March 2006

Visceral dysfunction and the shoulder fixation test

by Dr. Howard Loomis

One of the most difficult problems of differential diagnosis clinicians encounter in practice is determining an effective course of treatment for shoulder complaints. Once the obvious structural problems such as referred pain from the neck, ribcage, elbow, and wrist are ruled out, the problem can frustrate the patient and the doctor, especially when the patient has already been treated medically with cortisone shots.

Manifestation of shoulder pain from muscle contraction may originate from anywhere in the body. However, the most common points may be referred from the anterior neck, chest, ribs, abdomen, and even the legs. Palpation and a few simple range of motion tests are usually sufficient to uncover the cause of the most perplexing cases. Let's begin by describing the Shoulder Fixation test.

SHOULDER FIXATION TEST FOR MUSCLE CONTRACTION

The examiner stands behind the seated patient.

‑‑ When examining the right shoulder, the examiner reaches his/her left arm around the front of the patient's neck. Roll your left thumb behind the head of the right clavicle at the sternoclavicular articulation.

 ‑‑ With your right arm, passively abduct the patient's right arm past 90 degrees. It is more convenient to have the elbow straightened.

 ‑‑ Normally, the head of the patient's right clavicle will be felt to move posterior and inferior into the patient's chest as the arm reaches and passes 90 degrees.

Interpretation

*** Normal movement of the head of the clavicle during passive abduction of the arm with idiopathic shoulder problems is graded as a mild condition.

*** Restricted movement of the head of the clavicle during passive abduction of the arm accompanied by idiopathic shoulder problems is graded as a moderate condition. Restricted movement is often indicated by an audible but non‑painful "clicking" at the sternoclavicular articulation.

*** Lack of movement of the head of the clavicle during passive abduction of the arm accompanied by idiopathic shoulder problems is graded as a severe condition.

Problems originating in the digestive tract

You may have read my previous columns concerning the connections between the digestive organs and the cervical spine (C3 to C5) via the Phrenic nerve. In addition to palpable stress points in that area of the neck, stress points will also identify problems of the biliary system under the right anterior costochondral arch. Problems of pancreatic inadequacy can be found under the left anterior costochondral arch. These areas will also be responsible for the appearance of Pottenger's Saucer (loss of the normal dorsal kyphosis between T4 to T9).

In addition to inadequate digestion, poor bowel elimination is a very common cause of idiopathic shoulder pain. This can be quickly discerned by palpating the right Mc Burney point (ascending colon) and left Mc Burney point (descending colon).

Problems related to the upper extremity

Palpation of the muscles overlying the carotid tubercle on the anterior transverse of the 6th cervical spine will quickly identify problems emanating from the upper extremities. You can easily identify referred pain originating from carpal tunnel, tennis elbow (radius), or golfer's elbow (ulna). Once the offending joint problem is corrected, the idiopathic shoulder will be eliminated.

NEUROVASCULAR COMPRESSION SYNDROMES

Any of the following maneuvers may also produce and identify the cause of symptoms of numbness and tingling in the hand.

Problems related to the first rib

This syndrome is identified by having the patient extend their arms. Stand behind the patient and palpate the radial pulses bilaterally while the patient brings their shoulders back and down. When the pulse(s) are obliterated, the neurovascular bundle has between compressed between the first rib and the clavicle at a point where the brachial plexus joins the subclavian artery and crosses over the first rib.

Problems related to the pectoralis minor muscle

Stand behind the patient and have them bring their arms overhead, abducted, and slightly backwards. This position stretches the pectoralis minor muscle and narrows the space through which the neurovascular bundle traverses between the pectoralis minor muscle and the first rib. The test is positive if the radial pulses are obliterated.

The pectoralis minor muscle originates from the third, fourth, and fifth ribs anteriorly and inserts into the coracoid process of the scapula. The cords of the brachial plexus together with the axillary artery and vein descend over the first rib under cover of the pectoralis muscle.

Problems related to the suprascapular nerve

Pain in the shoulder can occur as a result of entrapment of the suprascapular nerve in its passage through the suprascapular foramen. The nerve becomes fully stretched when the arm is held across the chest in adduction. Further adduction places stress upon the scapulothoracic joint and causes traction upon the nerve.

Anterior Scalene Syndrome

Adson's Test is well‑known within our profession. It consists of turning the patient's head to the side of the symptoms, extending the head backwards, abducting the arm, and having the patient take a deep breath. The test is positive when this maneuver obliterates the radial pulse. What is not commonly appreciated is that stress points within the soleus muscle may be preventing complete remission of symptoms after correction of the cervical spine has been accomplished.

(Dr. Loomis welcomes input on the subjects covered in this column. To make a comment or ask a question, write to him at 6421 Enterprise Lane, Madison, WI 53719. Visit www.loomisinstitute.com online or call 800‑662‑2630 for information on upcoming Loomis Institute seminars.)