Exam 3: Upper body extermities

What is the function of the scapula?

It is a dynamic anchor and an origin point for muscles that attach to the humerus

What bone articulates with the scapla

The head of the humerus and the thorax

Elevation of the scapula is caused by

Levator scapulae, upper fibers of the traps, rhomboid minor and major

Abduction of the scapula is caused by

Serratus Anterior, Pec major and minor

Depression of the scapula is caused by

Lower trap, Pec minor and major, Lats, and Serratus anterior

Adduction of the scapula is caused by

Traps, Rhomboid major and minor

Downward rotation of the scapula is caused by

Rhomboid minor and major, Levator scapulae, Pec minor, Lats

Upward rotation of the scapula is caused by

Serratus anterior, Traps

Posterior tilt of the scapula is caused by

Lower traps, Serratus anterior, Caracobrachialis

Anterior tilt of the scapula is caused by

Pec minor, Biceps brachii, Levator Scapulae, Rhomoids minor and major

Forward head posture is (abnormality)

Anterior displacement of the head

Flexion of lower cervical spine

Extension of the upper cervical spine

Forward shoulder posture is (abnormality)

Protraction, elevation, and anterior tilting of the scapula

Anterior displacement of the acromion process

Winging of the scapula

What does a forward head/shoulder posture do to the body?

Requires the neck extensor muscles to work harder

• fatigue of the neck extensor muscles

• Implication for neck pain

What does poor scapular postioning alter?

Alters the length of the scapular muscles

• length tension relationship where muscles will have an optimal length for force production

What leads to weakness during shoulder movement?

Ineffective stabilization of the scapula

Does your shoulder have a decreased range of motion?

Yes

ROM of humerus during normal shoulder elevation

Humerus externally rotates. Scapular upwardly rotates externally rotates, and posteriorly tilt

Why is the ROM of humerus limited to certain movements when elevated?

These movements allow for the greater tubercle to cear the acromion process

Forward shoulder posture causes

Humerus will rotate internally and limit scapula motion. This will cause the greater tubercle to bump into the acromion process and limit ROM

Causes of poor posture

Imbalance between the postural and phasic muscles, and spinal alignment

Postural muscles include

Cervical extensors

Pectoralis major

Upper traps

Levator scapula

Sternocleidomastoid

Cervical extensors function

Lift, control and stailize the head and neck

Pec major function

Adduction, internal rotation and flexion of the upper arm at the shoulder

Upper trap function

Primary stabilizer/mover for the shoulder blade, neck, and collarbone

Levator scapula function

elevation and downward rotation of the scapula

Sternocleidomastoid function

Laterally flex and rotate the head and neck. Elevate the rib cage during inhalation

Phasic muscles

Neck flexors

Phasic muscle

Serratus anterior

Rhomboids

Lower traps

Neutralizer muscles

muscles that contract to eliminate unwanted secondary movement

• raising your arm (bicep) but not supinating your hand (pronator teres and quadratus neutralize)

Upper cross syndrome (weak)

Weak: Cervical flexors, Rhomboids, and Lower traps

Upper cross syndrome (tight)

Tight: Subocciptals, Upper traps, Levator, Pecs

Hyperlordosis (spinal alignment)

Excessive lumbar lordosis w/o compensation in the thorcic or cervical spines

Hyperlordosis (spinal alignment) includes

Forward head posture, Anterior pelvic tilt, and Knee hyper-extension, lordosis

Kypholordotic posture (spinal alignment)

Excessive lumbar lordosis with compensatory increase in thoracic kyphosis

Kypholordotic posture (spinal alignment) includes

Forward head posture, kyphosis, lordosis, anterior pelvic tilt, Knee hyper-extnesion

Swayback (spinal alignment)

Increased lumbar lordosis and thoracic kyphosis that cause the pelvis to shift anteriorly and hips extend

Swayback (spinal alignment) includes

Kyphosis of the chest, lordosis of the lower back, and anterior pelvic tilt

Flatback (spinal alignment)

Decreased lumbar lordosis and thoracic kyphosis

• posterior pelvic tilt

Scoliosis (spinal alignment)

Lateral curvature of the spinal column

Structural scoliosis

Congenital bony anaomaly of the vertebrae

Functional scoliosis

Caused by muscle imbalance or leg length discrepancy

Causes of poor spinal alignment?

Congenital spinal alignment

Imbalance between sides

Lumbo-pelvic muscle imbalance (lower cross syndrome)

Lower cross syndrome tight

Tight: Erector spinae, Iliopsoas (psoas major, and iliacus)

Lower cross syndrome weak

Weak: Abdominal, Gluteus maximus

Importance of assessing spinal alignment

Pelvic/spinal alignment can affect upper body posture

• Its important to asses the whole body alignment when assessing upper body injuries

What structures make up the Thoracic Outlet

Middle and Anterior Scalene

Brachial plexus

Axillary Artery

Subclavian artery/vein

First rib

Clavicle

Pec minor

Where is the Subcromial space?

The space between the humeral head and coracoacromial arch

What forms the croacoacromial arch?

