Cunningham technique

image21

How does it work?

This technique uses a combination of positioning and specific massage of the spasming biceps muscle.

Q –How does it overcome the static obstruction of the glenoid rim?

Static obstruction is overcome by asking the patient to push their chest out and shoulders back which “squares off” the angle of the shoulder (reducing scapular anteversion). 

Q - How does it overcome the dynamic forces of the spasming biceps and subscapularis?

The dynamic obstruction of the spasming biceps is actively reduced by massaging the muscle at the mid-humeral level. 

Q - How does it overcome movement inertia?

You may find that you have the humeral head/ glenoid rim interface perfectly positioned but nothing happens, even with the muscles fully relaxed. Even though the humeral head ‘wants’ to return to the rim there may be an inertia of movement that needs to be overcome. Overcoming this inertia can be helped by using the fact that the humeral head and the glenoid rim are in opposition and, being articular surfaces, are slippery. Therefore, producing a small amount of momentum by gently moving the humerus anteriorly/ posteriorly can cause these surfaces to slide against each other, facilitating reduction.

image22

Summary

Position your patient:

- With the humerus adducted, the biceps shortened and the operator’s wrist resting on the patient’s forearm, the patient will usually feel immediately more comfortable.

- Don’t pull, you’ll only get spasm, pain and an uncooperative patient. 

- The humerus can be gently moved forwards and back in order to find the perfect angle, and provide a small amount of momentum to allow the head to slide across the glenoid rim.

Position yourself:

- Face directly opposite to the patient and kneel next to them - this avoids any external rotation/flexion of the humerus (which happens if you start off too far away from your patient). 

- This closeness to the patient also means that they are resting their hand on your shoulder, not reaching for it and clutching with the fingers.

image23

Step 1 - Analgesic Position 1

Sit your patient up (without slouching, towel or pillow down spine) 

‘Hold’- take control of the affected limb with a 'hold.' This is a firm steady downward hold (not a pull) designed to move the humeral head towards where it needs to be, taking off some of the stretch from the capsule (reducing pain), and providing confidence to the patient that you have taken control of the limb. Once you are in this position, it can be useful to ask the patient their pain level, and explain again what you are going to do. It’s important to note that the elbow is not being supported from below, but is being placed in a downwards ‘hold’.

The affected arm is adducted (next to the body) and the elbow fully flexed (optimally shortens the biceps muscle, allowing full relaxation)

The humerus points directly down and should be in a neutral position (no forward flexion or external rotation)

Ask the patient to “shoulders back, chest out.” (reducing scapular anteversion and so reducing the static obstruction of the glenoid rim).

Kneel next to your patient and place your wrist onto their forearm, with their hand resting on your shoulder.


Sometimes once you have your analgesic position in place, the shoulder will reduce without any further moves. See how in this video (‘cunningham technique positioning.’)

cunningham technique

image24

Step 2 - Massage

Q – Where do I massage?

Start by gently massaging the trapezius and deltoids (this helps to relax the patient and reassure them that you are not going to do anything painful), move on to gently massaging the biceps at the mid humeral level.


Ask your patient to again put “shoulders back, chest out” and relax.

Massage the biceps (gently) at mid humeral level.

Wait for your patient to fully relax and the humeral head slips back into place.

Tell your patient that they will feel “strange” as the joint slips back in and not to fight this movement.

Continue to gently move the humerus forwards and back in order to find the perfect angle, and provide a small amount of momentum to allow the head to slide across the glenoid.

image25

Step 3 - anterior/posterior movements

The humerus can then be gently moved forwards and back in order to find the perfect angle, and provide a small amount of momentum to allow the head to slide across the glenoid.

This combines the principle of overcoming the movement inertia with the apposition of the slippery articular surfaces of the glenoid rim and the humeral head.

image26

Be patient!

This technique takes as long as it takes for your patient to relax, anything from seconds to minutes. 

Take your time positioning the patient (and yourself) comfortably and don’t pull! 

Models!

image27

Too hot for education?

I have had some stick from my registrars about this original photoshoot having an excess of chemistry for an educational demonstration. Fortunately for me, the beautiful model used in this shoot is my wife, Nicola!