Shoulder anatomy
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This presentation shows joints, bones ligaments, bursa tissues and muscles of human shoulder with some examples of shoulder pain and injuries
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Shoulder anatomy
- 1. B Y H O S S E I N K H O R R A M I P h D . D O M P, SHOULDER khorrami4@yahoo.com http://www.scribd.com/khorrami4
- 2. Shoulder bones • Humerus • Scapula • Clavicle • Ribs • Vertebrae
- 3. Dorsal View
- 4. Shoulder • Joints • Acromioclavicular(AC) joint • Glenohumeral (GH) joint, ball & socket joint • Sternoclavicular(SC) joint • Scapulothoracic joints • Ligaments • Tendons • Capsules • Bursa • Vessels • Brachial plexus • muscles • https://www.youtube.com/watch?v=D3GVKjeY1FM
- 5. Lateral View
- 7. STERNOCLAVICULAR JOINT • Saddle joint permitting the clavicle to move in all 3 planes • A fused SC would limit all shoulder motion! • SCJ disc • Separates the joint into two cavities • Clavicle-disc Disc-manubrium
- 9. SCJ, MOVEMENTS • Functions of the SCJ • Provide movement of the scapula (along with the • ACJ) • Absorb forces from the upper extremity • Elevatoin • Depression • Protraction • Retraction • Rotation
- 10. SCJ MVMT • Motions allowed at the SCJ • • Elevation-Depression of the clavicle • Elevation occurs with shoulder flexion and abduction • Depression with shoulder extension and adduction
- 11. SCAPULOTHORACIC JOINT • Elevation • Depression • Protraction • Retraction • Upward • Downward • Internal rotation( Tipping) • External rotation • Winging
- 12. • Protraction-Retraction of the clavicle • Occurs mostly between the disc and the manubrium • Protraction occurs with shoulder horiz adduction • Retraction with horiz abduction, shoulder extension
- 13. • Rotation • Occurs due to tightening of the coraco- clavicular ligament during humeral elevation (after 90) • If no posterior rotation available, can only get 120 of humeral elevation
- 14. AC & GH Joints
- 15. ACROMIOCLAVICULAR JOINT • Very difficult joint to characterize; wide variability in the size and shape of the lateral clavicle The ACJ is characterized as a plane synovial joint • ACJ disc Helps with mobility; Exists early in life but thins by age 20-30
- 16. ACROMIOCLAVICULAR JOINT • Function of ACJ • AC joint facilitates raising the arm up over the head • Acts like a strut to help with movement of the scapula resulting in a greater degree of arm rotation
- 17. ACJ • Supporting structures of ACJ • • ACJ capsule • Very weak, relies on ligaments for reinforcement • • Acromioclavicular ligaments • • Coracoacromial ligament • Coraco-clavicular ligament • Two sections • Conoid (medial) • Trapezoid (lateral) • Most important stabilizing structure at the ACJ Prevents clavicle from over-riding the acromion Transmits forces from the scapula to the clavicle
- 21. GLENOHUMERAL JOINT • Classic ball and socket • joint • • Composed of glenoid • fossa and humeral head • Fossa only articulates with 25% of the humeral head • • Sacrifices stability for mobility
- 23. GH JOINT • Coraco-acromial Arch • Prevents upward dislocation of the humeral head • Protects rotator cuff and humeral head from direct trauma
- 24. Shoulder Muscles • Deltoid • Subscapularis • Teres major & minor • Supraspinatus • Infraspinatus • Levator scapula • Biceps brachii • Latissimus dorsi • Trapezius • Rhomboid muscle • Pectoralis major & minor • Coracobrachialis • Serratus anterior • https://www.youtube.com/watch?v=t1zJwD0tWck
