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Dr. S. Nishan Silva (MBBS) Bones Clavicle Scapula Humerus Shoulder vs Shoulder Girdle Joints Sternoclavicular Joints Sternoclavicular Acromioclavicular Coracoclavicular ligaments “Suspensory ligaments of the upper extremity” Two components: ▪ Trapezoid ▪ Conoid Stronger than AC ligaments Provide vertical stability to AC joint Joints Sternoclavicular Acromioclavicular Glenohumeral Most common dislocated joint Lacks bony stability Composed of: Fibrous capsule Ligaments Surrounding muscles Glenoid labrum Ligaments Acromioclavicular Joint ▪ Acromioclavicular Ligament Ligaments Glenohumeral Joint ▪ Glenohumeral ligaments ▪ Superior ▪ Middle ▪ Inferior 25% humeral head surface in contact with glenoid Humeral head coverage increased to 75% with glenoid labrum Cartilage Glenoid labrum Shoulder Girdle Muscles Trapezius Trapezius Origin: superior nuchal line, external occipital protuberance, ligamentum nuchae and spinous processes of seventh cervical and all thoracic vertebrae Insertion: lateral third of clavicle, acromion, and spine of scapulartery Acton: upper fibers elevate scapula, lower fibers depress scapula; if scapula is fixed, one side acting along, draws head toward the same side, and turn face to opposite side; both sides together, draw head directly backward Latissimus dorsi Origin: spinous processes of lower six thoracic and all lumbar vertebrae, median sacral crest, and posterior part of iliac crest. Insertion: floor of intertubercular groove of humerus. Action: trunk fixed, extends, adducts and medially rotates arm ; arm fixed, elevates trunk. Shoulder Girdle Muscles Trapezius Serratus Anterior Winged Scapula Glenohumeral Muscles Rotator Cuff ▪ ▪ ▪ ▪ Suprispinatus Infraspinatus Teres Minor Subscapularis Subscapularis Supraspinatus Infraspinatus Teres minor Supraspinatus, infraspinatus, teres minor, subscapularis Form cuff around humeral head Keep humeral head within joint (counteract deltoid) Abduction, external rotation, internal rotation Subscapularis is an internal rotator of the arm. Supraspinatus assists the deltoid in abducting the arm, with its greatest contribution being the initiation of abduction. Infraspinatus and teres minor muscles both externally rotate the arm. Teres major Origin: dorsal surface of inferior angle of scapula Insertion: crest of lesser tubercle of humerus Action: medially rotates and adducts arm Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Pectoralis major Origin: medial half of clavicle,sternum,1th-6th costal cartilages. Insertion: crest of greater tubercle of humerus. Action: flexes, adducts and rotates arm medially; arm fixed, elevates trunk; elevates ribs 1-6,aidding in forced inspiration. Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid Deltoid Origin: lateral third of clavicle, acromion, and spine of scapula Insertion: deltoid tuberosity of humerus Action: abducts,flexes and medically rotates, extends, and laterally rotates arm Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid Biceps Arms outstretched with palms up at level of shoulder Forced supination of hand with elbow flexed at 90 degrees Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid Biceps Triceps Other structures Brachial Plexus Brachial Artery Formation: Five roots: formed by anterior rami of C5-C8 and T1 spinal nerves, roots C5~C7give rise to long thoracic n. Three trunks The upper trunk is formed by the joining of root C4,C5,C6. The middle trunk is the continuation of root C7. The lower trunk is formed by the joining of root C8 and T1. Six divisions: above clavicle, trunks form anterior and posterior divisions Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a. Position: passes through the scalene fissure to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords Main branches Lateral cord Musculocutaneous n. Lateral root to median n. Medial cord Medial root to median n. Ulnar n. Medial brachial cutaneous n. Medial antebrachial cutaneous n. Posterior cord radial n. axillary n. thoracodorsal n. Axillary artery Continuation of subclavian artery at lateral border of first rib Becomes brachial artery at lower border of teres major Divided into three parts by overlying pectoralis minor First portion, above muscle-gives rise to thoracoacromial a. Second portion, behind muscle-gives rise to lateral thoracic a. Third portion, below muscle-gives rise to subscapular a. anterior and posterior humeral circumflex a.; the former then divides into throcodorsal a. and circumflex scapular a. Axillary a. Thoracoacromial a. Lateral pectoral