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Shoulder (Glenohumeral) Joint Anterior to Posterior Manual Mobilization
Shoulder (Glenohumeral) Joint Anterior to Posterior Manual Mobilization is a manual therapy technique used by physiotherapists to reduce pain and increase range of motion in the shoulder. This technique involves the therapist applying gentle pressure to mobilize the shoulder from the front to the back. It can help to reduce scar tissue, improve joint range of motion and decrease joint pain. This type of manual therapy is commonly used to help with conditions such as tendinitis, rotator
Transcript
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This is Brent of the Brookbush Institute, and in this
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video we're going to go over a joint
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based manual therapy technique. If you're watching this video I'm assuming you're
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watching it for educational purposes, and that you are a licensed professional
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with joint based techniques within your scope. That means osteopath's. chiropractors,
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physical therapists, you're probably all in the clear. Physical therapy assistants,
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athletic trainers, massage therapist's you need to check with your governing body
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in your state or region, to see whether this is within your scope of practice.
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Personal trainers this is definitely not within your scope of practice. Of course
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all professions could use this video for purely educational purposes to help with
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learning biomechanics, anatomy, and of course palpation. In this video we're
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going to go over anterior to posterior humerus on glenoid fossa mobilization,
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commonly known as a shoulder AP. I'm going to have my friend Melissa come out,
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she's going to help me demonstrate. Now if I'm doing this mobilization, chances
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are I've already done some sort of functional movement assessment like the
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overhead squat assessment, or I've seen that wall shoulder mobility test that
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kind of looks like our serratus anterior activation, that is also a great
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functional exam. We'll probably follow that up with
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goniometery, something like internal and external rotation of the humerus, and
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then last I'm going to want to check passive accessory motion to see if there
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is arthrokinematic stiffness. Now we do have to be careful using this technique
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with the shoulder, the shoulder has a propensity to become both hypermobile
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that is too flexible, and hypomobile that's stiff. Now we only want to mobilize those
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individuals who have stiffness, somebody who is too flexible who gets this
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mobilization done, we might actually exacerbate their symptoms or actually
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make them worse. The last thing we want to do is take somebody who's too
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flexible, and make them even more flexible.. So now you've done your
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assessment, you determined that there is arthrokinematic stiffness and you're
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ready to do this mobilization, how do I place my hands? Well that all requires a
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little bit of knowledge of anatomy and palpation. Alright so the first thing I
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would recommend finding is just the acromion shelf, so the acromion shelf is
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that big bony shelf that kind of sits right between
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all of the muscle of the deltoid. So if you make a little muscle for me there
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Melissa good job, alright you guys see this like dent right here, this dent
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between her anterior middle and posterior right, that makes like a little
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'U' this way, that dent that is the acromion shelf. So you can have somebody
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kind of do this, get your fingers down on that bone, now go ahead and explore the
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edges of that bone, explore the edges of the acromion shelf. You need the person
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to stay nice and relaxed, good there we go nice and relaxed, so make sure their
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arm is supported by the table. Once you've felt through the acromion shelf
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you can actually start to feel like a divot underneath it, you can almost get
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your fingers underneath it, and then if you keep going down the arm this way a
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little bit you'll start to be able to sink your fingers around the humeral
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head. Now the humeral head obviously is the most proximal portion of our humerus
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bone, and that's going to be where we want to get our hands so we can do this
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mobilization. Although we're going to place our hand on the interior portion
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of the humerus I do recommend having a good idea of
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where all of the humeral head lies, like being able to get your hands on the
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posterior humeral head, kind of feeling how it goes down into the the neck of
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the humerus as you sink past the deltoids, and keep moving distally. What
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you'll notice about the anterior portion of the humerus is it's a lot more bumpy,
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so you have the greater and lesser tubercle there, and then you also have
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this ropey thing, this really thick rope and what that is is the biceps tendon.
