Download The shoulder complex

Introduction
The shoulder complex
Functional anatomy of the
upper extremity
The elbow and radioulnar joints
The wrist and fingers
Introduction
 Anatomical and functional characteristics of the
joint
 Movement characteristics
 Muscular actions
The shoulder complex
 Strength
 Conditioning
 Sport skills
 Injury
The shoulder complex
Sternoclavicular joint
Acromioclavicular joint (AC joint)
Scapulothoracic joint
Sternoclavicular joint
◎This
gliding synovial joint has a
fibrocartilaginous.
◎The joint is reinforced by three
ligaments and muscles :
The interclavicular ligament
The costoclavicular ligament -- the
main support for the joint
Glenohumeral joint (GH joint)
The sternoclavicular ligament
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Sternoclavicular joint
Sternoclavicular joint
Three degrees of freedom (3-DOF)
 The clavicle can move superiorly and
inferiorly in movement referred to as
elevation and depression. (30°~40°)
 The clavicle can move anteriorly and
posteriorly via movement termed
protraction and retraction. (30°)
 The clavicle can rotate anteriorly and
posteriorly along its long axis through
approximately 40°~50°.
Acromioclavicular joint
(AC joint)
Acromioclavicular joint
(AC joint)
 It is a small gliding synovial joint that is
not present in all individuals.
 This joint that most of the movements of
the scapula on the clavicle occur.
Acromioclavicular joint
(AC joint)
Acromioclavicular joint
(AC joint)
 This joint is reinforced with a dense
capsule and a set of acromioclavicular
ligaments lying above and below the joint.
 Close to the AC joint is the important
coracoclavicular ligament, which assists
scapular movements by serving as an axis
of rotation.
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Acromioclavicular joint
(AC joint)
Acromioclavicular joint
(AC joint)
 Scapula protraction (abduction) and
retraction (adduction) (30°~50°) –occurs as
the acromion process moves on the meniscus in
the joint and as the scapula rotates about the
medial coracoclavicular ligament.
 Scapula elevation and depression (30°) – at
acromioclavicular joint and is not assisted by
rotations about the coracoclavicular ligament. The
range of motion at the acromioclavicular joint for
elevation and depression is approximately 30°.
 Scapula upward and downward rotation
(60°) –clavicle moves on the meniscus in the joint
and as the scapula rotates about the trapezoid
portion of the lateral coracoclavicular ligament.
Scapulothoracic joint
 The scapula interfaces with the thorax via
the scapulothracic joint .
 This is not a typical articulation connecting
 The movements at the sternoclavicular joint
are opposite to the movements at the
acromioclavicular joint for elevation and
depression, protraction and retraction.
Glenohumeral joint (GH joint)
 Glenohumeral joint (shoulder joint) is a
synovial ball-and-socket joint, offering
the greatest range of motion and movement
potential of any joint in the body.
bone to bone. It is a physiological joint.
 Serratus anterior and subscapularis
Glenohumeral joint (GH joint)
Glenohumeral joint (GH joint)
 The joint contains a small, shallow socket
called the glenoid fossa. It is only onefourth the size of the humeral head.
 The joint cavity is deepened by a rim of
fibrocartilage referred to as the glenoid
labrum.
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Glenohumeral joint (GH joint)
Ligament
 There is minimal contact between the
glenoid fassa and the head of humerals, the
shoulder joint largely depends on the
ligamentous and muscular structures for
stability.
Ligament –Anterior side
Ligament –Posterior side
Joint support is provided
 The capsule
- The coracohumeral ligament
- Fibers of the subscapularis
- The pectoralis major
 The glenoid labrum
 The glenohumeral ligament
The joint is reinforced by:
 The capsule
 The glenoid labrum
 Fiber from the teres minor and
infraspinatus
Ligament
Movement characteristics
Superior aspect
 The glenoid labrum
 The coracohumeral ligament
 The supraspinatus
 Long head of the biceps brachii
Inferior aspect
 Capsule
 Long head of the triceps brachii
 Flexion (~180°)
- Be limited if the
shoulder joint is
external rotation. (in
max. ER just only 30°).