Formed by the acromion, coracoacromial ligament and coracoid process

What structures make up the subacromial space?

Supraspinatus tendon

Long head of biceps brachii

Subacromial bursa

Scapula movement at 0-30 degrees of shoulder elevation

No scapular movement

Scapula movement beyond 30 degrees of shoulder elevation

2:1 ratio of glenohumeral to scapulothoracic movement

What happens at 90 degrees of shoulder elevation

The greater tubercle abuts the acromion process

What does external rotation of the humerus allow?

Allow the greater tubercle to clear the acromion and achieve full shoulder elevation

What is Scapula Dyskinesis

The alteration of the nomal scapulohumeral rhythm caused by

• MUscle imbalance

• Spinal alignment

• Pain

What happens to the Scapula during an alteration of the normal scapulohumeral rhythm

Decreased scapular upward rotation, Scapula becomes more protracted

• Narrowing of subacromial space

• Compression of structures in subacromial space

How is joint stability of the Glenohumeral joint achieved?

Glenohumeral joint capsule/ligament

Rotator cuff muscles

Glenoid labrum

FOOSH

Fall On Out Stretched Hand

• force applied to the hand transmitted to uper extremity bones and joints

Clavicle fracture (traumatic injury)

Occurs primarily in the middle third

Mechanism: FOOSH/Direct impact

S&S: Patient supporting injured arm, head tilting towards injured side with chin turned away, pain, swelling, and deformity

Common sites of a Humeral fracture?

• Proximal humerus (surgical neck)

• Epiphyseal plate

• Humeral shaft

Humeral fracture (traumatic injury)

Mechanism: FOOSH, Dislocation, Direct blow

S&S: Pain, Swelling, Point tenderness, Decreased ROM

Complications: Risk damage to axillary nerve and posterior circumflex humeral artery

Sternoclavicular joint sprain/disloaction (traumatic injury)

Most dislocations are anterior

Mechanism: FOOSH, Direct blow

S&S: Pain with palpation and shoulder movement

Complications: Posterior dislocation may result in injury to the arteries, vein, and trachea

Acromioclavicular sprain (traumatic injury) is the

Damage to the capsule and ligaments around the AC joint

• Acromioclavicular ligament

• Coracoclavicular ligaments

“Shoulder separation”

Acromioclavicular sprain (traumatic injury)

Mechanism: FOOSH, Direct blow to the superior acromion

S&S: Pain with palpation over the AC joint and any shoulder movement, Step deformity, “Piano key” sign

Anterior Subluxations/dislocations is the

Anterior subluxation/dislocation of the humeral head causeing extensive damage to the joint capusl and structures around the joint

• has a high recurrence rate

Anterior subluxations/dislocations (traumatic injury)

Mechanism: Forced shoulder abduction and external rotation

S&S: Pain, Flattened shoulder contour, Arm carried in slight abduction and external rotation

Anterior subluxations/dislocations complications

Complications inlude

• Chronic instability

• Brachial plexus injury

• Axillary artery injury

• Rotator cuff tear

• Bankart lesion

• Hill-sachs lesion

Bankart Lesion

Tearung of the anterior labrum, as the humeral head dislocates anteriorly

Hill-Sachs Lesion

Damage to the posterior humeral head as the humeral head attempts to relocate

Posterior subluxations/dislocation (traumatic injury)

Less common

Mechanism: Froced adduction and internal rotation, Falling on an extended and internally rotated shoulder

S&S: Pain, Arm carried in adduction and internal rotation

SLAP Lesion stands for

Superior Labrum Anterior to Posterior lesion

SLAP lesion (traumatic injury) Mechanism

Mechanism: FOOSH

• tension of the long head of the biceps tears the superior portion of the glenoid labrum

• May be caused by chronis wear of the labrum (overhead athlete)

SLAP Lesion (traumatic injury) S&S

S&S: Pain during overhead activity

• Throwing athletes complain of “dead arm” and difficulty generatinf ball speed

Rotator cuff strain (traumatic injury)

Mechanism: FOOSH, Lifitng or pulling heavy objects (forceful muscle contraction)

S&S: Dull ache deep in the shoulder, Limited ROM

Biceps brachii rupture (traumatic injury)

Usually near origin of muscle at bicpital groove (40-60 yr olds)

Mechanism: Powerful contraction, May be caused by chronic wear of the tendon

S&S: Audible snap and pain, Protruding muscle bulge, Weakness with elbow flexion and supination

Subcromial impingement syndrome (overuse injury)

Irritation of anatomical structures within subacromial space

Mechanism: Compression of structures within subcromial spcae due to narrowing of the space

S&S: Diffuse pain radiating to the lateral shoulder (referred pain) that worsens with shoulder elevation above 90 degrees

What could cause narrowing of the subacromial space?

• Shoulder elevation during overhead activity

• Imbalance of scapular muscles

• Glenohumeral joint instability

• Hooked acromion process

• Swelling within the subacromial space

What can happen/included in a subacromial impingement?

