Thoracic Manual Therapy for Shoulder Dysfunction

Original Editor - Carla Benton and Ari Kapłan

Top Contributors - Jess Bell, Kim Jackson, Ewa Jaraczewska, Maram Salem, Admin, Dana Tew, Lucinda hampton, WikiSysop, Carla Benton and Vidya Acharya

Disclaimer: All manipulation techniques should only be performed by clinicians with appropriate training. If you do not have this training, use mobilisation alternatives. Informed consent is essential before any technique is applied. Written consent may be a regulatory requirement in your jurisdiction before applying Grade V manipulation.

Introduction

The shoulder does not work in isolation — its function depends on the thoracic spine, which provides the base on which the scapula and glenohumeral joint operate. The position of the thoracic spine significantly affects scapular kinematics during arm elevation. Mid-thoracic hyperkyphosis can restrict overhead range of motion and force compensatory overuse of the glenohumeral joint, while forward head posture affects scapular mobility, altering glenohumeral mechanics and potentially contributing to impingement.

Clinical Reasoning

There is evidence that interventions targeting the thoracic spine, including thoracic spinal manipulation, can help reduce shoulder pain and improve function. A useful clinical reasoning approach when selecting and evaluating interventions is to fail fast, fail often, and fail safe:

• Fail fast: reassess within 30 seconds to 2 minutes of each intervention. Mobility and motor control changes should be visible quickly; if they are not, move on.
• Fail often: regularly trial interventions and reassess. If an intervention is expected to produce a meaningful change, check it often to determine carryover.
• Fail safe: never violate safety protocols or contraindications (e.g., a lack of patient consent, osteoporosis, manipulation techniques that require force through a recently operated shoulder).

This approach is not, however, appropriate for patients with high irritability. Easily provoked, long-lasting pain limits the ability to reassess and switch approaches quickly.

Clinician-Applied Techniques

Joint mobilisation and manipulation techniques are graded I–V using the Maitland grading system. Grades I–IV are mobilisation techniques that involve oscillatory movements of varying amplitude and speed at different points in the joint's range of motion:

• Grade I: small amplitude movement at the beginning of the available range of movement
• Grade II: large amplitude movement within the available range of movement
• Grade III: large amplitude movement that moves to the point of limitation in the range of motion
• Grade IV: small amplitude movement at the end of the available range of motion

Grade V manipulations are high velocity low-amplitude (HVLA) thrusts used to address joint stiffness and restore mobility. The small movement distance (low amplitude) is delivered at rapid speed (high velocity) at the end of the joint's available range of motion to engage the joint's paraphysiological space. These techniques require specific training and should only be performed after a thorough patient assessment.

Manipulation techniques are proposed to produce short-term pain relief through modulation of the central nervous system. They may increase neuromuscular drive and shoulder muscle activity, particularly serratus anterior.

Mobilisation with movement (MWM) is another type of mobilisation technique. It combines a clinician-applied passive accessory joint glide with repetitive active or passive physiological movements.

This page focuses on Grade V manipulations and MWMs as techniques for addressing thoracic dysfunction in patients with shoulder pain.

Mid-Thoracic Techniques

Grade V Manipulation

Supine mid-thoracic manipulation: The patient is supine with their arms crossed. The clinician locates the target spinous process (e.g., T6). The patient's arm position is adjusted to control the degree of flexion or extension, allowing the clinician to lock to the target level. A quick, controlled thrust is then applied.

Mobilisation with Movement

Mid-thoracic SNAG (sustained natural apophyseal glide): The patient places their hands behind their neck with their elbows facing forward. The clinician contacts the target segment and uses the patient's arms as a fulcrum to create controlled extension through the stiff segment. This technique can be particularly useful for gaining mid-thoracic extension for overhead reaching.

Upper Thoracic / Cervicothoracic Junction Techniques

For acute and subacute stiffness, manipulation may be a useful first option. For long-standing forward head posture, a SNAG may be more effective than a thrust technique.

Grade V Manipulation

Upper thoracic side-bend thrust (targeting around C7-T1): The clinician blocks the target spinous process with one thumb and applies a gliding force just lateral to the level above. The clinician side-bends the patient to lock out the segment before the thrust is applied.

T2–T4 seated thrust: The patient places their hands behind their head with their elbows relaxed. The clinician threads their arms through the patient's arms, placing their hands at C7-T1 and using their chest against T2-T4 as a fulcrum. A forward drive creates the thrust.

Caution: Techniques that require the patient's arms to be positioned overhead or in external rotation may flare up shoulder symptoms. If the position provokes pain, choose a different technique or address the shoulder symptoms first.

