Kin 191 B – Shoulder Anatomy And Evaluation
Upcoming SlideShare
Loading in...5
×
 

Kin 191 B – Shoulder Anatomy And Evaluation

on

  • 5,941 views

 

Statistics

Views

Total Views
5,941
Views on SlideShare
5,200
Embed Views
741

Actions

Likes
3
Downloads
213
Comments
0

2 Embeds 741

http://www.orthopaedicprotocols.com 738
http://www.slideshare.net 3

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

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

    • KIN 191B – Advanced Assessment of Upper Extremity Injuries Shoulder Anatomy and Evaluation
    • Sternum
      • Manubrium – attachment site for clavicle
        • Jugular notch
      • Body
      • Xiphoid process
    • Sternum
    • Clavicle
    • 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)
    • Humerus
    • Scapula
      • Vertebral (medial), axillary (lateral) and superior border
      • Inferior and superior angles
      • Glenoid, subscapular, supraspinous and infraspinous fossas
      • Scapular spine
      • Acromion process
      • Coracoid process
    • Scapula
    • 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
    • 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
    • Sternoclavicular Joint
    • 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
    • Acromioclavicular Joint
    • 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”
    • Glenohumeral Joint
    • Glenoid Labrum
    • Scapulothoracic Articulation
      • Not a synovial joint – no bony articulation
      • Articulation via muscular attachments
    • 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
    • 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
    • Levator Scapulae
      • O: C1-4 transverse processes
      • I: superior angle of scapula
      • N: dorsal scapular
      • A: scapular elevation, downward rotation
    • 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
    • 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
    • Pectoralis Minor
      • O: anterior portion of ribs 3-5
      • I: coracoid process
      • N: lateral pectoral
      • A: anterior tilt of scapula
    • 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)
    • Latissimus Dorsi
      • O: T6-12 spinous processes, thoracolumbar fascia, iliac crest
      • I: intertubercular (bicipital) groove
      • N: thoracodorsal (middle subscapular)
      • A: adduction, internal rotation, extension
    • 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
    • Supraspinatus
      • O: supraspinous fossa
      • I: greater tuberosity
      • N: suprascapular
      • A: abducts and externally rotates humerus
    • Infraspinatus
      • O: infraspinous fossa
      • I: greater tuberosity
      • N: suprascapular
      • A: externally rotates humerus
    • Teres Minor
      • O: axillary (lateral) border of scapula
      • I: greater tuberosity
      • N: axillary
      • A: externally rotates humerus
    • Subscapularis
      • O: subscapular fossa
      • I: lesser tuberosity
      • N: upper and lower subscapular
      • A: internally rotates humerus
    • 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
    • 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
    • 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
    • Biceps Brachii
      • Long head – superior glenoid rim/tuberosity
      • Short head – coracoid process
      • I: radial tuberosity
      • N: musculocutaneous
      • A: elbow and shoulder flexion
    • Transverse Humeral Ligament
      • Bridges bicipital groove from greater to lesser tuberosity
      • Stabilizes long head of biceps tendon in groove
    • Coracobrachialis
      • O: coracoid proces
      • I: medial humeral shaft
      • N: musculocutaneous
      • A: flexion and adduction
    • 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
    • Brachial Plexus
    • Vascular Supply
    • 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
    • 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
    • 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
    • Location of Pain
      • Localized pain in shoulder typically associated with localized injury
      • Pain radiating proximally and/or distally increases likelihood of neurological involvement
    • 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
    • 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
    • Current Symptoms
      • Unusual sounds or sensations
      • Quantity and quality of pain, aggravating and alleviating factors
      • Radiating pain – neurological involvement
      • Dysfunction and/or decreased performance
    • 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
    • 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
    • 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
    • Lateral Structures
      • Deltoid contour (as before)
      • Acromion process
        • “ step off” deformity at AC joint (“piano key”)
      • Humeral position
        • Anterior or posterior displacement with dislocation
    • 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)
    • 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
    • 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
    • Special Tests
      • Range of motion testing
        • Active, passive and resistive ROM
        • Combination movements
      • Neurological evaluation
      • Vascular evaluation
      • Ligamentous/capsular testing
    • 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)
    • 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
    • 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
    • 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
    • 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
    • Scapular Ranges of Motion
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Ligamentous/Capsular Testing
      • To be discussed in detail with specific shoulder pathologies