SHOULDER
BY
H O S S E I N K H O R R A M I P h D . D O M P,
khorrami4@yahoo.com
http://www.scribd.com/khorrami4
Shoulder bones
• Humerus
• Scapula
• Clavicle
• Ribs
• Vertebrae
Dorsal View
Shoulder
• Joints
• Acromioclavicular(AC) joint
• Glenohumeral (GH) joint, ball & socket joint
• Sternoclavicular(SC) joint
• Scapulothoracic joints
• Ligaments
• Tendons
• Capsules
• Vessels
• Brachial plexus
• muscles
• https://www.youtube.com/watch?v=D3GVKjeY1FM
Lateral View
ANTERIOR VIEW
Acromioclavicular joint
Glenohumeral joint
AC & GH Joints
Ligaments & Tendons
Shoulder Ligaments
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
TRAPEZIUS MUSCLE
• Origin
• Occipital bone
• Spinous process of C7-
T12
• Insertion
• Lateral clavicle
• Acromion
• Spine of scapula
• Innervation
C3-C4 & XI( accessory
nerve)
Trapezius, functions
• Elevation of scapula
• Retraction(adduct) scapula
• Upwardly rotate scapula
• Depress scapula
• Neck extension
Latissimus Dorsi
LATISSIMUS DORSI
• Origin
• T7-T12(T6-T12)
• 9th -12th ribs
• Thoracolumbar fascia
• Iliac crest
• Crest of sacrum
• Insertion
• Bicipital groove of humerus
• Function
• Adduct
• Arm extension
• Internal rotation of arm at the shoulder
Levator Scapulae
• 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
Rhomboid Muscle
• Origin
• Spinous process C7-T1(minor)& T2-T5(major)
• Insertion
• Medial border of scapula
• Scapular retraction
• Elevation
Teres Major & Minor
Teres Major & Minor
• Origin
• Inferior border of
scapula
• Insertion
• Intertubercular groove
of Anterior humerus
• Function
• Adduct arm
• External rotation of
arm(minor)
SCALENE MUSCLE
ANTERIOR SCALENE
• Origin: TVP of C3-C6
• Insertion: scalene tubercle of first rib
MIDDLE SCALENE
• Origin: C3-C7
• Insertion: 1st rib
POSTERIOR SCALENE
• Origin: C5-C7
• Insertion: 2nd rib
INTERSCALENE TRIANGLE
• Subclavian art &
brachial plexus pass
through
Subscapularis
• Origin
• Subscapularis fossa
• Insertion
• Lesser tubercle of
humerus
• Function
• Medially rotation of
arm
• Adduction
Shoulder Muscles, anterior
Posterior View
AC Joint, posterior view
Supraspinatus
• Origin
• G.tubercle of humerus
• Insertion
• Supraspinous fossa
• function
• Abduction
• First 30o
Pectoralis muscles
• P.Major
• Clavicle
• Sternum
• Upper costal cartilage
• Bicipital groove
• P.Minor
• 3rd-5th ribs
• Coracoid process
• Flexion
• Adduction
Pectoralis Major
Shoulder Joint Muscles
Biceps Brachii, Action
• 2 joint muscle
• Shoulder flexion
• Elbow flexion
• Flexion
Biceps Brachii
Coracoid process
Short head
Long head
Radial tuberosity
Pectoralis Minor & Coracobrachialis
• Adduction
Brachialis
Ulnar tuberosity
Anconeus
Function:
Elbow extension
Lat.epicondyle of humerus
Olecranon of ulna
Triceps Brachii
Triceps Brachii
Infraglenoid of Scapula
Olecranon of ulna
Coracobrachialis
Line of lesser tuberosity
Deltoid Muscle
Clavicle
Acromion
Deltoid tuberosity of humerus
Spinous
Teres Major
Crest of lesser tuberosity
Inferior angle of scapula
Rotator Cuff Muscles
• Teres minor
• Supraspinatus
• Infraspinatus
• Subscapularis
Rotator Cuff Muscles, Teres Minor
• External rotation
• Adduction
Rotator Cuff, Lateral View
Supraspinatus
G.Tuberosity of humerus
Supraspinus fossa
Infraspinatus
G.Tuberosity of humerus
Infraspinous fossa
Infraspinatus
Teres minor
Triceps
Teres major
Teres Minor
G.Tuberosity of humerus
Subscapularis
L.Tuberosity of humerus
Teres major
Subscapularis Muscle
• Internal rotation
• Adduction
Infraspinatus Muscle
• External rotation
• Adduction
• Arm extension
Serratus Anterior
• 1st to 8th, or 9th ribs
• Antagonist of rhomboid
• Protract & stabilize scapula
• Pull forward scapula
• Depress scapula
Serratus Anterior
• Protraction of scapula
Transverse Section
Brachial plexus
• Musculocutaneous N.
