Evaluating the AC and SC joints is critical before beginning treatment. Visual assessment (bruising, erythema, edema), pain scale, the strength of surrounding musculature, and range of motion of the AC and SC joints should all be accounted for both before and after treatment.

The following will explore two somatic dysfunctions of the AC joint in this review that are treatable with muscle energy:

1. Internally rotated AC joint, or
2. Externally rotated AC joint

Palpation of the AC joint can be done by "walking" on hand down the spine of the scapula to the acromion, while the other hand travels down the clavicle laterally. Where these two points meet will be the AC joint. Let the patient's arm hang by there side in sight abduction of the shoulder with minimal flexion of the elbow. With the patient in this position, palpate the AC joint with one hand, and manipulate their shoulder into internal rotation, followed by external rotation. We compare this movement of the AC joint bilaterally. The somatic dysfunction is named the opposite of the restriction. For example, if the range of motion of the left and right AC joint is normal in internal rotation B/L, but the AC joint on the right has a restriction in the external rotation when compared to the left. The right AC joint is said to be internally rotated. One could also look at naming the somatic dysfunction as where the joint is "living." For example, if a patient has a left externally rotated AC joint, this means the AC joint allows for external rotation (AKA "living" in external rotation) and shows restriction in left internal rotation (when compared to the right AC joint).

For the SC joint, this text will also explore two possible somatic dysfunctions:

1. Adducted clavicle
2. Horizontally extended clavicle

Before getting into the evaluation of somatic dysfunction, it is imperative to understand the relationship between the shoulder and clavicle. The position of the clavicle is named for the movement at the lateral aspect of the clavicle! Abduction of the shoulders causes the medial edge of the clavicle (closest to SC joint) to drop inferior, and the lateral edge to rise superior (as if it is abducting with the shoulder).

You can also think of the clavicle and its movement as a see-saw. Flexion of the shoulder brings the arm anterior, and we would say the lateral edge of the clavicle travels anterior (horizontal flexion) with it, and the medial edge travels posterior. As we extend the shoulder, the arm moves posterior, and the lateral edge of the clavicle also travels posterior (horizontal extension), while the medial portion of the clavicle travels anteriorly. 

The SC joint can be palpated by following the clavicle medially with one hand and traveling laterally off the manubrium with the other. Evaluation of this joint is best with the patient in the supine position. 

To evaluate for an adducted clavicle:

• The provider should be at the head of the table, with the index finger on the superior portion of the SC joint.
• The patient (lying supine) will be instructed to shrug both shoulders to their ears simultaneously (this imitates the abduction of the shoulder)
• The provider will compare the SC joints at the peak of this shoulder shrug: whichever SC joint drops least inferior (or stays more cephalad in terms of the supine patient), is the adducted clavicle.
• To evaluate for a horizontally extended clavicle:
• The provider should be at the head of the table, with index fingers on the anterior portion of the SC joint.
• The patient (supine) is instructed to slowly move their shoulders into flexion.
• The provider compares the posterior movement at the SC joint, whichever SC joint does NOT drop posteriorly is said to be a horizontally extended clavicle.

Muscle Energy Technique for an Internally Rotated AC Joint:

1. Have the patient in a seated position, with the arm in slight abduction and elbow slightly flexed
2. While one hand monitors AC joint, use the other to "shake hands" with the patient and guide the AC joint into external rotation until the restrictive barrier is met
3. The patient internally rotates their shoulder against isometric resistance from the provider for 3 to 5 seconds.
4. The provider instructs the patient to relax and takes shoulder further into the restrictive barrier (thus, further into external rotation)
5. Repeat steps 3 and 4 multiple times (typically 3 to 5 times)

Muscle Energy Technique for an Adducted Clavicle:

1. Provider standing on the side of the table/patient (on the side of the adducted clavicle) and facing cephalad relative to the patient
2. The patient abducts arm on the side of dysfunction to 90 degrees with the thumb facing down.
3. The provider positions his/her thigh against the patient's abducted arm. The hand closest to the patient contacts the superior part of the SC joint.
4. Patient instructed to push arm into the provider's thigh, while the provider isometrically resists (for 3 to 5 seconds)
5. The provider instructs the patient to relax.
6. The provider abducts the shoulder further to the restrictive barrier while maintaining an inferior force on the SC joint.
7. Repeat steps 4 to 6 multiple times (typically 3 to 5 times)
8. Recheck 

Muscle Energy Technique for a Horizontally Extended Clavicle:

1. Provider standing on the side of the table/patient (opposite the side of the dysfunction)
2. Provider contacts the anterior surface of the dysfunctional SC joint with the palm of the hand
3. Instruct patient to bring the hand to the ceiling (flexion of the shoulder) and wrap an arm around the provider's trapezius area
4. The provider should then contact the scapular region with their free-hand.
5. The patient is instructed to try to bring scapula down towards the table, while the provider resists (for 3 to 5 seconds)
6. The provider instructs the patient to relax.
7. While relaxed, provider further pushes SC joint posterior while simultaneously bringing the patient's shoulder/scapula region anterior
8. Repeat steps 5 to 7 multiple times (typically 3 to 5 times)
9. Recheck

As one study states, significant adverse events are not well described or correlated with manual therapy use. For instance, there is no correlation to a musculoskeletal treatment with resulting gastrointestinal complications that we are aware of, although they rarely coincidentally occur. However, minor adverse events that require little to no follow-up are known to occur with manual therapy, such as headache, muscle soreness, and light-headedness.[12] Patients should refrain from strenuous activity after treatment and drink ample amounts of water.

Osteopathic manipulative treatment is an underutilized non-surgical alternative that can provide significant benefits to patients with somatic dysfunctions of the AC and SC Joints. As mentioned before, non-surgical approaches are best for AC injuries type I and II, and there is still dispute over types III and V. All non-surgical approaches should be exhausted prior to surgery, and muscle energy is a viable option to treat these non-surgical injuries while benefiting the surrounding stabilizing structures as well.

Interprofessional communication is something that lacks in terms of osteopathic manipulative treatment. As an osteopathic treatment, only DOs are familiar with the process (unless an MD has taken a separate course). With a large number of patient complaints stemming from the musculoskeletal origin, we need to educate physicians and mid-level practitioners about osteopathic manipulative treatment so patients can be directed to the proper physician to enhance patient care. [Level 5]

Interprofessional education of osteopathic manipulative treatment and awareness of which physicians in their area utilize this treatment modality is critical. These are simple techniques that can be taught and utilized by health care professionals.

Communication about patient progression is essential. Treatment by an osteopathic physician requires continual monitoring and progress communicated to the patient's primary physician or orthopedist.