FURTHER THOUGHTS

ON SHOULDER DYSFUNCTION:

The Sternoclavicular Fixation.

Clive Lindley-Jones B.Ed.(Hons) D.O. M.R.O. Diplomate I.C.A.K.

Fig 1. The Clavicle and ribs from above showing ABSTRACT· yoke structure of the shoulder girdle

The role of subclavius is looked at in who may well be the ones most able and relation to a possible new fixation willing to take his advise to heart. pattern found in shoulder dysfunction 23 involving a fixation at the In previous papers I have tried to sternoclavicular joints where subclavius explore the role that AK can have in is found to be weak bilaterally. unraveling many of the functional problems of the shoulder region and INTRODUCTION here I wish to open for discussion and your evaluation some initial and very The shoulder is in Cyriax's1 view the recent and therefore tentative findings most rewarding joint on the whole body on some new ways in which the shoulder possessing as he nicely puts it the region may go wrong and we may· ·use salient merits of honesty and curability. AK to evaluate and treat the problem. He goes on to point out that since This focuses particularly on the role of problems in the shoulder can be solved the small and often overlooked role of only clinically, diagnosis is open to every the subclavius muscle. clinician whether he/she has access to hospital facilities or not. Therefore in In his original work on the frozen his inimitable style, he advises every shoulder Goodheart4 pointed out the, clinician when faced with a painful sometimes pivotal role of this oft shoulder, to 'do it yourself'. It is, forgotten muscle. Hutchin5 more perhaps a little ironic, given his recently took our view of the role of hostility to those such as osteopaths fixation complexes further with her and chiropractors, with most skill and 2 experience with such problems, that it Lindley-Jones C. Applied Kinesilogy and the Thoracic Outlet Syndromes. I.C.A.K. – Europe Collected Papers 1992. is just such professionals especially pp 60-67 3 Lindley-Jones C. Applied Kinesiology and the Frozen those skilled in Applied Kinesiology, Shoulder Syndrom I.C.A.K. Europe Collected Papers. 1991 pp. 118-127 4 Goodheart G. The Frozen Shoulder Syndrome Collected Published Articles and Reprints 1st Ed. 1969 p.57 5 Hutchin A. Fixation of the Manubrio-Sternal joint and its 1 Cyriax J. Text Book of Orthopaedic Medicine vol 1 1982. Lovet Brother Relationship to the Xiphi-sternal Joint p127 I.C.A.K Europe Collected Papers 1991. pp. 128-130 work on the role of the joints around subclavius muscle to surround the the sternum. Following on an interest subclavian vein. It is possible thereby here I wish to propose the possible to see the close interrelation of role of subclavius in a new fixation subclavius with the anterior scalene: that of the sternoclavicular joints treatment of one causing stretching bilaterally. of the other.

But first a look at the anatomy of the FASCIA area. Barral6 well illustrates the ANATOMY importance in the thoracic inlet of the thoracic facial system. Subclavius is a small triangular muscle, between the clavicle and the . first rib. It arises from the junction of the first rib and its costal cartilage, in front of the costo clavicular ligament by a thick tendon which is prolonged along the interior margin of the muscle. It proceeds obliquely upwards and laterally to the groove on the under surface of the middle third of the clavicle where it attaches by muscle fibres. Occasionally, the latter attachment may also be to the coracoid process in Figure 2. Showing the Clavipectoral fascial addition to, or instead of the scapula. connection of subclavius and Pectoralis Minor (After Barral)

Its posterior surface is separated To further our understanding of the from the first rib by the subclavius role of subclavius in this area it is vessels and brachial plexus, its useful to understand the way in which anterior surface from the pectoralis the subclavian aponeurosis attaches to major muscle by the clavipectoral the anterior, inferior and posterior fascia. walls of the osteofibrous sheath of the subclavius muscle the superior part Remembering the importance of the being formed by the clavicle. The role of anterior scalene as a possible clavipectoral fascia inserts superiorly entrapper of the neuro-vascular on the sheath of the subclavius muscle bundle that passes between it and the and on the coracoid process. Lower middle scalene it is important to note down, it covers the clavipectoral here that the sheath of the anterior scalene unites with that of the 6 Barral J-P The Thorax 1991 p.19 triangle connecting the subclavius and pectoralis muscles. It surrounds the latter and merges with its aponeurosis, the skin of the auxiliary fossa and the brachial aponeurosis at the level of the coracobrachialis muscle and the short head of biceps brachii here becoming the suspensory ligament of the axilla. Any pull on the clavipectoral fascia possibly induced by dysfunction in the pectoralis muscle will then affect the subclavius.

