Download Think Outside the Box and Spine †Part 6‡: Shoulders and Elbows

Think Outside the Box and Spine (Part 6): Shoulders and
Elbows
By Kevin M. Wong, DC
During the course of this series of articles, of which this is the sixth and final installment, I have enjoyed
teaching you about the kinematic chain from the ground up: feet, ankles, knees, hips, wrists and hands.
From the beginning, I have tried to paint a clear picture of how biomechanical problems that begin in the
extremities can affect the entire axial kinematic chain clear up to the head. I hope you have found the
journey insightful and useful for your practice thus far.
Now, our focus shifts to the shoulders and elbows. We all realize how important these upper extremity areas
are and we experience this on a daily basis in the patients we treat. In the Oct. 7, 2011 issue of DC, I wrote
an article called "Shoulder Pain: Practical Tips for Examination and Treatment." I went into specific details
in a discussion on the shoulder that we will not delve into for this article. Here, let’s specifically address the
major misalignment patterns and concepts to keep in mind when treating your patients.
The Shoulder
The shoulders are an extremely common area in which to have pain and dysfunction. Frequently we see
patients who have come from some other type of health care practitioner. Orthopedists, neurologists and
physical therapists are a few of the health care providers who treat a the lion’s share of shoulder maladies.
Shoulder pain manifests itself in confusing ways. Patients can have pain from the shoulders move into their
arm, upper back, mid-back and/or neck. Headaches can eventually start as well (because of the trapezius
muscle insertion into the skull). Lingering cervicothoracic pain that is not going away is a good indicator of
shoulder problems. You need to be checking this.
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In our society, most health care providers and patients are solely
focused on "single-incident trauma" or "What just happened to you? How did you hurt yourself?" Practice
teaches us that more often than not, our patients do not know how they came to have pain. Some patients are
able to identify specifically how they were hurt, but for many more, the pain develops over time for various
reasons or no perceived reason at all. This is where your detective skills come into play.
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There are quite a few classic conditions involving the shoulder; frozen shoulder, impingement syndrome,
bursitis, capsulitis and tendonitis are some of the major ones. The unifying theme with almost all shoulder
conditions is the fact that the shoulder joints are misaligned. Without getting them into a better position
through adjustments, rehabilitation will be hampered.
Shoulder Anatomy, Subluxation Patterns and Adjustments
Most of your patients do not understand that the shoulder joints consist of more than just the ball and socket.
In fact, a lack of understanding and treatment of the other joints of the shoulder will not bring about healing
as quickly. As we review the shoulder girdle joints, picture yourself or your patient slumping forward into
bad posture. This gives you a feeling and a visual of how these joints will misalign.
Glenohumeral ((shoulder) joint: A multi-axial synovial ball-and-socket joint between the glenoid fossa of
the scapula (shoulder blade) and the head of the humerus (upper arm bone). A shallow socket, it requires the
presence of a fibrocartilaginous labrum to aid in support. The glenohumeral joint subluxates anterior inferior (AI). The appropriate adjustment is anterior to posterior, inferior to superior. (Figure 1)
Acromioclavicular (AC) joint: The junction between the acromion process and the distal clavicle. The AC
joint allows the arm to be raised above the head. It is a gliding synovial joint that acts as a pivot point for
movement of the scapula. When the AC joint subluxates, the distal clavicle moves superior. Adjust the
distal clavicle superior to inferior (S to I). (Figure 2)
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Sternoclavicular (SC) joint: A synovial joint composed of the sternal
end of the clavicle and the upper and lateral part of the cartilage of the first rib. They are separated by an
articular disc. When this joint subluxates, the proximal clavicle moves superior, anterior, medial (SAM).
Adjust the proximal clavicle posterior-inferior-lateral (SAM to PIL). (Figure 3)
Scapulothoracic joint: This is actually more commonly referred to as an articulation rather than a true joint.
It is formed between the anterior scapula and the posterior thoracic ribs 2-7. The musculotendinous
attachment to the skeleton is formed by the trapezius and serratus muscles. In terms of subluxation, an
external rotational pattern is common, as they follow the shoulder anteriorly. Internal rotation pattern is
possible. Use your motion palpation and movement patterns to find out. Adjust from external rotation to
internal rotation. (Figure 4)
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Rib joints (costovertebral, costotransverse and costosternal): Costotransverse joints are synovial and involve
the facets of the tubercles of ribs 1-10, forming joints with the corresponding thoracic vertebrae. They are
present in ribs 1-10. The costovertebral and costotransverse joints are found posteriorly, also in ribs 1-10.
Ribs 11 and 12 are floating. The subluxation pattern for both anterior and posterior ribs is superior. Adjust
superior to inferior on the rib head (S to I). (Figure 5)
The pictures above have the patient lying supine. In this case, you can use the drop table or apply directional
pressure with your fingers to gently move the bone. If you don’t have a drop table, use a speeder or toggle
board as a portable drop piece. You can also pull out your spring-loaded instrument and place the tip on the
appropriate bone in the correct direction.
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Most of us learned traditional manual adjustments for the shoulder as
taught in school. These methods do work. I caution you to make sure you are careful with how much force
you use, as the shoulder joints are often tender and patients have a tendency to tighten up. The bottom line is
to do what works for you and use the methods I discussed above to add to your tool belt.
The Elbow
Last, but not least, is the elbow joint. It is a synovial hinge joint between the humerus in the upper arm, and
the radius and ulna in the forearm, allowing the hand to be moved toward and away from the body. The
radioulnar joint shares joint capsule with the elbow joint, but plays no functional role at the elbow. The
elbow region includes the olecranon process and the lateral and medial epicondyles.
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The elbow joint moves through flexion, extension, supination and pronation. The pain felt here is often due
to overuse, as well as biomechanical dysfunction of surrounding bones. We see ailments like medial and
lateral epicondylitis (golfer’s and tennis elbow) and bursitis, to name a few. Misalignments of the elbow
region involve the radial head and the olecrenon process. (Figure 6)
Subluxation Patterns and Corresponding Adjustments
Radial head in pronation: Support the mid-forearm with the inferior hand. Gently grasp the elbow with the
superior hand, placing the thumb on the radial head and the fingers wrapping around to the front of the
elbow. Passively rotate the forearm from pronation to end range of supination and thrust gently. Often a
"pop" can be heard. (Figure 7)
Radial head in supination: Same setup as above, except in this case, you rotate the forearm from supination
to pronation and thrust gently. (Figure 8)
Olecrenon posterior: Inferior hand is on the forearm, and the contact
hand has the thumb, index and middle fingers contacting the olecrenon process. Now you are moving the
forearm into extension. Do not go to full extension! Leave a slight bit of flexion in the elbow as you thrust
gently on the olecrenon process. (Figure 9)
As I discussed in my previous article on the wrist/hand (part 5 of this series), if you find elbow issues,
always check the shoulders and neck. They are usually linked.
That brings us to the end of our comprehensive look at the extremities. I hope you have gleaned some tidbits
you can use in your practice to help your patients. Feel free to contact me if you have any questions.
Dr. Kevin Wong, a 1996 graduate of Palmer College of Chiropractic West, is an expert on foot analysis,
walking and standing postures, and orthotics. He lectures nationwide on spinal and extremity adjusting and
practices full-time in Orinda, Calif.
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