1. Peripheral Joint Mobilization -- Shoulder Joints
Huei-Ming Chai, PT PhD
School of Physical Therapy
National Taiwan University, Taipei, Taiwan
June 23, 2008

2. Manual Therapy
Joint mobilization for restoration of joint alignment or joint mobility
osteokinematics (physiological movement)
arthrokinematics (accessory movement)
Mulligan’s techniques: SNAG, MWM
Soft tissue mobilization for establishment of muscular balance (neuromuscular therapy)
PNF stretch
muscle energy technique
Sweden massage
deep friction massage
myofascial release
connective tissue massage
nerve mobilization
Chinese massage

3. Mobilization vs. Manipulation
mobilization: repetitive passive movement of varying amplitudes of low velocity applied at different parts of the range depending on the effects desired
manipulation: a high-velocity thrust of small amplitude performed at the limit of available movement

4. Rationales of joint mobilization
To relieve pain and muscle guarding increasing proprioceptive input to the spinal cord so as to inhibit ongoing nociceptive input to anterior horn cells and central receiving area
To restore accessory movement (joint play)

5. Concave-Convex Rule
convex on concave
concave on convex

6. Treatment Plane
treatment plane is the plane that parallel to the articular surface of the concave component of the joint to be treated
Kaltenborn FM:
direction of mobilization
define by treatment plane
Mulligan B:
always parallel or
perpendicular to
treatment plane only

7. Closed-Packed Position
The joint surface becomes maximally congruent.
The joint capsule and major ligaments become twisted, causing joint surface to approximate.
The joint become locked so that no further movement is possible in that direction.

8. Position of Joint
appropriate for the stage of the joint problem and the skill of the therapist:
resting position: for an acute problem or an inexperienced therapist
other starting position toward motion barrier: for a skilled therapist in non-acute condition

9. Hand placement fixation hand mobilizing hand
stabilization of the joint component to be fixed
mobilizing hand
placing as close to the joint as possible

10. Techniques (I) direction amplitude distraction gliding
depending on pain, muscle guarding or degree of limitation
Maitland's grades
Range: initial limited full I II
III IV V

11. Techniques (II) velocity
slow stretch for capsular or ligamentous tightness or adhesion: application with rhythm, slow speed, and the slack position
fast oscillation (rhythm: 2-3 cycles per second) for relieving of pain and muscle guarding in the
acute conditions as a treatment
chronic conditions to prepare for more vigorous stretching or to promote more relaxation of muscles controlling the joint

12. No Pain At All pain muscle spam vessel constriction
nociceptive stimulation
accumulation of
metabolites

13. Indications (I)
used in the joints with restriction of joint play that cause pain or restriction of physiological motion, especially in the cases due to capsular or ligamentous tightness or adhesion
For gentle mobilization carried out in the pain-free range
severe pain
spasm increased after testing
presence of neurological deficit
pain disturbing sleeping
For more vigorous mobilization
joint irritability minimal with muscle guarding on movement
mobility testing limited but does not aggravate pain
limitation of motion by tension of tissues rather than pain
no neurological deficit

14. Indications (II) For manipulation
used as a progression from vigorous mobilization that has not produced the maximum improvement of signs and symptoms considered possible
used as a primary treatment in joints with no articular inflammatory signs and the restricted joint has been identified through mobility testing
used in joints with minimal pain that appears only at the end of the range

15. Patient Response to Joint Mobilization
improved after treatment  continue treatment until symptoms are subside
exacerbated for hours after treatment but improved later  continue but decrease dosage
exacerbated immediately after treatment 
reassess patient’s condition
gentle traction of the treated segment
documentation of all physical findings
stationary after 3-5 treatments  re-evaluate patient’s condition

16. Absolute Contraindications
bacterial infection:
cellulitis
neoplasm with metastasis to bone:
malignancy or benign tumor (cancer)
recent fracture: psudoarthrosis
bone disease: Osteogenesis Imperfecta
potential destruction of ligaments or capsule: RA or dysplasia of odontoid process

17. odontoid process
transverse ligament

18. Relative Contraindications
joint effusion
in the status of acute inflammation
degenerative joint disease in acute stage or bony block
marked rheumatoid arthritis
osteoporosis
internal derangement
general debilitation
pregnancy
hypermobility in mobility testing
moderate to severe deformities
psychological changes
neurosis
hysteria
depression

19. Relative Contraindications
for spinal mobilization
vertebral artery insufficiency
ligament instability
neutral
rotation to left

20. Mobilization to the Shoulder Joint
Glenohumeral joint
Thoracoscapular articulation
Sternoclavicular joint
Acromioclavicular joint

21. Glenohumeral Joint (GHJ)
convex on cave joint
proximal component: concave glenoid cavity
distal component: convex humeral head
joint type: ball and socket
DOF = 3
flexion/ extension: posterior/ anterior glide
abduction/ adduction: inferior/ superior glide
external/ internal rotation: anterior/ posterior glide
Note: retroversion of the humeral head about 30º posterior to the frontal axis of the elbow joint (scapular plane)

22. Glenohumeral Joint (cont’d)
neutral position： anatomic position
resting position： 70 of shoulder abduction and 30 of flexion (horizontal adduction)
closed packed position： 90 of shoulder abduction and full external rotation

23. Basic Mobilization Techniques
distraction: anterolateral
inferior glide: inferolateral
posterior glide: posterolateral
anterior glide: anteromedial

24. Distraction of GHJ
force direction:
anterolateral

25. Inferior Glide of GHJ
force direction:
inferolateral

26. Posterior Glide of GHJ
force direction:
posterolateral

27. Anterior Glide of GHJ
force direction:
anteromedial

28. Advanced Mobilization Techniques
inferior glide with distraction
inferior glide with shoulder internal rotation
inferior glide in sitting position
posterior glide in sitting position

29. Inferior Glide of GHJ with Distraction
force direction:
inferolateral

30. Inferior Glide of GHJ with IR
force direction:
inferolateral

31. Posterior Glide of GHJ in Sitting
force direction:
posterolateral

32. Mobilization to the Shoulder Joint
Glenohumeral joint
Scapulothoracic articulation
Sternoclavicular joint
Acromioclavicular joint

33. Scapulothoracic Articulation (STA)
concave on convex
proximal component: convex rib cage
distal component: concave anterior surface of the scapula
motion: results of motions occurring at STJ and ACJ
scapular elevation/ depression
scapular abduction/ adduction
scapular upward/downward rotation
DOF = 3

34. Elevation of Scapula
force direction:
superior

35. Depression of Scapula
force direction:
inferior

36. Protraction/ Retraction of Scapula
force direction:
lateral

37. Distraction of the Scapula

38. Mobilization to the Shoulder Joint
Glenohumeral joint
Scapulothoracic articulation
Sternoclavicular joint
Acromioclavicular joint

39. Characteristics of SC Joint
proximal component -- sternum
saddle-shaped sternal manubrium
distal component -- clavicle
saddle-shaped medial end of clavicle
joint type: saddle joint
degree of freedom = 3
motions
elevation
depression
posterior
rotation A P
protraction
retraction

40. Mobilization to the Shoulder Joint
Glenohumeral joint
Scapulothoracic articulation
Sternoclavicular joint
Acromioclavicular joint

41. Acromioclavicular Joint
proximal component: convex lateral end of the clavicle
distal component: concave acromion process of the scapula
joint type: nearly plane joint
motion: shoulder girdle motion
scapular winging
scapular tipping
scapular upward/downward rotation
DOF = 3

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