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HLHP 3620
The Shoulder
I) The Shoulder Girdle
A) Bones
1) There are 2 bones that make up the shoulder girdle
a) scapula - flat
b) clavicle - long
2) These 2 bones connect to the axial skeleton by the articulation of the clavicle to the sternum
B) The Joints
1) Sternoclavicular (SC)
a) multi-axial arthrodial joint
b) movement
1) 15o anteriorly with protraction
2) 15o posteriorly with retraction
3) 45o superiorly with elevation
4) 5o inferiorly with depression
c) Support
1) anteriorly by the anterior sternoclavicular ligament
2) posteriorly by the posterior ligament
3) the costoclavicular and interclavicular prevent superior displacement
2) The Acromioclavicular (AC)
a) an arthrodial joint
b) movement - 20-30o total gliding and rotational motion depending on movements of the
shoulder girdle and joint
c) support 1) costoclavicular ligaments
2) if AC joint is injured the superior/inferior acromioclavicular ligaments help
3) Scapulothoracic
a) not a true synovial joint
1) missing synovial characteristics
2) moves as a result of the motion at the SC and AC joints
b) the movement - how the scapula moves on the rib cage
1) 25o abd/adduction
2) 60o up/downward rotation
3) 55o elevation-depression
c) support
1) muscle provide primary support
2) does not have ligamentous support
C) The Muscles
1) 5 Primary muscles
2) All 5 originate on the axial skeleton and insert on either the clavicle or scapula
3) Shoulder girdle muscles DO NOT attach to the humerus - nor do they produce ANY motion
at the shoulder joint.
4) Muscles of the shoulder girdle - provide “dynamic” stability to the scapula during ballistic
motions like throwing
5) Trapezius
a) Origin
1) Upper portion
A) base of skull
B) occipital protuberance
C) posterior ligaments of the neck
2) Middle portion
A) spinous processes of 7th cervical vertebrae
B) upper 3 thoracic vertebrae
3) Lower portion - spinous processes of 4-12 thoracic vertebrae
b) Insertion
1) Upper portion - posterior aspect of the lateral 3rd of clavicle
2) Middle portion
A) medial border of acromion process
B) upper border of the scapular spine
3) Lower portion - triangular space at the base of the scapular spine
c) Action
1) Upper portion
A) elevation of the scapula
B) extension of the head
C) these are thin, relatively weak fibers
2) Middle portion
A) elevation of the scapula
B) upward rotation of scapula
C) adduction (retraction) of scapula
D) Strong thick fibers -provide strong contributions to these motions
3)Lower portion
A) depression of the scapula
B) adduction (retraction) of scapula
C) upward rotation of scapula
D) These fibers assist in these motions
d) Palpation - large area lateral of spinal column from neck to T-12, to the scapula
e) Innervation 1)Accessory nerve (XI cranial nerve)
2)branches of C3 & C4
f) Roles
1)Primary role - fixation of scapula during deltoid action
2) By upwardly rotating the scapula the arms can be raised overhead
3) Prevents glenoid fossa from being pulled downward during lifting
g) Strengthening
1) Upper and middle - shrugs
2) Middle and lower
a) bent over rows
b) side arm, abduction
h) Flexibility
1) Upper portion - pull head and neck into flexion (or lateral flexion away from side being
stretched - while the hand on the side being stretched is holding a table, to keep the scapula in
depression
2) Middle portion - have a partner pull the scapula into full protraction
3) Lower portion a) lying on side
b) partner passively elevates and protracts scapula
6) Levator scapulae
a) Origin - transverse process c1-c4
b) Insertion - medial boarder of the scapula (above base of scapular spine)
c) Action - elevation of the medial margin of the scapula (if the scapula is fixed by the pect
minor, then the levator scapulae on both sides, extend the neck - or laterally flex if only one side
contributes
d) Palpation - it is deep to the trap. - cannot be palpated
e) Innervation - dorsal scapula nerve (C5) and branches of C3 & C4
f) Strengthening - shrugs
g) Stretching - rotate head, flex c-spine, keep scapula relaxed, and depressed
7) Rhomboid (major & minor)
a) Origin - spinous processes of c7 & t1-t5
b) Insertion - medial boarder of scapula below the spine
c) Action - major and minor work together
1) adduction (retraction) of scapula -scapula moves toward spinal column
2) Downward rotation from upward rotation
