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Dr. S. Nishan Silva(MBBS)
Bones Clavicle Scapula Humerus
Shoulder vs Shoulder Girdle
Joints Sternoclavicular
Joints Sternoclavicular Acromioclavicular
Coracoclavicular ligaments “Suspensory ligaments of the
upper extremity” Two components:
▪ Trapezoid▪ Conoid
Stronger than AC ligaments Provide vertical stability to AC
joint
Joints Sternoclavicular Acromioclavicular Glenohumeral
Most common dislocated joint
Lacks bony stability
Composed of: Fibrous
capsule Ligaments Surrounding
muscles Glenoid
labrum
Ligaments Acromioclavicular
Joint▪ Acromioclavicular
Ligament
Ligaments Glenohumeral
Joint ▪ Glenohumeral
ligaments▪ Superior▪ Middle ▪ Inferior
25% humeral head surface in contact with glenoid
Humeral head coverage increased to 75% with glenoid labrum
Cartilage Glenoid labrum
Shoulder Girdle Muscles Trapezius
Trapezius Origin: superior nuchal line,
external occipital protuberance, ligamentum nuchae and spinous processes of seventh cervical and all thoracic vertebrae
Insertion: lateral third of clavicle, acromion, and spine of scapulartery
Acton: upper fibers elevate scapula, lower fibers depress scapula; if scapula is fixed, one side acting along, draws head toward the same side, and turn face to opposite side; both sides together, draw head directly backward
Latissimus dorsi Origin: spinous
processes of lower six thoracic and all lumbar vertebrae, median sacral crest, and posterior part of iliac crest.
Insertion: floor of intertubercular groove of humerus.
Action: trunk fixed, extends, adducts and medially rotates arm ; arm fixed, elevates trunk.
Shoulder Girdle Muscles Trapezius Serratus Anterior
Winged Scapula
Glenohumeral Muscles Rotator Cuff
▪ Suprispinatus▪ Infraspinatus▪ Teres Minor▪ Subscapularis
Subscapularis Supraspinatus Infraspinatus Teres minor
Supraspinatus, infraspinatus, teres minor, subscapularis
Form cuff around humeral head
Keep humeral head within joint (counteract deltoid)
Abduction, external rotation, internal rotation
Subscapularis is an internal rotator of the arm.
Supraspinatus assists the deltoid in abducting the arm, with its greatest contribution being the initiation of abduction.
Infraspinatus and teres minor muscles both externally rotate the arm.
Teres major Origin: dorsal
surface of inferior angle of scapula
Insertion: crest of lesser tubercle of humerus
Action: medially rotates and adducts arm
Glenohumeral Muscles Latissimus Dorsi Pectoralis Major
Pectoralis major Origin: medial half of
clavicle,sternum,1th-6th costal cartilages.
Insertion: crest of greater tubercle of humerus.
Action: flexes, adducts and rotates arm medially; arm fixed, elevates trunk; elevates ribs 1-6,aidding in forced inspiration.
Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid
Deltoid Origin: lateral third of
clavicle, acromion, and spine of scapula
Insertion: deltoid tuberosity of humerus
Action: abducts , flexes and medically rotates, extends, and laterally rotates arm
Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid Biceps
Arms outstretched with palms up at level of shoulder
Forced supination of hand with elbow flexed at 90 degrees
Glenohumeral Muscles Latissimus Dorsi Pectoralis Major Deltoid Biceps Triceps
Other structures Brachial Plexus Brachial Artery
Formation: Five roots: formed by
anterior rami of C5-C8 and T1 spinal nerves, roots C5 ~C7give rise to long thoracic n.
Three trunks The upper trunk is formed by
the joining of root C4,C5,C6. The middle trunk is the
continuation of root C7. The lower trunk is formed by
the joining of root C8 and T1. Six divisions: above clavicle,
trunks form anterior and posterior divisions
Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a.
Position: passes through the scalene fissure
to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords
Main branches Lateral cord
Musculocutaneous n. Lateral root to median n.
Medial cord Medial root to median n. Ulnar n. Medial brachial cutaneous n. Medial antebrachial cutaneous
n.
Posterior cord radial n. axillary n. thoracodorsal n.
Axillary artery Continuation of subclavian artery
at lateral border of first rib Becomes brachial artery at lower
border of teres major Divided into three parts by
overlying pectoralis minor First portion, above muscle - gives
rise to thoracoacromial a. Second portion, behind muscle -
gives rise to lateral thoracic a. Third portion, below muscle - gives
rise to subscapular a. anterior and posterior humeral circumflex a.; the former then divides into throcodorsal a. and circumflex scapular a.
Axillary a.
Thoracoacromial a.
Musculocutaneous n.
