A Muscle Testing Approach To Shoulder Analysis

By James Randazzo, D.C.

To implement proper strategies for analysis, adjustment and rehabilitation of the shoulder, let us consider general concepts and guidelines that have been developed.
The information presented relies heavily on the work of Dr. Kevin Hearon and Dr. John Downes.

First, it is helpful to remember that, as chiropractors, we usually look toward the spine to discover the true cause of dysfunction. This is especially true with the shoulder. Since the scapular stabilizers attach to the spine, and their nervous innervation derives from the cervicals, many shoulder complaints seem to disappear when spinal adjustments are given.

Second, keep in mind that the upper extremity tends to manifest its symptoms away from the spine. Therefore, the true problem is typically proximal to the symptomatic area.

Third, don’t forget that the upper extremity is held in place by muscles and moved by muscles, with only one real joint (the sternoclavicular) holding the arm to the body. Therefore, do not neglect the SC joint or the soft tissue that can, and will, refer pain to all areas of the shoulder.

Lastly, appropriate rehabilitation and exercises are essential to effective case management.

History And Examination
Like all other areas of the body, a good history and exam should be completed. This would include appropriate orthopedic tests to determine the extent of the damage, as well as any X-rays that may be desired.

If the orthopedic tests and/or X-rays indicate true structural damage to the shoulder, in most cases the patient should be referred to another health-care provider for co-management.

In addition to the above, there are a series of muscle tests based on the mechanoreceptor theory of muscle testing that have proven valuable in finding which shoulder articulation is structurally and/or functionally the source of the problem. If the shoulder is acute, these muscle tests may all test weak due to pain. This would not be a reason to adjust the joints. In that case, you may want to give the usual P.R.I.C.E. (Protection, Rest, Ice, Compression, Elevation) advice, and do the muscle tests and possibly the adjustment at a later time.

These muscle tests can be performed with the initial exam and recorded for future reference or used immediately if the shoulder is to be adjusted on that visit. The muscle tests should be performed after the spine is cleared, using whatever technique you prefer.

The tests are as follows:

Pectoralis major–clavicular branch (PMC) for the SC joint;
Coracobrachialis for the acromial-clavicular (AC) joint;
Anterior deltoid (AD) for an anterior humerus (AH);
Teres major (TM) for a posterior humerus (PH); and
Biceps for biceps tendon (BT) dysfunction.

Since the muscle tests are designed to stress the crossed joint, they may vary from Kendal and Kendal. The adjusting moves are taught at Certified Chiropractic Extremity Practitioner (CCEP) seminars and elsewhere.

Both the muscle tests and adjustments are explained in Dr. Hearon’s books (access Web site http://www.kevinhearon.com) and my course Web site (http://wcb.life.edu/wcb/schools/45/04/jrandazz/10/links/ html).

Analysis Guidelines
Since the SC joint is the only true joint attaching the upper appendicular skeleton to the axillary skeleton, it should be checked first. Practitioners who use this shoulder analysis system consider a fixated SC to be the most overlooked cause of shoulder symptoms.

The SC is usually fixated, resulting in hypermobility at the AC and occasionally vice versa. For this reason, it is recommended that when the SC or AC needs to be adjusted, as per a weak muscle test, the opposite end of the clavicle is also adjusted in an attempt to help reset proprioception.
If a weak PMC or coracobrachialis is discovered, anchoring/blocking/challenging the suspected joint (SC or AC) in the direction of correction while re-testing the muscle should improve the strength of the muscle and give you added certainty as to the need for the adjustment. Once the joints have been adjusted and the PMC and coracobrachialis have tested strong, the practitioner should have the patient stress those joints to determine if they will maintain the correct biomechanics with the activities of daily living.

To stress the SC, the patient is instructed to do push-ups. To stress the AC, the patient should laterally circumduct their arms. Once these motions are performed, the muscle test should be repeated. If the muscles stay strong, the practitioner should move to next step of the protocol. If, however, the muscle tests again show weakness, the SC and AC need to be readjusted, and the muscle tests need to be rechecked. Then, the rest of the shoulder should be checked, and you should advise the patient to avoid these stressful motions until their next visit.

When the patient returns for the next visit, if the SC/AC muscle tests are again weak, the injury is typically a Grade 2 or Grade 3 sprain. In these cases, the patient will need either taping/strapping while healing or referral to another health-care provider.

After the SC and AC joints, the next joint to check is the glenohumoral (GH). Check both for an anterior humerus with the anterior deltoid muscle test and a posterior humerus with the teres major muscle test. If one of these muscle tests shows weakness, adjust the related joint.
However, if both the anterior deltoid and teres major are weak, it is, in most cases, not a GH problem. You either did not clear the SC/AC first or the scapular thoracic (ST) articulation is restricted. If both muscles are weak and you have already fixed the SC/AC, then check scapular thoracic motion. Then proceed to check for a biceps tendon problem.

The long head of the biceps tendon may need to be reset in the intertubercular groove. The tendon can become irritated and/or displaced for many reasons, but usually it occurs from a throwing motion. The patients will usually have pain over the tendon at the proximal humerus, and biceps strength will be reduced.

Therefore, a weak biceps is our muscle test. If this is present, adjust the tendon first lateral to medial. If this doesn’t strengthen the biceps, try the medial to lateral move variation.
Once you have completed SC, AC, AH, PH and BT, then check ST. If the scapular thoracic articulation is restricted, as compared to the contralateral side, then SC, AC and GH are under abnormal biomechanical stresses, which may deter normal restoration of motion. It’s essential to free up ST articulation with adjustments and/or make a referral to a soft tissue expert.

Along with these adjustments, exercises (such as wall angels) to restore motion and reset proprioception of the scapulars, as well as serratus anterior and rotator cuff exercises, help to stabilize and rehabilitate the shoulder.

Finally, remember when introducing patients to rehab exercises, in order to have a higher level of compliance, you should remember three axioms:

Keep it simple. Exercises should be easy to do and easy to remember (e.g., show them how to do it and give them handouts with photos, as well as therapy bands, to use at home).
Keep it short. Time is precious, so keep the home rehab routine to under 15 minutes.
Keep it pain-free. The patient should not work in painful areas, and the amount of weight and reps should be started at below what the practitioner believes is the patient’s ability.

About the authors: James Randazzo, D.C., is a 1994 graduate of Life University, where he teaches an extraspinal technique course as a faculty member of its technique and analysis department. He is a founding member of the university’s Division of Sports Chiropractic and shares responsibilities in providing care for its athletes. He manages a private practice and is a certified chiropractic extremity practitioner (C.C.E.P.). Inquiries may be directed to him at randazzo@life.edu.

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