- Passive flexion and
extension, there is
accompanying
anterior and posterior
translation.
 Hyperextension
(~60°)
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Movement characteristics
 Internal rotation and external rotation
 Abduction (~180°)
- Be limited by the internal
rotation. (in max IR just
only 60°)
externally 90°, for a total of 180° of rotation.
-
Be limited by abduction
 Hyperadduction (~75°)
Movement characteristics
 Horizontal flexion (~135°)
Movement characteristics
 Past 30° of abduction or 45~60°of flexion,
the ratio of glenohumeral to scapular
movement become 5:4.
 Horizontal extension (~45°)
-
There is 5° of humeral movement for every 4° of
scapular movement on the thorax.
 For the total range of motion through 180°
of abduction or flexion, the glenohumeral
to scapula ratio is 2:1.
-
Muscular actions
 Deltoid
- Generates 50% muscular
force for elevation of the
arm in Abd or flexion
- The deltoid increases with
increases abduction
- Most active through
90~180°
The 180° range of motion is produced by 120° of
glenohumeral motion and 60° of scapular motion.
Muscular actions
 Rotator cuff
- teres minors, subscapularis, infraspinatus,
supraspinatus
- Whole is capable of generating flexion or abd with
about 50% of the force
- In the early stages of abduction and flexion
through 90°,the rotator cuff applies a force to the
humeral head that keeps the head depressed and
stabilized in the joint
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Rotator cuff
Muscular actions
 Deltoid and rotator cuff for the
resting arm
 Trapezius and serratus anterior,
which work together to abduction,
elevation, upward rotation of
scapula in arm flexion and
abduction
 Levator scapulae and rhomboid,
which assist in elevation of the
scapula
Muscular actions
 Shoulder girdle concentric adduction or extension
(ex: swimming), creating these joint action are
latissimus dorsi, teres major, sternal portion of the
pectoralis major.
 The rhomboid muscle downward rotation the
scapula and work with the teres major and the
latissmus dorsi.
 The pectoralis minor depression and downward
rotate the scapula.
 The middle and lower portions of the trapezius
contribute to the retraction of the scapula with the
rhomboid.
Strength
 The adduction strength of the shoulder muscles is
twice that fot abduction
Muscular actions
 External rotation –infraspinatus and teres
minor
 Internal rotation –subscapularis, latissimus
dorsi, teres major, portions of the pectoralis
major.
 Horizontal flexion –pectoralis major,
anterior head of the deltoid
 Horizontal extension –infraspinatus, teres
minor, posterior head of the deltoid.
Conditioning
 Flexor and abductor
- Flexibility
- Manual resistance
- Weight training
 Strength
-
Adduction – Extension – Flexion – Abduction –
Internal rotation – External rotation
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Conditioning
 Extensor and adductor
- Flexibility
- Manual resistance
- Weight training
Conditioning
 Shoulder gridle
- Flexibility
- Manual resistance
- Weight training
Sport skills - Freestyle swimming
Conditioning
 Rotator cuff
- Flexibility
- Manual resistance
- Weight training
Sport skills -Activities of daily living
 Chair or wheelchair
muscle
Chair
raise
Long sit
elbow
flex
Long sit
elbow
flex+abd
Latissimus
dorsi
☆
☆☆
☆☆☆
Pectoralis
major
☆☆
☆
☆☆☆
Triceps
brachii
☆☆☆ ☆☆☆
☆☆☆
Sport skills -Overhand throwing
 pull-through (propulsion)
 recovery
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Sport skills -Golf swing
Injury
◎Trauma –external object
◎Repetitive joint actions –inflammatory
 The sternoclavicular joint –Strain, dislocate
and Subluxation
 Clavicle –fracture
 Acromioclavicular joint –disruption,
dislocate and Subluxation. Ectopic
calcification (overuse), degeneration
(cartilage).
