Maddie Pedlar

Manual Therapy for the Shoulder Complex

Clinical Application Worksheet

Course Objectives Covered: 2, 3, 5, 9, 12, 13.

Associated CAPTE Standards:
- 7D20: Evaluate data from the examination to make clinical judgments.
- 7D27: Competently perform physical therapy interventions to achieve patient/client goals and outcomes.
- 7D30: Monitor and adjust the POC in response to patient/client status.

Instructions:
 Impairment/limitation is provided.
 Select 3 varying manual interventions (mobs, STM, stretching, MWM, PNF, etc.) that would be most
appropriate to address the impairment or functional limitation.
o Prescribe manual interventions not only from this course but also techniques learned in PTH646 or during
your clinical experience.
o Must provide a VARIETY of techniques/ideologies (Don’t use all Maitland mobs in one impairment)
 Provide intent and details/dosage for chosen techniques.
o Intent = to create change within a particular structure (joint capsule, connective tissue, soft tissue, neural
tissues) that will contribute to reducing/eliminating the dysfunction/impairment. (e.g. applying a sustained
inferior glide to the GH joint during active shoulder abduction allows for improved clearance of greater
tuberosity under acromion.)
o Details/Dosage = rate/rhythm, amplitude, relationship to barrier, frequency/duration, reps/sets as it relates to
the general purpose (e.g. joint decompression, reduce pain, improve mobility) and based on the
methodology/school of thought (e.g.. Maitland, Kaltenborn, Mulligan, etc.). Link the joint mobilization
grading descriptions to this.
 Practice hands-on techniques with your partner.
 Scoring: .25 pts. per item (technique = .25, intent for technique = .25, dosage/details = .25, multiplied x 3 for
each impairment/limitation).

1. Decreased GHJ external rotation

Technique Intent
1. STM: Start by applying sustained
Subscapularis pressure on the tender points of
the subscapularis. This will
reduce adhesions in the muscle
tissue and should be followed up
with shortening and lengthening
the affected UE while holding
that sustained pressure. By
focusing on the tender areas, it
will aid in reducing pain with
movement.
2. GHJ Anterior By applying large oscillatory
Glide of the motions with an anterior glide
humeral head in into the barrier, this will increase
the glenoid cavity tissue extensibility and create
(Maitland Grade space in the joint capsule,
III) allowing for greater shoulder
mobility.
3. MET: By using autogenic inhibition to
Infraspinatus the infraspinatus muscle, this
(isometric will allow for the patient to gain
contraction) mobility in GHJ external
Dosage/Details
Hold sustained pressure for ~30 seconds or until there is a
release of tension in the tissue. Follow with the muscle
shortening and lengthening by internally and externally
rotating the shoulder while holding that sustained pressure.
Perform for 90 seconds and repeat 3 times through.
The patient should feel pain relief with improved GHJ ER
ROM.
Maitland Grade III: large amplitude, taken to 50% R1-R2 (into
the barrier); perform anterior glide oscillations for 30 seconds,
1-2 sets, and 1-5 reps.
Patient should have improved GHJ ER ROM since there
should be less tissue restrictions within the joint capsule
following oscillatory motions.
First find the end-range of shoulder IR and apply pressure at
the barrier. The patient then performs an isometric contraction
(resisting IR) and working the infraspinatus muscle, holding
for 3-5 seconds. After the patient relaxes for ~3 seconds,
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rotation. This technique will
mobilize the GHJ by lengthening
and shortening the infraspinatus
when going into IR and ER.
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passively move the patient into their new end-range and find
the new barrier. Repeat this technique 3-5 times through.
Patient should demonstrate improved mobility in shoulder ER.

