The Australian Physiotherapy & Pilates Institute Shoulder ...
Transcript of The Australian Physiotherapy & Pilates Institute Shoulder ...
08/08/2016
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The Australian Physiotherapy & Pilates Institute
Anatomy of the Shoulder and Upper Limb
The Australian Physiotherapy & Pilates Institute
Shoulder Complex
• Physiological joint between scapula and thoracic wall
• Shoulder complex (SC): sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic joints
Scapulothoracic joint (STJ)
Equipment - Level Two
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Anterior Posterior
Bony landmarks of scapulae
Equipment - Level Two
Anterior Posterior
Equipment - Level Two
• Base for muscle attachments
• Correct orientation optimises length tension
relationship of deltoid with abduction
– Van der Helm 1994
• Orientates glenoid to facilitate optimal congruency of
GH joint
• Lateral rotation increases available ROM at GH joint
• Laterally rotates to elevate acromion and prevent
impingement with GH elevation
Role of the scapula
Equipment - Level Two
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ROM Movement Joint motion
0 – 60 Flexion Glenohumeral
0 – 30 Abduction Glenohumeral
> 60 Flexion 2:1 scapula to
humeral
>30 Abduction 2:1 scapula to
humeral
Greatest contribution amount of scapula rotation occurs between 80 –
140° of elevation in scaption ( Bagg & Forrest 1998)
Scapulothoracic rhythm
Equipment - Level Two
• The dynamic orientation of the scapula in a
position to optimise the position of the glenoid
and so allow mobility and stability at the
glenohumeral joint.- Mottram S 1997
Equipment - Level Two
Scapula setting
• Position STJ in ideal position
• Maintain with isometric contractions of serratus
anterior and lower trapezius
• Common substitution strategies to avoid:
– Retraction with maximum depression
– Retraction with elevation
Scapula setting
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• Position STJ in ‘ideal position’?
• Superior angle of scapula level with T2 or T3
• Vertebral border 5 – 6cm from the midline
• Root of spine level with T3 or T4
• Inferior angle level with T7 – T9
• 30° anterior from the frontal plane- Irrang et al 1992
• In upward rotation
• Medial border and inferior angle flat against chest wall
• Ideal position should also be resting position
Scapula setting
Equipment - Level Two
• Practical Session
Scapula setting
Equipment - Level Two
• Medial attachment: medial third of superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous processes and supraspinous ligaments of C7 – T12
• Upper fibres insert to lateral third of clavicle
• Middle fibres run horizontally to attach to inner border of acromion and along length of crest of scapula
• Inferior fibres ascend and converge to a tendon which attaches medial end of the spine of scaplae
Trapezius muscle
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Functions:
• Upper fibres:
– elevate scapula? debatable
– Downwardly rotate scapulae
– Draw scapula backwards to elevate lateral end of clavicle and cause upward rotation of scapula
- Johnson et al 1994
• Middle fibres:
– retract scapula
– Stabilise during upward rotation
• Lower fibres:
– Depress scapula
– Upwardly rotate the scapula
– Resist lateral displacement of serratus anterior
Trapezius
Equipment - Level Two
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Serratus anterior
Equipment - Level Two
Anatomy:
• Originates external surface of upper 8 or 9 ribs
• Inserts anterior surface of medial border of scapula
Function:
• Major protractor of scapula
• Upwardly rotates scapula
• Elevates scapula
Serratus anterior (SA)
Equipment - Level Two
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• Upper and lower fibres of trapezius and SA work as force couple
to produce upward rotation if scapula- Palastanga et al 1994, Williams 1995
• As SA draws scapula laterally around chest wall, movement is
controlled by lower trapezius
• In elevation, this force couple works to counteract downward
rotation of deltoid on scapula
• Thus maintaining scapula in upward rotation and preventing
impingement
Muscle balance of STJ
Equipment - Level Two
Anatomy:
• Descends from C1 – C4 diagonally to insert on the medial superior border of the scapula
Function:
• Elevate, retract and downwardly rotate scapula
• Assists in stabilisation under load
- Mottram 1997
Levator scapulae
Equipment - Level Two
Anatomy:
• Minor: runs obliquely downwards
and laterally from the lower
ligamentum nuchae, C& and T1 to
attach on the medial scapula border
at the root of scapula
• Major: arises from T2 – T5 and
descends laterally to attach on the
medial border of scapula between
root and inferior angle
Function:
