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Amy W. Doolan, D.O. Clinical Faculty, Department of Family and Sports Medicine Edward Via College of Osteopathic Medicine – Virginia Campus Team Physician, Virginia Tech VOMA Fall CME Conference September 23, 2011 Review the anatomy of the shoulder Review the biomechanics of the shoulder Briefly touch on the physical examination of the shoulder, namely ROM Practice Assessing the shoulder looking for somatic dysfunction SC/AC/GH Joints, Scapulothoracic Articulation Practice correctly naming shoulder somatic dysfunction Practice the OMM treatments for shoulder somatic dysfunctions Springing/Ligamentous Balance/Articulatory/Muscle Energy/7 Stages of Spencer (Spencer Technique) A loosely constructed, highly mobile complex of bones, muscles and ligaments The humerus is suspended from the scapula by soft tissue, muscles, ligaments and a joint capsule Designed for increased mobility with only sufficient stability to provide a proper foundation for muscular function Deltoid Anterior (Flex/IR) Mid-portion (ABd) Posterior (Ext/ER) Pectoralis Major (ADd/flex/IR) Biceps (Flex) Triceps (Ext) Teres Major (ADd/IR) Latissimus dorsi (Ext/ADd/IR) The Rotator Cuff Supraspinatus (ABd) Infraspinatus (ER) Teres Minor (ER) Subscapularis (IR) Muscles Innervation Spinal Level Primary Flexors Deltoid (ant portion) Coracobrachialis Axillary Nerve Musculocutaneous Nerve C5 C5-6 Secondary Flexors Pectoralis Major (clavicular head) Biceps Primary ABductors Deltoid (mid portion) Supraspinatus Axillary Nerve Suprascapular Nerve C5-6 C5-6 Secondary ABductors Deltoid (ant & mid portion) Serratus Ant via Scapula Primary ADDuctors Pectoralis Major Latissimus Dorsi Anterior Thoracic Nerve (medial and lateral portions) C5-T1 Secondary ADDuctors Teres Minor Anterior Deltoid Primary Extensors Latissimus Dorsi Teres Major Deltoid (post portion) Thoracodorsal Nerve Lower Subscapular Nerve Axillary Nerve C6-8 C5-6 C5-6 Secondary Extensors Teres Minor Tricep (long head) Primary External Rotators Infraspinatus Teres Minor Suprascapular Nerve Axillary Branch C5-6 C5 Secondary External Rotators Deltoid (posterior portion) Primary Internal Rotators Subscapularis Pectoralis Major Latissimus Dorsi Teres Minor Subscapular Nerve (upper, lower portions) Ant thoracic nerves (med and lat) C5-6 Secondary Internal Rotators Deltoid (anterior portion) C5-T1 Trapezius Superior (Elev) Middle (Retract) Inferior (Depress) Levator Scapulae (Elev) Pectoralis Minor (Depress) Rhomboids (Retract) Serratus anterior (Protract) Muscles Innervation Spinal Level Primary Elevators Trapezius Levator scapulae Accessory Nerve Dorsal Scapular Nerve Cranial Nerve XI C3-4, C5 Secondary Elevators Rhomboid major Rhomboid minor Primary Protraction Serratus Anterior Long Thoracic Nerve C5-7 Primary Retraction Rhomboid major Rhomboid minor Dorsal Scapular Nerve Dorsal Scapular Nerve C5 C5 Secondary Retraction Trapezius Composed of 3 joints & one articulation Sternoclavicular joint (SC) Acromioclavicular joint (AC) Glenohumeral joint (GH) Scapulothoracic articulation All four work together in a synchronous rhythm for universal motion. Saddle shaped synovial joint Articular disc separates the articular surfaces and adds significant strength to the joint Depends on capsular ligament for strength Enables the humerus to achieve 1800 of ABduction A plane synovial joint that augments the range of motion (ROM) in the humerus. It is made up of the acromion process of the scapula and the lateral edge of the clavicle. It is surrounded by a fibrous capsule and an articular disc separates the surfaces. Primary strength is supplied by the acromioclavicular and coracoclavicular ligaments Coracoclavicular ligaments stabilize the clavicle to the scapula Conoid ligament primarily prevents anterior and superior clavicular displacement Trapezoid ligament is the primary constraint against compression of the distal clavicle into the acromion Multi-axial ball and socket Most of the support is provided by the rotator cuff (RC) Contraction of RC pulls the humerus down into lower/wider portion of the glenoid cavity Without the “dropping down”, full ABduction is impossible Hydrostatic component Labrum–ring of fibrocartilage that surrounds and deepens the glenoid fossa Increases the available contact area to approximately 70% Only part of the