VM4 - The Thorax - Treatments

Question 1

Hyoid

Answer 1

Mobility Test in all Directions - lateral, side bend, rotate, superior/inferior, anterior/posterior

Question 2

Middle Cervical Fascia - Hyoid Anchor

Answer 2

Superior Hand - hyoid - anchors

Inferior Hand - along clavicle, cartilage of 1st rib, manubrium
- may go over clavicle to stretch sub clavicle tissue

Question 3

Middle Cervical Fascia - Occipital Technique

Answer 3

One hand on occiput

Second hand omohyoid insertion medial to scapula notch

Question 4

Clavipectoral Fascia Long Lever Treatment (and Middle Cervical Fascia stretch)

Answer 4

The CPF connect thorax to arm. Shortens when you catch yourself falling down or tension on thorax, lungs or ribs

Put arm on the side involved into external rotation and abduction (to fix brachial aponeurosis)

Rest patient head on your abdomen

Cross arms with hands in coracoid processes and push them posteriolaterally and slightly inferiorly

Use abdomen or chest to sidebend neck away from abducted arm. The side bending of the neck stretches middle cervical fascia

Question 5

Clavipectoral Fascia Direct Treatment

Answer 5

To release fascia under pec major

Put arm on side treated into external rotation and abduction

Put thumbs under pec major to join fascia of pec minor (on top of pec minor, surf ribs)

Traction fascia by separating thumbs. Listen, don’t compress, do induction

Add arm movement as long lever. Ask patient to actively and slowly move arm into internal and external rotation to increase stretch of the fascia

Work into axillary fascia (continuous with the pectoral and clavipectoral fascia anteriorly, with the brachial fascia laterally, and with the fascia of the latissimus dorsi and serratus anterior muscles posteriorly and medially.)

Question 6

Palpation of Anterior Visceral Sheath - Pretracheal Fascia

Answer 6

Pg 28 of study guide

Question 7

Pretracheal Fascia / Visceral Sheath

Answer 7

Local listen then gentle mobility test to thyroid cartilage, cricoid cartilage, trachea

Treat as indicated with gentle mobilization or induction

Question 8

Palpation - Deep Cervical Fascia / Prevertebral Fascia

Answer 8

In anatomy I have a good slide for the anatomy here

Feel the anterior scalene muscle it is wrapped by deep cervical fascia. Go behind sternocleidomastoid and behind the clavicle to find scalene tubercle of first rib
Side bend head to same side and/or lift shoulder cephaldad to gain access.
Feel the distensible subclavian vein in front of anterior scalene muscle. Subclavian vein is soft, and easily compressed.
Feel the subclavian artery behind anterior scalene muscle. Look for pulse. It is lateral and posterior to scalene tubercle.
Feel the brachial plexus; it is more posterior and lateral than subclavian artery. The nerves feel like taught strings, like the longitudinal fibers of a tendon but smaller. Brachial plexus is about to dive under the clavicle.
Feel for the pleural dome. The pleural dome is a small space medial to scalene tubercle; appreciate its elasticity. With inhalation you may feel it pull caudad.

Question 9

Deep Cervical Fascia Treatment

Answer 9

Find anterior scalene (transverse process of C2-C6 to tubercle on 1st rib)

Engage anterior scalene at origin and insertion

Treat with induction or a direct stretch

Question 10

First Rib

Answer 10

Supine:

First rib is witness to tension on ipsilateral side. If it won’t compress =mechanical issue of rib. Resistance with some movement = compensation for an organ on that side, or reflects tension of the deep cervical fascia. If it compresses and doesn’t come back, something is pulling it down.

Compare both sides

Contact hand is spanning all along first rib

Avoid compressing shoulder

Sidebend neck to the side you’re testing

SEATED

Avoid compressing shoulder

Sidebend ipsolateral

Compression/decompression test. Decompression is mostly passive

Compare both sides

Treat with direct, listen and follow, or recoil

Question 11

Thyroid Palpation

Answer 11

Palpate lobes of thyroid. Should feel like tapioca pudding

Find isthmus

Palpate Motility

Any motility or mobility restrictions?

Any hard nodules?

