Invited Commentary

The painful dysfunctional shoulder. A new treatment approach

using Mobilisation with Movement
Brian Mulligan FNZSP (Hon). Dip MT

ABSTRACT
The literature that describes the concept of Mobilisation with Movement (MWM)
does not include specific MWM techniques for the shoulder girdle. These techniques,
which have only been developed over the last two years, appear to be clinically
effective and are therefore an important addition to the existing repertoire of MWM
techniques. Brian Mulligan. The Painful Dysfunctional Shoulder. A New Treatment
Approach Using Mobilisation with Movement. New Zealand Journal of Physiotherapy
31(3): 140-142.
Key words: shoulder pain and stiffness, mobilisations with movement, shoulder girdle

INTRODUCTION
Four recent cases illustrate the suitability of new
Mobilisation with Movement (MWM) techniques for
the shoulder girdle to a range of patient presentations.
Guidelines for the application of the techniques will
be outlined and implications discussed.

CASES
The first case is a 30 year old American physical
therapist and karate expert who had pain and
dysfunction of her shoulder for more than two
years. On presenting for treatment she said Im
desperate as no one knows what my problem is
and no one can fix it. On examination she had
winging of the scapula and was unable to raise
her arm above 90 degrees due to pain and stiffness.
The second case I met in Boston where I was
teaching. The 45 year old had been unable to raise
her arm above 90 degrees for one year due to pain
and stiffness.
The third case, a 24 year old rugby player, I saw
in the clinic three days post injury. He had landed
heavily on his shoulder with another player on top
of him and now was unable to raise his arm above
90 degrees due to considerable pain.
The fourth case, a 35 year old man presented with
typical signs and symptoms of an acromioclavicular
joint lesion. He was unable to lie on his shoulder
and had pain in the acromioclavicular joint with
shoulder adduction and at the end ranges of shoulder
flexion and abduction.
I treated the first patient only once but subsequently
met her again three weeks later in Seattle on a MWM
course. She reported that she was almost completely
better and was now back into all her karate activities.
The Boston patient, after her four-five minute
treatment, was able to flex her arm to almost full range
with no pain. I was only in Boston for the day and no
follow up was possible but the immediate results of
her treatment were certainly impressive. The footballer
regained over fifty per cent of his movement loss
without pain at the time of his first visit. After four
treatments over ten days he had a full pain free range
of active movement but some pain with overpressure
at end range. A longer rehabilitation could be predicted
in a case such as this where there was instability of
both the scapula and the glenohumeral joint. The

man with the acromioclavicular joint dysfunction

demonstrated a marked improvement after two
treatments.
These cases are representative of a wide spectrum
of patients for which this new MWM approach has
been found to be useful. These examples fall into
different age groups with both long (two years) and
short (three days) incapacity histories. In each case
no other therapy was given. Each patient was advised
to avoid over reaching and to try and maintain the
increased range of shoulder movement while avoiding
excessive use of the shoulder girdle. The results have
been spectacular. No pain was experienced by the
patient during treatment and the dysfunction was
corrected at the time of treatment.
Guidelines for application of MWM
techniques to the shoulder girdle
A reminder first to readers of the rules regarding
the use of MWM techniques to all regions including
the shoulder girdle.
1. They must never produce pain.
2. They must produce an immediate beneficial effect
(e.g. a painfree increase in range of movement).
3. With all MWM techniques overpressure must
be applied without pain to ensure their success.
4. Repetitions are considered necessary. For the
extremities my suggestion is three sets of ten.
5. There must be some lasting improvement. If
between visits the symptoms return, MWM
treatment may be discontinued. However the
therapist should first ensure that the patient
has followed advice including self-treat
recommendations where applicable.
Further to these rules it is emphasised that the
successful application of all MWM techniques and
in particular application of shoulder girdle
techniques relies on the good handling skills of the
therapist. Failure with MWM techniques can often
be attributed to inadequate therapist handling skills.
Therapists need to develop the ability to make minor
handling adjustments to achieve success.
Scapula positional changes
As a background to these new shoulder girdle
techniques I must confess, I have always said, when
considering a positional fault of the clavicle in