NERVE SUPPLY ACTION

Nerve supply to subclavius is by a Interestingly the precise action of branch of the brachial plexus which subclavius is not totally clear. Gray's derives its fibres from C5 & 6, passing sees it as probably pulling the points of in front of, or behind, the axillary vein the shoulder downwards and forwards before ending in subclavius. and steadying the clavicle, during movements of the shoulder, by bracing Fibres of these nerves anastomose with it against the articular disc of the the phrenic nerve, which explains why sternoclavicular joint. Grant's irritation of the phrenic nerve may 8 7 Anatomy taking the more static affect the subclavius. As Barral points 'cadaveral' approach of the surgeon out, such irritations can be of visceral considers the subclavius an unimportant (lung, liver, bladder) or peritoneal muscle valuable only as a buffer origin, since the peritoneum is partially between a fractured clavicle and the innervated by the superior part of the subclavian vessels. Willard9 also sees a phrenic nerve. small role for subclavius as a stabiliser of the clavicle seating the head of the clavicle into the sternoclavicular joint. Its leverage being low.

Subclavius is both difficult to palpate and to investigate electromyographically. Walther10 states that it appears to participate

8 Grants Atlas of Anatomy Ed.Anderson J.E. Edition 1978. 9-7 9 Willard F. The Thoracic Muscularture and Viscera Seminar. The European School of Osteopathy 23.1.98 7 Barral op.cit p.19 10 Walther D. Applied Kinesiolgy vol 1. 1982 p386 in the “crank” like action of the rather an indirect test has been clavicle during shoulder abduction. prescribed using therapy localization Clearly it must assist in protraction in as near to the muscle as possible and some way drawing the shoulder watching for a strong muscle to ventrally and caudally, and in so doing, weaken, Remembering that this only controlling upward movement of the tells where and not what is being clavicle.11 It appears to be partly therapy localised. responsible for the rotation motion of the clavicle during arm abduction. True to form, however, Beardell Walther12 points out that when there dividing the muscle into clavicular and is limitation of arm movement that scapular divisions devised tests to equates with the 30o of scapula evaluate their actions. These are o rotation obtained by clavicular primarily in the first 10 of abduction rotation, the subclavius should be with the arm held in full internal o considered for possible involvement. rotation in 180 of flexion held This is because the distal end of the against the ear. This requires clavicle elevates with 30o of hinge- assistance from a healthy deltoid type movement at the muscle. While some disagreement sternoclavicular articulation and remains in some circles as to the rotation of the crank shaped clavicle correctness of Beardell’s directions gives an additional 30 o for a total of for these tests, clinical use has 60 o elevation.13 proved productive as I hope to show below. APPLIED KINESIOLOGY & SUBCLAVIUS. Before going further however, it is of significance to note that Barral14 Classically, within AK, subclavius has observed that, it is mainly the smaller not been associated with any meridian muscles of the thorax, such as or organ, only neurolymphatic subclavius, that are the focus of his reflexes, anteriorly at the junction of attention. He finds problems of the the clavicle, sternum and 1st rib and larger muscles, such as trapezius, are posteriorly, at the lamina of T1. often secondary i.e. due to an "overflow" or cascade of Treatment has generally been related decompensations arising from to direct treatment to the muscle dysfunctions else where in the body. It using proprioceptive, fascial release is Barral's view, which contrasts or possibly spray and stretch somewhat with aspects of Applied techniques. It has not been thought Kinesiology, that small muscles retain possible to test the muscle directly, the "memory" of trauma much longer

11 Lockhart R. Hamilton G. & Fyfe F. Anatomy of the Human than large muscles and therefore have Body 1969. p199 12 Op. cit 13 Walther D. Applied Kinesiology: Synopsis 1989 p.439 14 Barral op. cit. p18 a greater overall effect on the body trapezius, pectoralis minor and and are more likely to be pathogenic supraspinatus. This latter can be tested and primary. quite adequately in the standard classical manner. Beardell’s muscle tests for subclavius requires the supine patient to abduct LIMBIC TECHNIQUE the arm 180 o to the side of the head. Internally rotate the arm until the In his article on Pitch, Roll & Yaw palmar surface of the hand faces away Technique and Limbic Technique 15 from the head. The doctor stands Goodheart goes to great and ipsilaterally braces the contralateral interesting length to explain the shoulder, with contact on the ipsilateral hypothesized relationship he observed forearm to abduct the arm through the between therapy localization to the coronal plane. nose, imbalance between the left and right sides of the brain and weakness in RECENT FINDINGS an indicator muscle which is neutralised by head turning to left and right. This In recent months while researching this Goodheart thought, indicated a fixation area in my practice I have noticed of the 7th cervical first rib area and a three factors of note: potential fixation of the 1st lumbar and 12th rib area, on a Lovett reactor basis. Firstly, the subclavius is involved in reactive muscle dysfunctioning with As might be surmised from its other related muscles far more often attachments, I have· observed a close that I had previously thought. relationship between weak ipsilateral subclavius muscles and this, now less Secondly, the so called “Limbic commonly discussed C7 1st rib fixation. Fixation” of C7 and the First rib is also often found, although it has not found FIXATION OF THE favour in recent AK literature. STERNOCLAVICULAR JOINT