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The reason I bring this up is that it's something that we don't really want to
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press on. If you really gear into somebody's bicep tendon while you're
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doing this mobilization it's going to hurt, if they have impingement syndrome
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it might be because it's inflamed, even if they don't have shoulder problems
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you're just doing this on your your partner or your practice partner, or one
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of your colleagues, or perhaps a mentor or teacher that you're practicing on,
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you start gearing down on their their biceps tendon, it's going to hurt no
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matter what, so we want to kind of know where that is so we can stay away from
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it; and once you have the whole kind of idea of where the humerus is I'm going
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to ask you to try to put, or at least imagine putting the humeral head right
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in the palm of your hand like so. Now you can use these fingers to kind of wrap
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yourself around the rest of the humerus and the acromion shelf, which might come
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in handy when we start trying to find the beginning of arthrokinematic
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motion, and the end of arthrokinematic motion. Now what I usually do
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with this hand is I'm going to have Melissa who'll be inside of my bicep, I'm
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going to hold her elbow like this, and now I have good control of abduction
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adduction, and a little control over flexion and extension. I could probably
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even internally rotate and externally rotate a little bit, like I have good
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control over arm. I'm going to use this hand again, put my palm down right over
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the anterior portion of her humerus, and then notice that once I'm in position
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guys my trunk -my chest is over my hands. So again I'm not going to manhandle this
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right, this is not how we do a mobilization that would actually get really tiring if
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let's say Melissa was twice my size which would make her absolutely huge, but
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if she was a very large person or had a very large arm, let's say I'm working on
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like a professional football player or something, that would, this would be
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almost impossible. You need to get used to using your body mechanics and save
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your own body, perhaps even before you think about saving the body of your
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patient because you got to do this all day. Alright because if you're seeing eight, nine, ten,
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twelve, twenty patients a day, you need to have good mechanics and and save your
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joints. So again I just have my client or patient reach in grab the inside of my
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bicep, I grab underneath their elbow, I have to control this hand over the
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anterior portion of the humerus, I'm just thinking about putting the humeral head
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right in the palm of my hand. Since I'm using such a broad surface area I don't
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usually have that problem with the biceps tendon,
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if I do I try to put the biceps tendon between my thenar eminence, all right so most
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of my pressure is coming here and the biceps tendon is falling in this groove
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here. I'm now just going to use the weight of my trunk to kind of find okay
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there's the first resistance barrier, and that's going to come on real quick with
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the shoulder and then I'm going to find the end, alright you got to be careful
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with the shoulder. Shoulder like I said is a very mobile joint, so if you press
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too hard you're going to push right out of the glenoid fossa; not that you're
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just locating the shoulder, but you will push the humeral head onto the posterior
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lip of the glenoid fossa, and if you can do that really easily then this is probably
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not somebody who needs this mobilization. The people who need this mobilization are
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the ones you press into and you feel like you have something to press into,
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there seems to be a certain amount of stiffness almost like you're pushing
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into the back of a leather strap, like a like a leather belt.
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Alright so beginning, feel like if I go any further than this all right like I'm
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going to start pushing through. Now I'm going to back off to 50% and we've
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talked about there's a lot of different protocols out there guys, and I just
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asked you to follow through with whatever protocol that you learned. I use
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generally the Maitland protocols for grade three and grade four mobilizations,
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If we're talking about getting mobility here and this isn't like a pain dominant
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patient. So we'll go to 50%, and then I can either do back off to where was my
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first resistance barrier, to 50% and do my grade threes which is that higher
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amplitude mobilization, or I can find my 50% and do my small amplitude
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mobilizations right at that resistance barrier, making this a little higher
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intensity. Now I'm going to do this until I feel a reduction in joint stiffness,
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and then the most important thing as I've said throughout all these videos is
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I'm going to reassess. Alright so to go through that just one more time guys.
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Hand on inside of bicep, I got her elbow, I'm going to take her to where I need
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herin abduction, adduction, more flexion, more extension, wherever
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you guys feel like you need to be to work through that stiffness. The palm of
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my hand goes over the humeral head, the anterior surface of the humeral head, trying to put the biceps tendon
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between my thenar groove there, find the first resistance barrier, the end,
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back off to 50%, and then do whatever grade I think is appropriate. I have my
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hand around Melissa's elbow, and her hand is up around my arm, although I know you
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can't see that you saw that in the previous shot. You guys can see Melissa's
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acromion shelf here, and then you guys should be able to palpate around the
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acromion shelf to define the subacromial space which is going to feel like a
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depression, then as I mentioned before you should take some time to try to
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palpate through the relaxed deltoid, to kind of outline the humeral head as it
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goes down into the the neck of the humerus here, but once you find the
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humeral head now we can place our palm on top of the anterior face of the
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humeral head, and I kind of mentioned before if you kind of strum across this
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way you'll feel a big rope like tendon there, that's the biceps tendon. I would
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put that in your inner thenar groove so that you don't place undue pressure,
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and now I can kind of feel like there you go there's your first first little
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bit of motion of the humeral head, and I can push down until the end of her
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glenohumeral motion there, and then back off to 50%, and then I can either go
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from initial resistance to 50% for some grade threes or maybe I can stay at 50%
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for grade 4's, but notice I'm using a nice wide palm
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getting a lot of surface area, and trying to keep any direct pressure off that
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biceps tendon for this joint mobilization. I'm doing my one to two
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oscillations per second for 30 seconds plus until I feel a reduction in arthro-
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kinematic stiffness, and of course i'm going to reassess. If i did one set and
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got a little reduction, I could maybe pull further into flexion see if I run
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into more stiffness. I could pull further out into abduction do another set and
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see if I run into more stiffness, as I have a lot of control over Melissa's arm
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here. So guys make sure you take the time to palpate the humeral head through the
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deltoid, palm over anterior face, biceps tendon in thenar groove. Make sure you
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feel for initial movement or first resistance barrier, and end of arthro-
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kinematic range, and follow through with your protocols. So there you have it
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assess, address, reassess. Make sure that every time you choose a joint based
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manual therapy technique it is based on an assessment, and that you return to
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that assessment after you've finished the intervention, to see if it was
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effective for the individual, the patient or client that you had in front of you.
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Ensure that you continue to learn your Anatomy because your Anatomy is going to
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help you with your hand placement, with understanding what a joint can do, with
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understanding what you may gain from this particular technique. And of course
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practice, you have to practice these techniques, hopefully not for the first
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time on a patient or client who just walked in the door. If you can, find a
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more senior instructor or mentor to give you some really good hands-on
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instruction, use your peers for some good feedback, and of course always look for
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live education to help with your manual therapy techniques. I know these videos
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make education very convenient, but there is no substitute
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for learning manual therapy in a live setting. I look forward to talking to you
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