2. ACJ pain and “tightness” reported with high overhead reaching

Technique Intent Dosage/Details
1. STM: Pec Minor By hooking fingers beneath the Hold sustained pressure for ~30 seconds or until there is a
pec major, inferior to the release of tension in the tissue. Follow with the unlocking
coracoid process, find the tender spiral moving three fingers into a clockwise and counter-
points of the pec minor muscle clockwise motion. Perform for 90 seconds and repeat 3 times
belly. Start with a sustained through.
pressure and follow with an
unlocking spiral of the muscle The patient should report feeling less tightness with increased
tissues. This will allow for the mobility with overhead reaching.
tense tissue to break up and have
greater extensibility.
2. ACJ Inferior By applying small oscillatory Maitland Grade IV: small amplitude, taken to 50% R1-R2
Glide of the motions with an inferior glide of (into the barrier); perform inferior glide oscillations for 30
clavicle on the the clavicle into the barrier, it seconds, 1-2 sets, and 1-5 reps.
acromion will allow for a greater joint
(Maitland Grade space between the acromion and Patient should have improved ACJ ROM when overhead
IV) clavicle. With the increase of reaching and should feel less tightness and greater tissue
joint space and tissue extensibility/flexibility.
extensibility, the ACJ will be
able to freely move with
decreased pain and increased
mobility.
3. MWM: Stabilize Stabilizing the clavicle with Stabilizing the clavicle into a depressed position will allow the
clavicle when shoulder flexion will not allow patient to actively move their shoulder into flexion (overhead
moving into the clavicle to rotate backwards, reaching) with decreased pain and increased mobility.
shoulder flexion therefore will not allow for
compensation of the acromion
during the movement. The After the patient reports pain-free movement with the
acromion will be moving stabilization, have the patient actively move through shoulder
independently of the clavicle flexion (overhead reaching) for 5-10 reps.
when creating the upward
motion of the arm.

3. Limitations and pain with reaching behind back for wallet

Technique Intent Dosage/Details
1. GHJ Anterior By applying large oscillatory Maitland Grade II: large amplitude, stopping short of R1;
Glide of the motions with an anterior glide perform anterior glide oscillations for 30 seconds, 1-2 sets, and
humeral head on of the humeral head, this will 1-5 reps.
the glenoid cavity provide pain relief with
of the scapula shoulder movement. Providing Patient should have reduced pain and improved mobility when
(Maitland Grade oscillations of the humeral head reaching behind their back for their wallet.
II) in the glenoid cavity will allow
for improved reaching behind
motion and increased space in
the joint capsule.
2. MET: The subscapularis muscle will First find the end-range of shoulder ER and apply pressure at
Subscapularis be utilizing an autogenic the barrier. The patient then performs an isometric contraction
(isometric inhibition technique to improve to resist ER and work the subscapularis muscle, holding for 3-5
contraction) shoulder mobility to reach seconds. After the patient relaxes for ~3 seconds, passively
behind the back (IR). The move the patient into their new end-range and find the new
shoulder will move into IR and barrier. Repeat this technique 3-5 times through.
ER, which will shorten and
lengthen the muscle tissues Patient should demonstrate improved ability to reach behind
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involved in reaching behind the
back.
3. MWM for As the patient extends,
Functional internally rotates, and adducts
Ext/IR/ADD their arm as much as they can
handle, the PT stabilizes the
scapula superiorly/anteriorly
and pulls inferiorly on the
cubital fossa of the UE. By
having this stabilizing and
distracting force, it will allow
the patient to have assistance to
move into a greater ROM when
reaching behind their back.
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their back for their wallet.
Stabilizing the scapula and providing an inferior directional
force on the cubital fossa while the patient actively moves into
an extension/internal rotation/adduction motion, this will allow
for the motion to be pain-free. Once a pain-free full ROM is
achieved, repeat this for 5-10 reps.
Patient should have pain relief with movement and increased
mobility.

4. Limited scapular protraction and upward rotation

Technique Intent Dosage/Details
1. STM: Rhomboids By compressing the muscle Hold sustained pressure on the insertion point for ~30
tissues at the insertion point on seconds or until there is a release of tension in the tissue.
the scapula, this will put the Passively protract/retract and upwardly/downwardly rotate
tight tissues on slack and allow the scapula while applying the sustained hold for 90
for greater scapular mobility seconds and repeat 3 times through.
(protraction) when moving the
arm passively. As a compressive Patient should demonstrate improved scapular mobility.
force is being applied on the
rhomboids, a hook grip is
applied around the scapula to
perform scapular mobilizations
(protraction/retraction and
upward/downward rotation).
2. Scapular Framing the scapula with both Perform protraction/retraction and upward/downward
Mobilizations: hands will allow for a stabilizing rotation mobilizations to the scapula for 30 seconds, 1-2
Scapular Clocks grip on the patient, in which sets, and 1-5 reps.
scapular mobilizations in all
planes can be performed. When Patient should demonstrate improved scapular mobility in
the patient is in a side lying all planes.
position, mobilizing the scapula
in a protraction/retraction and
upward/downward rotation
motion, this will allow for the
movement to be pain-free and
improve overall mobility.
3. Functional Positional By applying a positional release Apply elevation to ribs 3-5 toward the coracoid process and
Release: Pec Minor on the pec minor, this will allow hold for 90 seconds. Reposition as needed and repeat 2-3
for the muscle tissue to have times if necessary.
greater extensibility and less
tension. The relaxed pec minor Patient should demonstrate improved scapular upward
will then allow the scapula to rotation and shoulder flexion ROM.
come out of a downwardly
rotated position, which in turn
will allow for improved scapular
upward rotation and shoulder
flexion ROM.

