Shoulder Anterior Structures PDF

SHOULDER: ANTERIOR STRUCTURES Trapezius: Upper Fibers The trapezius is composed of three muscle groups: upper, middle, and lower. The flat superficial fibers of the three groups span from the base of the head to the bottom of the thoracic cage. The upper fibers travel from the occiput laterally to...

SHOULDER: ANTERIOR STRUCTURES Trapezius: Upper Fibers The trapezius is composed of three muscle groups: upper, middle, and lower. The flat superficial fibers of the three groups span from the base of the head to the bottom of the thoracic cage. The upper fibers travel from the occiput laterally to the clavicle; the middle fibers travel horizontally from the thoracic vertebrae to the scapula and acromion; and the lower fibers course upward laterally from the thoracic vertebrae to the spine of the scapulae. The trapezius fibers, particularly the upper fibers, are frequent sites of lesions because of their role as a force couple with other intrinsic muscles of the shoulder and cervical spine. Trapezius: Upper Upper middle Lower middle Lower Posterior deltoid Origin: Occiput, medial third of the superior nuchal line Insertion: Clavicle (posterior lateral third) Action: Scapular stabilization and rotation, shoulder and scapular elevation (shoulder shrug), head rotation to the opposite side, capital extension, cervical extension, cervical lateral flexion Innervation: Accessory (XI) nerve Latissimus dorsi Palpation Procedure E6296/Speicher/Fig. • Place the patient prone,09.01/532238/JG/R2 and stand or sit facing the patient. • Grasp the upper trapezius gently with your near hand, much like grasping a hamburger, to demarcate the upper trapezius fibers from the middle trapezius fibers, which course superficially over the superior scapulae. • Palpate from the clavicular attachment site to the occiput. • Stack your forefinger and middle finger and strum with firm pressure from a posterior to anterior direction using the clavicle as a base against which to apply pressure. • Once the trapezius bends at the neckline, orient your fingers perpendicular to the cervical spine and decrease the palpation pressure while strumming the superficial fibers medial to lateral. • Note the location of any tender points or fasciculatory response along the muscle and its attachments. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. 202 Trapezius (upper fibers) palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES PRT Clinician Procedure • The patient is supine, and you are either seated or standing. • Move the head into lateral flexion toward the lesion; then apply capital lateral flexion and rotation toward the lesion. • With your far hand, place the patient’s elbow into the proximal sternum or abdomen. • Then, with your far hand, grasp the anterior aspect of the flexed elbow, which at this time is typically at 90° of flexion. • Move the patient’s involved arm with your far hand into flexion. The position of comfort is typically found at approximately 90 to 120°. • Once the flexion position is found by either eliciting the fasciculatory response or determining optimal tissue relaxation, move the arm through horizontal adduction and abduction with the far hand. Then apply humeral rotation with the far hand, typically marked external rotation. • With your far hand at the patient’s elbow, apply distraction and compression to facilitate optimal joint and tissue relaxation. • With the thenar aspect of your near hand, apply a light inferior glide to the humerus. • Corollary tissues treated: Sternocleidomastoid, splenius capitis, cervical spleni, levator scapulae, cervical multifidi, rotatores Trapezius (upper fibers) PRT clinician procedure. See video 9.1 for the trapezius (upper fibers) PRT procedure. Patient Self-Treatment Procedure • Lie supine. A sofa is an ideal place to perform this self-release. • Use your opposite hand to monitor the tissue for the fasciculatory response and tissue positioning to fine-tune the treatment position. • Place your head and neck in a laterally flexed position with your chin pointed toward the involved shoulder. • Support the elbow at 90 to 120° of shoulder flexion with the elbow slightly flexed and the hand relaxed on the sofa or pillows. Also move the arm into slight external rotation. The elbow should be supported against the back of a sofa or bolstered in the treatment position with pillows. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Trapezius (upper fibers) patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 203 SHOULDER: ANTERIOR STRUCTURES Subclavius The subclavius is found where its name dictates, under the clavicle. It is a slender muscle running between the first rib and the clavicle, deep to the pectoralis major, which can make its palpation challenging. The subclavius serves the vital function of stabilizing the sternoclavicular joint and assisting respiration; therefore, lesions of this muscle are often present when scalene, sternocleidomastoid, and trapezius lesions are also present. Additionally, lesions of this tissue also frequently disturb the normal arthrokinematics of the sternoclavicular joint. Origin: First rib and cartilage Subclavius Insertion: Clavicle (inferior third surface) Pectoralis minor Coracobrachialis Serratus anterior Action: Assists shoulder depression; stabilizes the sternoclavicular joint by moving the clavicle forward during shoulder motion; elevates the first rib during inhalation Innervation: C5-C6 (subclavian nerve arising from the brachial plexus) Palpation Procedure • Place the patient in either a side-lying or supine position. • With the elbow flexed, position the patient’s 09.02/532242/JG/R1 involvedE6296/Speicher/Fig. arm in slight horizontal adduction. • Using your thumb or fingers, curl them under the clavicle, strumming up and down the length of the clavicle. • Note the location of any tender points or fasciculatory response along the muscle. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient in a supine position. • Grasp the patient’s wrist with the far hand and pull the involved limb across the patient’s body toward the patient’s opposite hip. • With the far hand, move the arm up and down the patient’s opposite flank while keeping the limb extended. Typically, the treatment position is found just above the iliac crest of the opposite hip. • Apply limb distraction with internal limb rotation with the far hand. • Corollary tissues treated: Pectoralis minor and major • Alternate position: If the patient can’t tolerate limb distraction, place the patient in a side-lying position. Grasp the posterior shoulder and move 204 Subclavius palpation procedure. Subclavius PRT clinician procedure. it into a protracted, adducted position with the far hand. Fine-tune with scapular depression or elevation and rotation with the far hand. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES Anterior Acromioclavicular Joint Acromioclavicular joint Acromion Coracoid process First rib Clavicle Scapula Palpation Procedure E6296/Speicher/Fig. 09.03/532245/JG/R2-alw • Place the patient supine or in a seated position. • Trace the clavicle to its lateral tip until you feel a small valley; this is the AC joint. • Just lateral and posterior to the valley is the acromion. Explore the joint from anterior to posterior. • Note the location of any tender points or fasciculatory response at the joint articulation. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. The articulation between the acromion of the scapula and the acromial end of the clavicle forms the acromioclavicular (AC) joint. The AC joint is often a site of irritation in the presence of rotator cuff weakness. Lesions at this joint can be found either at its anterior or posterior aspects. Anterior AC joint palpation procedure. PRT Clinician Procedure • The straight-arm PRT procedure used for the subclavius can be used to treat the anterior aspect of the AC joint, with one exception: the diagonal arm position across the body should be placed at the level of the anterior inferior iliac spine or lower. • Corollary tissues treated: Subclavius, pectoralis minor and major Anterior AC joint PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 205 SHOULDER: ANTERIOR STRUCTURES Deltoid The fibers of the deltoid are composed of three separate groups: the anterior, middle, and posterior. The broad triangular multipennate fibers of the deltoid cover most of the shoulder, working primary to abduct the arm. The deltoid also serves as a force couple to the intrinsic rotator cuff musculature. Pectoralis major (clavicular) Anterior deltoid Origin: Anterior: Lateral third of the clavicle Middle: Scapula (acromion, lateral superior surface) Posterior: Scapula (lower posterior border of the scapular spine) Middle deltoid Insertion: Deltoid tuberosity Action: Anterior fibers: Shoulder flexion, internal rotation, and horizontal adduction Pectoralis major (sternal) Middle fibers (primarily): Shoulder abduction Posterior fibers: Shoulder extension, external rotation, and horizontal abduction Innervation: C5-C6 (axillary nerve) E6296/Speicher/Fig. 09.04/532248/JG/R1 Palpation Procedure • Place the patient supine or in a seated position. • Start at the anterior crease of the shoulder just below the clavicle. • The anterior fibers of the deltoid are located just lateral to the tendon of the long head of the biceps. • Using either your thumb or fingers, stroke perpendicularly across the anterior fibers until you feel a distinct separation at the most lateral aspect of the shoulder, where the middle fibers are found. Continue to move posteriorly across the middle fibers to the next valley, where the posterior fibers begin. • Distinct, firm pressure is needed to demarcate the fiber groups. • Explore the fibers from their proximal insertions to their common distal insertion at the deltoid tuberosity. • Note the location of any tender points or fasciculatory response at the muscle and its sites of attachment. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 206 Deltoid palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES PRT Clinician Procedure • The patient is supine. • Using your far hand, grasp the patient’s elbow and move the patient’s arm, with the elbow in a relaxed flexed position (approximately 90 to 100°). • Then move the arm into horizontal adduction (middle fibers only) with the far hand. • Apply humeral distraction or compression with your far hand; then a slight inferior humeral glide with your near hand. • Apply humeral rotation with the far hand for fine-tuning. • Corollary tissues treated: Pectoralis minor, coracobrachialis, long head of the biceps tendon, middle deltoid Deltoid (anterior and middle fibers) PRT clinician procedure. Patient Self-Treatment Procedure • Lie supine. A sofa is an ideal place to perform this self-release. • Support the elbow at 90° of shoulder flexion with the elbow relaxed. The elbow should be supported against the back of a sofa or bolstered in the treatment position with pillows. • Use the opposite hand to monitor the tissue for the fasciculatory response and tissue positioning once bolstered to fine-tune the treatment position. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Deltoid patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 207 SHOULDER: ANTERIOR STRUCTURES Biceps Brachii Long Head Tendon The biceps brachii is composed of two muscle bellies, the long and short heads. The tendon of the long head is more cylindrical than the tendon of the short head and can be easily located at the anterior crease of the shoulder. Lesions of the tendon of the long head of the biceps brachii are often present in conjunction with conditions of the shoulder such as impingement syndrome, rotator cuff weakness, and instability. Lesions at this tendon may be present when these shoulder conditions manifest because the tendon and muscle reverse their role from a secondary to primary shoulder stabilizer and mover, which may cause excessive eccentric load to the tendon–muscle complex. Origin: Supraglenoid tubercle, glenohumeral capsule Biceps brachii (long head) Insertion: Radial tuberosity, bicipital aponeurosis Biceps brachii (short head) Brachioradialis Brachialis Action: Elbow flexion and supination, stabilization and depression of the humeral head into the glenoid fossa with deltoid contraction Innervation: C5-C6 (musculocutaneous nerve) Pronator teres Anterior Palpation Procedure • Place the patient supine with the elbow flexed and forearm supported.09.05/532252/JG/R1 E6296/Speicher/Fig. • Place two fingers at the anterior crease of the shoulder, perpendicular to the tendon of the long head of the biceps. The long head of the biceps is located in the intertubercular groove of the humerus, just lateral to the anterior crease of the shoulder. • Resistive elbow flexion with supination will make the tendon under palpation more prominent. • Strum lightly over the long head of the tendon. • Note the location of any tender points or fasciculatory response at the tendon. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 208 Biceps brachii (long head tendon) palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES PRT Clinician Procedure • Place the patient supine. • Using your far hand, grasp the patient’s elbow and move the arm through shoulder flexion to approximately 90 to 120°. • Move the arm through horizontal adduction with the far hand. • With your far hand, rotate the forearm into a supinated position. • Apply humeral distraction and compression with your far hand. • Corollary tissues treated: Biceps brachii, brachialis, anterior and middle deltoids See video 9.2 for the biceps brachii (long head tendon) PRT procedure. Patient Self-Treatment Procedure • Lie supine. • Use the opposite hand to monitor the tissue for the fasciculatory response and tissue positioning once bolstered to fine-tune the treatment position. • Place the dorsum of the hand on the involved side on the forehead with the elbow flexed and shoulder at approximately 90°. • The elbow and shoulder should be either bolstered or placed against the back of a sofa or another immovable object. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Biceps brachii (long head tendon) PRT clinician procedure. Biceps brachii (long head tendon) patient selftreatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 209 SHOULDER: ANTERIOR STRUCTURES Biceps Brachii Short Head Tendon Biceps brachii (long head) Biceps brachii (short head) Brachioradialis Brachialis Pronator teres The biceps brachii short head tendon originates from the apex of the coracoid process and traverses inferiorly next to the long head merging distally to form the bicipital aponeurosis. Unlike the long head of the biceps, the short head does not play a major role in the stabilization of the humeral head with deltoid contraction. Typically, the coracoid process is sensitive to palpation; therefore, light palpation of the tendon’s origin is necessary to limit guarding from overpressure. Origin: Coracoid process of the scapula Insertion: Radial tuberosity, bicipital aponeurosis Action: Elbow flexion and supination Innervation: C5-C6 (musculocutaneous nerve) Anterior Palpation Procedure • Place the patient supine with the elbow flexed and forearm supported. E6296/Speicher/Fig. 09.05/532252/JG/R1 • Locate the clavicle and trace it over to the anterior crease of the shoulder. The coracoid process is just below the inferior margin of the clavicle, just medial to the anterior crease of the shoulder. • Lightly apply a circular pressure to feel the coracoid process. • Move distally off the coracoid process, orienting your fingers perpendicular to the short head tendon of the biceps brachii. • Strum lightly over the short head tendon, which is medial to the long head tendon. • Resistive elbow flexion with supination will make the tendon under palpation more prominent. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient supine. • With your far hand, grasp the patient’s elbow, positioning it at 90°, then move the arm into approximately 90 to 100° of shoulder flexion. • Using your far hand, move the arm into a 90/90 horizontal adduction position, then rotate the forearm into a supinated position. • Apply humeral distraction and compression using your far hand or your torso if just applying compression. 210 Biceps brachii (short head tendon) palpation procedure. Biceps brachii (short head tendon) PRT clinician procedure. • Apply humeral and forearm rotation for finetuning with the far hand. • Corollary tissues treated: Biceps brachii, brachialis, anterior and middle deltoids T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES Subscapularis Greater tubercle Supraspinatus The subscapularis is the largest of the rotator cuff muscles, covering the anterior surface of the scapulae. It is also the only rotator cuff muscle to medially rotate the arm because of its insertion site at the lesser tubercle of the humerus. Origin: Scapular fossa Insertion: Lesser tubercle of the humerus, glenohumeral joint capsule Subscapularis Teres minor Action: Shoulder internal rotation, glenohumeral joint stabilization Innervation: C5-C6 (upper and lower subscapular nerves) Anterior Palpation Procedure • Place the patient in a side-lying position. • Flex the shoulder to approximately 70 to 90° and apply distraction anteriorly to pull the 09.07/532259/JG/R1 scapulaE6296/Speicher/Fig. off the chest wall. • While holding the arm, use your thumb or fingers to explore the inferior lateral margin of the scapula. While attempting to locate the inferior lateral surface of the scapulae, move under the latissimus dorsi and teres major during palpation. • Once your fingers or thumb are on the subscapular fossa, instruct the patient to internally rotate the arm to accentuate the subscapularis for palpation. Only the inferior margin of the subscapularis will be accessible to palpation. • Alternately, the patient can be palpated supine. When palpating supine, the arm and elbow should be in a supported 90/90 flexed position; apply slight distraction at the elbow. • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient supine. • With your far hand, grasp the arm above the elbow. • Using your far hand, move the shoulder into approximately 30° of extension and abduction. Subscapularis palpation procedure. Subscapularis PRT clinician procedure. • Apply humeral internal rotation with your far hand. • Using your far hand, apply humeral distraction or compression. • Corollary tissues treated: Latissimus dorsi, serratus anterior, teres major T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 211 SHOULDER: ANTERIOR STRUCTURES Serratus Anterior The majority of the serratus anterior is not accessible to palpation because of its coverage by the scapulae, latissimus dorsi, and pectoralis major. However, as its fibers extend anteriorly around the thorax, its