Download The brachial plexus & Osteopathic concepts in the shoulder

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
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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)
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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
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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)
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The Rotator
Cuff
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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
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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
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Composed of 3 joints & one articulation
Sternoclavicular joint (SC)
 Acromioclavicular joint (AC)
 Glenohumeral joint (GH)
 Scapulothoracic articulation
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All four work together in a synchronous
rhythm for universal motion.
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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
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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.
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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
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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
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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
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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
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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
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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.
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History
Inspection
Palpation
ROM
Muscle testing
Neurovascular
testing
Biomechanics
Specific Tests
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Forward flexion
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Extension
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rubbery feel and gives slightly
under pressure
 Intra-articular blockage:
inflexible and ROM ends
abruptly
180˚
45˚
40-45˚
Internal rotation
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55˚
Muscle weakness
Soft tissue contractures
Bony blockage
 Extra-articular blockage:
External rotation
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Possibilities for loss of ROM:
ADduction
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45˚
ABduction
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180˚
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Somatic dysfunctions
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Rest
NSAIDs, muscle
relaxants, analgesics
OMT correcting the
dysfunctional
components and
restoring neutral
mechanics
Muscle strengthening
Surgery in extreme cases
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Sternoclavicular joint motions:
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Superior/Inferior glide
 Movement in the frontal (coronal) plane
 Also called ADduction/ABduction
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Anterior/Posterior glide
 Movement in a horizontal (transverse) plane
 Also called horizontal extension/horizontal flexion
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Rotation on its long mechanical axis
 Anterior (internal)/Posterior (external)
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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
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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
jointNamed an ADduction
somatic dysfunction (superior
glide)
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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
jointNamed 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
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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
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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
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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
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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
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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
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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
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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)
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Assess for ease/restriction of motion
S
A
P
I
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Indications for the Spencer Technique
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Adhesive capsulitis, bursitis, tenosynovitis, arthritis
Purpose
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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
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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
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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
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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
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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.