5. Significant decrease in shoulder flexion ROM

Technique Intent Dosage/Details
1. STM: Latissimus By applying a sustained pressure to Hold sustained pressure on the tender point of the lats for
dorsi the tender point of the latissimus ~30 seconds or until there is a release of tension in the
dorsi muscle, provide a “lumbrical tissue. Manually shorten and lengthen the surrounding
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grip” around the tender spot and
hold. Then, while applying the
sustained pressure, perform
shortening and lengthening of the
surrounding muscle tissues with
both hands to assist in relaxing the
muscle tissue back to its original
length.
2. GHJ Posterior By applying a sustained posterior
Glide of the glide to the humeral head, it will
humeral head on allow for greater extensibility of
the glenoid cavity the tissues and take up the slack of
of the scapula the joint capsule. This will assist in
(Kaltenborn allowing for a greater movement in
Grade III) shoulder flexion ROM. It will
allow the humeral head to have
more room in the joint capsule
when rolling beneath the glenoid
cavity of the scapula.
3. MWM Shoulder Providing a stabilizing force on the
Elevation with no scapula allows for no
belt compensation when elevating your
shoulder. The humeral head will
have to work independently when
rolling on the stable glenoid cavity
of the scapula, allowing for a fluid
motion.
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tissues while applying sustained pressure for 90 seconds and
repeat 3 times through.
Kaltenborn Grade III: stretch on joint capsule and
surrounding articular structures; get into R2. Hold for 7
seconds and repeat for 10 reps total. After about 5 reps are
performed, assess PROM of shoulder flexion, and then
perform another 7 second sustained hold with 5 more reps,
followed by another reassessment of shoulder flexion
PROM.
Patient should demonstrate improved mobility and joint play
following this stretch-mobilization.
Stabilizing the scapula into a depressed, retracted, and
downwardly rotated position will allow the patient to
actively move their shoulder into flexion with decreased
pain and increased ROM.
After the patient reports pain-free movement with the
stabilization, have the patient actively move through
shoulder flexion for 5-10 reps while applying the stabilizing
force.

6. OH thrower with adaptive shortening of the posterior GHJ capsule

Technique Intent Dosage/Details
1. MET: PNF UE D1 PNF allows for First find the end-range of shoulder D1 flexion and apply pressure
flexion/extension neuromuscular re-education at the barrier. The patient then performs an isometric contraction to
(isometric contraction) of the affected extremity. resist D1 extension, holding for 3-5 seconds. After the patient
Utilizing a UE D1 PNF relaxes for ~3 seconds, passively move the patient into their new
autogenic inhibition end-range and find the new barrier. Repeat this technique 3-5 times
technique will allow for through.
greater tissue flexibility and
improved shoulder mobility. Patient should demonstrate improved mobility with OH throwing.
The tissues involved in OH
reaching will be lengthened
and shortened when moving
in the D1 flexion/extension
motions.
2. Glenohumeral HVLAT addresses multiple Maitland Grade V: small amplitude, high velocity at R2 and
HVLAT planes of motion and will beyond; once the barrier is reached, apply a high-velocity low
(Maitland Grade allow for improved mobility amplitude thrust through the barrier. Perform once.
V) in the GHJ. Since adaptive
shortening of the posterior The patient should have improved all around shoulder mobility
capsule affects all-around with increased OH motion ability.
motions of the shoulder, a
HVLAT is a good option to
address all areas.
3. STM: Pec Major By mobilizing the pec major Hold sustained pressure on the tender point of the pec major for
in a perpendicular ~30 seconds or until there is a release of tension in the tissue.
deformation with the heel of Follow with the unlocking spiral moving three fingers into a
the hand, this will assist in clockwise and counter-clockwise motion. Finally, provide
breaking up tight muscle associated oscillations to the affected UE by grabbing hold of the
tissue and decrease tension. wrist and moving UE in all directions to relax the muscle tissue.

