperses pain-producing chemicals.

b. Digital pressure stimulates production of endogenous opioids.
c. Trigger points activated by pressure act as counterirritants.
d. All of the above
39. What muscle refers pain to the mid-deltoid region of the shoulder?
a. scalenus anterior
b. serratus anterior
c. serratus posterior superior
d. supraspinatus
40. Based on standard protocol for using neuromuscular therapy to balance

muscles or muscle groups:
a. use inhibition to lengthen short tissue

b. use facilitation to strengthen weak muscles
c. lengthen first, strengthen second
d. all of the above

222
41. Which technique is not used for inhibition?
a. repeated contractions
b. muscle spindle cell inhibition
c. post-isometric relaxation
d. reciprocal inhibition
42. Which principle applies to neuromuscular therapy but not to connective

tissue therapy?
a. stretch reflex (Sherrington’s reflex)

b. thixotropy
c. hysteresis
d. creep
43. Which connective tissue technique combines digital pressure with

perpendicular force to produce local friction on a tendon or ligament?
a. skin rolling
b. skin pulling
c. cross-fiber friction
d. longitudinal friction
44. Which stretch uses two equal, opposite, and parallel forces separated by
distance and applied simultaneously to an object to produce rotation?
a. glenohumeral joint stretch

b. overhead stretch
c. cross-over stretch
d. force-couple stretch
45. Range-of-motion stretching is normally most effective if tension

(stretch) is applied while patients:
a. inhale
b. exhale
c. hold their breath
d. hyperventilate

223
46. Which condition(s) contraindicate range-of-motion stretching?
a. inflammation, infection, hemorrhage, or swelling around joints

b. instability or hypermobility
c. recent fractures or dislocations
d. all of the above
47. Which muscle with a sternal and clavicular origin can be stretched by
pushing the elbow in the direction of extension and lateral rotation?
a. pectoralis major
b. pectoralis minor
c. teres major
d. teres minor
48. Which muscles are stretched by pushing the head forward?
a. scalenus anterior and scalenus posterior

b. scalenus anterior and scalenus medius
c. scalenus medius and scalenus posterior
d. upper trapezius and levator scapulae
49. Which exercise is normally the first step in a progressive exercise

program after the acute stage of a glenohumeral joint injury?
a. pendular exercise
b. back-to-wall exercise
c. face-to-wall exercise
d. overhead exercise
50. Which activity is not likely to prevent neck or shoulder pain?
a. avoiding conditions that cause fatigue because of overuse

b. warming up before vigorous neck or shoulder movements
c. facing objects and standing close before moving or lifting the object
d. working stooped over with the arms above the shoulders

224
INDEX
22 Basic Muscles
Description, 8-11
Muscle testing, 82-86
ROM Stretching, 155-167
Trigger Points, 126-128
3-Point Touch Test, 76-77
8 Basic Shoulder Exercises, 173-174
Action (muscles), 22-25
Adhesive capsulitis, 92-96
Arndt-Schultz law, 113
Articulations (joint), 30, 33-34
Auscultation, 55
Back-to-Wall Test, 77
Beevor’s axiom, 113
Bibliography, 186-199
Breathing, 134, 154
Cold (cryotherapy), 94, 99
Connective tissue therapy, 135-143
Contraindications, 47, 105, 107, 110, 154
Creep, 113, 135, 137
Cross-fiber friction, 139-143
Cryotherapy, 104-105, 109
Facilitation-Inhibition, 113, 133-134
Force-couple stretch, 149-150
Frozen shoulder (adhesive capsulitis), 92-96
Glossary, 200-213
Head's law, 114
Heat (thermotherapy), 106-109
HEMME APPROACH acronym, 42-45
HEMME APPROACH concepts, 3-4
HEMME APPROACH scientific method, 3
HEMME APPROACH Quick Test, 87-90
Hilton’s law, 114
Hysteresis, 114, 135-136
Joints, 30, 33-34
Manipulation, 4

