Shoulder anatomy
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The document discusses the anatomy of the shoulder, including bones, joints, ligaments, tendons, muscles, nerves and common injuries. It describes the key bones of the shoulder like the humerus, scapula and clavicle. It also details the main joints of the shoulder such as the glenohumeral joint, acromioclavicular joint, and sternoclavicular joint. The document outlines the important muscles that act on the shoulder and their functions. Common shoulder injuries like rotator cuff tears, tendonitis, frozen shoulder and their treatments are summarized as well. Physical exam maneuvers for evaluating shoulder issues are presented.
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Shoulder anatomy
- 1. B Y H O S S E I N K H O R R A M I P h D . D O M P, SHOULDER khorrami4@yahoo.com http://www.scribd.com/khorrami4
- 2. Shoulder bones • Humerus • Scapula • Clavicle • Ribs • Vertebrae
- 3. Dorsal View
- 4. Shoulder • Joints • Acromioclavicular(AC) joint • Glenohumeral (GH) joint, ball & socket joint • Sternoclavicular(SC) joint • Scapulothoracic joints • Ligaments • Tendons • Capsules • Bursa • Vessels • Brachial plexus • muscles • https://www.youtube.com/watch?v=D3GVKjeY1FM
- 5. Lateral View
- 7. STERNOCLAVICULAR JOINT • Saddle joint permitting the clavicle to move in all 3 planes • A fused SC would limit all shoulder motion! • SCJ disc • Separates the joint into two cavities • Clavicle-disc Disc-manubrium
- 8. SCJ, MOVEMENTS • Functions of the SCJ • Provide movement of the scapula (along with the • ACJ) • Absorb forces from the upper extremity • Elevatoin • Depression • Protraction • Retraction • Rotation
- 9. SCJ MVMT • Motions allowed at the SCJ • • Elevation-Depression of the clavicle • Elevation occurs with shoulder flexion and abduction • Depression with shoulder extension and adduction
- 10. SCAPULOTHORACIC JOINT • Elevation • Depression • Protraction • Retraction • Upward • Downward • Internal rotation( Tipping) • External rotation • Winging
- 11. • Protraction-Retraction of the clavicle • Occurs mostly between the disc and the manubrium • Protraction occurs with shoulder horiz adduction • Retraction with horiz abduction, shoulder extension
- 12. • Rotation • Occurs due to tightening of the coraco- clavicular ligament during humeral elevation (after 90) • If no posterior rotation available, can only get 120 of humeral elevation
- 13. AC & GH Joints
- 14. ACROMIOCLAVICULAR JOINT • Very difficult joint to characterize; wide variability in the size and shape of the lateral clavicle The ACJ is characterized as a plane synovial joint • ACJ disc Helps with mobility; Exists early in life but thins by age 20-30
- 15. ACROMIOCLAVICULAR JOINT • Function of ACJ • Allows the ability to raise the arm above the head • Acts like a strut to help with movement of the scapula resulting in a greater degree of arm rotation
- 16. ACJ • Supporting structures of ACJ • • ACJ capsule Very weak, relies on ligaments for reinforcement • • Acromioclavicular ligaments • • Coracoacromial ligament • Coraco-clavicular ligament • Two sections Conoid (medial) Trapezoid (lateral) • Most important stabilizing structure at the ACJ Prevents clavicle from over-riding the acromion Transmits forces from the scapula to the clavicle
- 19. GLENOHUMERAL JOINT • Classic ball and socket • joint • • Composed of glenoid • fossa and humeral head • Fossa only articulates with 25% of the humeral head • • Sacrifices stability for mobility
- 21. GH JOINT • Coraco-acromial Arch • Prevents upward dislocation of the humeral head • Protects rotator cuff and humeral head from direct trauma
- 22. SCAPULOHUMERAL RHYTHM • During shoulder ABDuction or flexion • There is a 2:1 ratio between the GH joint motion and the scapulothoracic • joint that take place For every 2 degrees of GH ABD The scapula upwardly rotates 1 degree • Without scapular rotation, the humerus would not be able to attain full ROM, it would be impinged under the acromion
