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Transcript of Laureate International Universities - Blackboard Inc. International Universities ® Origin Medial...
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Anatomical Name?
Type of Joint?
What is the significance of a shallow glenoid fossa?
What are the 4 rotator cuff muscles (TISS)?
What is the purpose of the rotator cuff?
Name the 4 joints that comprise the shoulder complex
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Glenohumeral Joint
Ball and Socket
Great capacity for ROM, but unstable, so requires strong muscular support (rotator cuff)
Teres minor, Infraspinatus, Supraspinatus, Subscapularis
The rotator cuff muscles hold the humeral head down on abduction of the arm to prevent impingement of the supraspinatus tendon and jamming of the humeral head
Sternoclavicular, Acromioclavicular, Glenohumeral, Scapulothoracic Joints
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Pectoralis Major
Latissimus Dorsi
Subscapularis
Infraspinatus
Teres Major
Teres Minor
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Posterior Deltoid
Triceps
Latissimus Dorsi
Teres Major
Teres Minor
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Subscapularis
Teres Major
Latissimus Dorsi
Pectoralis Major
Anterior Deltoid
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Origin Medial 1/3 of sup. nuchal line of occipital bone EOP Ligamentum nuchae SP’s of C7-T12
Insertion Lateral 1/3 clavicle, acromion & spine of scapula
Action Upper Elevates scapula
Middle Retracts scapula
Lower Depresses, downwardly rotates & stabilises
scapula
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Origin SP’s T7-T12 Lx vertebra Crests of Sx & ilium Inferior 4 ribs
Insertion Floor of Intertubercular groove of humerus
ActionMedial rotation of humerus Adduction of humerus Extension of humerus
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Origin TP’s C1-C4
Insertion Superior medial angle of scapula
Action Elevates scapula Medially rotates scapula Stabilises scapula
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Origin SP’s C6-T5
InsertionMedial border of scapula
Action Retracts Elevates AdductsMedially rotates Stabilises scapula
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Origin Clavicular Head Anterior medial ½ clavicle
Sternal Head Anterior sternum Superior 6 costal cartilages
Insertion Lateral lip of Intertubercular groove Greater tubercle
Action AdductsMedially rotates humerus Clavicular head flexes humerus Sternal head extends humerus
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Origin Ribs 1-3 near costal cartilage
Insertion Coracoid process
Action Stabilises scapula by drawing it anteriorly & inferiorly
against thoracic wall
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Origin Superior 8-9 ribs
InsertionMedial border & inferior angle of scapula
Action Protracts (abducts) of scapula Upward rotation of scapula Elevates ribs when scapula is stabilised
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Origin Lateral 1/3 clavicle Acromion Spine of scapula
Insertion Deltoid tuberosity
Action Anterior Flexes & medially rotates humerus
Middle Abducts humerus
Posterior Extends & laterally rotates humerus
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Origin Dorsal surface of inferior angle of scapula
InsertionMedial lip of intertubercular groove
ActionMedial rotation Adduction
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Origin Supraspinous fossa of scapula
Insertion Greater tubercle of humerus
Action Abduction
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Origin Infraspinous fossa of scapula
Insertion Greater tubercle of humerus
Action Lateral rotation of humerus Adduction Holds humeral head in glenoid cavity
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Origin Inferior lateral border of scapula
Insertion Greater tubercle of humerus
Action Lateral rotation of humerus Adduction Holds humerus in glenoid fossa
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OriginSubscapular fossa of scapula
InsertionLesser tubercle of humerus
ActionMedial rotationAdductionHolds humeral head in glenoid cavity
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Origin Supraglenoid tubercle (long head) Coracoid process of scapula (short head)
Insertion Radial tuberosity
Action Flexes arm at shoulder weakly Flexes elbow Supinates forearm
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Origin –Long Head – infraglenoid tubercle of scapulaLateral Head – greater tubercle & posterior &
lateral humerusMedial Head – posterior & medial humerus
Insertion – Olecranon of ulna
Action – Extends forearm and arm
ROM - Extend elbow past 90°, stabilise elbow & contact at wrist bring elbow into flexion
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Origin – acromion, lateral spine of scapula
Insertion – Deltoid tuberosity of humerus
Action – Abducts humerus & slightly extends
ROM - Abduct arm & flex elbow to 90°. Stabilise shoulder & at elbow adduct arm towards torso while pushing slightly into flexion
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Origin – Lateral 1/3 clavicle, acromion and spine of scapula
Insertion – Deltoid tuberosity of lateral humerus
Action – Foward flexes and medially rotates humerus
