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A New Stretch for Pec Minor

imagePectoralis minor tightness is a common finding in people with shoulder dysfunction.  We’ve discussed how to stretch the pec minor in the past with mixed results – it’s a hard muscle to stretch well.  There are a few techniques I like to perform including pinning the muscle and relaxing in a positional release that fits my reverse posturing theory.  Chris Johnson has recently shared with me another great manual techniques that he has put a lot of thought and research into.

Stretching the Pec Minor

Decreased length of the pectoralis minor is a common impairment in patients presenting with shoulder dysfunction and musculoskeletal imbalances such as the “upper crossed syndrome.” Restrictions in pec minor length are problematic because they cause scapular protraction, loss of posterior scapular tilt, inhibition of the lower trapezius, and decreased width of the subacromial space. Identifying optimal treatment regimens is therefore critical to engender successful outcomes for patients exhibiting decreased pec minor length. Currently, a dearth of research exists pertaining to the most effective approach for improving the length of this muscle.

Borstad and Ludewig (J Shoulder Elbow Surg 2006) have conducted the only study to date, which specifically investigated the efficacy of three pectoralis minor stretches. Their results demonstrated that a corner stretch was superior to a supine and seated manual stretch. As Mike has mentioned, however, the corner stretch may subject the anterior capsule to deleterious forces, and patients need to be closely monitored to ensure proper execution of this stretch.

The technique in the below video is what I have anecdotally found to be the safest and most effective approach for increasing pectoralis minor length. This technique was predominantly influenced by the work of Shirley Sahrmann, Thomas Meyers, and Vladimir Janda, and involves a myofascial stretch followed by a retraining exercise of the posterior shoulder musculature. For the stretch portion of the technique, make sure that your pressure is applied at the level of the coracoid process (insertion of the pectoralis minor & origin of the short head of the biceps) rather than the humerus and direct your force into posterior scapular tilt. I generally hold this stretch for 90 seconds and repeat it 5 times based on the work of Magnusson et al (Scan J Med Sci Sports 1995).

 

Avoid applying excessive pressure distally at the level of the wrist as it may cause discomfort in the elbow region. Immediately following each stretch, I have the patient maintain the newly lengthened position for 10 seconds to retrain the posterior shoulder musculature, particularly the lower trapezius.

As part of a home program, I also have my patients assume anatomical position for 30 seconds periodically throughout the day to facilitate carryover. I specifically instruct them to stand with their feet shoulder width apart, gently tighten their abdominal wall, rotate their hands so the palms are facing forward, draw their shoulder blades down and back towards their back pants pockets, and gently retract the chin. I use this exercise as a postural “reset” anytime one finds themselves crossing their arms or assuming a hands on hips position.

I am confident that you will find this technique to be a “game changer” and I look forward to hearing your thoughts on it. I would also like to personally thank Mike for giving me the opportunity to share my clinical thoughts on his blog as well as Force Therapeutics for allowing me to share this video.

Chris Johnsonhttp://www.chrisjohnsonpt.com

Thanks for sharing Chris, I like it!  Yet another tool in our belt!  Try this stretch out and leave some feedback, I want to hear what everyone else thinks.

Subscapularis Release for Loss of External Rotation

image We have a great guest post today from my friend Trevor Winnegge.  Trevor wrote a nice article last year on complications following distal radius fractures that ranked as my number 1 guest post in 2009!  This time, he presents the results of really nice case series on restoring external rotation ROM using subscapularis release massage techniques.  Great idea and some common manual techniques that I use as well with all of my patients.  Thanks Trevor!

The Role of Soft Tissue Mobilization to Subscapularis to Improve External Rotation in a Type II SLAP Repair-A Case Series

Our clinic is a smaller clinic and doesn’t have the time or resources for a full research study but we did have the opportunity to perform a very small pilot study/case series. I decided to contribute this information because I think it is an underutilized technique and is valuable in assisting our post operative shoulder patients.

We looked at the role that subscapularis has on limiting external rotation (ER) in a post operative shoulder patient. Given that subscapularis is an internal rotator and also assists with some adduction, it is stretched with abduction and ER of the shoulder[1]. Many shoulder surgeries place the patient in a sling in the internally rotated position to some degree. Standard Type II SLAP repair protocols limit the passive range of motion (PROM) into ER to anywhere from 0-30 degrees for the first four weeks, limiting the ability of the subscapularis to stretch[2]. Therefore, we felt if we could perform soft tissue mobilization to the subscapularis in the initial post operative period while range of motion is limited, then they would be less stiff once they were allowed to progress into ER. To my knowledge there has been only one study to date looking at the role of soft tissue mobilization to subscapularis on improving ER and that was published in JOSPT in December of 2003[3]. In that study, conducted by Godges et al, they excluded any patient that was in the immediate four week post operative healing phase. We felt that this immediate healing phase is when we can be most successful at preventing excessive subscapularis tightness by performing soft tissue mobilization, thereby improving ER ROM once they are allowed to progress past 30 degrees of ER.

Research Design

We took four patients (two males, two females) between the ages of 17 and 26 who had undergone primary Type II SLAP repair and randomly assigned them into two groups. The first group received standard ROM treatment for all motions and had ER ranged only to 30 degrees per the doctors protocol. The second group had the same exact treatment, however also received five minutes of subscapularis soft tissue mobilization[4]. Soft tissue mobilization was performed while the patient was in sidelying for the first one or two treatment sessions until the patient had enough abduction ROM to allow for good access to subscapularis in a supine position. The technique was using thumb or fingertips to hook inside the lateral border of the scapula and dig deep down between the scapula and ribs. A combination of deep pressure and soft tissue mobilization were performed for a total of five minutes. Every patient in each group was seen at the one week post operative timeframe and was seen twice a week for the next three weeks.

Video Demonstration

I do have two videos of the soft tissue techniques. The first is for the immediate post op patient while patient is in sidelying. The second video is while the patient is in supine. This video also incorporates the soft tissue technique with some elevation ROM.

Results

The results were as we had expected. The group that received the soft tissue mobilization had about twenty five more degrees of ER ROM (measured with goniometer in 45 degrees of abduction while supine) at the four week mark than did the group that did not receive the treatment.

Control Group-ER ROM

 1 week post op4 weeks post op
Subject 110 degrees40 degrees
Subject 215 degrees38 degrees

Intervention Group- ER ROM

 1 week post op4 weeks post op
Subject 112 degrees64 degrees
Subject 215 degrees63 degrees

I understand that these results should be taken with a grain of salt, as strong conclusions can not be made with such a small sample size. As I previously stated we simply do not have the time or resources in our clinic to perform a large scale study. It is my hope that someone reading this who works in a much larger center can take this information and use it as a stepping stone to a full blown research study. Clinically, I use these techniques on a daily basis and achieve great results. I truly feel the results of a larger study would be quite similar. What was also interesting is that shoulder elevation was also improved in the soft tissue mobilization group. This is likely due to the close proximity of the latissimus dorsi to the subscapularis, it is hard to truly isolate the subscapularis. We focused on SLAP repairs, but Bankart repairs could also benefit from this as well as rotator cuff repair patients who require sling use for extended amounts of time, provided a subscapularis repair wasn’t performed. I think the possibilities for research in this area are endless and I would love to see it published as a large research study. Please give me any feedback if you currently use this technique, or tried it after reading this. It really works well.

clip_image001Trevor has been practicing PT for over 9 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.


[1] Palastanga, et al. Anatomy and Human Movement. Boston MA:Butterworth Heineman; 1993.

[2] Wilk K, Reinold M, Andrews J. Postoperative Treatment Principles in the Throwing Athlete. Sports Medicine and Arthroscopy Review. 2001;9:69-95.

[3] Godges et al. The Immediate Effects of Soft Tissue Mobilization with Proprioceptive neuromuscular Facilitation on Glenohumeral External rotation and Overhead reach. JOSPT. 2003; 12: 713-718.

[4] Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore MD:Williams and Wilkins; 1983.

What is the Best Stretch for the Pectoralis Minor?

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This post came about from some of the live Q&A that we had following my webinar last week on “assessing asymmetry in the overhead athlete – does asymmetry mean pathology?” (the webinar is now recorded and available for download if you couldn’t make the live session).  We discussed some asymmetries with the scapula and talked about stretching the pectoralis minor.  I thought this would be a good topic to post on for everyone to discuss.

The Effect of a Tight Pec Minor

There are a lot of theorized negative effects of a tight pec minor, mostly related to the position of the scapula:

The Best Stretch for the Pectoralis Minor?

As our knowledge has increased of the importance of posture and scapular position in normal shoulder function, the need to adequately lengthen the pectoralis minor becomes apparent.  Any restrictions in pec minor length will pull the scapula into a protracted and anterior tilted position, which has been shown to inhibit strength of the lower trapezius and decrease the width of the subacromial space.

A problem exists, however.  Many, if not all, of the standard stretches for the pectoralis minor place a decent amount of strain on the anterior capsule.  This is typically something that many patient populations would want to avoid.  We discussed some stretches for the pec minor in the past, but I wanted to talk about this again now that a year has past.

UPDATE: The results of the effectiveness of stretching the pec minor vary in the literature, some showing changes in pec minor length (PMI?) and scapular kinematics. I can’t help to think that the difference in outcomes are realted to the methodolgy of the stretching in the study. Some of showed very simple gross posture stretching. You could argue that the positive results are related to more effective stretching. SO, rather than say “stretching the pec minor” doesn’t help, it’s important to understand…

What does the evidence show?

There is some evidence behind stretching.  A study by Borstad in JSES in 2006 compared three different techniques of stretching and found that they all produced changes in muscle length, but that the doorway stretch was superior:

  1. The doorway stretch = +2.24 cm
  2. A manual stretch in the sitting position = +0.77 cm
  3. A supine manual stretch = +1.7 cm
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imageWhile the doorway stretch may have been superior, it has hard to coach and even more difficult to monitor when the person goes home and starts torquing on their shoulder.  This is a good exercise for some with adhesive capsulitis but I tend to avoid it in most patients that need pec minor stretching only.  I like the sitting stretch, I think it may be worth trying.  But I think we can improve on their supine manual imagestretch.  The arm should be in a different  position and I believe that proximal hand position is to far over the anterior aspect of the shoulder and not on the coracoid and pec minor.  If you look at the fibers of the pec minor, you’ll see that the muscle is orientated in a fashion that require a greater amount of elevation.  Just like any other stretch it is important to align the joint according to the position and orientation of the muscle origin and insertion.

Not a bad start in terms of efficacy but I wish there were more stretches involved in the study.

Home Stretch for the Pectoralis Minor

image So what do I do for patients at home if I don’t like the doorway stretch?  Considering this is likely a postural adaptation, I would like to see more of a low load long duration stretch of the joint.  I tend to do this mostly supine with a half foam roll, though a towel roll could substitute.  You can do this two ways, first by just laying supine with the foam imageroll  between your shoulder blades and allowing your shoulders to drop back and externally rotate.  The key is to relax in this position for a prolonged duration.  Secondly, I would add a more specific stretch to the pec minor by elevating the arms and repeating the hold.  I find these stretches to be safer and potentially as effective as a doorway stretch.

image Another thing worth mentioning is the thoracic pivot, which is a great tool that is even better than the half foam roll.  It is more comfortable and a more specific curve to meet your thoracic spine.  I use one and love it.  The draw back is that it is more expensive that a foam roll.  But I also have the cervical pivots and use them all the time on patients and myself to work on posture and reduce tension headaches, shoulder pain, and scapular dyskinesis.  Don’t buy them from OPTP, they are 25% less on Amazon.

Manual Stretching the Pectoralis Minor

I think we can do better using manual stretching in addition to the postural exercises I recommend above for at home.  To stretch the pec minor, I have settled on a manual supine technique the combines aligning the shoulder in the correction orientation of the pectoralis minor muscle fibers and stabilizing the muscle by the coracoid.  Notice I said stabilizing the muscle.  I place a broad four finger grip deep into the pec minor just off from the coracoid.  But it is important to note that I do this with the arm/pec in a loose position.  You need to think of it as stabilizing, or “pinning” as I call it, the pec minor down.  What you’ll find is that you will obtain a stretch in the pec (not the anterior shoulder) and you wont be able to bring the arm far down past the plane of the table.

Pin the muscle down with the arm loose:

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And then bring the arm down:

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Notice in these two photos below that by just adding this “pinning” of the pec minor I completely change stretch and take the strain of the anterior shoulder.  In this position it is also pretty easy to utilize some MET and ART techniques as well, both of which I have found effective.  The perspective is a bit hard to tell from the angle, but note that on the pinning stretch, the arm is about even with the table (perpendicular to the ground) to just barely past the table, without the pinning it dips about 20 degrees past the table:

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You’ll know if you are doing this stretch right but asking the person what they feel – nice stretch in the pec versus a stretch in anterior shoulder.  Sometimes they’ll even experience a tingle down their arm or in their hand, which is an obvious sign you are stretching too much of the anterior shoulder.  I should also mention, it takes 2-3 sessions for the patient to get used to this stretch as you finger tips in this area are not always comfortable.  Resist the urge to broaden you contact spot and use the palm of your hand etc, it never works as well.

So what do you think?  Have you tried any of these stretches?  Anything else I missed?

Pec Minor Photo: Wikipedia

Borstad, J., & Ludewig, P. (2006). Comparison of three stretches for the pectoralis minor muscle Journal of Shoulder and Elbow Surgery, 15 (3), 324-330 DOI: 10.1016/j.jse.2005.08.011