axillary fibers are accessible to palpation. Traditionally in therapy, the serratus anterior is dubbed the punching muscle because it assists in the protraction of the scapula when reaching forward. It also stabilizes the scapula against the chest wall to prevent winging and works with the upper and lower trapezius in a force couple to facilitate upward scapular rotation. Subclavius Origin: Ribs 1 through 8 (often 9 and 10 also) Pectoralis minor Coracobrachialis Serratus anterior Insertion: Scapula (ventral surface at vertebral border) Action: Scapular abduction, upward rotation, and depression; stabilizes the scapulae against the thoracic wall Innervation: C5-C7 (long thoracic nerve) Palpation Procedure • Place the patient supine or in a seated position. • The axillary fibers of the serratus anterior are located between the margins of the pectoralis E6296/Speicher/Fig. 09.02/532242/JG/R1 major and latissimus dorsi. • Place your fingers within the axillary region on the rib cage, just underneath the lower margin of the pectoralis major. • Orient your fingers perpendicular to the fibers of the serratus anterior or lay them across the ribs, pointing toward the head. • The serratus anterior musculature has a soft speed-bump feel as you strum across their fibers. • To accentuate palpation of the muscle, have the patient punch the arm toward the ceiling against your resistance while palpating. • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Serratus anterior palpation procedure. PRT Clinician Procedure • The patient is supine with the knees bolstered. • While palpating the serratus anterior with the near hand, grasp the patient’s wrist with your far hand and move the arm into approximately 20 degrees of shoulder flexion. 212 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES • Using the far hand, move the arm through adduction and abduction. Typically, the treatment position of the arm is found either at the side of the patient’s torso or in slight adduction over the ipsilateral anterior hip. • With the far hand, apply marked distraction of the arm downwards towards to the ipsilateral hip. • With the far hand, apply internal rotation to the arm. • Fine-tune with application of wrist extension or flexion with the far hand. • Corollary tissues treated: Teres major, latissimus dorsi, obliques, diaphragm, intercostals See video 9.3 for the serratus anterior PRT procedure. Serratus anterior PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 213 SHOULDER: ANTERIOR STRUCTURES Pectoralis Minor The pectoralis minor lies on the upper thorax underneath the pectoralis major. The fibers of the pectoralis minor are oriented perpendicular to those of the pectoralis major and course inferiorly from the coracoid process to their rib attachments to form the anterior wall of the axillary region. Because the neurovascular bundle of the neck and shoulder pass under the pectoralis minor, lesions of the pectoralis minor can result in neurovascular compression, which may facilitate the development of thoracic outlet syndrome. Subclavius Origin: Ribs 3 through 5 Pectoralis minor Coracobrachialis Serratus anterior Insertion: Coracoid process of the scapulae (medial and superior surface) Action: Scapular protraction and abduction, rib elevation during forced inspiration (when scapula is fixed), scapular depression Innervation: C5-T1 (medial and lateral pectoral nerves) Palpation Procedure • Position the patient supine. • The pectoralis minor can be palpated indirectly throughE6296/Speicher/Fig. application of deep palpation across its 09.02/532242/JG/R1 fibers, but over and through the anterior aspect of the pectoralis major. This palpation procedure is less painful than accessing the pectoralis minor under the pectoralis major which is also detailed below. • To palpate the pectoralis minor directly, abduct the arm to expose the axillary region. • Gently slide your fingers under the lateral border of the pectoralis minor and onto the anterior chest wall. • While palpating inward, you will feel the lateral border of the pectoralis minor. Move your fingers inward and down in a strumming fashion to feel the fibers of the pectoralis minor. Be careful to use gentle pressure when utilizing this palpation method because it is often very painful. • To accentuate palpation of the muscle, ask the patient to depress the shoulder during palpation. • Patients with a large amount of breast tissue can be positioned in a side-lying position to move the tissue and the pectoralis major off the anterior chest wall. The palpation procedure in this position is the same as described earlier. • Note the location of any tender points or fasciculatory response at the muscle. 214 Pectoralis minor palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The treatment is similar to that used for the subclavius, with the exception of often applying a greater amount of humeral distraction and internal rotation. • Place the patient in a supine position. • Grasp the patient’s wrist with the far hand and pull the involved limb across the body toward the opposite hip. • With the far hand, move the arm up and down the patient’s opposite flank while keeping the limb extended. • Apply significant limb distraction with marked internal limb rotation with the far hand. • Alternate position: Place patients who can’t tolerate limb distraction in a side-lying position. With the far hand, grasp the posterior shoulder and move it into a protracted, adducted position. Using the far hand, fine-tune with scapular depression or elevation and rotation. • Corollary tissues treated: Pectoralis major, subclavius, AC joint Pectoralis minor PRT clinician procedure. ○○ ○○ ○○ T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 215 SHOULDER: ANTERIOR STRUCTURES Pectoralis Major The fibers of the pectoralis major are separated into two major divisions: the clavicular (upper) portion and the sternocostal (middle and lower) portion. The two divisions form part of the anterior axillary wall. Fibers from both divisions converge into a common tendon to insert on the humerus. Origin: Clavicular fibers: Clavicle (sternal half) Pectoralis major (clavicular) Anterior deltoid Sternocostal fibers: Sternum (anterior surface), ribs 1 through 6, 2 through 6 rib cartilage, aponeurosis of obliquus