ROM - Forward flex arm to 30°. Contact anterior wrist and push arm towards table
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Origin – Lateral clavicle, acromion, lateral spine of scapula
Insertion – Deltoid tuberosity of humerus
Action – Abducts humerus
ROM - Abduct arm & flex elbow to 90°. Stabilise shoulder & at elbow adduct arm towards torso
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Origin Anterior distal ½ of humerus
Insertion Coronoid process & tuberosity of ulna
Action Flexes elbow
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Origin – Coracoid process of scapula
Insertion – Middle 1/3 of medial humerus
Action – Flexes & adducts humerus
ROM - Elbow flexed t0 90°.Arm forward flexed to 45°. Stabilise shoulder & at cubital fossa apply pressure into abduction
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Palpation Coracoid process on anterior shoulder near deltopectoral triangle, mobilise
anterior to posterior, if stiff/stuck ask client to use 10% of strength pushing shoulder towards ceiling for 10 seconds then relaxing as you gently push coracoids towards table.
Medial humerus & tendon moving laterally to medially.
Interesting Facts Musculocutaneous nerve pierces this muscle. Helps prevent downward dislocation of humerus. Median nerve and brachial artery lie deep to this muscle & can be
compressed when it is tight causing numbness in medial 3 fingers.
Practical Tendon along with axillary artery, median and musculocutaneous nerve can
be palpated & relocated when biceps & coracobrachialis are weak (elbow flexion) on medial arm by ‘flicking’ medial to lateral while moving from lateral rotation to medial rotation of the bent elbow.
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The ability of contractile structures to maintain joint integrity
1. Proprioception Contains many mechanoreceptors within the anterior &
inferior capsule They activate as the humeral head comes into contact
with the capsule, this sends a signal to muscles to stabilise & contain the humeral head
2. Rotator Cuff Muscles Maintain the centering of the humeral head Teres minor & Infraspinatus reduce strain on antero-
inferior GHL in abduction & external rotation Subscapularis provides anterior stability when arm is in
neutral & abduction
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What could the following symptoms indicate? Do they need referral? And to whom? Pain with overhead activities Pain at rest Loss of ROM?
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Tendonitis
Degenerative Joint Disease (DJD)
Bursitis
Calcific deposits
Rotator Cuff Injuries
Instability Poor inferiorly (common dislocation)
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Biceps Tendinitis & Tear Affects long head of biceps
Synovial sheath surrounding tendon may also be affected
Transverse ligament
Usually accompanied with some crepitus
Treatment Ice, NSAIDS & STT/massage therapy in the
form of transverse frictions to the tendon
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Rupture of the long head of biceps usually common in the older athlete (see pic)
Deformity is obvious becoming detached from proximal attachment & bunching up at distal arm
Often little pain & surprisingly strength is maintained
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Painful joints due to deterioration of cartilage and tissues supporting weight-being joints
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Calcium deposits form on tendons causing inflammation & pain
Quite common Unknown cause, not related to injury, diet or osteoporosis Pressure on surrounding tissues caused by reduction in space
between acromion & rotator cuff leads to impingement Calcific tendonitis affects people over 40
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Not a specific clinical diagnosis There are 4 rotator cuff muscles
Supraspinatus most commonly compressed Has decreased vascularity near insertion (slow to heal ) Progressive degradation of fibres may lead to calcific tendonitis
Many acute injuries involve high force loads to rotator cuff
Posterior rot cuff more commonly injured in throwing type activities (eccentric contraction)
Soft Tissue Treatment Deep friction to insertion of supra tendon will stimulate fibroblast
activity for proper healing Also reduce tension with deep longitudinal stripping
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Also known as ‘Frozen shoulder’
Common condition in which external rotation of humerus is restricted
Capsular fibrosis occurs & anterior capsule adheres to anterior aspect of humeral head
Abduction is restricted by locking & impingement
Therefore this movement should not be forced until external rotation is achieved
No specific cause can be determined for the stiffening Usually secondary to rotator cuff lesions
Affects women > men
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Tension is lost in superior joint capsule
Increased tone in rotator cuff muscles to compensate for loss of capsular stabilization
Increased tone of rotator cuff muscles which blend with capsule result in increased stress to capsule stimulating increase in collagen production
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Congenital elevation of the scapula, due to failure of descent of the scapula to its normal thoracic position during fetal life.