- 25. TRAPEZIUS MUSCLE • Origin • Occipital bone • Spinous process of C7- T12 • Insertion • Lateral clavicle • Acromion • Spine of scapula • Innervation C3-C4 & XI( accessory nerve)
- 26. Trapezius, functions • Elevation of scapula • Retraction(adduct) scapula • Upwardly rotate scapula • Depress scapula • Neck extension
- 27. Latissimus Dorsi
- 28. LATISSIMUS DORSI • Origin • T7-T12(T6-T12) • 9th -12th ribs • Thoracolumbar fascia • Iliac crest • Crest of sacrum • Insertion • Intertubecular sulcus of humerus • Function • Adduct • Arm extension • Internal rotation of arm at the shoulder
- 29. BICIPITAL GROOVE • Biceps brachii • Latissimus dorsi • Pectoralis major • Teres major
- 30. LATISSIMUS DORSI
- 31. • Origin • Transverse process of C1-C4 • Insertion • Medial border of scapula • Innervation • C3-C4 • Function • Cervical Spine: Extension, lateral flexion and ipsilateral rotation • Scapula: Elevation and downward rotation Levator Scapulae
- 34. Rhomboid Muscle • Origin • Spinous process C7-T1(minor)& T2-T5(major) • Insertion • Medial border of scapula • Scapular retraction • Elevation
- 35. Subscapularis • Origin • Subscapularis fossa • Insertion • Lesser tubercle of humerus • Function • Medially rotation of arm • Adduction
- 37. Posterior View
- 38. Rotator Cuff Muscles • Teres minor • Supraspinatus • Infraspinatus • Subscapularis
- 39. Rotator Cuff, Lateral View
- 40. Teres Major & Minor
- 42. Teres Major • Origin • Inferior border of scapula • Insertion • Intertubercular groove of Anterior humerus • Function • Adduct arm • Internal rotation of arm • Arm extension(not hyperextension)
- 43. Teres Major Crest of lesser tuberosity Inferior angle of scapula
- 44. Teres Minor • Is a rotator cuff muscle • Origin • Lateral border of scapula • Insertion • Greater tubercle of humerus • Function • Adduct arm • External rotation of arm
- 45. Teres Minor G.Tuberosity of humerus
- 46. Supraspinatus Supraspinus fossa G.Tuberosity of humerus
- 47. Supraspinatus • Origin • G.tubercle of humerus • Insertion • Supraspinous fossa • function • Abduction • First 30o
- 48. Infraspinatus Infraspinous fossa G.Tuberosity of humerus
- 50. Infraspinatus Muscle • External rotation • Adduction • Arm extension
- 53. Subscapularis Muscle • Internal rotation • Adduction
- 57. Pectoralis muscles • P.Major • Clavicle • Sternum • Upper costal cartilage • Bicipital groove • P.Minor • 3rd-5th ribs • Coracoid process • Flexion • Adduction
- 58. Pectoralis Major
- 60. Biceps Brachii, Action • 2 joint muscle • Shoulder flexion • Elbow flexion • Flexion
- 61. Biceps Brachii Short head Long head Radial tuberosity Coracoid process
- 64. Pectoralis Minor & Coracobrachialis • Adduction
- 65. & tuberosity of Ulna
- 67. Triceps Brachii
- 68. Triceps Brachii Infraglenoid of Scapula Olecranon of ulna
- 69. Coracobrachialis Line of lesser tuberosity
- 70. Deltoid Muscle Acromion Spinous Clavicle Deltoid tuberosity of humerus
- 71. Serratus Anterior • 1st to 8th, or 9th ribs • Antagonist of rhomboid • Protract & stabilize scapula • Pull forward scapula • Depress scapula
- 73. Serratus Anterior • Protraction of scapula
- 75. Brachial plexus • Musculocutaneous N. • Axillary N. • Radial N. • Median N. • Ulnar N.