• Axillary N.
• Radial N.
• Median N.
• Ulnar N.
BRACHIAL PLEXUS
ROM SHOULDER
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
Shoulder Movement
Movement Prime mover, other muscles
Elevation Trapezius
Depression Latissimus dorsi, subclavious
Protraction Serratus anterior,
Retraction Rhomboid
Scapular Movements
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)
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
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
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
Cross Arm Adduction (scarf Test)
• Tests AC joint
• A positive test commonly indicates a-c 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
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
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
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
Tendonitis
• Develop with repetitive overhead activities
• Playing tennis
• Pitching (baseball and golf)
• Painting
• Shoveling
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
Risk Factors Of Frozen Shoulder
• DM
• Stroke
• Lung disease
• RA
• Heart disease
• Immobilization
Treatment
• Ice pack
• Ultrasound
• LASER
• Pain free active assistive ROM
• Isometric exercises
• Isotonic exercises
• Stretching exercises
• Strengthening exercises
Strengthening Exercises
• Theraband
• Flexbar
• Weight
• Wand
• Pulley
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
Codman’s Exercise
• R-L 30 sec
• Back & forth 30 sec
• Circular motion,
30sec each
• 2 sets/day
• 5-6 days/week
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
Strengthening Ex.
• Help to keep shoulder joint stable
• Can relieve shoulder pain and prevent further injury
Walking Wall Stretch
• Using fingers on a
wall
• Hold 10-15 sec
• Reps 10-15
• 3 sets/day
Walking Table Stretch
• In sitting position
• Using fingers on a
table
• Hold 10-15 sec
• Reps 10-15
• 3 sets/day
Cane Stretch Exercise
• Lie down, face up
• Use a cane to push
affected arm
Towel Stretch Exercise
• Stretch external
rotators
• Stretch flexors
Corner Stretching Exercise
• Stretching PM
• Hold 20-30 sec
• Reps several times
Crossover Arm Stretch
• Posterior deltoid
• Hold 30sec
• Relax 30sec
• Repeat 4 times
• 5-6/week
Passive Internal Rotation
• Subscapularis
• Hold 30sec
• Reps 4 each side/
day
• 5-6/week
Passive External Rotation
• Stretch in Infraspinatus,
teres minor
• Hold 30sec
• 4 each side/day, slowly
• 5-6/wk
Sleeper Stretch
• Infraspinatus, teres
minor
• Hold 30sec
• 4 reps/day, slowly
• 5-6/wk
Standing Row
• Strengthening extensors
• Middle & lower trap
• 8-12 reps, slowly
• 3 sets/day
• 3/wk
External Rotation+ abduction
• Infraspinatus, teres
minor stregthening
• 8-12 reps, slowly
• 3 sets/day
• 3/wk
Internal Rotation
• Subscapularis & teres
major strengthening
• 8-10 reps
• 3 sets/day
• 3/wk
External Rotation
• Infraspinatus, teres minor,
posterior deltoid
• 8-10 reps, slowly
• 3 sets/day
• 3/wk
Elbow Flexion
• Biceps,
• 8-12 reps, slowly
• 3 sets/day
• 3 days/wk
Elbow Extension
• Triceps
• 8-12 reps, slowly
• hold 2 sec
• 3 sets/day
• 3 days/wk
Trapezius strengthening
• Middle & posterior
deltoid, middle trap,
supraspinatus,
• 20 reps, slowly
• 3-4 sets/day
• 3-5 days/wk
Scapula Setting
• Middle trap, serratus
anterior
• Hold 10 sec
• 10 reps
• 3 days/wk
Scapular Retraction/Protraction
• Middle trap, serratus
anterior, latissimus dorsi
• 8-15 reps, slowly
• 2 sets/day
• 3 days/wk
Bent Over Horizontal Abduction
• Middle & lower trap,
infraspinatus, teres
minor, post deltoid
• 8-12 reps
• 3 sets/day
• 3 days/wk
Internal & External Rotation
• Ant deltoid, pectoralis,
subscapularis, latissimus
• Post deltoid, infraspinatus,
teres minor
• 20 reps
• 3-4 sets/day
• 3-5 days/wk
External Rotation
• Stretch infraspinatus, teres
minor, posterior deltoid
• 8-10 reps, slowly
• 2 sets/day
• 3/wk
Internal Rotation
• Stretch subscapularis &
teres major
• 8-10 reps
• 2 sets/day
• 3/wk