Injury
 Coracoid process –fracture
 Scapula –fracture, bursitis
 Shoulder joint –trauma, repeated overuse,
dislocation, tearing the capsule or glenoid,
soft tissue injuries, impingement syndrome,
bicipital tendinitis…
The elbow and
radioulnar joints
 Ulnar-humeral joint
 Radiohumeral joint
The elbow and
radioulnar joints
Ulnar-humeral joint
 Ulnar-humeral joint is the articulation between
the ulna and the humeral and is the major joint
to flexion and extension of the forearm.
 Trochlea, coronoid process, coronoid fossa, olecranon
process, olecranon fossa…
 Radioulnar joint
 Medial and lateral epicondyles
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Ulnar-humeral joint
Ulnar-humeral joint
 Carrying angle –In the extended
position, because of asymmetry in
the trochlea. The carryint angle is
measured as the angle between a
line describing the long axis of
the ulna and line describing the
long axis of the humeral. From
10~25°.
Radiohumeral joint
Radioulnar joint
 The second joint participating in flexion
 Establishes movement between the radius
and extension of the forearm is the
radiohumeral joint.
and the ulna in pronation and supination.
 2 radioulnar articulations
- Proximal – radial notch of ulna
- Distal – ulnar notch of radius
Radioulnar joint
Ligament
 Collateral ligament –offer support and resistance to
valgus stresses
 In the neutral position, the
 Annular ligament –important for support radius
radius and ulna lie next to
each other, but in full
pronation the radius has
crossed over the ulna
diagonally.
 Interosseous membrane –
connecting the radius and
ulna.
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Movement characterisitics
Movement characterisitics
 The fully extended position the close-
 An extension movement is limited by the
packed position for the ulnarhumeral joint.
 The proximal radioulnar joint is its closepacker position in the semiprone position.
 Flexion (~145°), dality action required 100140°.
 Passive flexion (~160°)
 Hyperextension (5~10°)
 Pronation (70°)
 Supination (85°)
joint capsule and the flexor muscles, boneto-bone contact of the olecranon process.
 Flextion movement is limited by soft tissue,
the posterior capsule, the extensor muscles,
and the bone-to-bone contact of the
coronoid process.
 Pronation/Supinarion is limited by the
ligament, joint capsule, soft tissue.
Muscular actions
Muscular actions
 The elbow flexor
- Biceps brachii, brachialis, brachioradialis, pronator
teres, extersor carpi radialis
- The strongest flexor of the group is the brachialis.
- Biceps brachii is a two-joint muscle (flexion,
supination, pronation)
- Brachioradialis – rapid elbow flexion movement
and against resistance
 The elbow extensor
- Triceps brachii (long head, medial head, lateral
head) is the strongest arm muscle of all.
 Pronator quadratus and pronator teres
- Pronarot quadratus is the greater than teres
 Supinator
Strength
Conditioning
 Biceps brachii
Flexibility
Manual resistance
- Weight training
 The flexor muscle group is almost twist as strong
-
as the extensors at all joint position, making us
better pullers than pushers.
The extensor muscle strength is greatest from a
position of 90° of flexion.
In semiprone elbow position :
the maximum strength in flexion
Is most commonly use in daily activities
Pronation and supination strength greatest
-


-
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Conditioning
Conditioning
 Triceps brachii
 Pronator and supinator
Flexibility
- Manual resistance
- Weight training
-
-
Flexibility
Manual resistance
- Weight training
-
The wrist and fingers
 Radiocarpal joint
 Distal radioulnar joint
The wrist and fingers
 Midcarpal and intercapal joint
 Carpometacarpal joint
 Metacarpophalangeal joint
 Interphalangeal joint
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Carpals
The wrist and hand
 Two rows of carpals
-
-
Scaphoid (Most important carpals, support the
weight of the arm. When wrist flexion , the
midcarpal joint for 60%, the scaphoid for 40%.)
Lunate
Triquetrum
Pisiform
Trapezium
Trapezoid
Capitage (wrist extension, move quickly and close
scaphoid)
Hamate
Carpometacarpal joint (CMC
joint)
 Wrist deviation – these movement are
 The CMC joint providing the most movement for
created as the proximal row of carpals
glides over the distal now.