humeral head is in contact with the glenoid at any one time Also called scapulocostal joint Body of the scapula and the muscles covering the posterior chest wall Scapula serves as a mobile platform from which the upper limb operates Allows the scapula to glide medially, laterally, superiorly and inferiorly and rotate over the posterolateral chest cage Scapula aligns itself to allow the glenoid cavity to be in the best position to receive the head of the humerus Neurologically complex Movement of the scapula, humerus and clavicle are necessary for normal scapulohumeral ABduction Pain or stiffness may disturb synergy of motion The GHJ moves 120 degrees as the scapula swings about 60 degrees around the chest wall in a smooth 2:1 ratio. History Inspection Palpation ROM Muscle testing Neurovascular testing Biomechanics Specific Tests Forward flexion Extension • • • rubbery feel and gives slightly under pressure Intra-articular blockage: inflexible and ROM ends abruptly 180˚ 45˚ 40-45˚ Internal rotation 55˚ Muscle weakness Soft tissue contractures Bony blockage Extra-articular blockage: External rotation Possibilities for loss of ROM: ADduction 45˚ ABduction 180˚ • Somatic dysfunctions Rest NSAIDs, muscle relaxants, analgesics OMT correcting the dysfunctional components and restoring neutral mechanics Muscle strengthening Surgery in extreme cases Sternoclavicular joint motions: Superior/Inferior glide Movement in the frontal (coronal) plane Also called ADduction/ABduction Anterior/Posterior glide Movement in a horizontal (transverse) plane Also called horizontal extension/horizontal flexion Rotation on its long mechanical axis Anterior (internal)/Posterior (external) Joint motions are coupled ABduction (IG) is coupled with posterior (external) rotation ADduction (SG) is coupled with anterior (internal) rotation LATERAL LATERAL P A P A MEDIAL MEDIAL ABduction Inferior Glide Posterior Rotation External Rotation Horizontal Flexion Posterior Glide LATERAL LATERAL P A MEDIAL ADduction Superior Glide Anterior Rotation Internal Rotation P A MEDIAL Horizontal Extension Anterior Glide ABduction (IG)/ADduction (SG) 1. 2. 3. 4. 5. Physician stands at head of table Patient is supine Place tips of your fingers on the superior edges of the medial ends of the patient’s clavicle Ask your patient to shrug their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly (inferior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide) Horizontal Flex (PG)/Horizontal Ext (AG) 1. 2. 3. 4. 5. Physician stands at head of table Patient is supine Place tips of your fingers on the anterior edges of the medial ends of the patient’s clavicle Ask your patient to reach toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction Dx: L clavicle ant and sup glide (aDDuction somatic dysfunction) 1. Patient supine, physician stands on side opposite dysfunction 2. Place caudal hand firmly on table as high as possible in axilla 3. Patient uses hand opposite dysfunction to grab elbow on side of dysfunction, providing SC gapping 4. Low velocity, moderate amplitude (LVMA) springing applied laterally, posteriorly, inferiorly over medial clavicle 5. Recheck ADduction Somatic Dysfunction Physician standing on the side of the dysfunction Patient is supine 1. Take the patient’s arm on the side of the dysfunction and aBduct it to 90 degrees 2. Palpate the superior border of the SC joint with your hand 3. Hold the patient’s extended wrist and internally rotate the arm (thumb down) 4. Have the patient attempt to aDduct arm against your leg, while at the same time pressing inferiorly on the superior border of the SC joint. Resist the patient’s force with your thigh. Hold force for 3-5 seconds 5. Instruct patient to relax while simultaneously easing your counterforce 6. Take the arm to the new restrictive barrier (increase aBduction) 7. Repeat steps 4-6 a total of 3-5 times, or until the dysfunction is no longer present 8. Recheck your findings 4. 5. Dx: L clavicle ant and sup glide 1. 2. 3. Patient sits on table, physician on stool Place both thumbs under junction of medial/mid 3rd of clavicle and places fingers over each end Patient rests forearm over physician forearm 6. 