The midline landmark for the thyroid gland is to palpate from the cricoid cartilage to the first tracheal ring. Here lies the isthmus of the thyroid, at the first tracheal ring. It is very thin.
Take the head into flexion glide fingers along trachea, slide between muscles and trachea, without compression. Feel the thyroids’ lateral lobes extending cephaldad and caudad. Compress too much you will only feel the trachea, if too light will feel only skin.
In men the thyroid is thinner than in woman. And with pregnancy the thyroid is larger.
Thyroid motility (2 buds embryologically)
Inspir; superior and spreading laterally
Expir: inferior and narrowing

Question 12

Thyroid Motility

Answer 12

Inspir - external rotation, a spreading laterally and a superior glide

Expir - internal rotation, a narrowing and an inferior glide

Question 13

Trachea Motility - Superior Aspect

Answer 13

Inspir - rotates to the left and a small movement inferior

Expir - rotates to the right and slightly superior

Question 14

Superficial Cervical Aponeurosis Test

Answer 14

Question 15

Mid-Cervical Aponeurosis with a Long Lever

Answer 15

Question 16

Palpate Superficial Fascia

Answer 16

The superficial fascia is too thin to produce genuine restriction
The superficial fascia and platysma are closely related

Palpate Platysma muscle. (Muscle of facial expression.)
Palpate Trapezius muscle (back off to fascial layer)
Palpate Sternocleidomastoid muscle (back off to fascial layer)

Question 17

Palpate Middle Cervical Fascia

Answer 17

Find Hyoid.

Stabilize the hyoid with 2 fingers; use other hand to test distensibility all along thoracic inlet. (May actually see tightness with naked eye)

Test at clavicle, scapular notch, manubrium and first rib at scalene tubercle. Always compare both sides.
Fascia feels flat. Muscle feels round and thicker.

Release with direct stretch in specific directions indicated by testing and if needed recoil can be utilized. This fascia has contractile fibers.

Release with induction. Stabilize hyoid and do a local listening, use inhibition to find associated structures.

For future reference if in class at this time you don’t get a good release from the middle cervical fascia. Be aware there may be other associated structures that need to be addressed before the middle cervical fascia. If the subclavius muscle and conoid and trapezoid ligaments are restricted they will hinder your release efforts.

Question 18

Palpate Clavipectoral Fascia

Answer 18

Find coracoid process.
The clavipectoral fascia is bound by the clavicle, coracoid process and axilla.
It inserts superioirly on subclavius aponeurosis, lower down it surrounds pectoralis minor muscles and merges with skin of axillary fossa, and the brachial aponeurosis at the level of the coracobrachialis and short head of biceps brachii.
Anytime the middle aponeurosis is involved search clavipectoral for adhesions or fibrosis.
Technique: Put arm on affected side into external rotation and abduction to fix brachial aponeurosis. Place your contact on both coracoid processes. Stretch posterolateral and slightly inferior direction. Sidebend head to the opposite side (away from the targeted clavipectoral fascia). This side bend of head brings in middle cervical fascia, which inserts with the clavipectoral fascia onto the aponeurosis of the subclavius muscle.

Question 19

Palpate Pretracheal Fascia / visceral sheath

Answer 19

Gently mobility test the thyroid cartilage then local listen.
Gently mobility test the cricoid cartilage, then local listen.
Treat as indicated with gentle mobilization or do an induction

This pretracheal fascia begins at the bottom of the thyroid cartilage and continues to posterior pericardium (via thyropericardiac lamina). It wraps around the thyroid gland, covering in front of the trachea and esophagus. It forms the visceral sheath of the neck along with the buccopharyngeal fascia, which travels behind the esophagus.
The pretracheal fascia / visceral sheath has attachments to the midcervical fascia, the deep cervical fascia (prevertebral) and the vascular sheath.

Question 20

Palpate Anterior Neck

Answer 20

Hyoid bone C3-4
Thyrohyoid membrane (a very slight slope)
Thyroid cartilage Adam’s apple C-5
Cricothyroid ligament (another slope)
Cricoid cartilage C-6 round ring, where esophagus begins
Tracheal rings flat rings
Thyroid gland

Question 21

Palpate Vascular Sheath

Answer 21

Carotid artery-pulse
Internal Jugular vein it is very distensible
Vagus nerve
Be careful not to compress arteries.