Mobilisation with Movement

Cervicothoracic junction SNAG: The patient interlocks their fingers on their forehead. The clinician threads their arms through the patient's arms and places their hands on T1–T2 bilaterally. The patient's arms serve as the fulcrum as the clinician leans back.

Breathing Retraining

Faulty breathing patterns, such as excessive shoulder elevation or thoracolumbar junction extension with anterior rib flare, reduce rib mobility and perpetuate thoracic stiffness. Breathing retraining is one strategy to help reduce erector spinae hypertonicity and improve thoracic mobility. In some patients, joint mobility may need to be restored through soft tissue work, mobilisation, or manipulation before breathing retraining can be effective.

Breathing retraining typically begins in supine. First, ask the patient to place their hands on their lower ribs for tactile feedback. The aim is to encourage lateral and posterior rib expansion. If the patient is unable to achieve this pattern, the clinician can add manual tactile cues.

If the patient still struggles, diaphragmatic breathing can be introduced. Tactile cues, such as the patient's hands or a light ankle weight/sand weight, can provide feedback. Once diaphragmatic awareness is established, the focus returns to lateral rib expansion.

Once the patient has achieved this lateral rib expansion pattern in supine, they should start breathing retraining in other positions, progressing to sitting, standing and prone, as faulty patterns may re-emerge in different positions. Breathing can be integrated into all aspects of the rehabilitation programme, including stretching and strengthening exercises, and other daily tasks rather than just practised as a standalone exercise.

Patient Self-Mobilisation and Home Exercises

A test-retest protocol is recommended to measure the effectiveness of self-mobilisation techniques, even if changes are subtle.

Mid-Thoracic Soft Tissue Techniques

Foam roller: The foam roller is placed parallel to the spine along the erector spinae. The patient lies on it and rolls back and forth to provide soft tissue release.

Lacrosse or tennis ball: This provides more targeted soft tissue release to specific thoracic erector spinae segments. The patient places the ball between their body and the floor or a wall and rolls over the target area.

Mid-Thoracic Mobility Exercises

Barrel pour stretch: The patient reaches their arms wide as if holding a large barrel, then "pours" to one side. This stretch targets the erector spinae, rib soft tissue, and periscapular muscles (rhomboids, mid-trapezius). Patients should experiment with different angles to find the direction of greatest effect. Breathing can similarly be integrated into other self-mobilisation exercises to enhance mobility gains.

Thread the needle: From a quadruped position, the patient initiates thoracic rotation (trying not to lead with the arm). They should let their body weight fall onto their arm to provide the stretch. Adding 2–3 breaths with lateral rib expansion can amplify the stretch.

Modified open book stretch: The patient lies on their side. Instead of reaching their arm directly back, the patient "wipes their chest" — i.e., their hand stays on their chest, and they rotate through their thoracic spine. They can bring their arm down into the traditional open book position if they are asymptomatic in this position. Again, focused breathing can be added to this stretch.

Foam roller extension: The foam roller is placed perpendicular to the spine at the mid-thoracic level. The patient should place their hands behind their head or cross their arms over their chest. In this position, they perform single-segment extension repetitions or roll through each segment. A half-roll is preferred for less mobile or older people. If patients cannot get into this position, this exercise can also be performed in a chair.

Exercise ball supine extension: This exercise is appropriate for mid-to-late stage rehabilitation. The patient extends over the ball for combined thoracic extension and shoulder flexion. It is not appropriate for patients who are highly irritable or have limited thoracic extension.

Upper Thoracic and Cervicothoracic Junction Soft Tissue Techniques

Lacrosse ball or Theracane: This provides targeted soft tissue release to the periscapular area and along the thoracic spine. A Theracane may be more effective for higher segments where a lacrosse ball is likely to be displaced.

Upper Thoracic and Cervicothoracic Junction Mobility Techniques

Cervical retraction: The patient retracts their chin, which flexes the upper cervical spine and extends the lower cervical and upper thoracic spine. Patients with significant forward head posture may need to look slightly down first to accommodate the curve.

Exercise ball cervicothoracic junction self-mobilisation: The patient places both elbows on the ball, with their hands behind their neck, and fingers contacting the thoracic spine at approximately T1–T2. They roll their body forward to extend through the cervicothoracic junction. The motion should occur at the upper thoracic spine rather than the lumbar spine. This technique requires sufficient pre-existing range, and clinician-applied mobilisation or manipulation is usually needed first to gain enough motion for the exercise to be effective. It is not appropriate for patients who are highly irritable or if the arm position provokes shoulder symptoms.

Additional Resources

• The Effectiveness of Thoracic Manipulations on Shoulder Pain: A Case Report
• Manual Techniques for the Cervicothoracic Spine