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relation to the acromion it can only move up, forward

or somewhere in between. How wrong I have been!
Consider the shoulder girdle of a patient with a
painful loss of flexion. If the scapula is sitting higher
than normal then there will be some rotational
strain at the acromioclavicular joint. If the scapula
is winging slightly the angle between the clavicle
and scapula will increase when viewed from above.
Other positional changes may include internal
rotation of the scapula, where the inferior angle moves
in an arc away from the vertebral column and up with
the superior angle moving toward the vertebral
column, and lateral translation of the scapula on the
chest wall. All of these positional changes alter the
relationship of the surfaces at the acromioclavicular
joint and even the tracking of soft tissues may be
altered eg. long head of biceps with the possibility of
secondary tendinosis. (See Figure 1).
Figure 1. Anterior view of scapula positional changes Arrows indicate the positional changes that can occur
when shoulder flexion is painful and/or restricted.

towards the vertebral column. This application is

intended to control the relationship of the scapula to
both the clavicle and the chest wall. Maintain this
repositioning and ask the patient to raise the arm.
If the patient has not been able to move for many
months above the horizontal, assistance will be needed
to facilitate movement. If there is some pain good
handling skills will now be required. Alter the emphasis
of the repositioning so that more downward pressure
is given, perhaps more rotation, perhaps more
translation towards the thoracic spine and / or more
approximation of the scapula on the chest wall.
Clinicians quickly become adept at these
changes as they use the technique. The way the
arm is raised can be varied. A passage upward
between flexion and abduction may be the way to
start to avoid any discomfort. The aim is to raise
the arm higher with no pain (see Figure 3)
If after all these slight handling adjustments
movement cannot be achieved without pain,
abandon the technique. When movement without
pain can be achieved repetitions are recommended.
Three sets of ten is the usual prescription and after
each set of ten get the patient to actively raise the
arm to ascertain that the MWM technique is
increasing the range of motion.
Figure 2. Application of MWM shoulder girdle
technique - Therapist hand positioning. Note sponge
under hand on clavicle, placement of right hand on
spine of scapula and direction of right thumb.

Application of MWM techniques to the

shoulder girdle
The aim of the techniques is to correct the
positional changes described above. As part of the
assessment of a patient with restricted painful right
shoulder flexion, reposition the scapula and clavicle
and see if this enables the patient to move the arm
further without pain.
The therapist stands to the left side of the patient
presenting with right shoulder pain and reaches
across placing the heel of the left hand on the inner
third of the right clavicle. A sponge may be used
under the hand on the clavicle for patient comfort.
The thenar eminence of the right hand is placed
along the spine of the scapula with the thumb
straight and pointing laterally. (See Figure 2)
Firstly push both hands towards each other. This
secures the scapula to the chest wall. Now push down
on the spine of the scapula and at the same time
internally rotate it and finally glide the scapula medially

If the arm restriction has been present for many

months the patient may experience some latent
painful reaction from the treatment. However this
will settle quickly and any further reaction to
therapy would not be expected.
Further modification to the technique may be
required for some patients. For example, in the
case of the rugby player the humeral head had
to be translated posteriorly in the glenoid fossa
simultaneously with passive elevation. In this
case as a result of his fall he had a positional
fault at the glenohumeral joint as well as the
positional faults between the scapula, clavicle
and chest wall.

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Figure 3. Modification of MWM shoulder girdle

technique - Assistant helps the shoulder to flex and may
need to translate the humerus in the direction of arrow if
there is an accompanying glenohumeral positional fault.

CONCLUSION
This new shoulder girdle technique has most
certainly filled a rather large gap in my ability to
successfully treat the painful stiff shoulder.
Because of the positive effects I have witnessed
with the above procedures I now question the value
of some of the exercises that patients have

traditionally been encouraged to do. Take

pendulum exercises. With the trunk parallel to the
ground, I suggest that gravity could place the
shoulder girdle in an undesirable starting position.
Further more any forced passive shoulder
movement without some restraint on the shoulder
girdle may position the scapula in an undesirable
position. In addition, I have found the lateral chest
wall of these patients with excessive rotation and
lateral translation of scapula to be very tender on
palpation. This makes sense when the lateral
border of the scapula is invaginating this area
during shoulder elevation.
When teaching I always prefer to show
techniques being applied on real patients. The
interest and impact that this makes is the ideal
way to teach. Written articles like this equate with
the usual teaching practice of telling people what
to do rather than showing what can actually be
achieved. I just hope that what I have written will
be sufficient for the reader to understand and thus
have some of the excitement that I experience from
this new approach.

REFERENCE
Mulligan BR (1999) Manual Therapy Nags, Snags, MWMS
etc. (4th ed.) Wellington: Plane View Services Ltd.

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