The Importance of Restoring Thoracic

Arthokinematics for Optimal Shoulder Function

Michael Ashton
PT,DPT, ATC, CSCS, COMT, FAAOMPT

Objective
By the end of this presentation, you will
Understand the thoracic biomechanics and its
influence on ADLs, shoulder injuries/performance,
and lifting mechanics
Know thoracic arthrokinematics and its relation to
exercises
Know how to apply the appropriate locking
techniques to emphasis thoracic mobility during
exercise
Learn exercises to emphasize thoracic mobility in
relation to shoulder function

Biomechanics of the thorax

Rotation

Hsu et al

Thorax contributes most to axial rotation, 60% of motion came from thorax

Willem et al

Thorax contributed most to axial rotation, T4-8 produced 50% of total axial rotation.
Coupling of side-bending and axial rotation highly variable

Extension

Edmonston et al

Lateral radiographs and photographic image analysis of thorax during bilateral arm
elevation shows that the thorax extends, lower region>upper region

White and Panjabi

T1-5: 4 degrees
T7-9: 6 degrees
T10: 9 degrees
T11-12: 12 degrees

T6 vertebral level was the most rigid in terms of nervous system mobility.
Butler DS

Thoracic Biomechanics
Level
T1-2

Flexion

Flexion/extension
combined
4

Extension

Lateral Bending

Axial Twist

T2-3

T3-4

T4-5

T5-6

T6-7

T7-8

T8-9

T9-10

T10-11

T11-12

12

T12-L1

12

Thoracic Biomechanics Influence on

the Shoulder
Essential for overhead shoulder mechanics
Bilateral arm elevation

the integrated thorax (all regions) extends when both arms are
elevated overhead.

Unilateral arm elevation

the thorax rotates and laterally flexes towards the side of the elevating
arm.*
Theodoridis & Ruston9
Electromagnetic tracking of T2T7 during unilateral arm elevation.
Variable coupling of lateral flexion and axial rotation, most coupled
ipsilateral

Position of the thoracic spine affects position of the scapula

Flexed spine could lead to anterior tilting impairing retraction

Thoracic Joint Hypomobility

linked to decreased shoulder flexion,2
increased neck and shoulder pain,as well as
overuse injuries in the cervical and lumbar
spine.

Thoracic Spine Mostly affected by

Joint Hypomobility into Extension
Hypomobility
Joint(arthrokinematic) motion less than normal
True collagen shortening in the joint capsule and
surrounding fascia resulting in:
Loss of mobility of the capsuleroll/glide of joint
d gross range of motion
compression and torque on joint surface and tissue which
over time leads to osteoarthritis of that joint
Compensatory hypermobility and/or overuse injuries at
adjacent joints
Cervical, shoulder, lumbar

Osteokinematics vs Arthrokinematics
Osteokinematic Approach
Study of the motion of
bones regardless of the
motion of the associated
joints.
Angular motions are named
according to the axis about
which they rotate:
Treatment
Stretching techniques
ROM

Arthokinematics
Study of the motion of joints
regardless of the motion of the
bones.
Motions are named according to
the direction the joint surfaces
glide relative to each other
Terminology
Translatoric glide, roll, spin

Treatment Examples
Joint mobilization/manipulation
Joint mobilization
exercises/mullligan approach*

Thoracic hypomobility and shoulder

injuries

Wainner et al.

Norlander et al.

Biomechanical links can be made between different anatomical regions and concurrent symptoms such as
the thoracic spine facet joint and referral of pain to the neck and shoulder

Multiple references

pain and dysfunction of the second rib and cervicothoracic junction were identified in 40% of 101 individuals
with NSSP, which was not present in age-matched asymptomatic individuals.

Multiple references

139 laundry workers demonstrated that hypomobility of the cervicothoracic junction could increase the
probability of developing shoulderneck pain in the following 12 months by 3-fold.

Sobel et al

Coined the term, regional interdependence, to describe how impairment in one region, such as the cervical
or thoracic spine, can result in dysfunction elsewhere, such as the glenohumeral joint. Failure to address the
original impairment may, therefore, be responsible for the persistence of pain.

impairment of the cervicothoracic spine and ribs may increase an individual's risk of developing neck
shoulder pain and may contribute to an overall worse prognosis

Multiple References

Individuals with a shoulder impingement have statistically less thoracic mobility and a more kyphotic
thoracic spinal posture than individuals with healthy shoulders

Osteokinematics vs Arthrokinematics:
Thoracic Extension
Osteokinematics
the superior vertebra
extends relative to the
inferior vertebra (all four
regions).

Arthrokinematics
Facet joint surfaces
considered planar joints
the inferior articular process
of the superior vertebra
should glide inferiorly and
slightly posterior following
the joint's orientation,
which may be variable both
regionally and between
sides of the same segment.

Difference between Thoracic and

Shoulder Arthrokinematics

Major Disruptor to thoracic mobility?

Upper Crossed Syndrome

Forward Head Posture
(FHP)

Rounded Shoulders

Thoracic
Extension????
Scapular
Retraction???

