CHAPTER 13
The Shoulder
and Rib Cage
Introduction
Over the past decades, high-velocity, low-amplitude thrust (HVLAT) manipulation has been an effective means to treat a variety of shoulder problems, including frozen shoulder, general shoulder pain, scapular dyskinesis, impingement syndrome, rotator cuff injury and many more. Practitioners of manipulative therapy use various techniques, depending on the shoulder joint and/or lesion being treated. They primarily aim to alleviate muscular spasm, reposition a joint subluxation and fix ligamentous retraction (Lason and Peeters, 2014).
On the other hand, manipulation of the ribs or rib cage is usually performed to treat a number of chest and rib problems, including chest pain and tightness, asthma, pneumonia, rib pain and dysfunctions, rib fracture and dislocation, and middle back pain, to name a few. Manipulative therapy practitioners use hands-on manipulation techniques to improve mobility and function in the thoracic and rib-cage region. Therapeutically, they aim at addressing any specific dysfunctions in the region and increasing the strength of the surrounding muscles (William, Glynn and Cleland, 2015).
However, before deciding to perform a manipulative technique in both the shoulder and rib cage, a practitioner must make sure that no red flags or contraindications are present (Rivett, Thomas and Bolton, 2005). In addition, because adequate knowledge, skill and experience play a key role in preventing incidence of adverse events after manipulation, it is of critical importance for manual therapy practitioners to have appropriate training and education before applying a technique (World Health Organization, 2005; Ernst, 2007). They must know how to grade various manoeuvres and when to stop.
Therefore, this chapter is written to describe the various joints of the shoulder and rib cage, the range of motion in these joints and appropriate special tests to diagnose serious pathology in the regions. In addition, this chapter will also describe some of the common injuries to the shoulder and rib cage, and the red flags for manipulation.
Joints
The shoulder joint is one of the most complex joints in the human body. Unison of three bones – the humerus, scapula and clavicle – form this joint, connecting the upper extremity to the axial skeleton. These bones are positioned in a special harmony that allows very considerable movement of the shoulder in different stages of motion (Halder, Itoi and An, 2000). However, the shoulder joint lacks strong ligaments; for this reason, it heavily relies on the rotator cuff muscles for stability (Bigliani et al., 1996).
The rib cage, in contrast, is an osteocartilaginous frame in the chest, an arrangement of bones and cartilages that encloses the chest cavity and supports the shoulder girdle and upper extremities. It is made up of 12 pairs of ribs, the sternum and the 12 thoracic vertebrae (Mader, 2004). It shields the vital organs of the body, providing attachment sites for muscles and forming a semi-rigid chamber that can expand and contract during respiration (White and Folkens, 2005).
Table 13.1 The joints of the shoulder and rib cage | ||
Joint name | Description | Function |
Glenohumeral joint | •A multiaxial, ball-and-socket joint that is considered the most mobile in the body •Involves articulation between the humeral head and the lateral scapula •Responsible for linking the upper extremity to the trunk •Has mismatching and asymmetrical surfaces •Static stabilisers include the joint capsule, the labrum glenoidale, the articulating surfaces, the glenohumeral ligaments and the coracohumeral ligament | •Allows extensive mobility for upper extremities in almost all direction •Supports a wide range of motion, including flexion, extension, lateral and medial rotation, circular rotation, abduction and adduction |
Acromioclavicular joint | •A synovial joint at the top of the shoulder •Involves articulation between the lateral end of the clavicle and the medial edge of the acromion •Covered by a fibrous capsule and strengthened by the coracoacromial ligaments (the trapezoid and conoid ligaments) •Static stabilisers include the ligaments, intra-articular disc and capsule | •Serves to provide stability to the shoulder •Helps in transmitting forces between the clavicle and the acromion •Contributes to total arm movement |
•A synovial double-plane joint formed by the connection of the sternum’s upper portion and the clavicle’s medial end •Involves true articulation between the axial skeleton and the upper extremity •Consists of two sections, partitioned by a complete disc or meniscus •Static stabilisers include a thick capsule and supporting ligaments, such as costoclavicular, interclavicular and sternoclavicular ligaments | •Allows the clavicle to freely move in nearly all planes, allowing elevation, depression, protraction as well as retraction •Provides the shoulder the ability to thrust forward | |
Costovertebral joint | •A synovial joint that connects the head of the rib with the costal facets of adjacent vertebral bodies and the intervertebral disc in between •Composed of a fibrous capsule, the fan-shaped radiate ligament and the interarticular ligament | •Serves to support spinal movement •Helps the ribs to work in a parallel fashion while breathing |
Costochondral joint | •A hyaline cartilaginous joint that attaches the ribs to the costal cartilages •Involves articulation between the ribs and costal cartilage | •Serves to provide stability to the rib cage |
Costotransverse joint | •Forms when the tubercle of the rib articulates with the transverse process of the corresponding vertebra •Consists of a capsule, the neck and tubercle ligaments, and the costotransverse ligaments •Absent in T11 and T12 | •Helps the ribs to work in a parallel fashion while breathing |
Sources: Terry and Chopp (2000); Rockwood Jr et al. (2009); Van Tongel et al. (2012); Duprey et al. (2010); Palastanga and Soames (2011); Bontrager and Lampignano (2013) | ||
The shoulder joint is the most flexible and mobile joint in the entire human body. Its movements result from a complex dynamic relationship of bony articulations, tendinous restraints, ligament constraints and dynamic muscle forces (Terry and Chopp, 2000). The shoulder joint’s hyperactive mobility affords the upper extremity with a myriad range of motions, including abduction, adduction internal and external rotation, extension and flexion. In addition, the shoulder allows for scapular extension, ele-vation, depression and retraction (Quillen, Wuchner and Hatch, 2004). This extensive range of motion, in turn, enables the arm of the athlete to perform a versatile range of sports activities.