The scapula muscles are poorly defined or may be replaced by a fibrous band
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Look for asymmetry (anterior, posterior, side)
Anterior Position of head Shoulder (step deformity) Flattening of deltoid muscle (paralysis of C4/5) Inferior dislocation Bumps/fracture trauma
Posterior Scapula between T2-T7Winging (serratus anterior injury, long thoracic
nerve)
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Watch the following video on Shoulder ExaminationUW – Department of Family Medicine and Community Health (2008, Feb 21). Shoulder Exam. Retrieved fromhttps://www.youtube.com/watch?v=VSrLbzZzJU8&feature=youtu.be
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Flexion 160 -180deg
Extension 50 -60deg
Lateral Rotation 80 - 90deg
Medial Rotation 60 - 90deg
Abduction 170 - 180deg
Adduction 50 – 75deg
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Instruct to abduct arm to 90° keeping elbows straight, turn palm face up & continue to 180°, until hands touch overhead
Abduction requires glenohumeral movement & scapulothoracic movement
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From a neutral position, move the arm laterally across in front of the body
Limitations can be due to bursitis tears in the rotator cuff (especially Supraspinatus) and irritation of AC joint
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Perform if AROM is limited and assess for end feel
Can be done in seated or side-lying position
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With lateral rotation in a person with recurrent injury it can lead to dislocation
Abduction begins at the GH joint, but after 20 degreeswith the scapula starting to move after 20 the scapulothoracic joint comes into play
If the scapula seems to be fixed throughout the whole movement suspect a capsular problem.
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Place hand over acromion to prevent patient moving the body
Move arm into flexion & extension
Positive If limitations occur
Significance Can be due to bicipital tendonitis or bursitis
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Supine and seated position (as the orientation of the scapular will change in each position)
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Accessory movements should be observed Possible Conditions Sub-acromial bursitis Calcium deposits Tendinitis
During abduction of the arm, we are looking for a painful arc
This may be due to subdeltoid / subacromial muscles or a tear of the rot cuff
This pain is due to inflamed or torn structures under the acromion process and the coraco-acromial ligament.
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Initially the structures are not pinched under the acromion process Therefore the patient is able to abduct the initial 45-60
deg.
Further abduction causes pinching of structures & therefore pain
The patient is to abduct fully, if possible, the pain should decrease after 120
Often the pain is greater going up due to gravity, rather than coming down
The pain is also greater in active than in passive
If there is pain the client often will “hike” the shoulder using upper traps & lev scap
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Backward & forward glide of the humerus
Lateral distraction of the humerus
Backward glide of the humerus in abduction
Lateral distraction of the humerus in abduction
Movements of the sternoclavicular joint
Movements of the acromioclavicular
Scapular movements – to determine general mobility
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Only perform the tests relevant for your case/client
Some tests provoke symptoms, some relieve symptoms so take care
The reliability of the tests depends on the skill and ability of the practitioner so…. Practice makes perfect!