3) Elevation - this occurs with adduction
4) Fixes scapula during arm adduction or extension
5) Used during chinning - to prevent the scapula being pulled away from the chest
d) Palpation - cannot be palpated -deep to trap
e) Innervation - dorsal scapula nerve (C5)
f) Strength - chinning and dips
g) Flexibility - Scapula is moved passively into protraction while in depression
8) Serratus Anterior
a) Origin - upper 9 ribs, at side of chest
b) Insertion - anterior aspect of medial border of scapula
c) Action 1) abduction - medial boarder away from vertebrae
2) upward rotation
3) used during throwing, shooting, guarding
d) Palpation - front, lateral side of chest below the 5 & 6 ribs
e) Innervation - long thoracic nerve (C5, C6, C7)
f) Strengthening
1) push-ups - particularly last 5-10o of motion
2) bench and overhead press
3) Winging of scapula - weakness in serratus anterior - can lead to damage of long thoracic
nerve
9) Pectoralis minor
a) Origin - anterior surface of 3-5 ribs
b) Insertion - coracoid process of scapula
c) Action 1) Abduction (protraction) - brings scapular forward, and tilts lower boarder away from ribs
2) Downward rotation -during abduction
3) Depression - in upward rotation, it assists
d) Palpation - difficult to palpate
e) Innervation - Medial pectoral nerve (c8-t1)
f) Role
1) used in true abduction -push-ups (protraction w/o rotation)
2) most pushing movements
3) dips
g) Flexibility - wall pushups in the corner
10) Subclavius
a) Origin - superior aspect of 1 rib at junction of costal cartilage
b) Insertion - inferior groove of mid-portion of clavicle
c) Action 1) stabilize and protect SC
2) depression
d) Palpation - cannot be palpated
e) Innervation - Nerve fibers from c5 and c6
f) Strength - dips
g) Stretch - extreme elevation of shoulder girdle
Applied Anatomy
Elbow
A) Bones
1) Ulna 2) Humerus 3) Radius
B) Joint/Movements
1) The trochlea of humerus articulate with the trochlea fossa of ulna (flexion/extension)
2) The capitellum of humerus and proximal radius (gliding joint)
3) Radius & ulna articulate (pronation/supination)
a) proximal - radial notch of ulna & radius (technically a pivot joint - the radius “rolls”
over ulna)
b) distally - the radius and ulna
C) Muscles
1) Biceps brachii
a) Origin (two-heads)
1) top of the coracoid process
2) upper ridge of the glenoid fossa
b) Insertion - tuberosity of radius
c) Action - 2 joint muscle
1) Weak in actions at the shoulder
2) Most powerful flexor of elbow
3) Changes with hand position
a) in supination 1) it is the most powerful orientation
2) both flexes and supinates
b) in pronation
1) decrease in effectiveness
2) due in part to compromised angle of pull with the radius rotated
*note - the same muscles produce elbow flexion - both in pronation & supination
d) Exercise
1) curls
2) chinning
3) rope climbing
2) Brachialis
a) Origin - lower half of anterior portion of the humerus
b) Insertion - coronoid process of the ulna
c) Action - the only true flexor of the elbow
1) acts on the ulna only (which does not rotate)
2) flexes elbow whether in pronation/supination
3) Brachiradialis
a) Origin - Lower 2/3 of the outer condyloid ridge of humerus
b) Insertion - Outer surface of the lower end of the radius at the styloid process
c) Action
1) flexor
2) weak pronator/supinator
3) If pronated when flexes - it tends to supinates while flexing (and opposite is true)
4) most effective in flexion when halfway between pronation and supination
4) Triceps brachii
a) Origin - three heads
1) Long head - lower edge of glenoid cavity of scapula
2) Lateral head - upper 1/2 of posterior surface of humerus
3) Medial head - lower 2/3 of posterior surface of humerus
b) Insertion - Olecranon process of ulna
c) Action
1) Elbow extension
2) Assists in shoulder extension
3) Forceful pushing motions - e.g. push-ups
5) Anconeus
a) Origin - Posterior surface of the external condyle of humerus
b) Insertion - posterior surface of upper ulna and olecranon
c) Action 1) elbow extension
2) pulls the synovial capsule out of the way of olecranon
6) Supinator muscle
a) Origin - outer condyloid ridge of humerus and ulna
b) Insertion - outer surface of the upper 1/3 of radius
c) Action - supinates forearm
1) contributes more dramatically during supination and extension - turning a screwdriver
2) not as active during supination/flexion as the biceps brachii is the greatest contributor