Table 13.2 Normal range of motion in the shoulder | |
Motion type | Range of motion |
Forward flexion | 180° |
Extension | 45–60° |
Abduction | 150° |
Internal rotation | 70–90° |
External rotation | 90° |
Source: Adapted from Moses (2007) | |
In contrast to the shoulder, the rib cage is one of the least mobile regions in the human body, although it allows required mobility for the respiratory cycle. However, this mobility is attributable to the sternal and vertebral joints and the costal cartilages at either end of the rib structure. More precisely, movements of the ribs primarily rely on the orientation of costovertebral and costotransverse joints, which are routinely subjected to continual movement (Yoganandan and Pintar, 1998). In general, the movements of the ribs are normally around two axes. The upper rib motion resembles a ‘pump-handle’ and the lower rib motion resembles a ‘bucket-handle’. The axis for rib motion is outlined as a line running between the costovertebral joint and the costotransverse joint via the rib neck. The axis for upper rib rotation (ribs 2–6) orients towards the frontal plane, whereas the lower ribs (excluding ribs 11 and 12) lie more towards the sagittal plane (Crooper, 1996).
Common Injuries
A major injury to the shoulder and rib cage is often caused by a fall, motor vehicle accident, violent activity, sport accident or penetrating trauma. Such injuries usually lead to a fracture, and subsequently to pain and poor functioning at the shoulder and rib-cage regions. However, the shoulder is more prone to injuries compared with the rib cage because of its hyperactive mobility (Sofu et al., 2014). It is a site of many common injuries, including rotator cuff tears, frozen shoulder, tendonitis, bursitis, fractures, strains, sprains, dislocations and separations. On the other hand, although motor vehicle accident has been found to be the most common mechanism of injury for rib cage, rib fracture is one of the most common injuries to the chest, occurring in approximately 10% of all patients admitted after blunt trauma (Liman et al., 2003).
Table 13.3 Common injuries of the shoulder and rib cage | |
Characteristics | |
Glenohumeral dislocation | •Occurs when the articulation between the head of the humerus and the glenoid fossa is moved out of contact •Approximately 96% of all shoulder dislocations are anterior, with the rest being posterior •The annual incidence rate is 17 per 100,000 population •Usually occurs in young and middle-aged people |
Clavicle fracture | •A common acute shoulder injury frequently caused by a fall on the lateral shoulder •Accounts for 2.6% to 5% of all fractures (about 1 in every 20 fractures) and 44% of all shoulder girdle injuries in adults •Accounts for 10% to 16% of all fractures in childhood •Affects 30–60 cases per 100,000 population globally •Occurs 2.5 times more commonly in men than in women |
Acromioclavicular sprain | •A common injury in athletes and active persons •Usually results when a direct blow or force is applied to the acromion with the humerus adducted •Accounts for roughly 12% of all shoulder dislocations •Affects males more commonly than females, with a ratio of around 5:1 •Men between their second and fourth decades of life have the highest frequency of incidence |
Proximal humerus fracture | •A quite rare fracture and has a poor prognosis •Responsible for 1% to 3% of all fractures, and roughly 20% of all fractures of the bone •Annual incidence in people 16 years or older is 14.5 per 100,000, although gradually increases from the fifth decade •Occurs more frequently in elderly people •Usually results from a fall on to an outstretched arm |
Rib fracture | •Often results from a direct blow to the chest, but may also occur because of coughing or forceful muscular activity of the upper limb or trunk •Most frequently affects ribs 7 and 10 •Occurs more often in older persons than in younger adults •Symptoms include severe well-localised pain, pain during deep inspiration or with movement and grating sound with breathing or movement |
Sources: Dala-Ali et al. (2012); Krøner, Lind and Jensen (1989); Khan et al. (2009); Jeray (2007); Zlowodzki et al. (2005); Lynch et al. (2013); Quillen et al. (2004); Ekholm et al. (2006); Melendez and Doty (2015); Ombregt (2003) | |
Red Flags
Red flags help to identify serious pathology in patients with chronic pain. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event due to manipulation.
Table 13.4 Red flags for serious pathology in the shoulder and rib cage | |
Condition | Signs and symptoms |
Acute rotator cuff tear | •Trauma •Acute disabling pain in the shoulder •Sensory deficits •Significant muscle weakness •Positive drop-arm test |
Neurological lesion | •Unexplained wasting •Significant neurological deficit (e.g. sensory or motor) •Persistent headaches |
Radiculopathy | •Severe radiating pain •Pins-and-needles sensation in shoulder |
Dropped head syndrome | •Severe neck extensor muscle weakness •Profound sparing of flexors •Chin-on-chest deformity •Neck stiffness •Weakness of shoulder girdle |
Unreduced dislocation | •Major trauma •Epileptic fit •Electric shock •Loss of rotation and normal shape |
Myocardial infarction | •Chest pain or discomfort •Pressure or tightness in the chest •Shortness of breath, sweating, pallor, tremors, lightheadedness and nausea •History of a sedentary lifestyle •Previous history of ischaemic heart disease, abnormally high blood pressure, diabetes, smoking, elevated triglyceride level and hypercholesterolemia •Age: men over 40 years and women over 50 years •Symptoms lasting for 30–60 minutes |
Pericarditis | •Sharp or stabbing chest pain over the centre or left side of the chest •Increased pain with deep breathing, swallowing, coughing or left-side lying • Related posts: Stay updated, free articles. Join our Telegram channel
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