Question 22

Sternoclavicular Joint Techniques

Answer 22

Mobility test Posterior SC ligament:

To test take shoulder anteromedially which brings the medial clavicle posterior.
With the fingers of your testing hand accompany the posterior movement of the medial clavicle. With a restriction there is resistance to that movement.
Mobility test Anterior SC ligament:

To test take shoulder posterolaterally until medial clavicle moves forward. If there is resistance to movement there is a restriction.
Mobility test Interclavicular ligament:

Push alternately on both shoulders inferior and slightly posterior, so that medial clavicle moves upward. Monitor movement.
Treatment for SC ligaments: use a direct stretch and or recoil

The following corrections are all performed supine with hands on abdomen and legs extended.

Posterior SC ligament:

One hand over medial clavicle take it posterior and superolateral. other hand moves shoulder anteromedial.
Anterior SC ligament: WB pg.22

Practitioners’ hands are crossed. Contact the sternum close to sc joint on the side opposite you want to correct and other hand takes the lateral clavicle posterolateral; which brings medial clavicle anterior
Useful technique when subclavian or brachcephalic vessels are compromised.
Interclavicular ligament:

Use after sc ligament is corrected. Place both hands against medial sides of sc joint. Direction for correction is inferolateral and slightly anterior.
The following corrections are performed seated. Remember engaging tissue in its anatomic orientation can be advantageous.

Posterior SC ligament:

On the side you choose to treat take the patients arm on that side to rest on your same side, thigh (your foot is on the table) Surround that shoulder with your hand and take it anteromedially, and allow your other hand to take medial clavicle posterior and slightly lateral.
Anterior SC ligament: WB. Pg.23

Take patients opposite arm of affected side over your knee. Place the palm of your hand in supraclavicular fossa with thumb against posterior angle of rib1and 1st costovertebral joint.
Put your other hand on the parietal bone of opposite affected side with elbow resting on patients shoulder. Push clavicle anteroinferior and medial. Force comes through clavicular contact. Skull hand lines up the tension, involves the entire thorax.

Question 23

Costoclavicular Ligament

Answer 23

Supine, Mobility test and treatment keep same contacts.
Contact 1st rib under clavicle close to sternum, second contact is clavicle above rib contact.
Stretch clavicle superior and lateral OR stretch 1st rib inferior and medial.

Question 24

Subclavius Muscle

Answer 24

Treatment is to wake up the tissue with compression and then release, compress again. Release a little less then follow the listening.
Remember this has a connection with middle cervical fascia.

Question 25

Coracoid Ligaments

Answer 25

Trapezoid ligament
-Can use thumb or hypothenar eminence.
-Cross your hands .One thumb to stabilize medial coracoid process, other contact on medial acromioclavicular joint, push clavicle superolaterally. -Can push coracoid in opposite direction.

Conoid ligament

-One thumb on medial aspect of coracoid, other thumb pushes on lateral third of anterior edge of clavicle.
-Direction to stretch is posteriosuperiorly and medially.

Acromiocoracoid Ligament (within scapula)

-Cross hands. Contact coracoid. Contact acromion. Push your hand in opposite directions.

Coracohumeral ligament (Maintains biceps tendon in its groove)

-Cross hands. One contact on coracoid other on lesser tubercle of humerus. To make that contact arm is in external rotation. Stretch in orientation to fibers of ligament.

Acromioclavicular ligament

-Supine. Crossed hands Standing at patients head. One hand on acromion pushes posterolateral, other hand on clavicle pushes superomedial.

Question 26

JPB New Technique

Answer 26

Patient is supine. Get thumb underneath lateral clavicle.
Move patients arm medial and external rotation so clavicle lies on your thumb.
Move patients’ arm medially across body and push clavicle in same direction of arm.
Move arm back but maintain the clavicle. Go step by step it may be painful. By end of treatment it is no longer painful.
If the arm is too heavy hold their elbow. You must not use your energy.

Question 27

Palpate - Superficial Fascia