MMT Shoulder Muscles PDF

Testing the Muscles of the Upper Extremity Prof. Dr. Amir N Wadee Shoulder Joint  Shoulder Flexion Anterior Deltoid Ccoracobrachialis Shoulder Goniometry  Introduction 1. It is the measuring of angles created by the bones of the body at the joints. 2....

Testing the Muscles of the Upper Extremity Prof. Dr. Amir N Wadee Shoulder Joint  Shoulder Flexion Anterior Deltoid Ccoracobrachialis Shoulder Goniometry  Introduction 1. It is the measuring of angles created by the bones of the body at the joints. 2. These joints are measured by a goniometer. 3. It has a moving arm, stationary arm, and the fulcrum. 4. The fulcrum or body is placed over the joint being measured and on it is a scale from 0 to 180. 5. The stationary arm will be aligned with the inactive part of the joint measured, while the moving arm is placed on the part of the limb which is moved in the joint’s motion. 6. For example, when measuring knee flexion, the stationary arm will be aligned over the thigh in line with the greater trochanter of the femur.  Introduction - continue 7. The fulcrum is aligned over the knee joint or lateral epicondyle of the femur, and the moving arm with the midline of the leg or lateral malleolus. 8. Performing these tests is important for many reasons. The mobility of joints is important for diagnosis and determining the presence or absence of dysfunction. 9. In a chronic condition, goniometry can measure the progression of the disorder. An example of this is the progression of rheumatoid arthritis. 10. Furthermore, joint motion measurement can evaluate improvements or lack of progression during rehabilitation. 11. This not only provides motivation for the patient when there are improvements, but also can decipher if modifications need to be made if treatment is not effective.  Flexion R.O.M: - 0 – 180 degrees Patient Instructions: Once the goniometer is aligned properly ask the patient to lift the arm up just as if they were raising their hand to ask a question. Be sure that the patient keeps the palm of their hand facing in toward their body. Starting Position Patient is supine with arm at side and the palm of the hand facing the body. The fulcrum of the goniometer is placed over the acromion process. The stationary and moving arms are aligned with the midline of the humerus and lateral epicondyle. Ending Position The moving arm remains in line with the lateral epicondyle and midline of the humerus. The examiner supporting the patient’s extremity. The stationary arm should remain in its starting position, only now it should be in line with the lateral midline of the thorax. Normal ROM for glenohumeral flexion is 160 to 180º; in the picture the patient is in 180º of flexion.  Shoulder Flexion Anterior Deltoid Ccoracobrachialis  Muscles contribute to Shoulder Flexion Anterior Deltoid Origin: Anterior lateral third of the clavicle Insertion: Deltoid tuberosity on the lateral humerus Action: Shoulder Flexion Nerve supply: Axillary nerve c5-c6 - Palpation site: - Inferior to lateral third of clavicle Muscles contributes to Shoulder Flexion Ccoracobrachialis Origin: Coracoid process of the scapula Insertion: Middle 1/3 of the medial surface of the humerus Action: Shoulder Flexion Nerve supply: Musculotendinous nerve c5-c7 - Palpation site:In the axilla, under the inferior border of the pectoralis major muscle  Secondary Movers Middle deltoid Pectoralis major Biceps brachii  Normal and Good Position: Sitting with arm at side and elbow slightly flexed Stabilization: Stabilize scapula. Palpation Point: Between lateral portion of clavicle and coracoid process. Desired motion: Patient flexes arm to 90º (palm down to prevent lateral rotation with substitution by the Biceps brachii) Subject directive: “Hold your arm up and do not let me push it down.” Resistance: Is given above elbow.( Patient should not be allowed to rotate or horizontally adduct or abduct arm)  Fair The same as Normal and Good techniques but without given resistance  Poor Position: Patient sideling with arm at side resting on smooth board (or supported by examiner) and elbow slightly flexed. Stabilization: Stabilize scapula. Palpation Point: Between lateral portion of clavicle and coracoid process. Desired motion: Patient brings arm forward to 90º of flexion Trace and Zero Position: Back lying. Palpation: Examiner palpates fibers of anterior portion of Deltoid on anterior aspect of shoulder joint. Palpation site: Inferior to the lateral third of the clavicle. 2- Coracobrachialis Palpation site: In the axilla, under the inferior border of the pectoralis major muscle. Caution!!!!  Notes Range Of motion: 0-180º Factors Limiting Motion: 1- Stiffness of shoulder joint Tension of latissimus dorsi, posterior deltoid and teres major Fixation: Contraction Trapezius & Serratus anterior muscles. Serratus anterior and upper fibers of Trapezius assist in upward rotation of scapula as well as in fixation  Substitution: 1-Scapular elevation (upper trapezius) 2- Horizontal adduction (Pectoralis major) 3- Lateral rotation (biceps brachii)  Shoulder Extension Latissimus dorsi Teres Major Teres Minor  Extension ROM 0 – 180 degree 0 to 40/60 degrees (from neutral) Patient Instructions: Ask the patient to simply lift their arm off the table as far as they can. Starting Position Patient is prone with arm at side; make sure the head is facing away from the shoulder being tested. Elbow bent slightly and the palm facing in toward the body. The fulcrum is placed over the acromion process. The stationary and moving arms are aligned with the lateral midline of the humerus and the lateral epicondyle. Ending Position The moving arm remains in line with the lateral epicondyle and the examiner should support the patient’s extremity. The stationary arm in line with the midline of the thorax. Normal ROM for glenohumeral extension is 40 to 60º; in the picture the patient is in 61º of extension.  