prone Clasp the patient's forearm between your thighs and grip the shoulder between your hands. Rest the back of your fingers on the table and while you hold the shoulder firmly in position straighten your knees to produce the traction. You can move the hands into a variety of directions.
Tips: Most useful where accessory movements of antero-posterior and supero-inferior movement are required. Least useful where lying prone for any reason is a problem. Extra considerations: An adjustable table is essential to allow the patient to be lowered so that the arm is horizontal.
25.12 • (see facing page, top left) Articulation of shoulder supine Hold the acromion and the clavicle into the table and pull them slightly caudally while your other hand elevates the arm until resistance is felt. Different degrees of rotation and more or less abduction can be introduced to focus to particular parts of the joint.
Tips: Most useful where it is desired to isolate the clavicle from shoulder movement. Least useful in very kyphotic subjects as this range of movement can be very limited as the anterior tissues will be rather shortened.
25.13 • (see facing page, bottom left) Articulation of shoulder into external rotation sidelying Use your cephalic forearm to act as a fulcrum while that hand fixes the acromion and clavicle, and palpates the shoulder joint. The other hand introduces external rotation with varying degrees of flexion while your body assists the movement. The greater the degree of flexion in the shoulder the stronger this articulation will be.
Tips: Most useful where a strong mobilizing force is required. Least useful where there is any suspicion of lack of bone strength as this is a long lever on the humerus. Extra considerations: Try holding the joint on tension and rocking the whole body backward and forward into rotation.
25.14 • (see facing page, top right) Articulation into external rotation of shoulder sidelying In this hold, both of your hands are applied to the shoulder and your caudal elbow induces the rotary movement. This has the advantage that com-pressive force can be applied more firmly to the shoulder. This limits the range of motion from the joint itself which will therefore have a greater influence on the soft tissues.
Tips: As photograph 25.13.
25.15 • (see facing page, bottom right) Articulation into external rotation of shoulder sidelying Fix the lateral border of the scapula with your caudal hand and use your cephalic hand to hold the scapula firmly against the posterior wall of the thorax. Apply the external rotation force with your upper abdomen pressing down on the patient's elbow.
Tips: As photographs 25.13 and 25.14 but most useful in very flexible subjects to avoid scapulo-thoracic movement and focus into the shoulder itself.
25.16 • Articulation into external rotation of shoulder supine This very strong long lever articulation needs great care, but with your caudal hand you apply a postero-anterior force so that the shoulder can be externally rotated. The other hand is used rhythmically, to increase range of motion.
Tips: Most useful where a strong lever is required. Least useful where there is any fear of lack of bone strength. Extra considerations: Vary the angle of shoulder abduction to find the optimum.
25.17 • Articulation into external rotation and traction prone Face the head of the table and use your elbow to fix the scapula with your hand firmly applied in the cubital fossa. The other hand applies a force toward the patient's head, thereby levering the head of the humerus away from the glenoid. Varied ranges of extension and abduction and external rotation can be introduced.
Tips: Least useful in patients where lying prone is a problem for any reason.
25.18 • Traction and external rotation articulation to shoulder supine Face the head of the table and apply traction by placing your hand in the cubital fossa while the other hand applies the external rotation force.
Tips: Most useful as the scapula is held by the table and strong traction and external rotation can be applied. Least useful where the biceps tendons are sensitive as pressure on them will be a problem. Extra considerations: Vary the angle of abduction and flexion to find the optimum.
25.19 • Articulation into internal rotation of shoulder sidelying From in front of the patient you fix the shoulder with your cephalic hand while the caudal hand applies the internal rotation force.
Tips: Most useful where a strong force is required. Least useful in cases of severe movement restriction as the position will be difficult to attain. Extra considerations: Try applying a traction force at the same time.
25.20 • (top right) Articulation into internal rotation of shoulder sidelying Abduct the shoulder just sufficiently so that the patient's wrist is fixed behind the lower ribs. The internal rotation force will be much stronger in this position. The cephalic hand can either hold back on the scapula and clavicle or assist the rotary movement by pulling on the head of the humerus.
Tips: As photograph 25.19.
25.21 • Articulation into internal rotation of the shoulder sidelying Fix the scapula from behind with your torso and introduce the rotary movement by holding firmly with your cephalic hand while carefully pushing your caudal hand anteriorly.
Tips: Most useful where the scapula tends to wing excessively. Least useful in cases of severe movement restriction where the position may be difficult to attain. Extra considerations: Try using traction in addition to rotation.
25.22 • (top left) Articulation into internal rotation of shoulder prone In this operator viewpoint photograph you face the foot of the table and while fixing the scapula with your elbow, you apply a traction force through the patient's cubital fossa. Your other hand carefully raises the patient's hand toward the ceiling while maintaining pressure on the distal end of the forearm toward the table to induce traction.
Tips: Least useful where the patient may find prone lying a problem for any reason.
25.23 • Articulation into internal rotation and traction of shoulder supine In this operator viewpoint photograph you face the foot of the table and fix the shoulder to the table with your elbow while the hand in the cubital fossa acts as a fulcrum for the other hand. Push, at the same time, toward the table for the traction and toward the floor for the internal rotation.
Tips: Most useful where a strong force is required. Least useful where there is any elbow dysfunction. Extra considerations: Vary the angles of abduction and flexion for optimum results.
25.24 • (top right) Articulation of shoulder supine
Fix the lateral border of the scapula with one hand while firmly gripping the lower end of the humerus with the other hand which can induce rotation movements, elevation and traction as required. The fixation of the scapula causes the movement to be localized to the shoulder joint itself rather than the scapulo-thoracic articulation and naturally less range of motion will be achieved.
Tips: Most useful where there are adhesions in the inferior aspect of the capsule. Least useful in acute cases where this much abduction would be a problem.
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