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Apley’s Scratch Test Shoulder Apprehension Test Neer Impingement Test Acromioclavicular Shear Test Speed’s Test Yergason’s Test Drop-Arm Codman’s Test Lift-Off Sign Teres Minor Test Roos TestWright Test Adson Test
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Quickest way to evaluate shoulder ROM
Tests abduction & external rotation Patient reaches behind head to touch the superior
medial angle of the opposite scapula
Tests internal rotation & adduction Patient to reach in front and touch opposite acromion
Tests internal rotation & adduction Patient to reach behind back & touch inferior angle of
the opposite scapula
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Stand behind patient, anchor the scapula, & abduct the arm with your free hand.
The scapula should not move for the first 20 deg., but is very active around 80 deg.
Positive: if the scapula moves before 20 deg.
Significance: adhesive capsulitis
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Indication Suspected cases of shoulder dislocation/subluxation
Method Passively abduct and externally rotate the arm
Positive If patient resists any further movement of joint or has
a look of apprehension
Significance Chronic anterior shoulder dislocation / shoulder
instability
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Method Patient in sitting position Examiner cups hand over the deltoid muscle, with one
hand on the clavicle & the other on the spine of the scapula
Positive Pain or abnormal movement at the AC joint
Significance Indicative of AC joint pathology
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Indication Suspected bicipital tendinopathy
Method Examiner resists shoulder forward flexion by the patient
while the patient’s forearm is first supinated then pronated Alternative is to get the patient to resist eccentric
extension from 90° first with arm supinated then pronated
Positive Increased tenderness in bicipital groove especially with
arm supinated
Significance Bicipital peritonitis or tendonitis
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Resisted shoulder external rotation test Indication Evaluate for bicipital tendonitis in bicipital groove, & for
stability of biceps tendon within the groove Method Patient is standing or seated, elbow flexed to 90° Grasp patient’s wrist & support under elbow Hold the elbow against the trunk Ask patient to externally rotate against resistance
Positive Pain felt over bicipital groove or an audible click is produced
from that area (movement of longhead of biceps)
Significance Stability of biceps tendon Rupture of transverse ligament of bicipital groove
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Indication Helps asses rotator cuff tears, specifically
Supraspinatus contractile unit
Method Passively abduct the arm on the affected side Above horizontal, e.g. 110deg remove support and
ask patient to slowly lower their arm
Positive Unable to hold arm at 90deg abduction Hunching of the shoulder Unable to smoothly lower the arm Significance - tear
in rotator cuff muscle
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Indication Suspected dysfunction of subscapularis muscle
(tendinopathy or myofascial TrPs)
Method Patient places hand behind them with knuckles resting on
lumbar spine Therapist places their hand against the patient’s hand and
asks them to push against resistance
Positive – pain or weakness
Significance - tear or tendinopathy; MF/ TrPs
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Method Arm abducted at 90deg with elbow bent at 90deg client
tries to externally rotate against resistance
Significance Pain &/ or weakness indicates a positive test for teres
minor strain
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Indication Instability of biceps tendon in the groove
Method Place patients affected arm into full abduction;
externally rotate with the elbow extended
Positive Pain elicited from bicipital groove or a click is heard
or palpated
Significance Possible tear of transverse ligament
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Indication Suspected shoulder dislocation/ subluxation
Method Observe axillary folds with patient seated; compare
each side; heights, or distance between tip of acromion & axillary fold
Positive Axillary fold is lower on the suspected side
Significance Possible dislocation
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Indication Helps asses rotator cuff tears, specifically
Supraspinatus contractile unit
Method Patient’s arm is passively & forcibly flexed forward by
examiner while holding the other hand on the top of the shoulder
Positive Pain present with accompanying facial expression Pain in shoulder flexion
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MethodPatient’s arm is abducted to 90deg with resistance to
abduction provided by practitioner The shoulder is then medially rotated & angled
forward to 30deg (emptying can)
Positive Weakness or pain
Significance Supraspinatus abnormality; tear in Supraspinatus
tendon
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Characteristic symptoms Painful to lie with one shoulder forward Painful during pulling activities (opening doors) Painful to open jar lids, reaching or throwing Pain during last 30deg abduction (muscle is on stretch)
Method The patient resists external rotation with the arm bent
at 90deg and at the side of the body
Positive If pain is elicited
Significance Possible infraspinatus tendonitis