to this motion
7) Pronator teres
a) Origin 1) Lower part of the inner condyloid ridge of humerus and
2) medial side of ulna
b) Insertion - Middle 1/3 of the outer surface of the radius
c) Action
1) Flexion of elbow
2) Pronation of forearm
3) Typically - pronating while elbow is flexing
4) If pronator teres were to work alone - it would bring the back of the hand toward the
face
8) Pronator quadratus
a) Origin - Lower 1/4 of anterior surface of ulna
b) Insertion - Lower 1/4 of anterior surface of radius
c) Action
1) Pronation of forearm
2) Active during extension/pronation (along with triceps brachii - e.g.- using a
screwdriver)
3) Must be exercised during pronation motion (w/the triceps) to avoid assistance of
pronator teres
Hip
A) Bones
1) Femur
2) Acetabulum of pelvis
a) Upper 2/5 - ilium
b) Posterior & lower 2/5 - ischium
c) Anterior & lower 5th - pubis
B) Movements
1) Flexion/Extension
2) Abd/Adduction
3) Inward/outward Rotation
C) Comment about observing movement about the hip
1) Gravity has a large influence on which muscles are responsible motion about the hip
2) Movements against gravity - generally - concentric (from standing: a) drawing knee toward
chest - concentric BUT b) trunk flexion - eccentric)
3) Movements in the direction of gravity - generally - eccentric (squats - eccentric)
D) Muscles
1) Iliopsoas
a) Origin - Inner surface of ilium, base of sacrum and sides of bodies of the last thoracic
and all lumbar vertebrae
b) Insertion - Less trochanter of the femur and shaft just below
c) Action 1) Flexion of thigh at hip
2) Outward rotation of the thigh
3) When the thigh is fixed, the iliopsoas pulls on the vertebrae and flexes the spine
and pelvis on the thigh, as in rising to a sitting position from the supine positions
2) Sartorius
a) Origin - notch between the anterior-superior and anterior-inferior spines of the ilium
b) Anterior medial condyle of the tibia
c) Action
1) Flexion of the thigh at the hip
2) Flexion of the leg at the knee
3) Rotation of the thigh outward as it flexes the hip and the knee
d) Notes 1) It is a 2 joint muscle crossing both the hip and the knee
2) Acting as a flexor at both joints
3) Taylor’s muscle - helps to crosses legs
3) Rectus Femoris
a) Origin - Anterior-inferior iliac spine of the ilium
b) Insertion - Top of the patella and patellar ligament with the tibial tuberosity
c) Action
1) Flexion of the thigh at the hip
2) Extension of the leg at the knee
d) Muscles - Note about hip flexors
In general - the hip flexors pull the pelvis down in the front and up in the back. As
people age, the abdominal wall relaxes and does not hold the pelvis up - and a permanent forward
tilt and an increased lumbar curve results
4) Tensor Fasciae Latae
a) Origin - Anterior iliac crest and surface of the ilium just below the crest
b) Insertion - Iliotibial band of fascia on the thigh (1/4 of the way down)
c) Action 1) Flexion of the thigh at the hip
2) Horizontal abduction of the thigh
3) Tendency to inwardly rotate as it flexes
4) Aids in preventing outward rotation of the femur as it is flexed by other flexor
muscles
5) Gluteus Medius
a) Origin - Outer surface of the ilium just below the crest
b) Insertion - Posterior and middle surfaces of the greater trochanter of the femur
c) Action 1) Abduction of the thigh at the hip
2) Outward rotation as the thigh abducts
6) Gluteus Minimus
a) Origin - Outer surface of the ilium below the origin of the gluteus medius
b) Insertion - Anterior surface of the greater trochanter of the femur
c) Action
1) Abduction of the femur on the pelvis
2) Inward rotation as the femur abducts
d) Role - gluteus medius and minimus re important in preventing non-supporting hip from
sagging during walking. They serve the same role in running. In order to have a strong drive from
the legs, these muscles must be developed
7) Gluteus Maximus
a) Origin
1) posterior 1/4 of of the ilium crest
2) posterior surface of sacrum near the ilium
3) fascia of the lumbar area
b) Insertion - gluteal line of the femur and the iliotibial band of the fascia
c) Action
1) Extension of the thigh at the hip
2) Outward rotation of the thigh
3) Lower fibers - assist in adduction
4) Used in extension of thigh, beyond 15 degrees. It is important in extension of the
thigh with outward rotation
5) Used strongly in hopping, skipping, running and jumping.
