Transcript Document

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


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
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

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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.
Lateral pectoral n.
Musculocutaneous n.
Medial antebrachial cutaneous n.
Median n.
Ulnar n.
Medial brachial cutaneous n.
Intercostobrachial n.
Thoracodorsal n. & a.
Long thoracic n. & lateral thoracic a.
Name the muscles
for Horizontal
Adduction
 Pect Major (both)
 Corachobrachialis
 Deltoid (anterior)


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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)




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List the muscles that
do adduction of the
shoulder
Pectoralis major (lower
and upper below 90°)
Coracobrachialis
Latissimus dorsi
Teres major
List the muscles that do
abduction of the
shoulder
• Deltoid (all sections)
• Supraspinatus
• Pectoralis major
(upper past 90°)

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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.
Name the action
Teres Major
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
Subscapularis
Pect. Major
Deltoid
Supraspinatus
Teres Major
Infraspinatus
Teres Minor
What position are her shoulders in?
Flexion
What position is his right shoulder in?
Horizontal Abduction and
External 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
Position of their shoulders?
1.
Flexion
2.
Extension
What is the position of shoulders?
Extension

Pectoralis major

Latissimus dorsi
 Push-ups
 Chinning
 Pull-ups
 Robe climb
 Bench press
 Dips on parallel bars
 Throwing
 Pullover exercises
 Tennis serve
 Pulldown exercises
 Rowing
Shoulder action = ?
Shoulder muscle(s) = ?
Abduction
Deltoid
Supraspinatus
Shoulder action = ?
Shoulder muscle(s) = ?
Flexion
Ant Deltoid
Upper Pect Major
Coracobrach.
Shoulder action = ?
Shoulder muscle(s) = ?
Horizontal Add.
Ant. Deltoid
Pect. Major (both)
Coracobrachialis
Shoulder action = ?
Shoulder muscle(s) = ?
Horizontal Abduction
Latissimus Dorsi
Post. Deltoid
Teres Minor
Infraspinatus
Shoulder action = ?
Shoulder muscle(s) = ?
Adduction
Pect. Major (both)
Coracobrachialis
Latissimus Dorsi
Teres Major
Shoulder action = ?
Shoulder muscle(s) = ?
Horizontal Add
Ant. Deltoid
Pect. Major (both)
Coracobrachialis
Shoulder action = ?
Shoulder muscle(s) = ?
Extension
Lats
Post. Deltoid
Infraspinatus
Teres Major
Pectoralis Major (lower)
Teres minor
Shoulder action = ?
Shoulder muscle(s) = ?
External Rotation
Infrspinatus
Teres Minor
Post. Deltoid

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
Side arm dumbbell raises
Deltoid
Push-ups
Pectoralis major
Rowing and pull-overs
Latissimus dorsi
Internal Rotation
External Rotation
Internal Rotation
Subscapularis, Ant. Deltoid, Pect, Major, Lats. And Teres Major
External Rotation
Internal Rotation
External 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 subacromial bursae /
biceps tendon etc
underneath

Fig :
Name
Scapularretraction [7]
(aka scapular adduction)
Description
Muscles
The scapula is moved posteriorly and medially along the back,
moving the arm and shoulder joint posteriorly. Retracting both
rhomboideus major, minor, and trapezius
scapulae gives a sensation of "squeezing the shoulder blades
together."
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,
serratus anterior (prime mover), pectoralis minor and major
the scapulae are separated and the pectoralis major muscles are
squeezed together.
Scapularelevation [8]
The scapula is raised in a shrugging motion.
Scapulardepression [8]
The scapula is lowered from elevation. The scapulae may be
pectoralis minor, lower fibers of the trapezius, subclavius,
depressed so that the angle formed by the neck and shoulders is
latissimus dorsi
obtuse, giving the appearance of "slumped" shoulders.
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
True abduction: supraspinatus (first 15 degrees), deltoid;
two parts: True abduction of the arm, which takes the humerus
Upward rotation: trapezius, serratus anterior
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.
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
The humerus is rotated out of the plane of the torso so that it
points forward (anteriorly).
The humerus is rotated out of the plane of the torso so that it
points backwards (posteriorly)
pectoralis major, coracobrachialis, biceps brachii, anterior fibers
of deltoid.
latissimus dorsi and teres major, long head of triceps, posterior
fibers of the deltoid
Arm flexion [11]
Arm extension[11]
levator scapulae, the upper fibers of the trapezius
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
subscapularis, latissimus dorsi, teres major, pectoralis major,
so they are parallel to the ground. Medial rotation occurs when
anterior fibers of deltoid
the arm is rotated at the shoulder so that the fingers change
from pointing straight forward to pointing across the body.
Lateral rotationof the arm[12]
The opposite of medial rotation of the arm.
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 pectoralis major, subscapularis, coracobrachialis, biceps brachii,
the air lateral to the body. In circumduction, the arm is not lifted supraspinatus, deltoid, latissimus dorsi, teres major and minor,
above parallel to the ground so that "circle" that is drawn is
infraspinatus, long head of triceps
flattened on top.
infraspinatus and teres minor, posterior fibers of deltoid