externus abdominis Insertion: Greater tubercle of the humerus Middle deltoid Action: All fibers: Shoulder adduction, internal rotation, horizontal adduction; thorax elevation during forced inspiration (with both extremities fixed) Pectoralis major (sternal) Clavicular fibers: Shoulder internal rotation, flexion Sternocostal fibers: Shoulder extension Innervation: Clavicular fibers: C5-C7 (lateral pectoral nerve) E6296/Speicher/Fig. 09.04/532248/JG/R1 Sternocostal fibers: C6-T1 (medial and lateral pectoral nerves) Palpation Procedure When palpating the pectoralis major of women, it is advisable to palpate around the breast tissue, not directly through it. Because many women feel uncomfortable with palpation in this area, explain why palpation in this area is needed and how it will be done before proceeding. Most important, gain consent from the patient before performing the palpation procedure. The two methods for moving the breast tissue away from the chest wall to gain access to the pectoralis major and other chest wall muscles are to (1) place the patient in a side-lying position, which will facilitate the breast tissue to fall away from the chest wall, or (2) have the patient manually move the breast tissue medially. In the side-lying position: • Support the arm at the elbow while slightly flexing the shoulder upward. • Apply slight distraction to the shoulder at the elbow. • The pectoralis major can be grasped with the thumb underneath its inferior border while the fingers above are in position to strum across the clavicular and sternocostal fibers. • During palpation, passively flex and extend the shoulder to accentuate the upper and lower fibers. 216 Pectoralis major palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES In a supine position: • Slightly abduct the shoulder. • Locate the inferior medial clavicle and lateral surface of the sternum. From this location, drop your fingers off the bony structures and onto the clavicular fibers. • Orient your fingers perpendicular to the fibers and strum across them toward their common tendon at the coracoid process. • Continue to explore the middle and inferior sternocostal fibers in the same way you explored the clavicular fibers. • Ask the patient to internally rotate the shoulder to accentuate palpation of the muscle fibers. For both positions: • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Pectoralis major PRT clinician procedure. PRT Clinician Procedure • Place the patient supine. • Using the far hand, grasp the patient’s wrist with your dominant hand. • For the clavicular fibers, pull the arm across the chest above the nipple line. • For the sternal fibers, pull the arm diagonally across the chest at or below the nipple line. • With your far hand, apply humeral distraction and internal rotation. • Corollary tissues treated: AC joint, pectoralis minor, sternalis, sternocostal joint, serratus anterior T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 217 SHOULDER: POSTERIOR STRUCTURES Supraspinatus Greater tubercle Supraspinatus Infraspinatus The supraspinatus is one of the four rotator cuff muscles, which form the acronym SITS (supraspinatus, infraspinatus, teres minor, subscapularis). The muscle occupies the entire supraspinous fossa, traversing under the acromion as a tendon to insert on the greater tubercle of the humerus. A common method to place more emphasis on the supraspinatus during muscle testing is to use the empty can orthopedic special test. Origin: Supraspinous fossa of the scapula Insertion: Humerus (greater tubercle) Action: Shoulder abduction, shoulder external rotation, humeral head stabilization in the glenoid fossa Teres minor Posterior Palpation Procedure • To promote relaxation of the shoulder girdle, palpate while the patient is in a supine position, but you can also perform the palpation with the patient seated if necessary. E6296/Speicher/Fig. 09.11/532271/JG/R1 • Locate the spine of the scapula, then, using one or two fingers, strum the fibers of the supraspinatus either against or away from it, demarcating the fibers of the supraspinatus that run parallel to the scapular plane. • Follow the belly of the supraspinatus as it courses under the acromion. When the tendinous aspect is reached, strum over the fibrous tendon. • To accentuate this muscle, instruct the patient to abduct or externally rotate the humerus (or do both) during palpation. • Note the location of any tender points or fasciculatory response at the muscle, the tendon, or the supraspinatus attachment at the humeral head. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient supine and, with your far hand, move the shoulder into flexion and abduction while supporting the elbow with your far hand or torso. • The supraspinatus is typically most relaxed at 120° of abduction, with a greater amount of horizontal adduction positioning needed than the infraspinatus PRT procedure. 218 Innervation: C5-C6 (suprascapular nerve) Supraspinatus palpation procedure. Supraspinatus PRT clinician procedure. • With your far hand, apply external rotation. • Apply humeral distraction or compression with your far hand or torso to promote relaxation. • If possible, use the thenar aspect of your near hand to apply an inferior glide to the humerus to facilitate further relaxation. • Corollary tissues treated: Infraspinatus, upper trapezius, middle deltoid, teres minor T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES Infraspinatus Greater tubercle Supraspinatus Infraspinatus The infraspinatus, the I in the SITS acronym for the rotator cuff group, also assists the other rotator cuff muscles to stabilize the humeral head in the glenoid fossa, particularly during overhead movements. The infraspinatus is composed of three distinct muscle bellies that can be palpated individually. The infraspinatus occupies most of the infraspinous scapular fossa, but its tendon, unlike that of the supraspinatus, does not traverse under the acromion. Rather, it crosses over the lateral border of the scapular spine to attach to the humerus. Lesions of the infraspinatus are common when rotator cuff weakness or impingement is present. Origin: Scapula (infraspinous fossa) Teres minor Insertion: Humerus (greater tubercle) Posterior Action: Shoulder external rotation, humeral head