8) Six deep outward rotators
a) Names
1) piriformis
2) gemellus superior
3) gemellus inferior
4) obturator externus
5) obturator internus
6) quadratus femoris
b) Origin
1) sacrum
2) posterior postion of ishcium and obturator foramen
c) Insertion
1) greater trochanter
2) posterior aspect of the greater trochanter
d) Used in powerful lateral rotation of the thigh - exmaples - during overhand throwing
or swinging a baseball bat
9) Biceps femoris
a) Origin
1) tuberosity of the ischium
2) lower half of the linea aspera
3) outer condyloid ridge
b) Insertion - lateral condyle of the tibia and head of fibula
c) Action 1) Extension of the thigh at the hip
2) Flexion of the leg at the knee
3) Outward rotation of the femur
10) Semitendinosus
a) Origin - tuberosity of the ischium
b) Insertion - upper anterior medial condyle of the tibia
c) Action
1) Extension of thigh at hip
2) Flexion of leg at knee
3) Inward rotation of the thigh
d) notes 1) two-joint muscle
2) most effective when either extending hip, or flexing knee separately (if both motions
are occurring - weak contribution)
11) Semimembranosus
a) Action - tuberosity of ischium
b) Insertion - posterior surface medial condyle of the tibia
c) Action
1) Extension of the thigh at the hip
2) Flexion of the leg at the knee
3) Inward rotation of the thigh
12) Hamstrings
1) Comprised of the
a) semitendinousus, semimembranosus and bicep femoris
b) with the glut. max. - they serve as strong extensors of the thigh at the hip - when the
knee is straight or nearly so (ex - running, skipping, hopping, jumping)
c) used w/o glut max when hanging from a bar, by the knees
13) Pectineus
a) Origin - one inch wide space on front of pubis, above the crest
b) Insertion - rough line leading from the lesser trochanter down to the linea aspera
c) Action
1) Flexion of the thigh at the hip
2) Adduction of the femur on the pelvis
14) Adductor brevis
a) Origin - front of the pubis just below the origin of the longus
b) Insertion - lesser trochanter and upper 1/4 of the linea aspera
c) Action
1) Adduction of the thigh at the hip
2) Outward rotation as it adducts the thigh
15) Adductor longus
a) Origin - front of the pubis just below the crest
b) Insertion - middle 1/3 of the linea aspera
c) Action
1) Adduction of the thigh at the hip
2) Assists in flexion of the thigh at the hip
16) Adductor magnus
a) Origin - edge of entire ramus of the pubis and the ischium and tuberosity of the ischium
b) Insertion - whole length of the linea aspera and inner condyloid ridge
c) Action
1) Adduction of the thigh at the hip
2) Outward rotation as the thigh adducts
3) Backstroke kick, horseback riding
17) Gracilis
a) Origin - inner edge of the descending ramus of the pubis
b) Insertion - anterior, medial surface of tibia, below the condyle
c) Action
1) Adduction of the thigh at the hip
2) Flexion of the leg at the knee
3) Inward rotation of the thigh
Applied Anatomy
Knee
A) Bones
1) Tibia and femur (and patella)
2) Hinge joint (although some rotation does occur)
3) Patella serves to give an improved angle of pull to the quadriceps group
B) Cartilage
1) serves as cushion between the bones
2) Medial and lateral meniscii a) are located between the the medial and lateral aspects of the demur and the tibia.
