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Kin 191 B – Shoulder Anatomy And Evaluation
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Kin 191 B – Shoulder Anatomy And Evaluation

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  • 1. KIN 191B – Advanced Assessment of Upper Extremity Injuries Shoulder Anatomy and Evaluation
  • 2. Sternum
    • Manubrium – attachment site for clavicle
      • Jugular notch
    • Body
    • Xiphoid process
  • 3. Sternum
  • 4. Clavicle
  • 5. Humerus
    • Head and neck
    • Greater tuberosity
    • Lesser tuberosity
    • Bicipital (intertubercular) groove
      • Long head of biceps tendon
    • Deltoid tuberosity
    • Angle of inclination
      • Shaft of humerus and head of humerus in frontal plane (normally 130-150 degrees)
    • Angle of torsion
      • Shaft of humerus and head of humerus in transverse plane (significant variance amongst individuals)
  • 6. Humerus
  • 7. Scapula
    • Vertebral (medial), axillary (lateral) and superior border
    • Inferior and superior angles
    • Glenoid, subscapular, supraspinous and infraspinous fossas
    • Scapular spine
    • Acromion process
    • Coracoid process
  • 8. Scapula
  • 9. Plane of the Scapula
    • In anatomic position, glenoid angles 30 degrees from frontal plane – this is the plane of the scapula
    • More functional arc of motion than cardinal planes and places rotator cuff muscles in optimal length-tension relationship
  • 10. Sternoclavicular Joint
    • Proximal clavicle and manubrium
    • Anterior and posterior SC ligaments
      • Resist anterior and posterior displacement of proximal clavicle
    • Costoclavicular ligament
      • Inferior proximal clavicle and rib 1 – axis of movement for clavicle (elevation, depression, medial, lateral)
    • Interclavicular ligament
      • Connects both SC joints
    • Fibrocartilaginous SC disc
      • Functions similar to meniscus of knee, axis of rotation for clavicle
  • 11. Sternoclavicular Joint
  • 12. Acromioclavicular Joint
    • Distal clavicle and acromion process
    • Superior and inferior AC ligaments
    • Coracoclavicular ligament – provides most intrinsic stability to AC joint
      • Conoid portion – medial, triangular
        • Restricts superior clavicular motion
      • Trapezoid portion – lateral, quadrilateral
        • Restricts lateral movement of distal clavicle over acromion process
  • 13. Acromioclavicular Joint
  • 14. Glenohumeral Joint
    • Glenohumeral ligaments (joint capsule)
      • Superior, middle and inferior GH ligaments are thickenings of joint capsule
    • Coracohumeral ligament
      • Blends with superior joint capsule from coracoid process
    • Coracoacromial arch/ligament
      • Connects 2 prominences of the same bone, often involved in impingement syndromes/conditions
    • Glenoid labrum – deepens “ball and socket”
  • 15. Glenohumeral Joint
  • 16. Glenoid Labrum
  • 17. Scapulothoracic Articulation
    • Not a synovial joint – no bony articulation
    • Articulation via muscular attachments
  • 18. Muscular Anatomy
    • Muscles acting on the scapula
      • Rhomboid major/minor
      • Levator scapulae
      • Serratus anterior
      • Pectoralis minor/major
      • Trapezius
      • Latissimus dorsi
    • Responsible for
      • Moving glenoid to allow for increased shoulder ROM
      • Fixation of scapula on thorax to provide rotator cuff muscles base of support during contractions
  • 19. Rhomboids
    • O: major – T2-5 spinous processes, minor – C7, T1 spinous processes
    • I: vertebral (medial) border of scapula
    • N: dorsal scapular
    • A: scapular retraction, elevation, downward rotation
  • 20. Levator Scapulae
    • O: C1-4 transverse processes
    • I: superior angle of scapula
    • N: dorsal scapular
    • A: scapular elevation, downward rotation
  • 21. Serratus Anterior
    • O: anterior portion of ribs 1-8
    • I: vertebral (medial) border of scapula from superior angle to inferior angle
    • N: long thoracic