- 23. Shoulder Muscles • Deltoid • Subscapularis • Teres major & minor • Supraspinatus • Infraspinatus • Levator scapula • Biceps brachii • Latissimus dorsi • Trapezius • Rhomboid muscle • Pectoralis major & minor • Coracobrachialis • Serratus anterior • https://www.youtube.com/watch?v=t1zJwD0tWck
- 24. TRAPEZIUS MUSCLE • Origin • Occipital bone • Spinous process of C7- T12 • Insertion • Lateral clavicle • Acromion • Spine of scapula • Innervation C3-C4 & XI( accessory nerve)
- 25. Trapezius, functions • Elevation of scapula • Retraction(adduct) scapula • Upwardly rotate scapula • Depress scapula • Neck extension
- 26. Latissimus Dorsi
- 27. LATISSIMUS DORSI • Origin • T7-T12(T6-T12) • 9th -12th ribs • Thoracolumbar fascia • Iliac crest • Crest of sacrum • Insertion • Bicipital groove of humerus • Function • Adduct • Arm extension • Internal rotation of arm at the shoulder
- 28. BICIPITAL GROOVE • Biceps brachii • Latissimus dorsi • Pectoralis major • Teres major
- 29. LATISSIMUS DORSI
- 30. • Origin • Transverse process of C1-C4 • Insertion • Medial border of scapula • Innervation • C3-C4 • Function • Cervical Spine: Extension, lateral flexion and ipsilateral rotation • Scapula: Elevation and downward rotation Levator Scapulae
- 33. Rhomboid Muscle • Origin • Spinous process C7-T1(minor)& T2-T5(major) • Insertion • Medial border of scapula • Scapular retraction • Elevation
- 34. Teres Major & Minor
- 35. Teres Major • Origin • Inferior border of scapula • Insertion • Intertubercular groove of Anterior humerus • Function • Adduct arm • Internal rotation of arm • Arm extension(not hyperextension)
- 36. Teres Minor • Is a rotator cuff muscle • Origin • Lateral border of scapula • Insertion • Greater tubercle of humerus • Function • Adduct arm • External rotation of arm
- 38. SCALENE MUSCLE
- 39. ANTERIOR SCALENE • Origin: TVP of C3-C6 • Insertion: scalene tubercle of first rib
- 40. MIDDLE SCALENE • Origin: TVP of C3-C7 • Insertion: 1st rib
- 41. POSTERIOR SCALENE • Origin: C5-C7 • Insertion: 2nd rib
- 42. INTERSCALENE TRIANGLE • Subclavian art & brachial plexus pass through
- 43. Subscapularis • Origin • Subscapularis fossa • Insertion • Lesser tubercle of humerus • Function • Medially rotation of arm • Adduction
- 45. Posterior View
- 46. AC Joint, posterior view
- 50. Supraspinatus • Origin • G.tubercle of humerus • Insertion • Supraspinous fossa • function • Abduction • First 30o
- 51. Pectoralis muscles • P.Major • Clavicle • Sternum • Upper costal cartilage • Bicipital groove • P.Minor • 3rd-5th ribs • Coracoid process • Flexion • Adduction
- 52. Pectoralis Major
- 54. Biceps Brachii, Action • 2 joint muscle • Shoulder flexion • Elbow flexion • Flexion
- 55. Biceps Brachii Short head Long head Radial tuberosity Coracoid process
- 58. Pectoralis Minor & Coracobrachialis • Adduction
- 61. Anconeus Lat.epicondyle of humerus Olecranon of ulna Function: Elbow extension
- 62. Triceps Brachii
- 63. Triceps Brachii Infraglenoid of Scapula Olecranon of ulna
- 64. Coracobrachialis Line of lesser tuberosity
- 65. Deltoid Muscle Acromion Spinous Clavicle Deltoid tuberosity of humerus
- 66. Teres Major Crest of lesser tuberosity Inferior angle of scapula
- 67. Rotator Cuff Muscles • Teres minor • Supraspinatus • Infraspinatus • Subscapularis
- 69. Rotator Cuff Muscles, Teres Minor • External rotation • Adduction
- 70. Rotator Cuff, Lateral View
- 71. Supraspinatus Supraspinus fossa G.Tuberosity of humerus
- 72. Infraspinatus Infraspinous fossa G.Tuberosity of humerus
- 74. Teres Minor G.Tuberosity of humerus
- 76. Subscapularis Muscle • Internal rotation • Adduction
- 77. Infraspinatus Muscle • External rotation • Adduction • Arm extension
- 78. Serratus Anterior • 1st to 8th, or 9th ribs • Antagonist of rhomboid • Protract & stabilize scapula • Pull forward scapula • Depress scapula
- 80. Serratus Anterior • Protraction of scapula
- 82. Brachial plexus • Musculocutaneous N. • Axillary N. • Radial N. • Median N. • Ulnar N.