Median n.
Medial antebrachial cutaneous n.
Ulnar n.
Medial brachial cutaneous n.
Intercostobrachial n.Thoracodorsal n. & a.
Long thoracic n. & lateral thoracic a.
Lateral pectoral n.
Name the muscles for Horizontal Adduction
Pect Major (both) Corachobrachialis Deltoid (anterior)
Name the muscles for Horizontal Abduction
Deltoid (post) Infraspinatus Teres minor Lats
List the muscles that do flexion of the shoulder
Coracobrachialis Pectoralis major
(upper to 60°) Anterior Deltoid
• List the muscles that do extension of the shoulder
• Latissimus dorsi• Teres major• Posterior deltoid• Pectoralis major
(lower fibers to neutral)
List the muscles that do adductionadduction of the shoulder
Pectoralis major (lower and upper below 90°)
Coracobrachialis Latissimus dorsi Teres major
List the muscles that do abductionabduction of the shoulder
• Deltoid (all sections)• Supraspinatus• Pectoralis major
(upper past 90°)
List the muscles that do internal rotation of the shoulder
Subscapularis Latissimus dorsi Teres major Anterior deltoid Pect. major
• List the muscles that do external rotation of the shoulder
• Infraspinatus• Teres minor• Posterior deltoid
Name the muscle.
Coracobrachialis
Name the action
Adduction of the shoulder
Also, flexion and hor. add.
Name the muscle.
Subscapularis
Name the action
Internal rotation of the shoulder
Name the muscle.
Deltoid
Name the action
Abduction of shoulder
Name the muscle.
Infraspinatus
Name the action
External rotation
Name the muscle.
Teres Major
Name the action
Adduction of scapula
Name the muscle.
Teres Minor
Name the action if the humerus move directly to the posterior
Extension of the shoulder
Name the muscle.
Supraspinatus
Name the action
Abduction of the shoulder
Coracobrachialis Pect. Major
SubscapularisDeltoid
Supraspinatus Teres Major
InfraspinatusTeres Minor
What position are her shoulders in?
Flexion
What position is his right shoulder in?
Horizontal Abduction andExternal Rotation
What rotation action is his shoulder performing as he continues to through the ball?
Internal Rotation
What position are her shoulders in?
Flexion
What position are his shoulders in?
Horizontal abduction or Extension
1.2.
FlexionExtension
Position of their shoulders?
What is the position of shoulders?
Extension
Pectoralis major Push-ups Pull-ups Bench press Throwing Tennis serve
Latissimus dorsi Chinning Robe climb Dips on parallel bars Pullover exercises Pulldown exercises Rowing
Shoulder action = ?Shoulder muscle(s) = ? Abduction
DeltoidSupraspinatus
Shoulder action = ?Shoulder muscle(s) = ?
Flexion
Ant DeltoidUpper Pect MajorCoracobrach.
Shoulder action = ?Shoulder muscle(s) = ? Horizontal Add.
Ant. DeltoidPect. Major (both)Coracobrachialis
Shoulder action = ?Shoulder muscle(s) = ? Horizontal Abduction
Latissimus DorsiPost. DeltoidTeres MinorInfraspinatus
Shoulder action = ?Shoulder muscle(s) = ?
Adduction
Pect. Major (both)CoracobrachialisLatissimus DorsiTeres Major
Shoulder action = ?Shoulder muscle(s) = ?
Horizontal Add
Ant. DeltoidPect. Major (both)Coracobrachialis
Shoulder action = ?Shoulder muscle(s) = ?
Extension Lats Teres MajorPost. Deltoid Pectoralis Major (lower)Infraspinatus Teres minor
Shoulder action = ?Shoulder muscle(s) = ?