- 76. BRACHIAL PLEXUS
- 79. TOS
- 80. ROM SHOULDER
- 82. Shoulder Movement(10) Movement Prime mover, other muscles Flexion Pectoralis major, coracobrachialis Extension Latissimus dorsi Abduction Supraspinatus( first30o)+ Deltoid Adduction Infraspinatus, pectoralis major, latissimus dorsi Internal rotation Subscapularis External rotation Infraspinatous , teres minor
- 83. Shoulder Movement Movement Prime mover, other muscles Elevation Trapezius Depression Latissimus dorsi, subclavious Protraction Serratus anterior, Retraction Rhomboid
- 85. Rotator Cuff Injuries • Tendonitis • OA • Bursitis • Impingement syndrome • 1/3 cases of shoulder pain • Narrowing space of humerus & Acromion • Pain on abduction 60-120o • Anatomical enlargement of joint(AC)& Swelling of tendon and/or bursae, or weakness of scapulothoracic M. (e.g. Serratus anterior)
- 86. Rotator Cuff Injuries • Rotator cuff tear( tennis shoulder) • Most common cause of shoulder pain • Pain during motion & night • Muscular atrophy & weakness • Labral tears • Rim of soft tissue in glenoid • Connect with biceps tendon • Injury, age
- 87. SPEED TEST • The test is best performed with the patient in a relaxed sitting position • The arm to be tested should be in about 60 degrees of front flexion with the forearm supinated and the elbow fully extended • In the starting position the examiner forcefully presses down on the patient’s arm at the forearm • The patient attempts to resist the pressure of the examiner • Alternatively the patient attempts to forward flex the shoulder while the examiner resists
- 88. Positive Speed Test • If pain is reported in the bicipital groove • Weakness in maintaining the forward flexion position will also likely be noted • A positive test is indicative of long head of biceps tendon instability or tendonitis • Tenderness on palpation of the bicipital groove also indicates bicipital tendinitis • When the therapist stops pushing down on the arm a sudden jerking motion may result • Pain at this point may indicate a positive test for sub-acromial bursitis
- 89. Cross Arm Adduction (Scarf Test) • Tests AC joint • A positive test commonly indicates AC joint osteoarthritis or A-C joint ligament injury such as a ligament sprain or joint separation • The A-C joint is very prone to injury due to the small articulation surfaces that are quite incongruent • The two surfaces are the distal end of the clavicle and the acromion process of the Scapula • Injuries usually occur due to Falls and in contact sports
- 90. Cross Arm Adduction (Scarf Test) • The examiner should stand behind the patient on the side being tested • Grasp the patient’s arm just distal to the elbow and passively flex the patient’s shoulder to 90o • Then maximally adduct the patient’s shoulder (bring it across their body towards the other shoulder) • A positive test is considered if the patient reports pain during the adduction motion or localized pain in the AC joint
- 91. Kim Test • Purpose • Detection of a posteroinferior labral lesion • A - With the patient in a sitting position with the arm 90 degrees of abduction, the examiner holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force is applied • B - while the arm is elevated 45 degrees diagonally upward, downward and Backward force is applied to the proximal arm • A sudden onset of posterior shoulder pain indicates a positive test result, regardless of accompanying posterior clunk of the humeral head .