Affects of UCS/Forward Head Posture

Mid-cervical Spine C3-6

Hyperextension leading to

Diminished intervertebral foraminal size and together with

degenerative changes causes ischemia and neuropathic
symptoms

Apex is usually C5-6

Neurologically affects
Shoulder
elbow

Cervico-thoracic Spine

CT and upper thoracic spine are fixed into flexion

Hypomobile into extension, sidebending and rotation

Affects of UCS/FHP
Shoulder Girdle
Shoulders are rounded bring the scapula in a
protracted and internally rotated position
Glenoid is facing more anterior, lateral and inferior
Biomechanics of the GH, AC and SC joints are
compromised
Proximal end of clavicle close packed against sternum
Distal end of clavicle close packed against acromion

Affects of UCS/FHP
Shoulder Girdle

Chronically protracted scapula with the thoracic

spines inability to extend compromises shoulder
flexion and abduction leading to:

Rotator cuff impingement under the acromion

Degenerative problems associated with SC and AC joints
Anterior shoulder capsule laxity

Disrupts the length-tension curve by holding muscles

in a chronically lengthened position predisposing
them to early fatigue due to the weakened
lengthened position
Scapular retractors
Rotator cuff muscles

Lifts affected: vertical and horizontal

push and pull activities

Upper Crossed Syndrome

Typical Corrective Approach
Self myofascial release
Stretching (static,dynamic,neuromuscular)
Positional Isometrics/isolated strengthening
Integrated dynamic movement/function

Whats Missing from the Tradition Approach?

Specific Joint Mobility of the Thoracic Spine
Osteokinematic Approach vs Arthrokinematic Approach

Research proves thoracic mobilization has a

positive affect on shoulder performance!!!

Regional interdependence and manual therapy

directed at the thoracic spine

Treatment to the thoracic spine may

biomechanically restore the 15 of thoracic
extension required to achieve full shoulder
elevation, improve the recruitment of muscles in
the shoulder girdle or have a neurophysiological
effect on pain and dysfunction.
Additional effects on the shoulder girdle region
after thoracic manipulation include increased
middle trapezius activity in individuals with
rotator cuff tendinopathy and increased lower
trapezius strength in asymptomatic individuals.

Thoracic Manual Therapy in the Management of NonSpecific Shoulder Pain: A Systematic Review

Thoracic manual therapy accelerated recovery

and reduced pain and disability immediately
and for up to 52 weeks compared with usual
care for NSSP.

The Effects of Self-Joint Mobilization on Thoracic Extension

Utilizing a High Density Foam Roller

The aim of this study was to determine the effect of thoracic self-joint mobilization
on active thoracic extension using a high density foam roller. Thoracic extension
was defined by the distance between C7 and T12
Twenty-three healthy college students participated in the study. Subjects were pretested for maximum thoracic extension. Subjects were randomly assigned to one
of two groups, the intervention group or the control group
The protocol consisted of two self-mobilization sessions each day for 14 days using
a high density foam roller. Following completion of the protocol, both groups were
again measured for maximum thoracic extension.
Results revealed significant increase in thoracic extension for the intervention
group after the 14 day protocol

Specificity is key

Coupling Rules
Abduction/flexion of hips= extension of
lumbar
Adduction/flexion of hip= flexion of lumbar
spine

Locking techniques

Coordinative locking
Ligamentous locking
Artificial locking
Joint Locking Locking

Artificial Locking
Use of external devices to prevent motion
from occurring
Wedges, tables, tennis balls, bolsters, foam, floor,
wall, hand towel, etc.

Example

Ligamentous Locking (Counter

Curve)
Take up maximal tension on collagen into a
particular direction to prevent motion
Usually taken up in one plane of motion
proximal and/or distal to the area being
trained
Performed when collagen is healthy and can
tolerate stretching

Coordinative Locking
Person actively prevents motion into an area
Provides the least amount of real protection
during an exercise, as no real resistance is
present to prevent motion
Most difficult. Would be considered the final
progression of locking techniques
Example: Simply instruct the person to not
allow the lower back to arch

Joint Locking
Joint Surfaces are compressed to take tension
of capsule and ligaments to prevent the
segment(s) form participating in the exercise
Indicated for Hypermobile segments

Practical Guidelines
Remember Thoracic Arthrokinematics as it
relates to shoulder
Bilateral arm elevation
the integrated thorax (all regions) extends, lower
greater than upper
T6 most rigid

Unilateral arm elevation

the thorax rotates and laterally flexes towards the side
of the elevating arm.*

Practical Guidelines
When to perform
Immediately after soft tissue work and before dynamic movements
In between exercises
Cool Down
When not to perform
In the presence of a hypermobility in the thoracic spine
individuals who are not comfortable performing the self-mobilization i
In the presence of pain
In the presence of a known pathology that could be exacerbated by
the exercise
suspected fracture
neurological symptoms

Practical Guidelines
Do not re-create the compensatory and
structural deficit
Compensatory
Transition areas of the spine tend to be the most
mobile (will travel the path of least resistance0
C7/T1
T11-L2

Glenohumeral joint (already mobile in nature)

Practical Guidelines
Joint mobilization prior to general mobilization exercise

Nonphysiologic motion created

Muscle cannot produce more force than which can be absorbed by

Begin exercise from resting position progressing toward end range

Thoracic spine resting position: Neutral

Focus on collagen elasticity rather than plasticity for performance

Elastic range: the first stop or end-feel

Accomplished with more reps(30+) and shorter hold times (0-2 sec holds)

Plastic range- second stop

Makes for longer but weaker collagen

Clasp Hand behind the base of the neck (not skull) to

prevent/exacerbate cervical hyperextension

Simple Warm Up Progression

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