 The close-packed position for the wrist, is
in a hyperextension position.

-
 The close-packed position for the
-
the thumb, offers very little movement for the four
fingers .
At first ray, or thumb, is a saddle joint. Between
the trapezium and the first metacarpal.
For the thumb (CMC joint)
Flexion/extension (50~80°)
Abduction/adduction (40~80°)
Rotation (10~15°)
midcarpal joint is radial flexion.
Metacarpophalangeal joint
Metacarpophalangeal joint
 Metacarpophalangeal joint (MCP joint) of
the four fingers are the condyloid (髁狀)
joint.
 Movement in two plane (for four fingers):
- flexion-extension (Flexion 70~90°, most flexion
 MCP joint for the thumb is a hinge (鉸鏈)
joint allowing motion in only one plane.
 Flexion (30~90°)
 Extension (~15°)
in the little finger and least in the index finger.
Extension 25°, is limited wrist hyperextension and
enhanced with the wrist flexion)
- abduction-adduction (~20°, abduction is limited
the fingers flexion, because the collateral ligament
become tight)
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Interphalangeal (IP) joint
Muscular actions
 Most of the muscle acting at the wrist and
 Interphalangeal (IP) joint –thumb
- Flexion (~90°)
finger joint originate outside the hand in the
region of the elbow joint.
 The wrist flexion
- Flexor carpi ulnaris, flexor carpi radialis,
palmaris longus
- Medial epicondyle
- Flexor carpi ulnaris (strongest flxor) and
flexor carpi radialis are the most to wrist
flexion
Muscular actions
Muscular actions
 Proximal interphalangeal (PIP) joint
- Flexion (~110°)
 Distal interphalangeal (DIP) joint
 The wrist extension
- Extensor carpi ulnaris, extensor carpi
radialis longus, extensor carpi radialis
brevis
- Lateral epicondyle
 Ulnar deviation
- Flexor carpi ulnaris
- Extensor carpi ulnaris
 Radial deciation
- Flexor carpi radialis
- Extensor carpi radialis longus and brevis
 Finger flexion
- Flexor digitorum profundus /superficialis
- Medial epicondyle
 Lumbricales and Interossei (at MCP joint)
- Flexor (in the palm)
- Extensor (in the dorsal)
Strength
 The wrist in ulnar flexion increases the
strength output of the PIP and DIP flexor
muscles to the greatest extent, followed by
wrist hyperextension and lastly wrist
flexion.
 The grip can be loosened if the wrist is put
in a flexion position.
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Conditioning
Conditioning
 Wrist extensor and flexor
 Finger
Flexibility
- Manual resistance
- Weight training
-
-
Flexibility
Manual resistance
- Weight training
 Power grip
-
 Precision grip
Injury
Injury
 Colles’ fracture
-
Distal end of the radius fracture
 Bennett’s fracture


-
Fracture to the thumb at the base of the first
metacarpal
Mallet finger
Aculsion injury to the extensor tendon at the distal
phalanx
Boutonniere deformity
By aculsion or stretching of the middle branch of
the extensor mechanism, creates a stiff and
immobile PIP articulation
 Jersey finger (Flexor Digitorum Profundus
Rupture)
Avulsion of the finger flexor, cause by forced
hyperextension of the distal phalanx
 Trigger finger
- 指的是指頭因為深屈肌(deep flexor)肌腱
(tendon)，由於在指頭基部形成結節
(nodule)，使得手指頭在彎曲而想伸直時會卡
在肌腱滑車(pulley)，以致尾端指節無法完全
伸直；或者在伸直時會有阻力，形成類似扣板
機的情形，所以稱之為板機指
-
Carpal tunnel syndrome
 Tenosynovitis
is the inflammation of the fluid-filled sheath
(called the synovium) that surrounds a tendon.
Symptoms of tenosynovitis include pain, swelling,
and difficulty moving the particular joint where the
inflammation occurs.
 Carpal tunnel syndrome
- is a medical condition in which the median nerve
is compressed at the wrist, leading to paresthesias,
numbness and muscle weakness in the hand.
-
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~The end~
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