The techniques are described outside the context of integrating the whole. They must not be used this way but only if properly indicated by that context. They can otherwise introduce disorder into the structure instead of order.
Narrow Shoulder Blades
One of several aspects when analyzing the yoke of the shoulder-girdle structurally is the comparison of its suspension in front and in back in a horizontal sense. This determines to a large part whether the shoulder has slid forward or back around the convex plane of the ribcage. The posterior suspension can be assessed by determining the distances between spine and shoulder blade and shoulder blade and humerus. Both can be short or overstretched, or the picture can be mixed. The shoulder blades are very often narrow, too close to the spine, with externals. This drives the thoracic spine forward and pushes out the chest. But also some internals use this as a structural strategy to compensate the downward drag of the chest.
The scapula is fastened to the spine by two layers. Superficially, the fan-shaped fascia of the trapezius from the occiput to T12 draws the scapula towards the spine. Depending on its internal differentiation it also pulls up or down or helps rotate the scapula. The layer below consists of three tensional structures containing the scapula medially. Cranially, the levator scapulae which holds up the scapula at the angulus superior also helps to restrict its lateral displacement. Caudally, the upper free margin of the latissimus dorsi aids in refraining the scapula from going lateral by way of the angulus inferior which it covers. But the main connection between spine and scapula is formed by the rhomboids which regulate the laterality of the scapula. In narrow shoulder blades they are in primary shortness. It can be thought that the rhomboideus minor coming *om the cervical spine together with the levator scapulae influences more the spacing of the superior part of the scapula. The rhomboideus major would affect more the body of the scapula and its lower part. Below this layer there should be no restriction so that the scapula is able to slide freely on the outside of the ribcage.
A relatively quick and smooth way of organizing these fasciae is described. The client lies on her back with the hand on the side being worked on resting on the belly. The legs should be put up to provide maximal reduction of tension in the upper back. Sitting at the side of the table, facing the client, one hand slides under the back, the “working hand”. The other goes from distal and axially under the elbow to the distal upper arm. Sensitivity is best when it is held only with two or three fingers which are in front and in back of the septum intermusculare brachii mediate. This is usually a tight string anchored at the medial epicondyle.
In the supine position, the arm is more posterior than in standing and with respect to normal, and the upper arm is usually rotated externally more. Because of this the posterior suspension has no or little tension and is flaccid. The arrangement of the client’s hand on the abdomen helps to stretch the posterior suspension a little because the humerus is rotated externally less, and the shoulder lies a little more lateral. The controlling hand on the medial epicondyle lifts the elbow, and the shoulder comes out, distal, and forward a little. When the slack of the tissue has been taken up, the shoulder is also lifted, i.e. it comes out and forward, sliding around the curved plane of the ribcage. The client’s hand on the belly serves as a fulcrum point. It should be sensed heavy, and during manipulation by the controlling hand under the elbow a little pull and push is felt on it. It should not slide, however.
The weight of the shoulder should be felt clearly. Often clients involuntarily hold it and so must be asked to relax it again. The controlling hand, holding the elbow in the air, now senses the whole posterior suspension like a sling from elbow to spine, in which the shoulder and upper thorax hang passively like a heavy weight in a net. By taking the elbow out – taking care that the shoulder comes lateral with it passively and back in, inducing the upper arm to tend toward medial rotation, lifting and releasing in the sagittal dimension, and adding some distal traction when appropriate, various portions of the upper part of the posterior suspension of scapula to spine can be emphasized. The working hand can then find the shortest strings in trapezius and rhomboids and lengthen them, going lateral or obliquely across them. By “melting” the tissue of knots especially at the spinal attachments and those on the medial margin of the scapula, further equalizing of tension can be achieved.
The technique permits to organize a large sheet of fascia. Areas are also available where the tissue is glued down to the ribcage. The intention is relatively superficial and broad, though. Of course the intercostal spaces can also be reached if the controlling hand doesn’t tense the posterior suspension much, but this would be for different indications.
It makes sense and can probably not be avoided to describe structural situations by using the functional system provided by anatomy. There, certain functions are assigned to certain muscles, and when this terminology is used in the structural context it is understood implicitly that their connective tissue or fasciae are meant. So when the externally rotated humerus is at issue, it is reasonable to look for the muscles effecting external rotation functionally. They are the infraspinatus, the teres minor, and the supraspinatus. The deduction is natural and correct that with the structurally externally rotated humerus the connective tissue accompanying these muscles is short. This means that these fasciae are shorter than they would be normally, and because this is associated with them being rigid they don’t permit the muscles to lengthen appropriately when needed. Furthermore, this implies that the structural bias is due to a fascial imbalance because the internal rotators are not shorter, or not so much as the external rotators.