stabilization in the glenoid fossa Innervation: C5-C6 (suprascapular nerve) Palpation Procedure • Place the patient prone or supine. • Locate the spine of the scapula. E6296/Speicher/Fig. 09.11/532271/JG/R1 • Using one or two fingers, strum the upper fibers of the infraspinatus upwards against the spine of the scapula and for the middle and inferior fibers, pin and strum them against the scapula. With the patient supine, gravity and the weight of the thorax can be used to facilitate palpation of the infraspinatus against the scapula. • Follow the belly of the infraspinatus as it courses over the lateral border of the scapula. • To accentuate this muscle, instruct the patient to externally rotate the humerus during palpation. • Note the location of any tender points or fasciculatory response at the muscle, the tendon, or its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Infraspinatus palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 219 SHOULDER: POSTERIOR STRUCTURES Infraspinatus > continued PRT Clinician Procedure • Place the patient supine. • With your far hand, move the shoulder into flexion and abduction while supporting the elbow with your far hand or torso. • Typically, the infraspinatus requires minimal horizontal adduction positioning, unlike the supraspinatus. • The infraspinatus is typically most relaxed at 100 to 120°. • With your far hand, apply external rotation. • Apply humeral distraction or compression with your far hand or torso to promote relaxation. • If possible, use the thenar aspect of your near hand to apply an inferior glide to the humerus to facilitate further relaxation. • Corollary tissues treated: Supraspinatus, upper trapezius, middle deltoid, teres minor Infraspinatus PRT clinician procedure. See video 9.4 for the infraspinatus PRT procedure. 220 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES Teres Minor Greater tubercle Supraspinatus The last of the three rotator cuff muscles to produce external shoulder rotation, the teres minor lies directly medial to its cousin, the teres major, and inferior to the infraspinatus. This small cylindrical muscle is located along the upper lateral edge of the scapula. Origin: Scapula (proximal two thirds of the dorsal axillary border) Infraspinatus Insertion: Humerus (greater tubercle) Action: Shoulder external rotation, humeral head stabilization in the glenoid fossa, shoulder adduction (weak) Teres minor Innervation: C5-C6 (axillary nerve) Posterior Palpation Procedure • Place the patient prone or supine. • Locate the lateral axillary border of the scapula. • Strum across the upper lateral axillary border E6296/Speicher/Fig. 09.11/532271/JG/R1 of the scapula to locate the muscle belly of the teres minor, which can be grasped between the fingers at the axilla much like a hamburger. • During palpation, instruct the patient to externally and internally rotate the arm to help you differentiate between the teres minor and teres major. The teres minor will contract with external rotation but not internal rotation. • Note the location of any tender points or fasciculatory response at the muscle, tendon, or its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient can be treated in either a supine or a prone position. • With your far hand, support the shoulder at the forearm and elbow. The elbow can also be supported on your knee. • With your far hand, move the shoulder into approximately 20 to 30° of extension. • Apply marked external rotation with your far hand. • Apply humeral compression or distraction with your far hand to create further relaxation. • Corollary tissues treated: Infraspinatus, supraspinatus, subscapularis, posterior deltoid Teres minor palpation procedure. Teres minor PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 221 SHOULDER: POSTERIOR STRUCTURES Teres Major Infraspinatus Teres minor Teres major Rhomboid major Even though the teres major and teres minor share a name, the teres major is not considered a rotator cuff muscle. The teres major rotates the arm internally, whereas the teres minor rotates the arm externally. The teres major is oriented along the lateral border of the scapula, and its tendon lies behind the latissimus dorsi (the tendons of both converge for a brief period). Because of its anatomical relationship and similar muscle action, the teres major functions as a synergist with the latissimus dorsi. Origin: Scapula (dorsal surface) Insertion: Humerus (lesser tubercle) Action: Shoulder internal rotation, adduction, and extension Innervation: C5-C6 (lower subscapular nerve) E6296/Speicher/Fig. 09.14/532280/JG/R1 Palpation Procedure • Place the patient prone or supine. • Locate the lateral border of the scapula. • Grasp the lateral border of the scapula with your thumbs and fingers much like you would a hamburger, and strum the teres major against the dorsal lateral surface of the scapula. • Follow the fibers proximally as they converge with the latissimus dorsi at the axillary region. • To accentuate the palpation of this muscle, have the patient internally rotate the arm. • Note the location of any tender points or fasciculatory response at the muscle, tendon, or its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient can be treated in either a supine or a prone position. • With your far hand, support the shoulder at the forearm and elbow. The elbow can also be supported on your knee. • With your far hand, move the shoulder into approximately 20 to 30° of extension. • Apply marked internal rotation with your far hand. • Apply humeral compression or distraction with your far hand to promote further relaxation. • Corollary tissues treated: Latissimus dorsi, subscapularis, posterior deltoid 222 Teres major palpation procedure. Teres major PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES Latissimus Dorsi Trapezius: Upper Upper middle Lower middle Lower Posterior deltoid Latissimus dorsi The superficial and thin fibers of the latissimus dorsi, one of the broadest muscles in the body, ascend from the low back to cover the posterior thorax to the axilla. The winglike appearance of the back formed during a bodybuilding pose is produced from the contraction of the latissimus dorsi. The superior fibers are almost horizontal, but as they pass over the scapulae, they move into a more