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Muscle Imbalance Evaluation and Treatment of the Neck, Upper Back

and Shoulder AreasJose S. Figueroa, D. O.

Physical Medicine and Rehabilitation, NMM/OMM

IOMA, Spring 2010

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Objectives• Review some concepts of muscle imbalances and the evaluation

and treatment of key muscles as contributors to chronic musculoskeletal dysfunction in the neck, upper back and shoulder areas.

• Be introduced to the evaluation and treatment of muscle imbalances of the upper quarter:– Evaluate Proprioception– Evaluate for the presence of faulty muscle “firing” patterns– Diagnose and manually treat tight/short muscles– Diagnose weak or pseudo-paretic muscles– Teach a home exercise prescription to address the tight/short and weak or

pseudoparetic muscles– Follow-up for re-evaluations and exercise adjustments– Teach patients how to self-treat certain common somatic dysfunctions

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Most of the information in this lecture is derived from the works

of

• Phillip Greenman, D.O.(he is the one in the pictures)

• Dr. Vladimir Janda, a specialist in rehabilitation medicine at the University of Charles, Prague, Czechoslovakia, deceased in 2006

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Road Map Common UE muscles and their reaction to injury• Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop:• Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short

muscles• HEP for the weak or pseudoparetic muscles• Summary and Conclusions

Table 1. Common upper extremity muscles and their

reaction to injury

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Neck and Trunk Erector Spinae Group -Lumbar Region -Cervical RegionQuadratus LumborumScalenesSternocleidomastoid

Deep Cervical Spine FlexorsErector Spinae muscles -Mid-thoracicRectus AbdominisExternal ObliquesInternal ObliquesTransversus Abdominis

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Shoulder Girdle Levator ScapulaeUpper TrapeziusPectoralis MajorLatissimus DorsiFlexors of UE

Middle TrapeziusLower TrapeziusRhomboidsSupraspinatusInfraspinatusSerratus AnteriorDeltoidExtensors of UE

Stand Up, Please

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Please ½ of You Remain Still and look for:

• Forward shoulders (“rounded shoulders”)• Head placed in a forward position• Arms internally rotated

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Upper Crossed Syndrome• Forward head

posture• Straightening of

the cervical lordotic curve

• Extension of the upper cervical spine

• Increased kyphosis of the cervico-thoracic junction

• Internal rotation of the shoulder girdles.

http://medical-dictionary.thefreedictionary.com/syndrome

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop:• Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short

muscles• HEP for the weak or pseudoparetic muscles• Summary and Conclusions

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Diagnosis of Muscle Imbalances Three Specific Types of Clinical Testing

• Evaluate Proprioception– Through balance testing

• Evaluate the sequence of muscle contraction (muscle “firing” patterns) during specific movements to evaluate which muscles contract out of sequence, acting as if they were weak

• Evaluate asymmetry in muscle lengths– Muscles are isolated as much as possible and then

tested for symmetry in their lengths and compared with estimations of normal

Treatment of Muscle Imbalances

General Principles:• Goal: restoration of proper muscle length, strength

and control of muscle function• Start with OMM• May need a home exercise prescription (HEP)• HEP should address muscle control (i.e.,

proprioception re-training)• When treating muscle imbalances: Quality of movement is

more important than quantity

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General Treatment Sequence

1. Establishing a process of re-evaluations to monitor progress

2. Establish a level of patient commitment to follow through

3. Re-training proprioception– home exercises (single leg stance)– PT (more advanced intervention)

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General Treatment Sequence4. Stretching the tight muscles

– manual stretches in the office (Dr. or PT)– home stretches (self-stretches)

5. Re-training or strengthening late contracting (pseudoparetic) or weak muscles

– home “strengthening” exercises

6. Teaching the patient how to self-treat specific recurring somatic dysfunctions on their own

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DIAGNOSIS AND TREATMENTS OF COMMON MUSCLE IMBALANCES OF

THE NECK, UPPER BACK AND SHOULDER

HANDS-ON SESSION

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short

muscles• HEP for the weak or pseudoparetic muscles• Summary and Conclusions

Evaluate and Treat Impaired Proprioception

• Goal: the capacity to symmetrically stand on one leg with arms crossed and eyes closed for 30 seconds (eyes open and eyes closed)– Do the best possible if unable to reach goal

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Look to your feet, Please

• Remove your shoes• See if you can shorten one of your feet now• Let’s test each other’s SINGLE LEG standing

balance

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short

muscles• HEP for the weak or pseudoparetic muscles• Summary and Conclusions

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Evaluating Muscle Firing Patternsof

Upper Quarter Muscles

Upper Quarter Firing Pattern Tests

• Cervical Flexion Test Supine• Shoulder Abduction Test• Scapular Stabilization Test• Scapular Depression Test

Cervical Flexion Test Supine

• Start position patient is supine• Cervical Test Normal: the neck curls as it flexes• Cervical Test Abnormal: the neck cannot curl

and the head is thrust forward due to weak deep neck flexors and overactivity of the sternocleidomastoids (SCMs).

Shoulder Abduction

• The muscle firing pattern (sequence of contractions) is evaluated.

• Normal sequence for shoulder abduction while seated is: 1. Supraspinatus2. Deltoid3. Infraspinatus4. Middle and lower trapezius5. Contralateral quadratus lumborum

Shoulder Abduction

• Most common substitution pattern is:– Shoulder elevation by the levator scapulae and

upper trapezius (can lead to and perpetuate impingement)

– Early firing of the quadratus lumborum even on the ipsilateral side

Scapular Stabilization Test

• Position one: patient on hands and knees on the table

• Position two: patient lifts one hand. The scapula on the side with the hand on the floor is evaluated for winging.

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Scapular Stabilization Test

• Excessive winging of the medial border of the scapula occurs because of weakness and lack of stabilization by the lower trapezius, serratus anterior, and rhomboid muscles

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short

muscles• HEP for the weak or pseudoparetic muscles• Summary and Conclusions

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Evaluating and Treating Muscle Length Asymmetry

of Upper Quarter Muscles

Evaluate Asymmetry of Muscle Lengths

• Isolate to one muscle as best possible• Find the tight muscles and treat them with

manual stretching at the clinic.– “Supercharges” the patient’s home stretching

routine– Sustained Stretch: 20-30 secs, 2 or 3 reps.– Muscle Energy: Post-isometric Relaxation and

Stretch• Then give them home stretches

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Upper Trapezius/SCM: Length Test and Manual Stretching

Upper Trapezius/SCM: Self Stretch

Levator Scapula: Length Test and Manual Stretching

Levator Scapula: Self Stretch

Scalenes: Length Test and Manual Stretching

Scalenes: Self Stretch

Pectorales Major: Length Test and Manual Stretching

Pectorales Major Test/Manual Stretch Supine

Pectorales Minor: Observe for Tightness

• Patient supine• Operator observes for

the relative anterior posterior position of the shoulders.

• Tightness of the pectoralis minor is shown as one shoulder elevates off the table.

Pectorales Major: Self Stretching

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Latissimus Dorsi: Length Test and Manual Stretching

Manual Stretch

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Latissimus Dorsi: Self Stretching

Re-Evaluate the Sequence of Muscle Contraction

• In order to assess for weak muscles or pseudoparetic muscles

• Prescribe strengthening (or re-training) exercises at home if needed

• Again: Quality of motion is most important

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short

muscles HEP for the weak or pseudoparetic muscles• Summary and Conclusions

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Strengthening / Retrainingof

Upper Quarter Muscles

Cervical Flexors

Lower Trapezius

Serratus Anterior

Rhomboid and Lower Trapezius

Rhomboid StrengtheningLower Trapezius Strengthening

HEAD AND SHOULDER POSTURE EXERCISE

Sit Up Straight, Please

• Stand with feet four inches apart• Arms at side, thumbs point forward• Tighten buttocks• Rotate thumbs, arms and shoulders out and back while

inhaling, squeezing the shoulder blades together in the back

• Maintain this position while pulling the shoulders down and exhaling

• Hold while correcting the head posture:– Bring head back to bring ears in line with shoulders– Do not point nose up or down, do not open mouth

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Re-training Exercises Usually Target

• Deep Cervical Flexors• Lower Trapezius• Serratus Anterior• Rhomboids • External Rotators of the shoulder• Core strengthening, especially in patients who

are active in sports and / or manual labor

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Road Map Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short

muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions

Summary: Designing and Sequencing the HEP

• OMM Treatment first, if there are somatic dysfunctions present

• Get a Commitment to Exercise from the patient• Evaluate balance and Tx if needed• Evaluate the tight muscles, do manual stretches and

prescribe stretches• Evaluate for weak muscles if the stretches do not take care

of the problem.• Prescribe re-training/strengthening exercises if needed• Once muscles start to act more balanced, start a general

bilateral aerobic & strength training program in line with the patient’s goals

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If Not Progressing• Assess for Non Compliance• If Compliant…Perpetuating Factors like:

– Undiagnosed Pathology (ex: Myofascial pain, ligament laxity, etc.)

– Ergonomic derangements at home or work– Poor sleep– Poor sports training (usually over-training)– Aerobic or Anaerobic Deconditioning, thus

requiring cardio or resistance training– Other: vitamin deficiency, etc.

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Conclusion• Exercise: long history in the healing arts• Numerous exercise equipment systems have

been developed and are currently in the market

• But many health professionals have limited knowledge and understanding of how to prescribe exercises that are appropriate for their patients

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Conclusion

• Generic programs can be helpful• Each patient is an individual and may require an

exercise program specific for his/her problem• If you practice the preceding principles and

procedures you will have the added skill to identify specific problems and prescribe appropriate exercises to restore proper muscle symmetry and control, and ultimately improve the function of your patients.

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Questions

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