n. Musculocutaneous n. Medial antebrachial cutaneous n. Median n. Ulnar n. Medial brachial cutaneous n. Intercostobrachial n. Thoracodorsal n. & a. Long thoracic n. & lateral thoracic a. Name the muscles for Horizontal Adduction Pect Major (both) Corachobrachialis Deltoid (anterior) Name the muscles for Horizontal Abduction Deltoid (post) Infraspinatus Teres minor Lats List the muscles that do flexion of the shoulder Coracobrachialis Pectoralis major (upper to 60°) Anterior Deltoid • List the muscles that do extension of the shoulder • Latissimus dorsi • Teres major • Posterior deltoid • Pectoralis major (lower fibers to neutral) List the muscles that do adduction of the shoulder Pectoralis major (lower and upper below 90°) Coracobrachialis Latissimus dorsi Teres major List the muscles that do abduction of the shoulder • Deltoid (all sections) • Supraspinatus • Pectoralis major (upper past 90°) List the muscles that do internal rotation of the shoulder Subscapularis Latissimus dorsi Teres major Anterior deltoid Pect. major • List the muscles that do external rotation of the shoulder • Infraspinatus • Teres minor • Posterior deltoid Name the muscle. Coracobrachialis Name the action Adduction of the shoulder Also, flexion and hor. add. Name the muscle. Subscapularis Name the action Internal rotation of the shoulder Name the muscle. Deltoid Name the action Abduction of shoulder Name the muscle. Infraspinatus Name the action External rotation Name the muscle. Name the action Teres Major Adduction of scapula Name the muscle. Teres Minor Name the action if the humerus move directly to the posterior Extension of the shoulder Name the muscle. Supraspinatus Name the action Abduction of the shoulder Coracobrachialis Subscapularis Pect. Major Deltoid Supraspinatus Teres Major Infraspinatus Teres Minor What position are her shoulders in? Flexion What position is his right shoulder in? Horizontal Abduction and External Rotation What rotation action is his shoulder performing as he continues to through the ball? Internal Rotation What position are her shoulders in? Flexion What position are his shoulders in? Horizontal abduction or Extension Position of their shoulders? 1. Flexion 2. Extension What is the position of shoulders? Extension Pectoralis major Latissimus dorsi Push-ups Chinning Pull-ups Robe climb Bench press Dips on parallel bars Throwing Pullover exercises Tennis serve Pulldown exercises Rowing Shoulder action = ? Shoulder muscle(s) = ? Abduction Deltoid Supraspinatus Shoulder action = ? Shoulder muscle(s) = ? Flexion Ant Deltoid Upper Pect Major Coracobrach. Shoulder action = ? Shoulder muscle(s) = ? Horizontal Add. Ant. Deltoid Pect. Major (both) Coracobrachialis Shoulder action = ? Shoulder muscle(s) = ? Horizontal Abduction Latissimus Dorsi Post. Deltoid Teres Minor Infraspinatus Shoulder action = ? Shoulder muscle(s) = ? Adduction Pect. Major (both) Coracobrachialis Latissimus Dorsi Teres Major Shoulder action = ? Shoulder muscle(s) = ? Horizontal Add Ant. Deltoid Pect. Major (both) Coracobrachialis Shoulder action = ? Shoulder muscle(s) = ? Extension Lats Post. Deltoid Infraspinatus Teres Major Pectoralis Major (lower) Teres minor Shoulder action = ? Shoulder muscle(s) = ? External Rotation Infrspinatus Teres Minor Post. Deltoid Side arm dumbbell raises Deltoid Push-ups Pectoralis major Rowing and pull-overs Latissimus dorsi Internal Rotation External Rotation Internal Rotation Subscapularis, Ant. Deltoid, Pect, Major, Lats. And Teres Major External Rotation Internal Rotation External Rotation Abduction (to work the supraspinatus) Factors Predisposing to Shoulder Pain Instability of glenohumeral joint Weakness in scapular stabilizing muscles Previous injury (dislocation of glenohumeral joint, separation of AC joint) Hypomobility of cervical or thoracic spine Postural dysfunction Muscle imbalances Differentiation of Shoulder Pain Active inflammation: pain that occurs or increases at night Irritation of a sensory nerve root: sharp pain, numbing, & tingling in a dermatome Rotator cuff injury: pain at lateral portion of upper arm, painful limitation when elevating arm overhead Bicipital tendinitis: well-localized pain at anterior portion of head of humerus & aggravation with Speed’s test Adhesive capsulitis: stiffness in shoulder, dramatic loss of arm motion (especially external rotation) Differentiation of Shoulder Pain Impingement: pain over anterior humerus, loss of internal rotation, & painful Neer’s test Instability: clunking in shoulder with active circumduction & excessive joint play in