vertical orientation distally. Origin: T6-T12 spinous processes, L1-L5 spinous processes via the thoracolumbar fascia, ribs 9 through 12, posterior third of the ilium, supraspinous ligament Insertion: Humerus (intertubercular groove) Action: Shoulder extension, adduction, and internal rotation; spine hyperextension; pelvis elevation with arms fixed Innervation: C6-C8 (thoracodorsal nerve) Palpation Procedure • Place the patient prone.09.01/532238/JG/R2 E6296/Speicher/Fig. • Locate the lateral border of the scapula. • Grasp the fibers of the latissimus dorsi and teres major at the lateral border of the scapula and roll them between the fingers to feel the demarcation between them. The most lateral fibers are those of the latissimus dorsi. Trace the fibers superiorly and inferiorly. • To accentuate the muscle, ask the patient to extend the arm toward the feet against resistance. • Note the location of any tender points or fasciculatory response at the muscle, tendon, or its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient can be either prone or supine. • With your far hand, place the arm in approximately 30° of extension. • Adduct and abduct the arm with your far hand until you feel the fasciculatory response or maximal relaxation, or both. • Using your far hand, apply humeral internal rotation. • Apply humeral distraction or compression by grasping above the wrist with the far hand. Latissimus dorsi palpation procedure. Latissimus dorsi PRT clinician procedure. • Corollary tissues treated: Teres major, lower trapezius T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 223 SHOULDER: POSTERIOR STRUCTURES Posterior Acromioclavicular Joint Acromioclavicular joint Palpation Procedure • Place the patient prone. • Trace the clavicle to its lateral tip until you feel a small valley, which is the AC joint. E6296/Speicher/Fig. 09.16/532286/JG/R1 • Just lateral and posterior to the valley is the acromion. Explore the joint from its anterior to its posterior joint line. • Note the location of any tender points or fasciculatory response at the joint articulation. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient prone. • Stand on the side opposite the side of the shoulder to be treated. • Using your far hand, move the arm into extension and adduction while applying humeral distraction across the body to the patient’s opposite hip. • Apply internal humeral rotation with your far hand above the patient’s wrist. • Corollary tissues treated: Inferior trapezius, serratus posterior, rhomboids 224 The articulation between the posterior aspect of the acromion of the scapula and the acromial end of the clavicle forms the posterior acromioclavicular (AC) joint. The posterior AC joint is often a site of irritation in the presence of rotator cuff tear and weakness. Lesions at this joint can be found at either its anterior or posterior aspects. Posterior AC joint palpation procedure. Posterior AC joint PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES Trapezius: Lower Fibers Trapezius: Upper Upper middle Lower middle Lower Posterior deltoid Latissimus dorsi Palpation Procedure • Place the patient prone. E6296/Speicher/Fig. 09.01/532238/JG/R2 • Locate the lower border of the scapular spine and the T12 spinous process. The lower fibers of the trapezius course between these two locations. • Because the lower fibers of the trapezius are superficial and thin, ask the patient to raise the arms in a superman position to bring out their density under palpation. • Strum lightly across the lower fibers with the palpation fibers oriented toward the opposite scapula. • Note the location of any tender points or fasciculatory response at the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient in a prone position with the head and neck in slight extension, if possible. • Stand on the opposite side to be treated. • Use the posterior AC joint PRT clinician procedure, but apply marked humeral distraction with the far hand. • Alternatively, grasp the shoulder with your far hand and apply shoulder depression, retraction, and medial rotation. The trapezius is composed of three muscle groups, upper, middle, and lower. The lower fibers course upward laterally from the thoracic vertebrae to the spine of the scapula. The lower fibers work in concert with the upper fibers to produce scapular depression. Origin: T6-T12 spinous processes, supraspinous ligaments Insertion: Scapular spine Action: Scapular adduction, depression, and upward rotation Innervation: C3-C4 (cervical plexus) with contribution from the accessory (XI) nerve Trapezius (lower fibers) palpation procedure. Trapezius (lower fibers) PRT clinician procedure. • Corollary tissues treated: Posterior AC joint, latissimus dorsi, serratus posterior, thoracic erector spinae, rhomboid major T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 225 SHOULDER: POSTERIOR STRUCTURES Rhomboid Minor Rectus capitis posterior minor Superior oblique Rectus capitis posterior major Inferior oblique Longissimus capitis Levator scapulae Rhomboid minor Rhomboid major The rhomboid minor is located just above its neighbor, the rhomboid major. The rhomboid minor courses the medial border of the scapula in line with the scapular spine to the spinous processes of C7-T1. The minor and major both lie deep to the trapezius, but are superficial to the thoracic erector spinae; therefore, firm palpation is needed to demarcate their fibers. Lesions of these tissues are present in most people with poor postural control (e.g., rounded shoulders) or with conditions of the shoulder. Origin: C7-T1 spinous processes, lower ligamentum nuchae Insertion: Scapula (root of the spine on the medial or vertebral border) Action: Scapular adduction, downward rotation, and elevation Innervation: C5 (dorsal scapular nerve) Palpation Procedure • Place the patient prone. E6296/Speicher/Fig. 09.18/532292/JG/R1 • Locate the spine of the scapula and trace over to its vertebral border. The fibers of the rhomboid minor insert on the scapula at this location. • Stack your forefinger and middle finger and strum across the fibers of the rhomboid minor with the tips of your fingers oriented toward the shoulder of the same side. • Note the location of any tender points or fasciculatory response at the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Rhomboid minor palpation procedure. PRT Clinician Procedure • Place the patient prone. • Stand on the opposite side of the shoulder to be treated. • With your far hand, grasp the cap of the shoulder and depress the shoulder down toward the opposite hip while applying scapular adduction. • Apply scapular rotation (clockwise) with your far hand. • Tip the vertebral border of the scapula down toward the rib cage with either your far thumb or your far hand or forearm. 