Tight muscles n pectoralis major (not shown) n pectoralis minor (Fig.2a) n upper trapezius (Fig.2b) n levator scapulae n sternocleidomastoid (Fig.2a)

Figure 1: Upper crossed syndrome of the shoulder and neck

Weak muscles n lower and middle trapezius (Fig.2b)

n serratus anterior (not shown) n rhomboid major (Fig.2b) n rhomboid minor (lies under upper trapezius fibres)

PECTORALIS MINOR

STERNO- CLEINOMASTOID

band. There are several soft tissue techniques that can be utilised to “re-set” the resting tone of the muscle involved. These techniques will only have a permanent effect if the cause of the muscular dysfunction is identified and corrected, for example correction of posture, or removal of emotional stress.

Upper crossed syndrome A common presentation around the upper quadrant, which is responsible for recalcitrant neck and shoulder pain, is the upper crossed syndrome (7). This produces the characteristic muscle imbalance seen in figure 1.

Muscles which are prone to tightness generally have a “lowered irritability threshold” and are willingly activated at the onset of movement, hence creating abnormal movement patterns. These imbalances and movement dysfunctions can have direct influence on joint surfaces, causing abnormal motion which could precipitate further dysfunction, which could in turn be associated with pain (Fig.3). Hence, abnormal movement causes pain, which will then cause abnormal movement. Therefore, therapists should identify and treat the cause of the pain rather than focus on the source of the pain.

Figure 2a: Muscles involved in the upper crossed syndrome (anterior aspect)

TABLE 3: REFERRAL AREAS AROUND THE GLENOHUMERAL JOINT FROM ACTIVE TRIGGER POINTS

Muscle in which trigger point lies

Trapezius Scaleni

Pectoralis major

Sternal Clavicular

Pectoralis minor Subclavius Supraspinatus Infraspinatus

Teres minor Teres major Subscapularis

Anterior deltoid Posterior deltoid

Coracobrachialis Biceps brachii

Brachialis Triceps

22 AREA OF REFERRAL

Strong referral Posterior aspect ACJ

n Anterior deltoid n Lateral side of arm to elbow Anterior deltoid

Lateral deltoid

n Anterior deltoid n Middle of biceps belly n Lateral deltoid

Distal aspect of posterior deltoid Posterior deltoid

Posterior deltoid to lateral scapular border

Anterior deltoid to middle of antero-lateral humerus

Posterior deltoid to lateral aspect of spine of scapula Anterior deltoid

Lateral and posterior deltoid

n Lateral head of triceps n Anterior deltoid

Anterior deltoid to tendon of biceps Anterior arm over biceps belly

Posterior deltoid Weak referral

Posterior deltoid Anterior deltoid

Anterior deltoid Infraclavicular area

Scapula position An important area to concentrate on around the shoulder girdle is the resting position of the scapular. The resting position of the scapular and the function of the muscles of the shoulder girdle have a major effect on the stability and motion of the scapular. Often patients with chronic muscular neck pain (and associated trigger points with levator scapulae and upper trapezius), have a mal-positioned scapular, which will be downwardly rotated, bringing the inferior angle of the scapular closer to the spine.

This can put the upper fibres of trapezius into a permanent stretch which can cause an increase in resting tone within the muscle. As part of the assessment process, passively placing the scapular in its optimal position (superior angle in line with T2 and the inferior angle in line with T7 (see Fig.4)), and then re-assessing the patient’s symptoms, will generally have a beneficial effect. Part of the treatment process therefore must be to provide the patient with some suitable rehabilitation exercises to correct this positional fault. Care needs to be taken if when assessing a patient, it is noted that the shoulder girdle is elevated on the side of pain. This may be due to mechanosensitivity of one or more of the nerve roots exiting in the cervical region, and the elevation of the shoulder girdle is a protective effect to reduce the traction on the nerve. If

sportEX dynamics 2010;24(Apr):20-23

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