• Retract, downwardly rotate and
elevate scapula
Equipment - Level Two
Rhomboid minor & major
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Anatomy:
• Minor: Arises from R3 – R5 and
ascends laterally to insert onto
coracoid process
Function:
• Exerts strong pull on coracoid
process onto protraction and
downward rotation
Pectoral minor
Equipment - Level Two
Anatomy
• Arises from spinous processes of
inferior 6 thoracic vertebrae,
thoracolumbar fascia, iliac crest,
and inferior 3 or 4 ribs and inserts
into the intertubercular groove of
humerus
• Small slip to the inferior angle of
scapula
Function
• Extends, adducts, and medially rotates humerus
Latissimus dorsi
Equipment - Level Two
Suprapinstus:• Arises supraspinous fossa and
inserts into superior facet on greater tuberosity of humerus
• Initiates and assists deltoid in abduction of arm
Infraspinatus:• Arises infraspinous fossa and inserts into the
middle facet on greater tuberosity of humerus
• Laterally rotates arm and helps to hold humeral head in glenoid cavity
Terres minor:• Arises superior part of lateral border of
scapula and Inserts into inferior facet on greater tuberosity of humerus
• Laterally rotates arm and helps to hold humeral head in glenoid cavity
Rotator Cuff
Equipment - Level Two
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Subscapularis:
• Arises subscapular fossa of
scapula and inserts into
lesser tuberosity of humerus
Action:
• Medially rotates arm and
adducts it and helps to hold
humeral head in glenoid
cavity
Rotator Cuff
Equipment - Level Two
Sternocleidomastoid
Scalenes
• Anterior
• Middle
• posterior
Superficial neck muscles
Equipment - Level Two
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Biomechanics of the Shoulder Complex
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The Australian Physiotherapy & Pilates Institute
Upper Limb ControlDepends on:• Strength of muscle• Angle of pull• Line of action of the resultant muscle
force• Rotary and stabilizing or dislocating
components• Shoulder girdle designed for mobility• ↓stability• Muscles provide stability• Strength vital with weakness related to injury
The Australian Physiotherapy & Pilates Institute
Scapular PostureNormal alignment:
• Vertebral border is parallel to the spine• Vertebral border is ~ 7cm from midline• located between T2 and T7• Scapula is flat against the thorax• Scapula is rotated ~30° anterior to the frontal plane – scapular plane
Sahrmann (2010)
The Australian Physiotherapy & Pilates Institute
Humural PostureNormal alignment includes:
• <1/3 of humeral head protruding in front of the acromion
• Neutral rotation should be present
• Proximal and distal ends are in the same vertical line
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The Australian Physiotherapy & Pilates Institute
Scapulo-Humeral Rhythm
• Without scapular motion humerus only abduct/flex 120 degrees• acromion prevents further motion.• scapula must rotate for humerus to clear acromion• ratio of 2:1• 2 degrees of glenohumeral rotation to every degree of scapular rotation• Maintains length – tension relationship• Key to efficient shoulder function.• Scapular upward rotation, posterior tilt and ER
Kibler and Sciascia (2009)
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The Australian Physiotherapy & Pilates Institute
Scapular DysfunctionCan lead to :
• Impingement• Shoulder pain worse with overhead movements• Overuse injuries• Tendinopathies• Thoracic Outlet Syndrome• Weakness/numbness in arm and hand• Instability• Clicking and/or clunking, shoulder slips out• Cervical Pain
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Excessive scapular protraction ↓maximum rotator cuff strength by 23%.
Kebaetse et al (1999)
• Maximal rotator cuff strength achieved in a position of‘neutral scapular protraction/retraction’,• excessive protraction or retraction demonstrated decreased rotator cuff abduction strength
Smith et al (2002)
Scapular Dysfunction
The Australian Physiotherapy & Pilates Institute
Common Shoulder injuries
The Australian Physiotherapy & Pilates Institute
Common Shoulder Injuries
• Shoulder Impingement Syndrome (SIS)• Rotator Cuff Tear/Tendinopathy• Shoulder instability• Bicipital Tendonopathy• Labral tear• AC joint sprain• Clavicular fractures
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The Australian Physiotherapy & Pilates Institute
Upper Limb Anatomy
The Australian Physiotherapy & Pilates Institute
Movements of the Elbow
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Movements of the Wrist
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The Australian Physiotherapy & Pilates Institute
Muscles of the Upper Arm
The Australian Physiotherapy & Pilates Institute
Key Pilates Points