    • A: scapular protraction and upward rotation, fixates vertebral border of scapula to thorax
  • 22. Pectoralis Major
    • O: clavicular head – medial half of clavicle, sternal head – lateral portion of sternum
    • I: greater tuberosity of humerus (lateral lip of bicipital groove)
    • N: medial and lateral pectoral
    • A: sternal head – shoulder depression and horizontal adduction, clavicular head – flexion, internal rotation and horizontal adduction
  • 23. Pectoralis Minor
    • O: anterior portion of ribs 3-5
    • I: coracoid process
    • N: lateral pectoral
    • A: anterior tilt of scapula
  • 24. Trapezius
    • Upper fibers
      • Base of occiput/upper cervical spinous processes to distal clavicle, elevate and upwardly rotate scapula
    • Middle fibers
      • Lower cervical/upper thoracic spinous processes to acromion process, retract scapula
    • Lower fibers
      • Lower thoracic spinous processes to spine of scapula, depress and upwardly rotate scapula
    • N: accessory nerve (CN XI)
  • 25. Latissimus Dorsi
    • O: T6-12 spinous processes, thoracolumbar fascia, iliac crest
    • I: intertubercular (bicipital) groove
    • N: thoracodorsal (middle subscapular)
    • A: adduction, internal rotation, extension
  • 26. Muscular Anatomy
    • Muscles acting on the humerus
      • Rotator cuff (SITS)
        • Supraspinatus, infraspinatus, teres minor, subscapularis
      • Deltoid
      • Pectoralis major
      • Latissimus dorsi
      • Teres major
      • Long head of triceps
      • Biceps, short/long head
      • Coracobrachialis
  • 27. Supraspinatus
    • O: supraspinous fossa
    • I: greater tuberosity
    • N: suprascapular
    • A: abducts and externally rotates humerus
  • 28. Infraspinatus
    • O: infraspinous fossa
    • I: greater tuberosity
    • N: suprascapular
    • A: externally rotates humerus
  • 29. Teres Minor
    • O: axillary (lateral) border of scapula
    • I: greater tuberosity
    • N: axillary
    • A: externally rotates humerus
  • 30. Subscapularis
    • O: subscapular fossa
    • I: lesser tuberosity
    • N: upper and lower subscapular
    • A: internally rotates humerus
  • 31. Deltoid
    • Anterior fibers – distal clavicle, shoulder flexion, horizontal adduction and internal rotation
    • Middle fibers – acromion process
    • Posterior fibers – spine of scapula, shoulder extension, horizontal abduction and external rotation
    • I: deltoid tuberosity
    • N: axillary
    • A: shoulder abduction
  • 32. Teres Major
    • O: inferior angle of scapula, axillary (lateral) border of scapula
    • I: medial lip of bicipital groove
    • N: lower subscapular
    • A: internal rotation, adduction, extension
  • 33. Triceps Brachii
    • Long head – inferior glenoid rim/tuberosity
    • Lateral head – lateral and posterior proximal humerus
    • Medial head – medial distal humerus
    • I: olecranon process
    • N: radial
    • A: extends elbow, long head adducts and extends humerus
  • 34. Biceps Brachii
    • Long head – superior glenoid rim/tuberosity
    • Short head – coracoid process
    • I: radial tuberosity
    • N: musculocutaneous
    • A: elbow and shoulder flexion
  • 35. Transverse Humeral Ligament
    • Bridges bicipital groove from greater to lesser tuberosity
    • Stabilizes long head of biceps tendon in groove
  • 36. Coracobrachialis
    • O: coracoid proces
    • I: medial humeral shaft
    • N: musculocutaneous
    • A: flexion and adduction
  • 37. Neurovascular Anatomy
    • Neurological anatomy
      • Brachial plexus review
    • Vascular anatomy
      • Subclavian artery becomes axillary artery as it passes first rib, which becomes brachial artery as it passes distal to teres major
  • 38. Brachial Plexus
  • 39. Vascular Supply
  • 40. Bursae
    • Subacromial bursa
    • Sits superior to rotator cuff tendons in subacromial space
    • Reduces friction from movement of overlying deltoid
    • Provides protection against inferior surface of acromion process