passive motion test for glenohumeral joint Pain originating in glenohumeral joint: rarely felt at joint, but over lateral brachial region Characteristics of Shoulder Pain (vs. neck pain) Elicited or increased from active shoulder motion & relieved by rest Isometric challenge will be painful with localized lesion Painless weakness in arm & shoulder muscles from motor nerve root problem in cervical spine Common Dysfunctions and Injuries of the Shoulder Rotator cuff tendinitis (supraspinatus tendinitis) Infraspinatus tendinitis Subscapularis tendinitis Adhesive capsulitis (frozen shoulder) Impingement syndrome Instability syndrome of the glenohumeral joint Common Dysfunctions and Injuries of the Shoulder Bicipital tendinitis Subacromial (subdeltoid) bursitis Acromioclavicular ligament sprain Suprascapular nerve entrapment Costoclavicular syndrome (part of thoracic outlet syndrome) Pectoralis minor syndrome (part of thoracic outlet syndrome) Abduction/adduction Painful arc of abduction – sensitive, not specific Impringement of inflammed subacromial bursae / biceps tendon etc underneath Fig : Name Scapularretraction [7] (aka scapular adduction) Description Muscles The scapula is moved posteriorly and medially along the back, moving the arm and shoulder joint posteriorly. Retracting both rhomboideus major, minor, and trapezius scapulae gives a sensation of "squeezing the shoulder blades together." Scapularprotraction[7](aka scapular abduction) The opposite motion of scapular retraction. The scapula is moved anteriorly and laterally along the back, moving the arm and shoulder joint anteriorly. If both scapulae are protracted, serratus anterior (prime mover), pectoralis minor and major the scapulae are separated and the pectoralis major muscles are squeezed together. Scapularelevation [8] The scapula is raised in a shrugging motion. Scapulardepression [8] The scapula is lowered from elevation. The scapulae may be pectoralis minor, lower fibers of the trapezius, subclavius, depressed so that the angle formed by the neck and shoulders is latissimus dorsi obtuse, giving the appearance of "slumped" shoulders. Arm abduction [9] Arm abduction occurs when the arms are held at the sides, parallel to the length of the torso, and are then raised in the plane of the torso. This movement may be broken down into True abduction: supraspinatus (first 15 degrees), deltoid; two parts: True abduction of the arm, which takes the humerus Upward rotation: trapezius, serratus anterior from parallel to the spine to perpendicular; and upward rotation of the scapula, which raises the humerus above the shoulders until it points straight upwards. Arm adduction[10] Arm adduction is the opposite motion of arm abduction. It can be broken down into two parts: downward rotation of the scapula and true adduction of the arm. Downward rotation: pectoralis minor, pectoralis major, subclavius, latissimus dorsi (same as scapular depression, with pec major replacing lower fibers of trapezius); True Adduction: same as downward rotation with addition of teres major and the lowest fibers of the deltoid The humerus is rotated out of the plane of the torso so that it points forward (anteriorly). The humerus is rotated out of the plane of the torso so that it points backwards (posteriorly) pectoralis major, coracobrachialis, biceps brachii, anterior fibers of deltoid. latissimus dorsi and teres major, long head of triceps, posterior fibers of the deltoid Arm flexion [11] Arm extension[11] levator scapulae, the upper fibers of the trapezius Medial rotation of the arm [12] Medial rotation of the arm is most easily observed when the elbow is held at a 90-degree angle and the fingers are extended subscapularis, latissimus dorsi, teres major, pectoralis major, so they are parallel to the ground. Medial rotation occurs when anterior fibers of deltoid the arm is rotated at the shoulder so that the fingers change from pointing straight forward to pointing across the body. Lateral rotationof the arm[12] The opposite of medial rotation of the arm. Armcircumduction[13] Movement of the shoulder in a circular motion so that if the elbow and fingers are fully extended the subject draws a circle in pectoralis major, subscapularis, coracobrachialis, biceps brachii, the air lateral to the body. In circumduction, the arm is not lifted supraspinatus, deltoid, latissimus dorsi, teres major and minor, above parallel to the ground so that "circle" that is drawn is infraspinatus, long head of triceps flattened on top. infraspinatus and teres minor, posterior fibers of deltoid