225
Meltzer’s law, 114
Muscles, 6-11
Action, 22-25
Range of motion, 73
Neck and Shoulder Illustrations, 12-21
Neuromuscular therapy, 129-134
Observation, 54
Orthopedic Testing, 68-80
Painful-Arc Test, 78
Supraspinatus Test, 79
Drop-Arm Test, 79-80
Biceps-Tendon Test, 80
Scapular Rotation and Winging Test, 80
Pain cycles, 64-70
Pain-producing chemicals, 4, 65, 115, 118
Palpation, 54-56
Passive range-of-motion testing, 76
PDQ, 52
Pectoralis minor syndrome, 101
Percussion, 55
Range of motion (muscles), 73
Range-of-motion stretching, 144-167
Referred pain, 57-59
Rehabilitation model, 69-70
Rotator cuff tear, 91-92
Scalene anticus syndrome, 96-100
Scapulohumeral rhythm, 35-39
Sherrington’s laws, 114
Sherrington’s reflex, 114
SITS muscles, 27-28, 34
Soft-tissue impairments, 1, 62-64
Symmetry test, 75
Thermotherapy, 106-109
Thixotropy, 114, 135-136
Thoracic outlet syndrome (scalene anticus syndrome), 96-100
Trigger points therapy, 115-128
Vertebrobasilar accidents, 48-49
Wolff’s law, 114

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HEMME APPROACH TO

NECK AND SHOULDER

INSTRUCTIONS FOR THE ANSWER SHEET

This course is not easy. Since 12 hours of continuing education credit

Above all else, please follow these three instructions:

X COMPLETE THE TOP OF THE ANSWER SHEET.

Y ANSWER QUESTIONS 1 THROUGH 50.

Z RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED.

Copyright, David H. Leflet, 1995

Published by HEMME APPROACH PUBLICATIONS

The author grants permission to photocopy limited portions of

Although the author has made every effort to ensure the

It is also the responsibility of the practitioner to determine the

HEMME APPROACH TO NECK AND SHOULDER PAIN

NECK AND SHOULDER PAIN ANSWER SHEET

Please circle the best answer.

HEMME APPROACH PUBLICATIONS

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

If we have permission to use your comments, please sign below.

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH ................................................................................ 42

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

MODALITIES ............................................................................................ 104

HEMME APPROACH TO NECK AND SHOULDER PAIN

Adhesions .............................................................................................. 137

EXERCISE ................................................................................................. 170

SELECTED BIBLIOGRAPHY.................................................................. 186

GLOSSARY ............................................................................................... 200

HEMME APPROACH QUIZ..................................................................... 214

INDEX ........................................................................................................ 224

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH SCIENTIFIC METHOD

1. Identify problem presented by the patient.

1. neuromuscular therapy: affects nerve and muscle tissue

HEMME APPROACH TO NECK AND SHOULDER PAIN

1. trigger point therapy (neutralize trigger points)

Anatomy and Physiology

A. flexion: a forward motion perpendicular to the scapula

HEMME APPROACH TO NECK AND SHOULDER PAIN

Horizontal abduction means about the same as horizontal extension and

A. elevation: upward movement of the scapula relative to the thorax

HEMME APPROACH TO NECK AND SHOULDER PAIN

A. flexion or extension: sagittal plane

Standard directional terms for describing body structures, locating

Although soft-tissue structures provide far more restraint in the shoulder

HEMME APPROACH TO NECK AND SHOULDER PAIN

HEMME APPROACH TO NECK AND SHOULDER PAIN

1. SCALENUS ANTERIOR (cervical)

2. SCALENUS MEDIUS (cervical)

3. SCALENUS POSTERIOR (cervical)

Shoulder and Back

4. BICEPS BRACHII (shoulder joint)

5. CORACOBRACHIALIS (shoulder joint)

HEMME APPROACH TO NECK AND SHOULDER PAIN

7. INFRASPINATUS (shoulder joint)

8. LATISSIMUS DORSI (shoulder joint)