  • 41. Rotator Cuff Muscle Activity
    • During shoulder (GH) abduction:
      • At ~70 degrees, humeral head depressed by infraspinatus, teres minor and subscapularis to allow humeral head to clear acromion process
      • At ~115 degrees, humeral head externally rotated by infraspinatus and teres minor to clear greater tuberosity of humerus under acromial arch
  • 42. Scapulothoracic Rhythym
    • During first 30 degrees of GH abduction, scapular is “setting” – may have slight upward rotation
    • From 30-180 degrees, for every 2 degrees of GH motion is 1 degree of scapular motion (rotation)
    • During first 90 degrees, scapula rotates with SC joint as pivot point
    • During last 90 degrees, scapula rotates with AC joint as pivot point
      • Conoid portion of coracoclavicular ligament becomes taut and produces posterior rotation of clavicle allowing for more AC and scapular motion
  • 43. Location of Pain
    • Localized pain in shoulder typically associated with localized injury
    • Pain radiating proximally and/or distally increases likelihood of neurological involvement
  • 44. Onset of Symptoms
    • Acute onset
      • Fracture, GH subluxation or dislocation, AC sprain
    • Chronic/insidious onset
      • Inflammatory conditions (tendonitis, bursitis)
      • Pain after activity first, then during, and finally at all times
  • 45. Mechanism of Injury
    • Direct trauma or forces
      • Acute soft tissue and/or bony injury
    • Repetitive overhead movements (throwing, swimming, tennis)
      • Overuse syndromes, inflammatory conditions, impingement syndromes
  • 46. Current Symptoms
    • Unusual sounds or sensations
    • Quantity and quality of pain, aggravating and alleviating factors
    • Radiating pain – neurological involvement
    • Dysfunction and/or decreased performance
  • 47. History of Previous Injury
    • Previous cervical spine injury can predispose individual to shoulder injury from neurological compromise (weakness)
    • Prior AC or GH injury can affect shoulder biomechanics and thereby increase the risk of overuse conditions/muscle imbalances
  • 48. General Postural Assessment
    • Head
      • Lateral flexion or rotation may indicate muscle spasm and/or cervical nerve root injury
    • Upper extremity
      • Splinted to side of body/rib cage
      • Forearm supported
      • “ limp arm” from brachial plexus injury
      • Deformity from GH dislocation
  • 49. Anterior Structures
    • Level of shoulders
      • AC joints, SC joints, clavicle
    • Clavicular contour
      • Displacement with joint injury or fracture
    • Deltoid contour symmetry
      • Normally rounded, may be flattened secondary to GH dislocation or axillary nerve injury
    • Biceps brachii symmetry
      • Bulges from biceps tendon rupture
  • 50. Lateral Structures
    • Deltoid contour (as before)
    • Acromion process
      • “ step off” deformity at AC joint (“piano key”)
    • Humeral position
      • Anterior or posterior displacement with dislocation
  • 51. Posterior Structures
    • Vertebral alignment - scoliosis
    • Scapular position symmetry
      • Superior angle at T2 spinous process, inferior angle at T7 spinous process
      • “ winging” scapula
    • Muscle tone
      • Increased tone secondary to spasm/injury
      • Decreased tone (atrophy) secondary to neurological compromise or disuse
    • Humeral position (as before)
  • 52. Palpation – Anterior Structures
    • Jugular notch
    • SC joint
    • Clavicle
    • Acromion process
    • AC joint
    • Coracoid process
    • Humeral head
    • Greater tuberosity
    • Lesser tuberosity
    • Bicipital groove
    • Humeral shaft
    • Pectoralis major
    • Coracobrachialis
    • Deltoid
    • Biceps brachii
  • 53. Palpation – Posterior Structures
    • Spine of scapula
    • Superior angle
    • Inferior angle
    • Rotator cuff
      • Subscapularis
      • Supraspinatus
      • Infraspinatus
      • Teres minor
    • Teres major
    • Rhomboids
