Supraspinatus (RC) Insertion (I) Lateral/anterolat humeral head (greater tuberosity)

Subscapularis (RC-a rotator cuff muscle) Insertion and origin (I&O)

I- Anteromedial humeral head (lesser tuberosity)& O- Anterior scapula

Levator scapulae I superoposteromedial (superior angle of) scapula

Bicep brachialis (LH), groove ligament Anterior humeral head(in bicipital groove)

Infraspinatus/teres minor tendons (RC) I Posterolateral humeral head(inferoposterior greater tuberosity)

Subacromial (aka subdeltoid) bursa& attachments (ligamentous & tendinous) to the coracoid

Anterior, anteromedial, & anterolateral shoulder

ACJ Anterior and superior

GHJ, GH ligaments, and labrum Anterior & posterior approaches

Lift-off Subscapularis Sensitivity 8/9

Belly Press Subscapularis Can also be + with...SLAP (superior labral anterior posterior) injury, “lesion”, or tear. Sensitivity 0.2-.0.32

Anterior-anterior to the glenoid tubercle (O of LH bicep tendon). Posterior- posterior to the glenoid tubercle

Speed’s Bicipital Tendinopathy and SLAP Tears

Specificity 0.75

Jobe’s (full and empty Can) Supra (and infra) spinatus The full IR (empty can) of outstretched arm isolates the supraspinatus from the deltoid [about 90 degrees F, add 30 degrees abduction, full IR of arm (thumb down)]

Yocum’s Place affected arm on contralateral shoulder with elbow F; + if pain when patient tries to raise elbow

Supraspinatus tendinopathy Sensitivity 79-80%

Sub-acromial/deltoid Bursitis Sensivity 36-40%

Lift-off lag sign subscapularis 13/16 full thickness tears

IR lag sign subscapularis More sensitive than active Lift-off

ER lag sign supra/infraspinatus/teres minor Sensitivity 8%, specificity 97% for rotator cuff tear

Drop Arm Test supraspinatus Especially of the supraspinatus. Stand behind and/or on the involved side. Passively abduct the patient’s shoulder to 90 degrees and have patient try to slowly lower the arm. If pain, weakness or sudden drop is present then the test is positive.

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Prolo BD 10cc/11.4cc 10cc/12.5cc

15-18% D 3.44cc 3.5cc Of D50

0.25% Lido 3cc 3cc Of 1%

0.0625% Bupivicaine

3cc 3cc Of 0.25%

Sterile water or NS 2cc 3cc

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Trigger/ neural 24- 72 hours, if greater than 18h post 1st neral repeat weekly

Neural Prolo 24-72h, then weekly

Prolo 1-4 (6x) 1-4 weeks- After 1 treatment 2 weeks 25% increase in

strength, 6 weeks, 85% increase then 2 years will see max benefit

PRP +adipose or PRP+BMA +/- Adipose Adipose and or BMA tissue transplant + PRP 1st, then PRP alone (“booster) in 4 weeks. Repeat in 2-3 months as needed

Muscle Origin Insertion

Pectoralis Major Medial clavicle, CCJs2-7, aponeurosis of abdominal oblique

Crest of greater tubercle of humerus (several cm distal and medial to supraspinatus I)

Pectoralis Minor Superolateral surface ribs 3-5 Medial coracoid process

Serratus anterior Superior Anterolateral surface ribs 1-8 Medial border of the anterior scapula including superior, medial and inferior angles

Teres Major Dorsal surface of the inferior angle of the scapula, excluding the very inferior tip occupied by the latissimus dorsi

Crest of lesser tubercle of humerus, inferior to the subscapular and medial to the latissimus dorsi

Latissimus Dorsi Spinous process T6-S5 blending with the supraspinatous ligament, lumbar aponeurosis, post iliac crest ligament complex

Inferior intertubercular groove of the proximal anterior

Trapezius Occipital protuberance, medial superior nuchal line of occipital, ligament nuchae, Sps and supraspinatous ligament C7-T12

Superior, anterior and post border of lateral clavicle, superomedial and acromion border, superolateral border spin of scapula

Muscle Origin Insertion

Deltoid Anterolateral clavicle wrapping around the outside rim of the ACR, along the post rim of the lateral 4/5s spine of scapula

Deltoid tubercle on lateral humerus, just proximal to midshaft

Rhomboids minor Ligamentum nuchae, SPs C7 and T1

medial/ posteromedial rim of the scapula at its spine (just caudal to the I of leviator scapula and cephalad to R. maj I). Level t4

Rhomboids Major SPs and supra-spinatous ligament T2-5

Inferior to medial scapula border, inferior to the spine

Serratus post sup (intermediate depth)

SPs and lamina C7-T4 Angle of ribs 2-5

Coracobrachialis Medial coracoid, p/m to SHB Anteromedial humerus, midshaft

Hackett, George S. Ligament and Tendon Relaxation. Charles C Thomas, 1958.

Netter, Frank H., and Sharon Colacino. Atlas of Human Anatomy. Navartis, 1997.

Gulihar, Abhinav, et al. “Articular Cartilage and Local Anaesthetic: A Systematic Review of the Current Literature.” Journal of Orthopaedics, vol. 12, 2015, doi:10.1016/j.jor.2015.10.005.

AOAPRM Lectures/ Conferences