b) the meniscii are thicker on the outside edge
C) Ligaments
1) Cruciate
a) anterior and posterior - they cross within the interior of the knee, between the femur and
tibia
b) they maintain inner stability
2) Collateral
a) Medial (tibial) and lateral (fibular)
b) Medial collateral ligament attach to the medial meniscus
c) Injury to the medial collateral ligament generally occurs from a blow to the lateral side
d) Injury to the lateral collateral ligament are infrequent
D) Capsule
1) Is located under the patella and between the surfaces of the tibia and the femur
2) There are more than 10 bursae located in the capsule - and are positioned to absorb shock
and reduce friction
E) Movements
1) Flexion
2) Extension
F) Muscles
1) Several muscles were discussed with relation to their function at the hip, but produce motion
at the knee
a) rectus femoris (knee extensor
b) sartorius (knee flexor)
c) biceps femoris (knee flexor)
d) semitendinosus (knee flexor)
e) semimembranosus (knee flexor)
f) gracilis (knee flexor)
2) The gastrocnemius - is a two joint muscle that crosses the ankle and the knee - serves as a
knee flexor
3) The two joint muscles are most effective when either the origin or insertion is fixed by
contraction of neutralizer muscles that prevent movement in the direction of pull
4) Kicking a football - leaning back raises and fixes the origin of the rectus femoris to allow it to
be a more effective knee extensor of the knee
5) Quadricep group
a) critical for jumping
b) comprised of
1) rectus femoris - only 2 joint muscle
2) vastus lateralis (largest)
3) vastus medialis
4) vastus intermedius
c) all attach through the patella tendon to tuberosity of tibia
d) often 3-4 times stronger than hamstrings
e) Rectus Femoris
1) Origin - anterior-inferior spine of ilium
2) insertion - top of patella and patellar ligament to the tibial tuberosity
3) Action
a) Flexion of the thigh at the hip
b) Extension of the leg at the knee
f) Vastus Lateralis (externus)
1) Origin - outer surface of femur below the greater trochanter and upper half of the linea
aspera
2) Insertion - outer 1/2 of the upper boarder of patella and patella ligament to the tibial
tuberosity
3) Action - extension of the leg at the knee
g) Vastus Intermedius
1) Origin - Upper 2/3 of the anterior surface of the femur
2) Insertion - upper boarder of the patella and patellar ligament to the tibial tuberosity
3) Action - Extension of the leg at the knee
h) Vastus Medialis (internus)
1) Origin - whole length of the linea aspera and the internal condyloid ridge
2) Insertion - Inner 1/2 of the upper portion of the patella and patellar ligament to the tibial
tuberosity
3) Action - extension of the leg at knee
i) Notes
1) all 3 vastus muscles are used with and w/o the rectus femoris in knee extension
2) used in - walking, running and keeping the knees straight during standing
3) During hip flexion - rectus femoris is ineffective as a knee extensor - and the vastus
muscles work to extend the knee
6) Hamstring group
a) primarily knee flexors and secondary hip extensors
b) injuries are common
c) quadriceps antagonists
d) comprised of
1) semitendinosus
2) semimembranosus
3) biceps femoris
e) all originate on ischial tuberosity of pelvis
f) semimembranosus and semitendinosus insert on the medial side of the tibia
g) rectus femoris inserts
1) lateral tibial condyle and head of the fibula
2) second head - on the linea aspera of the femur
7) Popliteus
a) Origin - posterior surface of the outer condyle of the femur
b) Insertion - upper posterior-medial surface of the tibia
c) Action - flexion of the leg at the knee
d) Notes 1) it is the only “typical” flexor at the knee-all other flexors are 2 joint muscles
2) works with cruciate ligaments to prevent hyperextension