External Rotation
InfrspinatusTeres MinorPost. Deltoid
Side arm dumbbell raisesDeltoidPush-ups Pectoralis majorRowing and pull-oversLatissimus dorsi
Internal RotationExternal Rotation
Internal Rotation
Subscapularis, Ant. Deltoid, Pect, Major, Lats. And Teres Major
External Rotation
External Rotation
Internal Rotation
Abduction (to work the supraspinatus)
Factors Predisposing to Shoulder Pain Instability of glenohumeral joint Weakness in scapular stabilizing muscles Previous injury (dislocation of glenohumeral joint, separation of
AC joint) Hypomobility of cervical or thoracic spine Postural dysfunction Muscle imbalances
Differentiation of Shoulder Pain Active inflammation: pain that occurs or increases at night Irritation of a sensory nerve root: sharp pain, numbing, &
tingling in a dermatome Rotator cuff injury: pain at lateral portion of upper arm,
painful limitation when elevating arm overhead Bicipital tendinitis: well-localized pain at anterior portion of
head of humerus & aggravation with Speed’s test Adhesive capsulitis: stiffness in shoulder, dramatic loss of
arm motion (especially external rotation)
Differentiation of Shoulder Pain Impingement: pain over anterior humerus, loss of internal
rotation, & painful Neer’s test Instability: clunking in shoulder with active circumduction &
excessive joint play in passive motion test for glenohumeral joint
Pain originating in glenohumeral joint: rarely felt at joint, but over lateral brachial region
Characteristics of Shoulder Pain (vs. neck pain) Elicited or increased from active shoulder motion & relieved by
rest Isometric challenge will be painful with localized lesion Painless weakness in arm & shoulder muscles from motor
nerve root problem in cervical spine
Common Dysfunctions and Injuries of the Shoulder Rotator cuff tendinitis (supraspinatus tendinitis) Infraspinatus tendinitis Subscapularis tendinitis Adhesive capsulitis (frozen shoulder) Impingement syndrome Instability syndrome of the glenohumeral joint
Common Dysfunctions and Injuries of the Shoulder Bicipital tendinitis Subacromial (subdeltoid) bursitis Acromioclavicular ligament sprain Suprascapular nerve entrapment Costoclavicular syndrome (part of thoracic outlet syndrome) Pectoralis minor syndrome (part of thoracic outlet syndrome)
Abduction/adduction Painful arc of
abduction – sensitive, not specific
Impringement of inflammed sub-acromial bursae / biceps tendon etc underneath
Fig :
Name Description Muscles
Scapularretraction [7] (aka scapular adduction)
The scapula is moved posteriorly and medially along the back, moving the arm and shoulder joint posteriorly. Retracting both scapulae gives a sensation of "squeezing the shoulder blades together."
rhomboideus major, minor, and trapezius
Scapularprotraction[7](aka scapular abduction)
The opposite motion of scapular retraction. The scapula is moved anteriorly and laterally along the back, moving the arm and shoulder joint anteriorly. If both scapulae are protracted, the scapulae are separated and the pectoralis major muscles are squeezed together.
serratus anterior (prime mover), pectoralis minor and major
Scapularelevation [8] The scapula is raised in a shrugging motion. levator scapulae, the upper fibers of the trapezius
Scapulardepression [8]
The scapula is lowered from elevation. The scapulae may be depressed so that the angle formed by the neck and shoulders is obtuse, giving the appearance of "slumped" shoulders.
pectoralis minor, lower fibers of the trapezius, subclavius, latissimus dorsi
Arm abduction [9]
Arm abduction occurs when the arms are held at the sides, parallel to the length of the torso, and are then raised in the plane of the torso. This movement may be broken down into two parts: True abduction of the arm, which takes the humerus from parallel to the spine to perpendicular; and upward rotation of the scapula, which raises the humerus above the shoulders until it points straight upwards.
True abduction: supraspinatus (first 15 degrees), deltoid; Upward rotation: trapezius, serratus anterior
Arm adduction[10]
Arm adduction is the opposite motion of arm abduction. It can be broken down into two parts: downward rotation of the scapula and true adduction of the arm.
Downward rotation: pectoralis minor, pectoralis major, subclavius, latissimus dorsi (same as scapular depression, with pec major replacing lower fibers of trapezius); True Adduction: same as downward rotation with addition of teres major and the lowest fibers of the deltoid
Arm flexion [11] The humerus is rotated out of the plane of the torso so that it points forward (anteriorly).
pectoralis major, coracobrachialis, biceps brachii, anterior fibers of deltoid.
Arm extension[11] The humerus is rotated out of the plane of the torso so that it points backwards (posteriorly)
latissimus dorsi and teres major, long head of triceps, posterior fibers of the deltoid
Medial rotation of the arm [12]
Medial rotation of the arm is most easily observed when the elbow is held at a 90-degree angle and the fingers are extended so they are parallel to the ground. Medial rotation occurs when the arm is rotated at the shoulder so that the fingers change from pointing straight forward to pointing across the body.
subscapularis, latissimus dorsi, teres major, pectoralis major, anterior fibers of deltoid
Lateral rotationof the arm[12] The opposite of medial rotation of the arm.infraspinatus and teres minor, posterior fibers of deltoid
Armcircumduction[13]
Movement of the shoulder in a circular motion so that if the elbow and fingers are fully extended the subject draws a circle in the air lateral to the body. In circumduction, the arm is not lifted above parallel to the ground so that "circle" that is drawn is flattened on top.
pectoralis major, subscapularis, coracobrachialis, biceps brachii, supraspinatus, deltoid, latissimus dorsi, teres major and minor, infraspinatus, long head of triceps
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