    • Levator scapulae
    • Trapezius
    • Latissimus dorsi
    • Posterior deltoid
    • Triceps brachii
  • 54. Special Tests
    • Range of motion testing
      • Active, passive and resistive ROM
      • Combination movements
    • Neurological evaluation
    • Vascular evaluation
    • Ligamentous/capsular testing
  • 55. Active Ranges of Motion
    • Flexion – 180 degrees
      • Biceps brachii, coracobrachialis, anterior and middle deltoid, pectoralis major (clavicular head)
    • Extension – 60 degrees
      • Posterior deltoid, latissimus dorsi, teres major, triceps brachii (long head)
  • 56. Active Ranges of Motion
    • Abduction – 180 degrees
      • Deltoid, supraspinatus, biceps brachii
    • Adduction - ~45 degrees if shoulder flexed slightly to avoid body interference
      • Pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps brachii
  • 57. Active Ranges of Motion
    • Internal rotation – limited by body in neutral position, 70-80 degrees at 90/90
      • Subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid
    • External rotation – 40-50 degrees in neutral position, 80-90 degrees at 90/90
      • Infraspinatus, teres minor, supraspinatus, posterior deltoid
  • 58. Active Ranges of Motion
    • Horizontal abduction – 45 degrees from plane of scapula at 90 degrees abduction
      • Posterior deltoid, infraspinatus, teres minor
    • Horizontal adduction – 120 degrees from plane of scapula at 90 degrees abduction
      • Pectoralis major, anterior deltoid
  • 59. Active Ranges of Motion
    • Scapular protraction
      • Serratus anterior, pectoralis minor
    • Scapular retraction
      • Trapezius, rhomboids, levator scapulae
    • Scapular elevation
      • Upper trapezius, levator scapulae, rhomboids
    • Scapular depression
      • Lower trapezius, pectoralis minor, subclavius
    • Scapular downward rotation
      • Rhomboids, pectoralis minor
    • Scapular upward rotation
      • Trapezius, serratus anterior
  • 60. Scapular Ranges of Motion
  • 61. Apley’s Scratch Tests
    • Touch opposite shoulder in front
      • Adduction, horizontal adduction, internal rotation, scapular protraction
    • Touch opposite shoulder in back
      • Abduction, external rotation, scapular protraction, elevation and upward rotation
    • Touch opposite scapula from behind
      • Adduction, internal rotation, scapular retraction and downward rotation
  • 62. Passive Ranges of Motion
    • Critical to stabilize proximal segment in order to accurately assess end feel – patient positioning
    • Flexion and extension – firm end feel
    • Abduction – firm end feel (GH and total)
    • Adduction – not typically assessed
    • ER/IR – firm end feels
    • Horizontal abduction/adduction – firm end feels unless soft tissue obstructs adduction
  • 63. Resisted Ranges of Motion
    • Must stabilize proximal segment to isolate movement and/or muscle/s
    • Graded on 0-5 scale – keep in mind effects of gravity, especially in presence of significant weakness
  • 64. Gerber Lift-Off Test
    • Humerus internally rotated and dorsal aspect of hand placed against back
    • Positive test for subscapularis weakness if unable to lift hand off spine
  • 65. Scapular Winging
    • Perform “push-up” against wall
    • Positive test for serratus anterior weakness and/or long thoracic nerve injury if vertebral (medial) border of scapula lifts off thorax
  • 66. Neurological Evaluation
    • Brachial plexus dermatomes and myotomes
    • Sensory and motor tests for terminal branches of brachial plexus
      • Axillary, radial, median, ulnar, musculocutaneous
    • Awareness of innervation of muscles acting on scapula and humerus
  • 67. Vascular Evaluation
    • Axillary pulse can sometimes be palpable in axilla
    • Brachial pulse felt along medial shaft of humerus or in cubital fossa near biceps tendon
    • Radial pulse is most common evaluation site
  • 68. Ligamentous/Capsular Testing
    • To be discussed in detail with specific shoulder pathologies