- 83. BRACHIAL PLEXUS
- 86. TOS
- 87. ROM SHOULDER
- 89. Shoulder Movement(10) Movement Prime mover, other muscles Flexion Pectoralis major, coracobrachialis Extension Latissimus dorsi Abduction Supraspinatus( first30o)+ Deltoid Adduction Infraspinatus, pectoralis major, latissimus dorsi Internal rotation Subscapularis External rotation Infraspinatous , teres minor
- 90. Shoulder Movement Movement Prime mover, other muscles Elevation Trapezius Depression Latissimus dorsi, subclavious Protraction Serratus anterior, Retraction Rhomboid
- 92. Rotator Cuff Injuries • Tendonitis • OA • Bursitis • Impingement syndrome • 1/3 cases of shoulder pain • Narrowing space of humerus & Acromion • Pain on abduction 60-120o • Anatomical enlargement of joint(AC)& Swelling of tendon and/or bursae, or weakness of scapulothoracic M. (e.g. Serratus anterior)
- 93. Rotator Cuff Injuries • Rotator cuff tear( tennis shoulder) • Most common cause of shoulder pain • Pain during motion & night • Muscular atrophy & weakness • Labral tears • Rim of soft tissue in glenoid • Connect with biceps tendon • Injury, age
- 94. SPEED TEST • The test is best performed with the patient in a relaxed sitting position • The arm to be tested should be in about 60 degrees of front flexion with the forearm supinated and the elbow fully extended • In the starting position the examiner forcefully presses down on the patient’s arm at the forearm • The patient attempts to resist the pressure of the examiner • Alternatively the patient attempts to forward flex the shoulder while the examiner resists
- 95. Positive Speed Test • If pain is reported in the bicipital groove • Weakness in maintaining the forward flexion position will also likely be noted • A positive test is indicative of long head of biceps tendon instability or tendonitis • Tenderness on palpation of the bicipital groove also indicates bicipital tendinitis • When the therapist stops pushing down on the arm a sudden jerking motion may result • Pain at this point may indicate a positive test for sub-acromial bursitis
- 96. Cross Arm Adduction (Scarf Test) • Tests AC joint • A positive test commonly indicates AC joint osteoarthritis or A-C joint ligament injury such as a ligament sprain or joint separation • The A-C joint is very prone to injury due to the small articulation surfaces that are quite incongruent • The two surfaces are the distal end of the clavicle and the acromion process of the Scapula • Injuries usually occur due to Falls and in contact sports
- 97. Cross Arm Adduction (Scarf Test) • The examiner should stand behind the patient on the side being tested • Grasp the patient’s arm just distal to the elbow and passively flex the patient’s shoulder to 90o • Then maximally adduct the patient’s shoulder (bring it across their body towards the other shoulder) • A positive test is considered if the patient reports pain during the adduction motion or localized pain in the AC joint
- 98. Kim Test • Purpose • Detection of a posteroinferior labral lesion • A - With the patient in a sitting position with the arm 90 degrees of abduction, the examiner holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force is applied • B - while the arm is elevated 45 degrees diagonally upward, downward and Backward force is applied to the proximal arm • A sudden onset of posterior shoulder pain indicates a positive test result, regardless of accompanying posterior clunk of the humeral head .