7. Patient instructed “Lean forward slightly toward me” until clavicle supported by physician thumbs. Patient then told “Slightly turn body away from me.” This gaps SC. Physician carries patient’s shoulder post to gap/balance AC Medial end of clavicle elevated by rotating around thumb pivot point. Clavicle taken to point of ligamentous balance through adjustment of patient’s body position Test resp phase and have patient hold in best phase as long as possible as physician makes minor adjustments Repeat step 6 until best motion (avg 3 times) - Recheck Horizontal Extension Somatic Dysfunction Physician standing on the side of the dysfunction Patient is supine 1. Have the patient grasp the back of your neck with the arm/hand on the dysfunctional side 2. Contact the anterior surface of the involved SC joint with one hand while your other hand supports/elevates the scapula farther until motion is felt in the SC joint 3. Have the patient attempt to pull you down toward them while you simultaneously push the medial clavicle in a posterior direction. Resist the patient’s force by gently leaning back. Hold force for 3-5 seconds 4. Instruct patient to relax while simultaneously easing your counterforce 5. Take the arm to the new restrictive barrier by leaning backward and raising arm (increase horizontal flexion) 6. Repeat steps 3-5 a total of 3-5 times, or until the dysfunction is no longer present 7. Recheck your findings Superior/Inferior Glide 1. 2. 3. 4. Physician places fingers on distal clavicle at AC joint. Palpate position of distal clavicle in relation to acromion Spring inferiorly on distal clavicle to assess for motion Assess for restriction of gapping at AC joint. AC gapping External Rotation A ADduction P Internal and External Rotation Physician stands behind patient Patient is seated 1. ABduct the patient’s arms to 90 degrees 2. Flex patient’s elbows to 90 degrees 3. Assess internal and external rotation. Make sure you keep the arms in 90/90 position. Assess both sides at the same time 4. Dysfunction is named for the free motion EX: if the left AC joint does not external rotate as far as the right AC joint, the dysfunction is named an internal rotation somatic dysfunction of the left AC joint Internal Rotation Somatic Dysfunction Physician standing on the side of the dysfunction Patient is supine 1. ABduct the dysfunctional arm to 90 degrees and flex the elbow to 90 degrees 2. Externally rotate the shoulder to the restrictive barrier while stabilizing the arm above the elbow with your knee 3. Have the patient attempt to internally rotate their shoulder. Resist the patient’s force with your arm/hand. Hold force for 3-5 seconds. 4. Instruct patient to relax while simultaneously easing your counterforce 2. Take the shoulder to the new restrictive barrier by increasing external rotation 3. Repeat steps 3-5 a total of 3-5 times, or until the dysfunction is no longer present 4. Recheck your findings External Rotation Somatic Dysfunction Physician standing on the side of the dysfunction Patient is supine 1. ABduct the dysfunctional shoulder to 90 degrees and flex the elbow to 90 degrees 2. Internally rotate the shoulder to the restrictive barrier while stabilizing the arm above the elbow with your knee 3. Have the patient attempt to externally rotate their shoulder. Resist the patient’s force with your arm/hand. Hold force for 3-5 seconds. 4. Instruct patient to relax while simultaneously easing your counterforce 2. Take the shoulder to the new restrictive barrier by increasing internal rotation 3. Repeat steps 3-5 a total of 3-5 times, or until the dysfunction is no longer present 4. Recheck your findings 1 Dx: R clavicle superior glide 1. 2. 3. 4. 5. Patient sits on table, physician stands behind 2 Physician grasps pt’s elbow or forearm Physician places pad of thumb of other hand behind lateral end of clavicle with fingers over ant surface of clavicle Physician applies ant/inf pressure w/thumb on lateral side of clavicle, flexes pt’s elbow and extends/adducts humerus to gap AC (1) Physician firmly holds clavicle ant/inf w/thumb and fingers. Shoulder extended further and circulatory articulatory sweep applied, carrying elbow first post (2), then sup, and finally anteromedially while maintaining adduction and capsular tension (3) 3 4. 5. Dx: R clavicle superior glide 1. 2. 3. Patient sits on table, physician on stool Place both thumbs under junction of medial/mid 3rd of clavicle and places fingers over each end Patient rests forearm over physician forearm 6. 