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After applying a sustained Perform the unlocking spiral and associated oscillations for 90
pressure to the pec major seconds each. Repeat the entire cycle twice through and reassess
muscle belly, perform the shoulder mobility of the overhead thrower.
unlocking spiral, and follow
that up with associated
oscillations to reduce the
muscle tension even further.
BONUS (not required, but +1 point overall if all scenarios listed below are completed per the following instructions):
For each listed dysfunction above, consider a therapeutic exercise to correspond and build off your manual therapy
intervention. Must consider:
- purpose and dosing (dosing specific for joint or soft tissue extensibility to improve ROM, improving strength, or
increasing endurance)
- a potential progression and regression of your chosen exercise based on patient capabilities and symptoms. This might
mean considering additional causes or contributions to the dysfunction listed: (e.g., soft tissue extensibility or muscle
recruitment limitations contributing to ACJ pain and limitations with OH reaching). Be creative!!

1. Decreased GHJ external rotation AROM.

a. Therapeutic exercise: Wand/cane external rotation in standing
b. Purpose: to improve GHJ flexibility and external rotation ROM
c. Dosing: perform exercise for 2 sets and 3 reps while holding the shoulder ER position for 30 seconds
d. Progression: utilize a theraband instead of a wand to improve ROM and work on strengthening shoulder
external rotators
e. Regression: perform wand exercise in supine to eliminate working against gravity

2. ACJ pain and “tightness” reported with high overhead reaching

a. Therapeutic exercise: wall slide with foam roller in standing
b. Purpose: strengthens serratus anterior and allows for greater shoulder mobility when overhead reaching
c. Dosing: perform wall slides 10x for 3 sets, while rolling up and down slow and controlled
d. Progression: wrap a theraband around both wrists while sliding up on the foam roller to provide resistance
and assist with shoulder strengthening
e. Regression: perform wall slides without the foam roller in standing or perform overhead slides while in
supine

3. Limitations and pain with reaching behind back for wallet.

a. Therapeutic exercise: behind the back shoulder stretch with towel in standing or sitting
b. Purpose: to stretch and improve flexibility of the internal rotators
c. Dosing: perform stretch 3x and hold for 30 seconds
d. Progression: perform shoulder stretch with a theraband instead of a towel to add resistance and improve
shoulder strength
e. Regression: perform shoulder stretch with hands behind back and fingers interlaced in standing or prone to
lessen the amount of stretch on the shoulders

4. Limited scapular protraction and upward rotation

a. Therapeutic exercise: prone scaption (Y’s) and supine serratus punch with dumbbells
b. Purpose: to strengthen shoulder muscles involved with upward rotation and protraction
c. Dosing: perform each exercise 10x for 3 sets
d. Progression: perform scaption (Y’s) in standing with dumbbells to force working against gravity and
perform a push-up “plus” to intensify strengthening the protractors
e. Regression: perform scaption table slides while sitting in a chair to eliminate resistance and have gravity
assist and perform supine serratus punch with body weight instead of adding dumbbells to lessen resistance

5. Significant decrease in shoulder flexion ROM

a. Therapeutic exercise: shoulder flexion AAROM in supine with wane/cane
b. Purpose: to improve shoulder mobility and strengthen shoulder flexor muscles
c. Dosing: perform exercise 3x with a 30 second hold
d. Progression: perform shoulder flexion AROM with theraband or dumbbells in supine to add resistance and
allow for shoulder flexor muscles to work harder
e. Regression: perform shoulder flexion AROM in prone with affected UE off the table

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6. OH thrower with adaptive shortening of posterior GHJ capsule

a. Therapeutic exercise: sleeper stretch in a side lying position
b. Purpose: to improve ROM of shoulder internal rotators
c. Dosing: hold stretch for 30 seconds for 3 reps and 2 sets
d. Progression: perform sleeper stretch with more overpressure and hold for 1-2 minutes if able to allow for a
greater stretch and increased flexibility
e. Regression: perform sleeper stretch in standing to have gravity assist