- 92. LAG Test • Purpose • To test for rotator cuff tears of the Subscapularis tendon • Technique • Patient is seated with examiner behind patient • The affected arm is brought into maximal internal rotation behind the back • Examiner controls patient's arm at the elbow and wrist/hand which is passively brought into 20 degrees of extension taking the forearm and hand away from the back • Instruct patient to actively maintain this position as examiner releases the wrist but maintains support at the elbow • A LAG is indicative of a subscapularis tendon tear describe the magnitude of the LAG in 5 degree intervals with an obvious drop indicating large or massive tear and a smaller lag revealing a partial tear • https://www.youtube.com/watch?v=qi3KK_-R7ZY
- 93. Tendonitis • Develop with repetitive overhead activities • Playing tennis • Pitching (baseball and golf) • Painting • Shoveling
- 94. Adhesive Capsulitis(frozen shoulder) • Inflammation and stiffness of GH joint capsule • Loss of both AROM & PROM • Constant pain • Worsen pain at night & cold weather • Mostly women 40-60 YO
- 95. Risk Factors Of Frozen Shoulder • DM • Stroke • Lung disease • RA • Heart disease • Immobilization
- 96. Treatment • Ice pack • Ultrasound • LASER • Pain free active assistive ROM • Isometric exercises • Isotonic exercises • Stretching exercises • Strengthening exercises
- 97. Strengthening Exercises • Theraband • Flexbar • Weight • Wand • Pulley
- 98. Exercise Protocol • At least 4 weeks and more for maintenance • Warm up with walking, stationary bike • After Codman’s ex., Start with stretching • Finish with stretching • Pain free
- 99. Codman’s Exercise • R-L 30 sec • Back & forth 30 sec • Circular motion, 30sec each • 2 sets/day • 5-6 days/week
- 100. Stretching Exercises, goals • Make more flexibility • Prevents contracture • Restoring range of motion and preventing injury • Gently stretching after strengthening exercises can help reduce muscle soreness and keep muscles long and flexible
- 101. Strengthening Ex. • Help to keep shoulder joint stable • Can relieve shoulder pain and prevent further injury
- 102. Walking Wall Stretch • Using fingers on a wall • Hold 10-15 sec • Reps 10-15 • 3 sets/day
- 103. Walking Table Stretch • In sitting position • Using fingers on a table • Hold 10-15 sec • Reps 10-15 • 3 sets/day
- 104. Cane Stretch Exercise • Lie down, face up • Use a cane to push affected arm
- 105. Towel Stretch Exercise • Stretch external rotators • Stretch flexors
- 106. Corner Stretching Exercise • Stretching PM • Hold 20-30 sec • Reps several times
- 107. Crossover Arm Stretch • Posterior deltoid • Hold 30sec • Relax 30sec • Repeat 4 times • 5-6/week
- 108. Passive Internal Rotation • Subscapularis • Hold 30sec • Reps 4 each side/day • 5-6/week
- 109. Passive External Rotation • Stretch in Infraspinatus, teres minor • Hold 30sec • 4 each side/day, slowly • 5-6/wk
- 110. Sleeper Stretch • Infraspinatus, teres minor • Hold 30sec • 4 reps/day, slowly • 5-6/wk
- 111. Standing Row • Strengthening extensors • Middle & lower trap • 8-12 reps, slowly • 3 sets/day • 3/wk
- 112. External Rotation+ abduction • Infraspinatus, teres minor stregthening • 8-12 reps, slowly • 3 sets/day • 3/wk
- 113. Internal Rotation • Subscapularis & teres major strengthening • 8-10 reps • 3 sets/day • 3/wk
- 114. External Rotation • Infraspinatus, teres minor, posterior deltoid • 8-10 reps, slowly • 3 sets/day • 3/wk
- 115. Elbow Flexion • Biceps, • 8-12 reps, slowly • 3 sets/day • 3 days/wk
- 116. Elbow Extension • Triceps • 8-12 reps, slowly • hold 2 sec • 3 sets/day • 3 days/wk
- 117. Trapezius strengthening • Middle & posterior deltoid, middle trap, supraspinatus, • 20 reps, slowly • 3-4 sets/day • 3-5 days/wk
- 118. Scapula Setting • Middle trap, serratus anterior • Hold 10 sec • 10 reps • 3 days/wk
- 119. Scapular Retraction/Protraction • Middle trap, serratus anterior, latissimus dorsi • 8-15 reps, slowly • 2 sets/day • 3 days/wk
- 120. Bent Over Horizontal Abduction • Middle & lower trap, infraspinatus, teres minor, post deltoid • 8-12 reps • 3 sets/day • 3 days/wk
- 121. Internal & External Rotation • Ant deltoid, pectoralis, subscapularis, latissimus • Post deltoid, infraspinatus, teres minor • 20 reps • 3-4 sets/day • 3-5 days/wk
- 122. External Rotation • Stretch infraspinatus, teres minor, posterior deltoid • 8-10 reps, slowly • 2 sets/day • 3/wk
- 123. Internal Rotation • Stretch subscapularis & teres major • 8-10 reps • 2 sets/day • 3/wk