But the situation is more complicated than that. First of all, external rotation suggests such a rotation around the axial midline of the upper arm or of the humerus, neglecting everything else. From the structural point of view this does not suffice to gain an understanding of the situation or may even hinder it because the view is systemic. Therefore, an externally rotated humerus must be considered in a larger context. If the rest of the body including the important forearm is disregarded to make some kind of analysis possible, there are two essential aspects from which one cannot abstract. The upper arm can be high or low as expressed by the shoulder, and it can be anterior or posterior. The second is the more imminent consideration. It appears that the external humerus, which is a common condition, entails also a clear anterior or posterior displacement of the upper arm. This means for both that the arm is closer to center because in both cases the arm slides away from the lateral apex of the convex contour of the ribcage and around it more medially.
The anterior external humerus means that the pectoralis major, which is an internal rotator, is not overstretched. The humerus is more forward and medial, and this outweighs the potential “gain” in length by the external rotation, at least in marked cases. So the pectoralis major is also in primary shortness although in a different manner. With the posterior external humerus the latissimus dorsi is similarly not “longer” because its possible “gain” from the external rotation is cancelled by the whole humerus being farther back and medial. In this case the pectoralis major may be stretched and in secondary shortness, as in the first case the latissimus dorsi might be.
Anatomy may be “exculpated” – which means that it cannot and does not intend to explain structural characteristics – by considering a particular aspect of the functional side. The two internal rotators mentioned come from far away from the trunk. They are joined by shorter internal rotators from the scapula: the teres major and the subscapularis. Very much in contrast to this the external rotators all originate from the scapula only. The consequence is that external and internal rotation of the humerus, structurally as well as functionally, don’t behave as a symmetrical system, or reciprocally.
The external humerus is less complex than the internally rotated one. Whatever its position in space is, high or low, anterior or posterior, and whether the scapula is too wide or too close to the spine, the distance between scapula and humerus in back is too small. An additional aspect is also present and needs to be taken into account: with the external humerus the triceps is always too medial. The result is something like a thick packet behind the shoulder joint consisting of short external rotators and the too medial triceps, aggravated depending on the configuration by too short or overstretched internal rotators.
The move proposed makes some space in the “packet” to prepare the ground for further more specific differentiation and organization. When the body is already fairly integrated and the tissue resilient, it serves to organize the whole area more specifically.
The client is supine on the table. Standing or kneeling on the side of the head a little to one side, facing down on her, the hand of my more lateral arm goes under her upper arm from lateral. The elbow of my more medial arm is set down on the medial margin of the humerus, just touching the humeral head slightly. The ulnar side of this arm is placed as tangentially as possible down along the medial side of the shaft of the humerus. The hand is on the dorsal side of the client’s forearm, keeping it pronated. The forearm tends even more than the upper arm towards external rotation in the supine position, which locks off the back of the shoulder joint. So this hand helps opening it by probating the forearm, and it also detaches the humerus a little from the scapula axially by applying distal traction. By also flexing and extending the elbow a little it further helps to optimize conditions at the shoulder.
The hand in back goes medial, turns anterior and out again around the triceps, and hooks into the angle where the external rotators, mainly the teres minor, attach to the humerus, from anterior. Getting a clear sense of the place pushes the humerus cranial and anterior (lifts it). This is balanced by the elbow on the anterior side of the upper arm. It should not bear down too much. The whole humerus is now under control, and playing it from the hand in back to the elbow and arm in front and back again assures a clear feeling of the tensional situation and preserves sensitivity.
With most clients the arm on the anterior side must take the client’s arm distal, overcoming the shift in the cranial direction induced by the fingers in back. With the posterior humerus it will allow the fingers in back to lift the client’s arm, bringing it more anterior toward normal and even exaggerating a bit. With the anterior humerus it will keep it more back, toward the table. The main intention is however that both my hands and arms rotate the humerus internally and at the same time coax it laterally away from the body. My elbow and the ulnar side of my forearm, going through the pectoralis major proximally, take the medial edge of the humerus posterior and lateral by hanging into the attachments of the internal rotators at the humerus. The fingers in back pull out the humerus rolling it internally at the same time. Both elbow and fingers in back go to the bone tangentially, not directly on it. There is a wedge-like quality to the move when the head of the humerus is brought lateral while my hand on the client’s forearm maintains pronation and refrains the client’s elbow from going out or even takes it medial a little by effecting an extension.
Figure 1 – Before and after “Narrow Shoulder Blades”, and after “External Humerus” technique.
I usually do the move in two parts. In the second my fingers in back go higher, to the area of the infraspinatus attachment. They are in the right place when they sense the medial excursion of the contour of the humeral head at about the collum chirurgicum.
The elbow can be replaced by the fingers of the hand in front. This allows to work more specifically in the front, too. But it loses the control from the forearm which is important when the intention is broad.
The fingers in back must be sensitive when going into this touchy area. They contact the bone a little distal and then slide cranial along it. In this way they avoid mashing tissue and especially bypass the nerves and vessels in the spatium axillare laterale.