The clavicle is mentioned often in early osteopathic literature, yet relatively little attention seems to have been given to it in modern times. Although the nomenclature given to lesion positions was attractive, and gave specific directions of force to be applied to reverse the positions, it also limited thinking into certain directions only. Some specific directions of fixation are common, but modern thinking is much more directed toward function, and techniques designed in such a way that they can restore perceived deficits of function.
The clavicle can be thought of in isolation, or as a structure influenced by trauma, posture and occupational disorders. It can be considered as a bone with a pair of joints attaching it to the sternum and the scapula. Whatever the type of thinking, the main object of osteopathic technique is to restore normal mobility where it has been lost. This aims to re-introduce integrity of function to the pectoral girdle that may have diminished if the clavicle is not working properly.
Precautions are minimal, except that hyper-mobility of the joints can occur, and then techniques applied will be irrelevant and indeed may worsen the situation. Some techniques use the arm as a lever, but possible shoulder conditions may need protection, or alternative techniques sought in these cases.
The clavicle acts as a prop to join the arm to the body and to protect the vessels and nerves underneath it. It is essentially a stable unit, but when the stability is lost, disproportionate symptoms and dysfunction of the arm may occur. This in turn can make restoration of function of the clavicle an important part of any syndrome affecting the upper thoracic or shoulder area. Many 'difficult' upper thoracic cases will respond well if clavicular dysfunction is attended to as a major part of the treatment approach.
24.1 • Articulation of clavicle sidelying Stabilize the scapula with your body and while you hold the clavicle down circumduct the shoulder. Varied degrees of abduction will influence the sterno-clavicular or acromio-clavicular joints or simply place the main emphasis on the shaft of the bone.
Tips: Most useful when the muscles attaching superiorly to the clavicle are involved. Least useful when the use of the shoulder as a lever would be a problem. Extra considerations: Try using different phases of respiration.
24.3 • Articulation of clavicle supine Mold the patient's wrist and forearm firmly against you so that as your hand applied to the clavicle fixes toward the table, a small straightening of your knees will perform the articulation. The opposite can be applied if you gently lift the clavicle with your fingertips and apply a downward pressure through the patient's arm.
Extra considerations: Try using varied angles of rotation of the shoulder.
24.2 • Articulation of sterno-clavicular joint sitting Stabilize the scapula with your body and hold down on the medial end of the clavicle. Abduct the patient's arm and extend and externally rotate it to apply a pull along the length of the clavicle. Due to the shape of the joint, the most common dysfunction is a riding upwards and medially of the sternal end of the clavicle. In a true subluxation, this technique may produce a realignment of the joint but it will not last, as the capsule and ligaments will have been disrupted, probably permanently.
Tips: Most useful where for any reason the recumbent patient position is a problem. Least useful in very mobile subjects where it would be difficult to achieve a localization. Extra considerations: Try using different phases of respiration.
24.4 • Thrust to acromioclavicular joint supine Fixation in the acromio-clavicular joint is most usual on the anterior aspect and can be addressed well with this technique. To avoid excessive tension on the brachial plexus when the tug is applied, the patient's head is sidebent and rotated to the same side. Pull steadily on the distal part of the forearm and above the elbow with the other hand. Make small circumduction movements and vary the angles of flexion and abduction of the shoulder until tension is felt to accumulate in the acromio-clavicular joint. Apply the thrust without releasing the previously applied tension as otherwise a whipping action will occur which makes the technique ineffective.
Tips: Least useful when gleno-humeral dysfunction is present.
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