Peripheral Joint Mobilization

-- Shoulder Joints
Huei-Ming Chai, PT PhD
School of Physical Therapy
National Taiwan University, Taipei, Taiwan
June 23, 2008

Manual Therapy
Joint mobilization for restoration of joint alignment or
joint mobility
osteokinematics (physiological movement)
arthrokinematics (accessory movement)
Mulligans techniques: SNAG, MWM

Soft tissue mobilization for establishment of muscular

balance (neuromuscular therapy)

PNF stretch
muscle energy technique
Sweden massage
deep friction massage
myofascial release
connective tissue massage
nerve mobilization
Chinese massage

Mobilization vs. Manipulation

mobilization: repetitive passive movement of
varying amplitudes of low velocity applied at
different parts of the range depending on the
effects desired
manipulation: a high-velocity thrust of small
amplitude performed at the limit of available
movement

Rationales of joint mobilization

To relieve pain and muscle guarding
increasing proprioceptive input to the spinal
cord so as to inhibit ongoing nociceptive input
to anterior horn cells and central receiving
area
To restore accessory movement (joint play)

Concave-Convex Rule

convex on concave

concave on convex

Treatment Plane
treatment plane is the plane that parallel to the articular
surface of the concave component of the joint to be
treated
Kaltenborn FM:
direction of mobilization
define by treatment plane
Mulligan B:
always parallel or
perpendicular to
treatment plane only

Closed-Packed Position
The joint surface becomes maximally
congruent.
The joint capsule and major ligaments
become twisted, causing joint surface to
approximate.
The joint become locked so that no further
movement is possible in that direction.

Position of Joint
appropriate for the stage of the joint problem
and the skill of the therapist:
resting position: for an acute problem or an
inexperienced therapist
other starting position toward motion barrier: for a
skilled therapist in non-acute condition

Hand placement
fixation hand
stabilization of the joint component to be fixed

mobilizing hand
placing as close to the joint as possible

 direction

Techniques (I)

distraction
gliding

amplitude
depending on pain, muscle guarding or degree of
limitation
Maitland's grades
IV
III
II
V
I
Range: initial

limited

full

Techniques (II)
velocity
slow stretch for capsular or ligamentous tightness
or adhesion: application with rhythm, slow speed,
and the slack position
fast oscillation (rhythm: 2-3 cycles per second) for
relieving of pain and muscle guarding in the
acute conditions as a treatment
chronic conditions to prepare for more vigorous
stretching or to promote more relaxation of muscles
controlling the joint

No Pain At All
pain
muscle spam
vessel constriction

nociceptive stimulation

accumulation of
metabolites

Indications (I)

used in the joints with restriction of joint play that

cause pain or restriction of physiological motion,
especially in the cases due to capsular or ligamentous
tightness or adhesion
For gentle mobilization carried out in the pain-free
range

severe pain
spasm increased after testing
presence of neurological deficit
pain disturbing sleeping

For more vigorous mobilization

joint irritability minimal with muscle guarding on movement

mobility testing limited but does not aggravate pain
limitation of motion by tension of tissues rather than pain
no neurological deficit

Indications (II)
For manipulation
used as a progression from vigorous
mobilization that has not produced the maximum
improvement of signs and symptoms considered
possible
used as a primary treatment in joints with no
articular inflammatory signs and the restricted
joint has been identified through mobility testing
used in joints with minimal pain that appears
only at the end of the range

Patient Response to Joint Mobilization

improved after treatment continue
treatment until symptoms are subside
exacerbated for hours after treatment but
improved later continue but decrease
dosage
exacerbated immediately after treatment
reassess patients condition
gentle traction of the treated segment
documentation of all physical findings

stationary after 3-5 treatments re-evaluate

patients condition

Absolute Contraindications
bacterial infection:
cellulitis

neoplasm with metastasis to bone:

malignancy or benign tumor (cancer)

recent fracture: psudoarthrosis

bone disease: Osteogenesis Imperfecta
potential destruction of ligaments or capsule:
RA or dysplasia of odontoid process

odontoid process

transverse ligament

Relative Contraindications

joint effusion
in the status of acute inflammation
degenerative joint disease in acute stage or bony block
marked rheumatoid arthritis
osteoporosis
internal derangement
general debilitation
pregnancy
hypermobility in mobility testing
moderate to severe deformities
psychological changes
neurosis
hysteria
depression

Relative Contraindications
for spinal mobilization
vertebral artery insufficiency
ligament instability

neutral

rotation to left

Mobilization to the Shoulder Joint

Glenohumeral joint
Thoracoscapular articulation
Sternoclavicular joint
Acromioclavicular joint

Glenohumeral Joint (GHJ)

convex on cave joint
proximal component: concave glenoid cavity
distal component: convex humeral head

joint type: ball and socket

DOF = 3
flexion/ extension: posterior/ anterior glide
abduction/ adduction: inferior/ superior glide
external/ internal rotation: anterior/ posterior glide

Note: retroversion of the humeral head about

30 posterior to the frontal axis of the elbow
joint (scapular plane)

Glenohumeral Joint (contd)

neutral position anatomic position
resting position 70 of shoulder abduction
and 30 of flexion (horizontal adduction)
closed packed position 90 of shoulder
abduction and full external rotation

Basic Mobilization Techniques

distraction: anterolateral
inferior glide: inferolateral
posterior glide: posterolateral
anterior glide: anteromedial

Distraction of GHJ
force direction:
anterolateral

Inferior Glide of GHJ

force direction:
inferolateral

Posterior Glide of GHJ

force direction:
posterolateral

Anterior Glide of GHJ

force direction:
anteromedial

Advanced Mobilization Techniques

inferior glide with distraction
inferior glide with shoulder internal rotation
inferior glide in sitting position
posterior glide in sitting position

Inferior Glide of GHJ with Distraction

force direction:
inferolateral

Inferior Glide of GHJ with IR

force direction:
inferolateral

Posterior Glide of GHJ in Sitting

force direction:
posterolateral

Mobilization to the Shoulder Joint

Glenohumeral joint

Scapulothoracic articulation
Sternoclavicular joint
Acromioclavicular joint

Scapulothoracic Articulation (STA)

concave on convex
proximal component: convex rib cage
distal component: concave anterior surface of the
scapula

motion: results of motions occurring at STJ

and ACJ
scapular elevation/ depression
scapular abduction/ adduction
scapular upward/downward rotation

DOF = 3

Elevation of Scapula

force direction:
superior

Depression of Scapula

force direction:
inferior

Protraction/ Retraction of Scapula

force direction:
lateral

Distraction of the Scapula

Mobilization to the Shoulder Joint

Glenohumeral joint
Scapulothoracic articulation

Sternoclavicular joint
Acromioclavicular joint

Characteristics of SC Joint
proximal component -- sternum
saddle-shaped sternal manubrium

distal component -- clavicle

elevation

saddle-shaped medial end of clavicle

joint type: saddle joint

degree of freedom = 3

depression

motions
P
A

retraction
protraction

posterior
rotation

Mobilization to the Shoulder Joint

Glenohumeral joint
Scapulothoracic articulation
Sternoclavicular joint

Acromioclavicular joint

Acromioclavicular Joint
proximal component: convex lateral end of
the clavicle
distal component: concave acromion process
of the scapula
joint type: nearly plane joint
motion: shoulder girdle motion
scapular winging
scapular tipping
scapular upward/downward rotation

DOF = 3


hmchai@ntu.edu.tw
http://www.taiwanpt.net