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  • An Assessment of the Shoulder



    By Dawn Lewis

    One of my teaching assistants recently asked me how to alleviate tension deep in the shoulder.  The tension he is talking about is high up in the shoulder and posterior, between the inferior belly of omohyoid and the levator scapulae.  He believes it is the upper posterior fibers of serratus anterior, and it might be, but it is also possible that it is posterior scalene as it makes its way to the posterior lateral second rib or the upper fibers of iliocostalis cervicis as they make their way to the transverse processes of C4 through C6.

    If the tension is the upper fibers of serratus anterior, the tension would be along the posterior lateral aspect of the upper 2 ribs and under the superior aspect of the scapula.  Depending on where we believe the attachment of the omohyoid is on the superior border of the scapula (please see this article for discussion of omohyoid anomalies, https://efullcircle.com/omohyoid-muscle/), serratus anterior may be too lateral to be the issue.

    The posterior scalene muscle originates from the transverse processes of C5 through C7.  As it makes its way down to the lateral aspect of the second rib, it passes right between levator scapulae and the inferior belly of omohyoid.  Posterior scalene also dives under the superior aspect of the scapula to reach the second rib.

    Iliocostalis cervicis originates from directly posterior on the upper 6 ribs.  So, not posterior medial between the scapula and spine, and not posterior lateral toward the axilla, but on the posterior ribs under the scapula.  As the muscle makes its way to the transverse processes of C4 through C6, the fibers move slightly medial.  This means that at the superior shoulder, where the tension in question is, iliocostalis cervicis runs between levator scapulae and the inferior belly of the omohyoid muscle.

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    Determining which muscle you are working with can be difficult.  The upper fibers of serratus anterior will be attached to the anterior aspect of the scapula.  Serratus anterior has 8 digitations, each attaching to one of ribs 1 through 8.  Those digitations leave the individual ribs and come together to form one muscle belly on the posterior lateral ribcage, which is anterior to the lateral aspect of the scapula.  So, if the issue is serratus anterior, the fibers will move from lateral to medial, will be closer to the scapula than the ribcage, and will end at the anterior aspect of the medial border of the scapula.

    If the muscle you are feeling is posterior scalene, the fibers will run at a mild diagonal from the lower cervical vertebrae and extend far more lateral than the fibers of iliocostalis cervicis.  These fibers will not feel like they are against or attaching to the anterior aspect of the scapula.  The fibers of iliocostalis cervicis will feel as if they are running at that same diagonal at the transverse processes of the lower cervical vertebrae, but they will quickly change direction as they attach to posterior aspect of the first rib.

    Now that we understand the muscle possibilities for this deep shoulder tension, let’s look at what could be causing this tension.  One of the main things I would look at when presented with deep tension in the superior shoulder is the position of the clavicle and upper ribs.  Generally the clavicle sits slightly diagonal with the sternoclavicular joint being inferior to the acromioclavicular joint.  Both clavicles should have a similar diagonal line.

    If the clavicle is in an increased diagonal position it will shorten the natural length between the base of the neck and the outer edge of the shoulder.  Sometimes you can sit at the top of the table and see that one shoulder extends away from the body more than the other.  If you place your hands on the superior shoulders and push inferior on one shoulder and then the other, most often the shortened shoulder with the clavicle at an increased diagonal position will have not move inferior well.

    When the shoulder is pulled superior and toward the neck, the scapula is also pulled superior and medial, and the upper ribcage is pushed toward midline.  In this position, all the muscles of the superior shoulder will be shortened.  Decreased length between the neck and lateral shoulder will shorten upper trapezius, middle trapezius, and supraspinatus, while the ribcage moving toward midline will shorten posterior scalene, serratus anterior, and iliocostalis cervicis (as well as pectoralis minor and serratus posterior superior).

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    Sometimes I see clients who only have mild pain from this position.  Those who have substantial pain generally have a secondary issue, namely that the ribcage, while being pushed toward midline, is also moving inferior.  One way we assess this is by checking the balance of the sternoclavicular joints.  As our example, let’s say that we have a client whose right shoulder is shortened.  The enhanced diagonal position of the clavicle is visually clear.  The acromioclavicular joint on the right is more superior than the left.

    When we place our thumbs across the superior edge of the medial clavicles, however, the right medial clavicle is more inferior than the left.  This suggests that the ribcage on the right, while being pushed toward midline, is also inferior, while the shoulder girdle (i.e. the scapulas and clavicles) on the right is superior.

    This position creates an interesting conflict for serratus anterior; posterior, anterior, and middle scalene; and iliocostalis cervicis.  The fibers of the muscles are being mechanically shortened by the position of the shoulder girdle, while also being stretched by the inferior position of the upper ribcage.  This results in deep tension in the superior shoulder, and sometimes in the lateral shoulder and glenohumeral joint as well.

    Treatment must include releasing the muscles, ligaments, and fascia that hold the shortened shoulder in place, plus releases for the muscles, ligaments, and fascia that are pulling the upper ribcage inferior.  Additionally, and not detailed in this article, treatment should include assessing what is happening at the elbow and with the forearm; with the neck and the head (particularly the head); and with the hip girdle.