7. Patient instructed “Lean forward slightly toward me” until clavicle supported by physician thumbs. Patient then told “Slightly turn body away from me.” This gaps SC. Physician carries patient’s shoulder posterior to gap/balance AC Lateral end of clavicle elevated by rotating around thumb pivot point. Clavicle taken to point of ligamentous balance through adjustment of patient’s body position Test resp phase and have patient hold in best phase as long as possible as physician makes minor adjustments Repeat step 6 until best motion Palpate position of humeral head in glenoid fossa, comparing sides Physician stabilizes scapula Grasp humerus at head or just distal Apply anterior (pull forward)/posterior (push backward) pressure with thumb and fingers Distract (pull down inferiorly)/compress (push up superiorly) with hand looking for evidence of sulcus sign Pull medially/laterally (may have to change hand grasp position) Assess for ease/restriction of motion S A P I Indications for the Spencer Technique Adhesive capsulitis, bursitis, tenosynovitis, arthritis Purpose To provide a diagnostic series of movements that test the range of motion and articular glides of the shoulder and examine each group of muscle for restriction To provide a treatment for each muscular restriction that is found during examination of the shoulder Series of proprioceptive neuromuscular facilitation techniques Can be expanded to include ME treatment Physician stabilizes scapula Physician engages barrier of joint Patient pushes against (away from barrier) Repeat 3-5 times Taking up slack and engaging new barrier each time Engages all of the muscles around the GH joint Both diagnostic & therapeutic The seven stages of motions are: 1. Engage GH extension barrier with elbow flexed 2. Engage GH flexion barrier with the elbow flexed 3. Circumduction with compression Start small circles, then gradually 1 2 increase size Clockwise and counterclockwise May also do ME of IR/ER barriers 3 4. Circumduction with traction on straight arm Start small circles, then gradually increase size Clockwise and counterclockwise 5. Engage abduction barrier 6. Adduction/IR with elbow flexed 7. GH pump with distraction and compression along straight arm 4 5 6 7 3. 4. Dx: Humeral head ant/sup 1. 2. Pt sits end of table, physician on side of dysfunction Monitor humeral head w/post hand and places palm and/or fingers of ant hand on medial aspect of humerus as high in axilla as possible 5. 6. Pt lays hand of dysfunctional arm across chest, grasps elbow or wrist w/other hand to pull elbow across chest against counterforce of physician’s hand to gap GHJ. Pt also lifts elbow to assist physician w/superior glide. Position humerus into int/ext rot by lifting/depressing elbow to obtain ligamentous tension balance Test respiratory phases and pt holds breath as long as possible in best phase, making minor adjustments to other positions as needed. Repeat step 5 until best motion Physician can assess for static/dynamic asymmetry Physician can physically take scapula through ROM, assessing for ease/restriction 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Patient in lateral recumbent position with physician at side of table Hook fingers of cephalad hand over superior angle of scapula. Grasp elbow with opposite hand, resting patient’s arm on physician’s cephalad forearm (1) Carry scapula inferiorly and laterally to muscular restrictive barrier Apply sufficient force to feel muscles relax Force is slowly relaxed Stretching repeated rhythmically until max response obtained Move fingers to medial scapular margin (2) Carry scapula laterally and repeat #4-#6 Move fingers to inferior angle (3) Carry scapula superiorly and laterally, repeating #4-#6 1 2 3 Ward, R., D.O. Foundations for Osteopathic Medicine. 2nd ed. Chapter 47:Upper Extremities. Lippincott, Willliams and Wilkins, 2003. Nicholas NS. Atlas of Osteopathic Techniques. Philadelphia, Pa, Philadelphia College of Osteopathic Medicine,1974;320325. Kimberly, P. Outline of Osteopathic Manipulative Procedures. The Kimberly Manual. Chapter 11:Upper Extremity;231-240. Hoppenfeld, Physical Examination of the Spine and Extremities. Chapter 1:Physical Examination of the Shoulder. Karageanes, Principles of Manual Sports Medicine. Chapter 17: The Shoulder. Netter, Atlas of Human Anatomy 2nd Edition.