- 99. LAG Test • Purpose • To test for rotator cuff tears of the Subscapularis tendon • Technique • Patient is seated with examiner behind patient • The affected arm is brought into maximal internal rotation behind the back • Examiner controls patient's arm at the elbow and wrist/hand which is passively brought into 20 degrees of extension taking the forearm and hand away from the back • Instruct patient to actively maintain this position as examiner releases the wrist but maintains support at the elbow • A LAG is indicative of a subscapularis tendon tear describe the magnitude of the LAG in 5 degree intervals with an obvious drop indicating large or massive tear and a smaller lag revealing a partial tear • https://www.youtube.com/watch?v=qi3KK_-R7ZY
- 100. Tendonitis • Develop with repetitive overhead activities • Playing tennis • Pitching (baseball and golf) • Painting • Shoveling
- 101. Adhesive Capsulitis(frozen shoulder) • Inflammation and stiffness of GH joint capsule • Loss of both AROM & PROM • Constant pain • Worsen pain at night & cold weather • Mostly women 40-60 YO
- 102. Risk Factors Of Frozen Shoulder • DM • Stroke • Lung disease • RA • Heart disease • Immobilization
- 103. Treatment • Ice pack • Ultrasound • LASER • Pain free active assistive ROM • Isometric exercises • Isotonic exercises • Stretching exercises • Strengthening exercises
- 104. Strengthening Exercises • Theraband • Flexbar • Weight • Wand • Pulley
- 105. Exercise Protocol • At least 4 weeks and more for maintenance • Warm up with walking, stationary bike • After Codman’s ex., Start with stretching • Finish with stretching • Pain free
- 106. Codman’s Exercise • R-L 30 sec • Back & forth 30 sec • Circular motion, 30sec each • 2 sets/day • 5-6 days/week
- 107. Stretching Exercises, goals • Make more flexibility • Prevents contracture • Restoring range of motion and preventing injury • Gently stretching after strengthening exercises can help reduce muscle soreness and keep muscles long and flexible
- 108. Strengthening Ex. • Help to keep shoulder joint stable • Can relieve shoulder pain and prevent further injury
- 109. Walking Wall Stretch • Using fingers on a wall • Hold 10-15 sec • Reps 10-15 • 3 sets/day
- 110. Walking Table Stretch • In sitting position • Using fingers on a table • Hold 10-15 sec • Reps 10-15 • 3 sets/day
- 111. Cane Stretch Exercise • Lie down, face up • Use a cane to push affected arm
- 112. Towel Stretch Exercise • Stretch external rotators • Stretch flexors
- 113. Corner Stretching Exercise • Stretching PM • Hold 20-30 sec • Reps several times
- 114. Crossover Arm Stretch • Posterior deltoid • Hold 30sec • Relax 30sec • Repeat 4 times • 5-6/week
- 115. Passive Internal Rotation • Subscapularis • Hold 30sec • Reps 4 each side/day • 5-6/week
- 116. Passive External Rotation • Stretch in Infraspinatus, teres minor • Hold 30sec • 4 each side/day, slowly • 5-6/wk
- 117. Sleeper Stretch • Infraspinatus, teres minor • Hold 30sec • 4 reps/day, slowly • 5-6/wk
- 118. Standing Row • Strengthening extensors • Middle & lower trap • 8-12 reps, slowly • 3 sets/day • 3/wk
- 119. External Rotation+ abduction • Infraspinatus, teres minor stregthening • 8-12 reps, slowly • 3 sets/day • 3/wk
- 120. Internal Rotation • Subscapularis & teres major strengthening • 8-10 reps • 3 sets/day • 3/wk
- 121. External Rotation • Infraspinatus, teres minor, posterior deltoid • 8-10 reps, slowly • 3 sets/day • 3/wk
- 122. Elbow Flexion • Biceps, • 8-12 reps, slowly • 3 sets/day • 3 days/wk
- 123. Elbow Extension • Triceps • 8-12 reps, slowly • hold 2 sec • 3 sets/day • 3 days/wk
- 124. Trapezius strengthening • Middle & posterior deltoid, middle trap, supraspinatus, • 20 reps, slowly • 3-4 sets/day • 3-5 days/wk
- 125. Scapula Setting • Middle trap, serratus anterior • Hold 10 sec • 10 reps • 3 days/wk
- 126. Scapular Retraction/Protraction • Middle trap, serratus anterior, latissimus dorsi • 8-15 reps, slowly • 2 sets/day • 3 days/wk
- 127. Bent Over Horizontal Abduction • Middle & lower trap, infraspinatus, teres minor, post deltoid • 8-12 reps • 3 sets/day • 3 days/wk
- 128. Internal & External Rotation • Ant deltoid, pectoralis, subscapularis, latissimus • Post deltoid, infraspinatus, teres minor • 20 reps • 3-4 sets/day • 3-5 days/wk
- 129. External Rotation • Stretch infraspinatus, teres minor, posterior deltoid • 8-10 reps, slowly • 2 sets/day • 3/wk
- 130. Internal Rotation • Stretch subscapularis & teres major • 8-10 reps • 2 sets/day • 3/wk