226 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES • With the palm of your near palpation hand, translate the fascia and muscular tissues up toward the rhomboid minor in line with the orientation of its fibers. The palm should be placed on the opposite side of the vertebral column, if possible. • Corollary tissues treated: Rhomboid major, trapezius (upper and middle fibers), infraspinatus, supraspinatus See video 9.5 for the rhomboid minor PRT procedure. Rhomboid minor PRT clinician procedure. Patient Self-Treatment Procedure • Lie prone. • Place a pillow under the anterior aspect of the shoulder to encourage scapular retraction or adduction. • Place the shoulder in a slightly depressed position with the palm facing up. • This self-treatment procedure can also be used for the rhomboid major. • Maintain the treatment position until the fasciculatory response abates or for three to five minutes. Rhomboid minor self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 227 SHOULDER: POSTERIOR STRUCTURES Rhomboid Major Rectus capitis posterior minor Superior oblique Rectus capitis posterior major Inferior oblique Longissimus capitis Levator scapulae Rhomboid minor Rhomboid major The rhomboid major and rhomboid minor perform similar actions at the shoulder. However, because of the major’s fiber orientation and size, it produces more powerful scapular adduction. Lesions of the rhomboid major are prevalent in the majority of the population because of the postural demand on these fibers, but they are most prevalent in those who exhibit shoulder girdle weakness. Origin: T2-T5 spinous process, supraspinous ligament Insertion: Scapula (between the scapular root and the inferior scapular angle) Action: Scapular adduction, downward rotation, and elevation Innervation: C5 (dorsal scapular nerve) Palpation Procedure • Place the patient prone. E6296/Speicher/Fig. 09.18/532292/JG/R1 • Locate the spine of the scapula and trace over to its vertebral border. The upper fibers of the rhomboid major insert on the scapula at this location; the lower fibers, at the inferior angle. • Stack your forefinger and middle finger and strum across the fibers of the rhomboid major with the tips of your fingers oriented vertically toward the head. • Note the location of any tender points or fasciculatory response at the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Rhomboid major palpation procedure. PRT Clinician Procedure • Place the patient prone. • Stand on the opposite side of the shoulder to be treated. • With your far hand, grasp the middle of the upper arm pinning it against the side of the thorax. 228 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES • Pull the arm toward you with your far hand. Keeping the arm in contact with the thorax will retract the scapula and rotate the thorax toward the spine. • Tip the vertebral border of the scapula down toward the rib cage with either your far thumb or your far hand or forearm. • With the palm of your near palpation hand, translate the fascia and muscular tissues horizontally toward the rhomboid major in line with the orientation of its fibers. The palm should be on the opposite side of the vertebral column, if possible. • Corollary tissues treated: Rhomboid minor, trapezius (middle fibers), serratus anterior, thoracic erector spinae Rhomboid major PRT clinician procedure. Patient Self-Treatment Procedure See the rhomboid minor self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 229 SHOULDER: POSTERIOR STRUCTURES Levator Scapulae Levator scapulae Rhomboids Supraspinatus Teres minor Infraspinatus Teres major The levator scapulae extends from the superior angle of the scapula to the transverse processes of C1-C4. Its fibers are deep to the trapezius, but reveal themselves for palpation at the lateral neck, bracketed between the splenius capitis and posterior scalene. The inferior fibers, which arise from the superior angle of the scapula, can be palpated indirectly through the trapezius fibers. Origin: C1-C4 transverse processes Insertion: Superior angle of the scapula Action: Scapular elevation, abduction, and downward rotation; cervical extension; lateral flexion and rotation to the same side Innervation: C3-C4 (ventral rami); C5 (dorsal scapular nerve) Palpation Procedure E6296/Speicher/Fig. 08.10/532205/JG/R1 • The patient should be prone or in a seated position. • Locate the vertebral border of the scapula and trace it upward to the superior angle or tip of the scapula. • Stack your forefinger and middle fingers and orient them toward the middle of the upper trapezius. • To access the inferior fibers of the levator scapulae at the scapula, apply firm downward pressure over and through the middle trapezius fibers and strum across the fibers to feel their density. • Note the location of any tender points or fasciculatory response along the muscle and its scapular attachment. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient prone. • With your far hand, move the arm through abduction while palpating the inferior fibers of the levator scapula through the overlying trapezius fibers with the near hand. Once the most relaxed position or fasciculatory response is felt, stabilize the arm against the edge of the treatment table with your leg. • Place the thenar aspect of your far hand at the lower lateral border of the scapula with your fingers oriented over the superior scapular angle. 230 Levator scapulae palpation procedure. Levator scapulae PRT clinician procedure. • With your far hand, translate the scapula upward; then apply rotation with your dominant hand. • Tilt the superior angle of the scapula downward with the fingers of your far hand. • Corollary tissues treated: Trapezius (upper fibers), rhomboid minor T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics.