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DOI: 10.1016/B978

Sterno-clavicular jointErland Pettman

CHAPTER CONTENTS

Introduction 212

Anatomy of the sterno-clavicular joint 213

Biomechanics of the sterno-clavicular joint 214

Pathology of the sterno-clavicular joint 215

Patients requiring a medical/surgical consult 215

Patients with indication for physical therapyintervention 216

Diagnosis of the sterno-clavicular joint 216

Management of the sterno-clavicular joint 216

Anterior disc /manubrial rotationmobilization (left shoulder) 216

Posterior disc /manubrial rotationmobilization (left shoulder) 217

Inferior clavicular/disc glide (right shoulder) 217

Posterior clavicular/disc glide(right shoulder) 217

Adjunct exercises 218

Conclusion 218

INTRODUCTION

A literature search on the sterno-clavicular joint rapidlymakes the reader aware that there are a very limitednumber of publications on this joint and these predom-inantly cover medical and surgical concerns. Anatomicaland biomechanical references are designed, most often,to support medical or surgical interventions. From aphysical therapy perspective this joint would appear to

be the ‘poor cousin’ of the shoulder girdle in both inter-est and research. However, whilst bemoaning this factthe reason almost certainly lies in the joint’s inherentstrength and stability. These factors will be covered inthe sections on anatomy and biomechanics.

What is most interesting to the writer, however, is thisjoint’s proposed ability to work in concert with the tho-racic spine to facilitate the function of elevation throughflexion/abduction without compromise to the neurovas-cular structures that supply the upper limb. In view ofour upper limbs we must accept the fact that they enableus to be primate ‘brachiates’, i.e. we are able to locomotewith our upper limbs. Whilst, as we get older and heavierthis seems an unlikely premise we need merely to viewchildren at a playground or study gymnasts to realize thisis at least one of the functions of the human upper limband something we have in common with all otherprimates.

In all anatomy texts the author of the chapter hasread that the shoulder girdle ‘ends’ at the manubrium.Emphasis is, therefore, placed on how the clavicle movesat the sternomanubrial articulation. The writer’s paperentitled ‘The functional shoulder girdle’ (Pettman 1984)inferred that during functional movements of the shoul-der girdle there is indeed another biomechanical com-ponent to this joint that needs to be considered, andthat is manubrio-sternal motion, i.e. that dictated bythe thoracic spine. Given the dearth of biomechanicalresearch regarding this joint the writer must at leastpresent a proposed biomechanical model, based onobservation and palpation, which might lead to furtherresearch. Within this proposal will be a clinically rea-soned explanation as to how thoracic and/or sterno-clavicular dysfunction may directly affect gleno-humeraljoint function.

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Chapter | 15 | Sterno-clavicular joint

ANATOMY OF THE STERNO-CLAVICULAR JOINT

Descriptive anatomy of this joint is well covered in textssuch as Gray’s Anatomy (Standring 2004). Therefore, theemphasis here should be on functional and comparativeanatomy. In embryological development the clavicle ispresent in almost all mammals. However, in quadrupedsthe clavicle becomes a vestigial or rudimentary structurehelping to provide muscle attachments that produce amuscular ‘sling’ to support the weight of the thorax, neckand head. A fully developed, osseous clavicle that con-nects the scapula to the manubrium only exists in pri-mates. This bony strut enables primates to enjoy a verylarge range of upper limb motion, especially away fromthe midline of the body. Such motion gives primates thefunctional advantages of grasping, thrusting (throwing orpunching), and brachiation (swinging).

Specialization of function within different primategroups appears to depend upon the position of the scap-ula bone (lateral or posterior to the thorax) (Chan2007) and the curvature(s) of the clavicle (Voisin 2006).The distinctive ‘S’ shape of the human clavicle has beenlikened to a ‘crank’. This enables our muscles to supporta relatively heavier body weight during brachiation butalso to increase the power and velocity of upper limbmovements such as throwing. However, that same ‘S’shaped clavicle does poorly with compressive loading, itsweak spot being the junction between the medial convex-ity and its lateral concavity. This fact is underscored bythis mid-shaft region being the most prevalent site for cla-vicular fractures during compressive loading such as a falldirectly on the shoulder or on the outstretched hand(Denard et al 2005). Most fractures of this region areuncomplicated but on rare occasion may lead to brachialplexus involvement, pulmonary dysfunction or evendeath (Kendall et al 2000).

The medial end of the clavicle bone presents a large,bulbous head. Its surface is concave horizontally and con-vex vertically giving it a saddle-shaped appearance. Histo-logical analysis of the clavicular head (Ellis & Carlson1986), at least developmentally, shows plates of cartilagewithin the bone. This is a direct comparison with the headof the mandible (Wolford et al 1994), both designed pre-sumably to absorb extreme stresses and strains. Thecorresponding surface of the sternum reciprocally has anobvious concave surface vertically and a slight convexityhorizontally. Since the articulating surface of the clavicu-lar head is over twice that of the manubrial surface thisapparent incongruence, whilst enabling large amplitudeof motion makes the joint potentially very unstable. It isthe role of the joint’s ligamentous structures to maintainstability (Iannotti & Williams 1999). Ligaments of thesterno-clavicular joint include the intra-articular ligament

or disc, the inter-clavicular ligament, the capsular (supe-rior) ligament, and the costo-clavicular ligament.

There is some disagreement as to whether this intra-articular ligament serves primarily as a ligament or as anintra-articular disc and this will be discussed later. Thisdense fibrous structure has a strong peripheral capsularattachment that completely divides the joint into separatecavities (DePalma 1959), which in itself hints at a discretefunction for each of the joint’s cavities. Occasionally,there may be some central connection between the twojoint cavities but this is believed to be secondary to wearand tear. Inferiorly, the disc arises from the synchondrosisof the first rib cartilage and the manubrium. Superiorly, itattaches to the superior and medial aspects of the medialclavicle at the lateral joint margin but blends with thefibres of the capsular (superior) ligament.

The interclavicular ligament, as its name suggests,blends with the same ligament of the opposite side. Also,it is attached to the superior part of the manubrium andblends with the ipsilateral capsular (superior) ligament.

The capsular (superior) ligament, perhaps the strongest ofthe sterno-clavicular joint ligaments, really representsantero-superior and posterior reinforcement (or thickening)of the articular capsule, the antero-superior being thethickest.

Working in concert these above three ligaments affordboth strength and static stability to the sterno-clavicularjoint with the shoulder girdles in a resting, weight depen-dent position. This has been referred to as ‘shoulder poise’where the distal end of the clavicle is passively supportedslightly higher than its medial end. As a passive supportmechanism they represent a significant saving in muscularenergy expenditure to help carry objects on the shouldergirdles (for example, a yoke, satchel, and even a child)or carry objects by hand (hunted game, water containers,and suitcases). Also, passive shoulder poise is essential forefficiency of manual activities that require minimal shoul-der girdle excursion (for example, moulding clay, cookingand using the computer mouse). With regard to stability,the most important of the three ligaments appears to bethe capsular (superior) ligament. Cadaveric experiments(Bearn 1967) have clearly demonstrated that static ‘clavic-ular poise’ is independent of myofascial support, or evensupport from the interclavicular and intra-articular discligaments. Once the capsular ligament is torn minimalforce is needed to tear the intra-articular ligament, leadingto superior dislocation and disruption of the sterno-cla-vicular joint. If the posterior part of the capsular ligamentalso fails then posterior dislocation is possible which maylead to more serious health or even life-threatening com-plications due to compression of mediastinal structures.

The costo-clavicular ligament is also called the rhom-boid ligament because of the orientation of its fibres.For this ligament there appears to be some disagreementas to its actual morphology (Tubbs et al 2009). Tradition-ally this ligament has been described as a ‘flattened’ cone.

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The best way to visualize this is to take a polystyrenepaper cup and draw oblique parallel lines around itsperimeter. Now squash it flat. The drawn lines wouldresemble a rhomboid if viewed from anterior and poste-rior. However the lateral and medial margins of the cupwould appear to continue the spiralling lines originallydrawn. As such, the fibres of the ligament would indeedbe capable of resisting clavicular motion in all directionsand planes, except for one and that is depression of theclavicle in neutral. The argument within the literature asto its morphology is whether there is an interposing bursa(or space) between the anterior and posterior sets of fibresor if they form one solid mass. Regardless the orientationthis ligament’s fibres are clearly designed to resist anymotion of the clavicle away from its neutral ‘poise’. Theanterior fibres appear particularly vulnerable to excessiveelevation and protraction of the shoulder girdle, whichthis author feels, from cadaveric observation, is theclose-packed position of the sterno-clavicular joint.

During full elevation of the humerus (through flexion/abduction) the shoulder girdle (scapula and clavicle)moves into depression and retraction. The disagreementas to whether the clavicle elevates or depresses (Ludewiget al 2004) is probably the result of different instructionsto the observed models. If the model is asked to elevatetheir hand as high as they can, then elevation of the clavi-cle will result. However, this author believes that func-tional elevation requires a stable, depressed clavicle.

During full elevation recruitment of lower trapeziuscoincides with activation of subclavius muscle (Konstantet al 1982). This would make sense since the motionprobably coincides with the greatest stress placed on thesterno-clavicular joint for either throwing or brachiation.The ‘shunt’ action of subclavius would be most appropri-ate now for stability of the sterno-clavicular joint. In thisauthor’s experience most costo-clavicular ligament inju-ries (treatable by physical therapy) occur when there isforceful elevation thrust of the arm with a correspondingelevation and protraction of the shoulder girdle. Thisforced lateral displacement of the clavicle would not beresisted by the appropriate reflex shunt action of subcla-vius rendering the anterior fibres susceptible to damage.Individuals who might perform such an action are limitedto certain athletes (for example, shot putters, javelinthrowers, racquet players) but also those performinghousehold tasks (for example, cleaning a bathtub,painters).

BIOMECHANICS OF THE STERNO-CLAVICULAR JOINT

At the sterno-clavicular joint, the clavicle is clearly capableof moving through at least two cardinal planes, i.e. thehorizontal (35� of combined protraction and retraction)

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and vertical plane (30–35� degrees of elevation) (Iannotti& Williams 1999). The joint is therefore considered to pos-sess two degrees of freedom that are both pure swings. Thelargest displacement, however, is 45–50� of rotation (Ian-notti &Williams 1999, Ludewig et al 2004) around the longaxis of the clavicle (that is, motion through a sagittal plane)but this author wonders if this can truly be considered adegree of freedom?

The joint is clearly divided into two separate anatomicalcompartments suggesting two separate functions (similarto the temporomandibular joint). If the posterior edgeof the lateral end of the clavicle is palpated during inspira-tion and expiration rotation of the bone is clearly felt.This is because the clavicle is ‘crank’ shaped, and as themanubrium rises with inspiration elevation of the medialend of the clavicle produces a posterior rotation aroundits longitudinal axis. Since there is no other displacementof the clavicle (shoulder girdle) obvious it is assumed thatthe rotational motion at the sterno-clavicular joint occurswithin the medial component (disc/manubrium) of thejoint. So it could well be argued that the sterno-clavicularjoint complex has indeed got three degrees of freedom ofmotion.

The large, superficial head of the clavicle is easily pal-pated during motion of the shoulder girdle on a relativelystationary manubrium. From full retraction towards pro-traction the most obvious motion initially appears as aposterior male (convex on concave) glide but this glideonly occurs through the first two-thirds of the range (fromfull retraction to neutral poise). After that, as protractioncontinues an anterior rotation is apparent, representing afemale (concave on convex) glide.

A similar change in glides is apparent when the joint ispalpated from full depression to full elevation of theshoulder girdle where there is initial inferior male glidefollowed by a superior anterior female glide. Understand-ing that the male motion occurs at the disc/claviclecomponent and the female from the disc/manubriumcomponent allows for a very simple palpatory assessmenttechnique to discern which component is in dysfunction,or indeed whether the whole complex might be deranged.

Considering the dearth of biomechanical research rele-vant to physical therapy, at this point the author sees fitto propose an interaction between clavicular motion andmanubrial motion during elevation of the arm throughflexion and abduction based on clinical experience andextrapolation of anatomical knowledge. As the arm is ele-vated through flexion/abduction the initial motionappears to occur at the gleno-humeral and acromio-clavic-ular joints on a relatively fixed clavicle. The inferior angleof the scapula displaces laterally and anteriorly to producean upward rotation of the scapula and its glenoid surface,the motion occurring at the acromio-clavicular joint. Atabout 150� of elevation the inferior angle stops moving.Presumably fixated by an isometric contraction of lowerserratus anterior muscle, the axis of shoulder girdle

Chapter | 15 | Sterno-clavicular joint

motion now shifts from the acromio-clavicular joint tothe sterno-clavicular joint and the shoulder girdle is seento depress and retract in the last 30–50� of arm elevation.It might be reasonably assumed that the clavicle shouldsignificantly rotate posteriorly. However, if the clavicle ispalpated during this terminal range minimal, if any, rota-tion is sensed. To solve this apparent conundrum onemust now study what is occurring at the manubrium.

As the arm is elevated beyond 150� upper thoracicmotion can be both seen and palpated. The upper tho-racic spine extends, ipsilaterally rotates, and side-bendstowards the moving arm. The first thoracic vertebra, firstrib, and manubrium now all move in concert, dictatedby thoracic spine motion. This is easily felt at the manu-brium by palpating bilaterally just below the first rib car-tilage. The manubrium also side-bends and rotatestowards the elevating arm. So the manubrium is nowmoving under the clavicle producing a relative anteriorrotation of the sterno-clavicular joint. This simultaneousmotion of both the clavicle and the manubrium ensuresthat there is no resultant posterior rotation of the clavicle.The main question now is: why would this be necessary?

The deep cervical fascia blends with the posterior andsuperior periosteum of the clavicle. If the clavicle were torotate posteriorly up to 45�, as has been suggested, the deepcervical fascia would undergo an extreme increase in ten-sion potentially compromising the neuro-vascular tissuepassing through it, a distinct disadvantage for a brachiator.

Although not strictly a sterno-clavicular joint disruptionor injury, an inability for the thoracic spine to move appro-priately during the final stages of arm elevation wouldprevent the disk/manubrium component of the sterno-clavicular joint from de-rotating the clavicle. Clinically,those who perform habitual or sustained arm elevation intheir recreational or work environment would potentiallycomplain of signs or symptoms of abnormal neural tensionwithin the arm and/or damage to distal shoulder girdlestructures from mechanical compensation. For this reasonassessment of thoracic and manubrial motion should be aroutine part of shoulder girdle assessment.

PATHOLOGY OF THESTERNO-CLAVICULAR JOINT

For the physical therapist pathologies of the sterno-clavicular joint are best divided into two main sections,i.e. those requiring a medical/surgical consult and thosewith an indication for physical therapy intervention.

Patients requiring a medical/surgicalconsult

The sterno-clavicular joint is susceptible to any of thepathologies that affect synovial joints (Iannotti &

Williams 1999, Higginbotham & Khun 2005). Whilstnot attempting an exact medical diagnosis, the therapistneeds to be able to identify patients suffering from serioustraumatic injuries and non-traumatic or degenerativearthritic conditions. Dislocations, although uncommon,represent the greatest threat to articular function. Theycan occur in anterior, superior, and posterior directions.Dislocations can be the result of direct trauma to the clav-icle or manubrium as may occur in motor vehicle acci-dents or sports. They also result from indirect trauma,especially to the postero-lateral shoulder (superior andposterior dislocations) and antero-lateral shoulder (ante-rior dislocations) (Iannotti & Williams 1999).

The posterior dislocation is of greatest concern becauseof the threat to retro-sternal structures such as the tracheaand major blood vessels (Rodrigues 1843, Worman &Laegus 1967, Cooper et al 1992). If these structures areinvolved the patient may well be observed as havingbreathing problems and changes in skin colour due tovascular or airway compromise.

Dislocations tend not to be subtle. The therapist maysuspect them from a history of extreme trauma, a grossloss of motion of the upper limb, and an obvious observ-able and palpable change in the natural contours of thesterno-clavicular joint. During palpation of motion(described later) the therapist may detect gross disruptionof the anticipated (male to female) motion sequence.

Although the clavicle is the first long bone to beginossification, it is the last to complete it. The epiphysis ofthe medial end of the clavicle ossifies in the 18th–20thyear and fuses with the shaft between the 23rd–25thyears. Direct and indirect trauma to the medial end ofthe clavicle may result in epiphyseal disruption, even frac-ture. Closely resembling the presentation of a dislocation,only medical examination can provide an accurate diag-nosis (Iannotti & Williams 1999).

Hyperostosis at the sterno-clavicular joint (Dihlmannet al 1993, Noble 2003), felt initially by the therapist asan apparent bony hypertrophy of either the clavicularhead or the manubrium could signify serious pathology,and a medical consult is certainly warranted (Fritz et al1992). However, the author has seen two cases of physealtrauma where fracture or disruption were ruled out butthe trauma resulted in benign hyperostosis of the headof the clavicle. Apart from the distressing cosmetic appear-ance, joint function and stability in these two casesappeared normal.

The sterno-clavicular joint has been shown to suffer fromalmost all potential causes of non-traumatic arthritis, themore common including septic arthritis, rheumatoid arthri-tis, tuberculosis, and ankylosing spondylitis. The author hasrarely seen gouty arthritis as is mentioned in the literature(Kearn et al 1999) but clearly it cannot be ruled out. The pre-sentation of a painful, hot, and swollen joint with no historyof injury should immediately raise enough concern for thetherapist to request a medical consult.

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Patients with indication for physicaltherapy intervention

These patients will include those with sprains and strainsof the sterno-clavicular joint. Acute traumatic arthritismay present with enough pain, swelling and dysfunctionthat a medical consult should be sought. They are mosteffectively treated with a resting sling and subsequentreferral to physical therapy.

The location of pain from sterno-clavicular joint injuryis most commonly in the joint itself, but distal referral forexample to the neck, shoulder, and arm is also possible(Hassett & Barnsley 2001). With sub-acute and chronic(traumatic) arthritis the therapist’s main concern iswhether joint motion has been lost, and if so assess whichcomponent of the joint is responsible.

Another concern would be the possibility of any liga-mentous sprain. The author is unaware of any confirmeddiscrete tests for the intra-articular disc ligament, capsu-lar ligament, or inter-clavicular ligament. However ifarticular motion is normal but localized pain is repro-duced by overpressure of shoulder girdle movements, aligamentous injury must be suspected. Accurate palpa-tion followed by deep transverse friction massage(DTFM) and ultrasound would appear to be the treat-ment of choice.

Unlike the other ligaments the costo-clavicular ligamentcan be stressed discretely. With the patient in contralateralside-lying, the therapist moves the (affected side) gleno-humeral joint into extension and adduction. Applyingpressure through the elbow the therapist then pushes theshoulder girdle into full elevation and protraction.Continued pressure through the patient’s elbow now pro-vides a lateral distractive force to the sterno-clavicularjoint, maximally stressing the costo-clavicular ligament.In this author’s opinion and experience, the anterior fibresare the most likely to be injured. They are accessible toDTFM if the shoulder girdle is positioned into depressionand retraction (posterior rotation of the clavicle).

Osteoarthrosis is suspected when crepitation or even‘clunking’ are detected during motion palpation. Onepaper on cadaveric dissection of the sterno-clavicularjoints suggested that 80% of people over 50 may haveosteoarthrosis of this joint (Hagemann & Ruttner 1979).Since cadaveric dissection can rarely be correlated withsymptoms it is unclear how much symptomatology thiscondition is responsible for. In the author’s experienceminor, asymptomatic joint crepitation is common in thepresence of normal joint function and should probablybe ignored. However, if the crepitation or clunking is sig-nificant, or corresponds to the reproduction of thepatient’s symptoms then a medical consult should besought. The degenerative state of the joint may help inan eventual prognosis, but also in determining the appro-priate magnitude of force used in physical therapy proce-dures (Frosi et al 2004). It is worth remembering that all

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resisted forces on the upper limb must ultimately be trans-ferred to the sterno-clavicular joint.

DIAGNOSIS OF THE STERNO-CLAVICULAR JOINT

As was inferred earlier the size of the clavicular head, cou-pled with the fact it is located so superficial, enables thetherapist to easily palpate sterno-clavicular joint motion.Following the taking of a history and observation the ther-apist palpates the anterior surface of the head of theclavicle.

From a position of full retraction the patient isinstructed to pull their shoulder girdles into protraction.In normal motion the therapist should be able to feelthe head of the clavicle move initially posteriorly (maleclavicular/disc motion). At the position of neutral ‘poise’the motion should be felt to change to a female (disc/manubrial motion) anterior glide (roll). From a positionof full depression the patient is instructed to lift theirshoulder girdles into elevation. In normal motion thetherapist should be able to feel the head of the claviclemove initially inferiorly (male clavicular/disc motion).At mid-range this motion is felt to change to a femalesuperior/anterior roll. This simple test enables the thera-pist to decide which articular component is lacking.

MANAGEMENT OF THE STERNO-CLAVICULAR JOINT

Options for physical therapy management have beenprovided above in the section on pathology. The empha-sis in this section will be on manual therapy interventionand adjunct exercises for patients with mechanical sterno-clavicular joint dysfunction. Techniques address eitherdisc/manubrial restrictions (anterior and posterior rota-tion) or clavicular/disc estrictions (inferior glide andposterior glide).

Anterior disc /manubrial rotationmobilization (left shoulder)

The patient is placed on the right side lying facing thetherapist. The therapist is standing, facing the patient.The therapist’s left middle and ring finger tips are tuckedposterior and inferior to the lateral edge of the patient’sleft clavicle. The therapist’s right hand grasps the inferiorangle of the scapula. Passively draws the patient’s leftshoulder girdle into elevation and protraction until ante-rior rotation is sensed to cease (Fig 15.1).

The therapist instructs the patient to take a short breathin followed by a long breath out. As the patient breathes

Fig 15.1 Mobilization for anterior rotation of the femalecomponent (elevation and protraction).

Chapter | 15 | Sterno-clavicular joint

out increased anterior rotation of the clavicle is taken upby passively increasing elevation and protraction and alsoby the therapist’s left hand pulling the posterior edge ofthe clavicle upward and forward. The procedure isrepeated until no further motion can be elicited.

Posterior disc/manubrial rotationmobilization (left shoulder)

The patient’s starting position is the same as describedabove. In this technique and in contrast to the above tech-nique for anterior rotation, the therapist’s middle and ringfingers are over the superior aspect of the posterior edge ofthe lateral clavicle. The therapist moves the shoulder gir-dle into depression and retraction until posterior rotationof the clavicle ceases (Fig 15.2).

The patient is instructed to take a short breath out fol-lowed by a long breath in. As increased posterior rotationof the clavicle is detected the therapist pushes the patient’sshoulder girdle into further depression and retraction

Fig 15.2 Mobilization of posterior rotation of the femalecomponent (depression and retraction).

with an accompanying push on the posterior edge of theclavicle inferiorly by the therapist’s left fingers. This proce-dure is repeated until no further motion can be elicited.

Inferior clavicular/disc glide (rightshoulder)

The patient is supine. The therapist is standing adjacent tothe patient’s opposite shoulder girdle. The therapist’s leftthumb pad or thenar eminence is placed over the superioraspect of the head of the patient’s right clavicle. The thera-pist’s right hand draws the patient’s right shoulder girdleinto elevation until the inferior glide of the clavicularhead ceases (Fig 15.3).

The therapist instructs the patient to resist an attempt topush the right shoulder girdle into depression. An inferiorglide of the right clavicular head will be detected and thismotion slack is taken up by pressure from the therapist’sleft thumb. Any slack in right girdle elevation is nowtaken up by the therapist’s right hand. This procedure isrepeated until no further motion is perceived.

Posterior clavicular/disc glide (rightshoulder)

The patient is supine. The therapist is standing on theopposite side to the joint being treated. The therapistgrasps the patient’s right shoulder with their left handand instructs the patient to place their right hand ontherapist’s left arm. The therapist’s right thumb or thenareminence is placed over the anterior surface of the headof the patient’s right clavicle (Fig 15.4).

The patient is instructed to resist the therapist’s attemptto push the patient’s right shoulder girdle into retraction.A posterior motion of the clavicular head will be noted andtherapist’s right thumb takes up the slack. Any increased pro-traction is taken up by therapist’s left hand. This procedure isrepeated until no further motion is perceived.

Fig 15.3 Mobilization of the inferior male glide (elevation).

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Fig 15.4 Mobilization of the posterior male glide (protraction).

Part | 3 | The shoulder region

Adjunct exercises

Active exercises to maintain range of motion of the sterno-clavicular joint gained by passive mobilizations shouldsimply be instructed in functional sets, that is, they shouldhave an emphasis on either a combination of elevationand protraction or on a combination of depression andretraction. With regard to normal sterno-clavicular jointfunction, however, the author cannot overemphasize theneed for normal thoracic joint motion. Manual mobiliza-tion and manipulation techniques to restore mobility in

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this region have been described in Chapter 11 and shouldbe reviewed and included for optimal management ofpatients with sterno-clavicular joint dysfunction as indi-cated by the examination findings. Addressing this com-ponent of sterno-clavicular joint dysfunction may alsonecessitate additional thoracic spine exercises to facilitateshoulder girdle depression and retraction (extension andipsilateral side bending/rotation of the thoracic spine) orgirdle elevation and protraction (flexion and contra-lateral side bending/rotation of the thoracic spine).

CONCLUSION

The sterno-clavicular joint seems poorly understood andmore poorly researched, but it is accepted that this is, inpart, due to the rarity of significant injury to the joint.However, as physical therapists continue to gain the priv-ilege of direct access to patients it is essential they becomeaware of how to differentiate between pathological condi-tions of this joint that may be either health or life threat-ening demanding a medical consult or that require aphysical therapy intervention. Also, much more work isrequired by all interested parties to investigate the bio-mechanical role of the thorax in sterno-clavicular jointfunction and its potential patho-biomechanical interac-tion with upper limb function.

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