Patients often present in osteopathic practice with dysfunctions and disorders of the gleno-humeral articulation and the shoulder area generally. The shoulder can be described as a structure that is slung from the occiput, and tethered to the pelvis, so, like all other areas of the body, cannot be considered in isolation. The joint itself can manifest mechanical derangement as well as pathological conditions, particularly those involving the capsule and the surrounding muscles and tendons.

Special precautions that must be considered when working on the shoulder with manual techniques include the possibility of bone-weakening conditions such as osteoporosis, as some of the levers used will be long and potentially strong, and excess force could possibly compromise bone strength. In practice the amount of force used should never be enough to cause bone damage even in a diseased state. However, it may not always be realized how much leverage is being applied. From the point of view of indications, accurate diagnosis of the cause of any particular syndrome is not always easy. Pain due to inflammatory disorders and secondary protection of hypermobility may not be responsive to physical treatment and much wasted time, discomfort and expense can be avoided by recognizing this. As the joint is a ball and socket, thrust techniques directly applied to the shoulder do not play a large part in the treatment of dysfunctions.

25.1 • Kneading shoulder muscles supine This is an operator view of the technique. It shows the hands applied with the use of a 'wringing' action to the soft tissues to work either the anterior, superior or even the posterior aspects of the joint. Varying degrees of abduction, compression and rotation can be used to aim the forces to the tissue or area desired. The technique can be applied with the medial hand while the other one remains still, or the medial hand can remain still while the operator's body and other hand move in varied directions together. There are many more variations of this hold than would appear at first glance, and a little experimentation will reveal some interesting changes in target tissue with only small adjustments of hold and pressures.

Tips: Most useful in cases where shoulder dysfunction permits a reasonable degree of abduction. Least useful in acute capsular conditions where abduction beyond a small range is impossible. Extra considerations: As with all techniques that are designed to work on soft tissues, the duration of the hold is an important element. A finite quantity of time of several seconds with the tissues under slight sustained pressure is necessary to produce a significant change. Simply stretching and immediately releasing the tissues will produce a less efficient result as fluid interchange will not have had time to take place.

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