• Rotator cuff tendinopathy

• Subcromial bursitis

• Biceps tendinopathy

What is Rotator cuff tendinopathy (overuse injury)

Tendinosis of the rotator cudd tendon

• Commonly in supraspinatus tendon

• Can result in partial or complete thickness tear

• Occurs near insertion on greater tuberosity (has poor blood flow)

Rotator cuff tendinopathy (overuse injury)

Mechanism: Subacromial impingement/overuse

S&S: Deep pain within the shoulder, Difficulty performing activities of daily living

Subacromial bursitis (overuse injury)

Inflammation of the subacromial bursa

Mechanism: Subacromial impingement

S&S: Diffuse pain radiating to the lateral shoulder (referred pain) that worsens with shoulder elevation about 90 degrees

Biceps tendinopathy (overuse injury)

Degenerative change in the long head of the biceps

Mechanism: Subacromial impingement, Overuse of biceps brachii

S&S: Tenderness over bicipital groove, swelling, crepitus due to inflammation, Pain with overhead activites

Thoracic outlet syndrome is the

Compression of the brachial plexus, subclavian artery and/or vein within the thoracis outlet

Common loactions of thoracic outlet compression

• Between anterior and middle scalene

• Between clavicle and 1st rib

• Between pec minor and rib cage

• Underneath cervical rib

Thoracic outlet syndrome (overuse injury)

Mechanism: Tightness of the scalene and pec minor muscle which could be due to poor posture, Repetitibe overhead activity

S&S: depends on if its Neurogenic, Venous, or Arterial

Thoracic outlet syndrom Neurogenic (overuse injury)

• Compression of brachial plexus

S&S: Upper extermity heaviness, fatguability, neck shoulder and face pain, paraesthesia, weal grip strength

Thoracic outlet syndrom Venous (overuse injury)

• Compression of subclavian vein, often in young athletes due to repetitive shoulder hyper-abduction with external rotation

S&S: Heavy arm and Upper extermity edema

Thoracic outlet syndrom Arterial (overuse injury)

• Compression of subclavian artery

S&S: Often asymptomatic, hand and finger pain, paraesthesia, absence of distal pulse in postionas of arterial compression

Neers impingement sign (Subacromial impingement)

How: Patients shoulder placed in internal rotation, While maintaining shoulder internal rotation passively flex the shoulder to end range

Postive: Pain in subacromial space between 90-180 degree flexion

Hawkins-Kennedy test (subacromial impingement)

How: Patients shoulder placed in 90 degree flexion with elbow flexed at 90 degree, While maintaining shoulder flexion passively internally rotates the shoulder

Positve: Pain in subacromial space near end range

Empty can test (Supraspinatus pathology (impingement, RC tear, tendinopathy)

How: Patients shoulders elevated 90 dgerees in a scapular plane. With patients thumb pointing down apply downward pressure at the wrist

Positive: Weakness or pain accompanying the movement

O’Brien’s test (Labral pathology)

How: Patients shoulder in 90 degrees flexion and 15 degrees horizontal adduction. With patients thumb pointing down (placing the shoulder in internal rotation) apply downward pressure at the wrist

Positive: Pain or clicking eithin the glenohumeral joint experienced with the arm internally rotated but is decreased during external rotation

Speed’s test (Long Head of biceps tendinopathy)

How: Patient sitting with elbow extended and pal facing forward. Resists shoulder flexion while palpating for tenderness over the bicipital groove

Positive: Pain over LH biceps tendon

Yergason’s test (LH biceps tendinopathy)

How: Patient sittng with elbow flexed at 90 degrees and forearm pronated. Resist elbow flexion and supination

Positive: Pain or snapping in the bicipital groove

Roo’s test (thoraci outlet syndrome)

How: Patient abducts both arms and flexes elbows to 90 degrees. Patient opens and closes the hands for 3 minutes

Positive: Inability to maintain the testing position or replication of motor/sensory symptoms

Allen’s test (thoracic outlet syndrome)

How: Examiner palpates the patients radial pulse. Examiner abducts the patients shoulder and flex the elbow to 90 degrees and externally rotates the arm while asking the patient to rotate the head away from the shoulder that is being examined

Positive: Diminshed or disappearance of the radial pulse

Adson’s test (Thoracic outlet syndrome)

How: Examiner palpates the patients radial pulse. Examiner extends and externally rotates the patients shoulder while asking the patient to turn the head toward the shoulder that is being examined, extending the neck and take a deep breath

Positive: Diminshed or disappearance of radial pulse

Military Brace test (Thoracic outlet syndrome)

How: Patient standing, examiner palpates the patients’s radial pulse. Patient retracts and depresses the shoulders as if coming to military attention, and extend the shoulder

Positive: Diminshed or disapperance of radial pulse

Median Nerve in the hand is located

Goes to the thumb, pointer and middle fingers

Ulnar nerve in the hand is located

Goes to the pinky, and ring finger both anterior and posteriorly

Radial nerve in the hand is loacted

Posterior aspect of the thumb, pointer, and middle finger

Phases of Overhead throwing motion

Wind up, Stride, Arm cocking, Arm acceleration, Arm deceleration, Follow-through