Thirdly, and most recently, I have In inspiration the movement of the rib observed what appears to be a new cage is assisted by the secondary fixation, at the sternoclavicular joint, respiratory functions of the scalenes which is invariably found in bilateral and sternocleidomastoid as well as the weakness of subclavius. intercostals. As Hutchin16 observed in relation to fixations in the manubrium REACTIVE MUSCLE PATTERNS sternum, with inspiration the whole of It appears necessary to employ the the shoulder girdle is raised by these muscle tests devised by Beardell to muscles elevating the upper ribs, find the often related reactive 15 Goodhear G. Pitch, Roll and Yaw Technic and Limbic patterns between subclavius, upper Technic Journal of IAPM Spring 1983 16 Hutchin A. op. cit.p128 thrusting their anterior extremities with one hand. As with fixations forward, and carrying forwards and nothing will occur until the area is in upward the body of manubrium motion. At this point a change in muscle sternum. The clavicles attach to the strength will be observed. manubrium on its super lateral border at the sternoclavicular joint. This joint Thoughtful readers will at this stage possesses some 60o range of elevation, say to themselves, ah yes, but what 60o of rotation and 30o of forward about K27. It is well known that at the movement, the range being limited by junction of the first rib, clavicle and the fact that the trapezius and sternum lie two important points from rhomboid muscles are at full stretch the AK point of view. The first is restraining the scapula. Movement of Kidney 27 two tsun from the mid line, the joint can be envisaged if one sees it this point along with CV8 at the as being at the apex of an imaginary umbilicus, and other points and actions cone. The circumference of the base of is used to screen for neurological this cone is described by the lateral disorganisation. It is, therefore end of the clavicle, which can sweep in a mandatory to screen this out before circle. As Basmajian17 observed, while diagnosing a fixation at this point as the lateral end of the bone sweeps at this could confuse the issue and lead to will in arcs of many circles, the medial erroneous results. end has merely to glide in its socket. The second point to remember is that With its strong ligaments, articular this same point is the anterior disc and the subclavius muscle acting as neurolymphatic reflex for both the a dynamic ligament this remains a subclavius and the intrinsic muscles of surprisingly stable joint. the spine. It is, therefore important to Cyriax18 notes a rare condition, he calls know what one is on and what the a posterior sternoclavicular syndrome. significance of that is before jumping Pain is in the posterior neck but all to conclusions. structures are found to be normal there. Interestingly, I have observed an, as Resolution is only to be found according yet unresolved facet to this to Cyriax by addressing the posterior phenomenon, namely that if the patient sternoclavicular joint, with a syringe in T.L's the joint and the occiput at the his case. Could he have stumbled on a same time then muscle strength will fixation pattern? Perhaps not! change without movement of the joint. When a bilateral subclavius weakness is This suggests some direct cranial observed, get the patient to therapy interconnection. While this is not hard localise over the sternoclavicular joints to envisage the exact reason for this is as yet unclear.

17 Basmajian J. Primary Anatomy 7th.Ed. 1976. p87 TREATMENT 18 Op.cit.p125 To find the correct direction to treat this, challenge the clavicle in different directions with the thumbs and treat in the phase of respiration that negates the challenge. This is usually inspiration.

Occasionally direct work on the subclavius may be required, but normally releasing the sternoclavicular joint will be sufficient

CONCLUSION

After an in depth look at the anatomy of the area, noting, particularly the fascial connections between pectoralis minor and subclavius, and the phrenic nerve's anastomosing with the nerve supply to subclavius from C5 & 6, a subtle role for the subclavius muscle in shoulder dysfunction has been observed.

The role of subclavius in C7 first rib fixations, the so called 'Limbic technique' was explored.

The role of subclavius and Beardell's muscle tests for it, pectoralis minor and upper trapezius, are introduced as a further means of deepening your evaluation of shoulder dysfunction particularly related to sometimes overlooked reactive muscle patterns.

This links a newly postulated fixation pattern of the sternoclavicular joint to shoulder, thoracic outlet, cervical dorsal and first rib dysfunction, leaving still some questions unanswered to date, regarding the role of the cranium or stomatognathic system in this finding.