Shoulder Extension Latissimus dorsi Teres Major Teres Minor  Muscles contribute to Shoulder Extension Latissimus dorsi Origin: a- Spines of lower 6 thoracic and lumbar vertebrae b- Posterior surface of sacrum& Posterior aspect of crest of ileum c- Lower 3-4 ribs d- Inferior angle of scapula Insertion:Intertubercle groove of humerus Action:Shoulder Extension Nerve supply: Thoracodorsal nerve C6-C8 - Palpation site: - Along the midaxillary line on the trunk.  Posterior deltoid Origin: - Posterior border of scapular spine - Insertion: - Deltoid tuberosity on thelateral humerus - Nerve supply: - Axillary nerve c5-c6 - Palpation site: - Inferior and lateral to the spine of the scapula  Muscles contribute to Shoulder Extension Teres Major Origin: Lower 1/3 of the axillary border of the scapula Insertion: Medial lip of intertubercular groove of humerus Action: Shoulder Extension Nerve supply: Subscapular nerve C5- C6. - Palpation site: - Lateral to the inferior angle of the scapula  Muscles contribute to Shoulder Extension Teres Minor Origin: Posteriorly on upper & middle aspect of lateral border of scapula Insertion: Posterior surface of greater tubercle of the humerus Action: Shoulder Extension. external rotation Nerve supply:Axillary Nerve: C5, C6. Palpation site: - Lateral border of the scapula superior to the inferior angle of the scapula  Secondary Movers Long head of the triceps brachii  Normal & Good Position: Prone with arm medially rotated and Adducted (palm up to prevent lateral rotation). Stabilization: Stabilize scapula. Desired Motion: Patient extends arm through range of motion. Subject directive: “Lift your arm as high as you can toward the ceiling and hold it. Do not let me push it down.” Resistance: Is given proximal to elbow.  Fair Position: Prone with arm at side. Stabilization: Stabilize scapula. Desired Motion: Patient extends arm through range of motion. Subject directive: “Lift your arm as high as you can toward the ceiling and hold it. Do not let me push it down.”  Poor Position: Sideling with arm flexed and resting on smooth board (or supported by examiner). Stabilization: Stabilize scapula. Desired Motion: Patient extends arm in position of medial rotation through range. of motion.  Trace & Zero Position: Prone. Examiner palpates fibers of Teres major on lower part of axillary border of scapula (not shown) and fibers of Latissimus dorsi slightly below.  The latissimus dorsi is palpated (along the midaxillary line on the trunk) inferiorly and lateral to the inferior angle of the scapula on the side of the thoracic wall as the subject attempts to extend the shoulder. The teres major palpated lateral to the inferior angle of the scapula and the posterior deltoid palpated inferior and lateral to the spine of the scapula. (Shown: palpating the latissimus dorsi).  Note Range Of motion: - 180 to 0 degrees - 0 to 40/60 degrees (from neutral) Factors Limiting Motion: 1-Tension of shoulder flexor muscles. 2-Contact of greater tubercle of humerus with acromion posteriorly. Fixation: Contraction of Rhomboideous major and minor and Trapezius muscles. Weight of trunk  Substitution: The subject may attempt to lift and rotate the trunk. During unsuccessful attempts to shrug the shoulder the inferior angle of the scapula will move medially toward the cervical spine (scapular adduction), and downward motion (rotation) also may occur.  Effect of weakness: Latissimus dorsi: decreased strength of shoulder extension and lateral trunk flexion (side bending) Posterior deltoid: decreased strength of shoulder extension and internal rotation. Teres major: decreased strength of shoulder extension  N.B: The latissimusdorsi is a powerful shoulder extensor Is important in some movements as climbing, walking with crutches and walking between parallel bars Active during forceful activities such as swimming, rowing/paddling, or chopping movements. Act as an accessory muscle of respiration The teres major is occasionally known as the “little latissimus”, it pulls the shoulder downward to help stabilize the head of the humerus during abduction. Shoulder Horizontal Abduction Deltoid (posterior portion)  Range of motion (ROM): 0 – 45 degree (from neutral) 0 – 135 degree (from complete horizontal abduction to complete horizontal adduction)  Preferred starting position: The subject should be sitting with the shoulder in neutral rotation. The shoulder should be abducted to 90 degrees with the elbow in 90 degrees of flexion.  End position: The shoulder should be in a position of maximal horizontal abduction with the scapula fully adducted.  Goniometric alignment: Axis: The superior aspect of the acromion process through the head of the humerus Stationary arm: Align along the midline of the shoulder siting the base of the neck Moving arm: Align along the midline of the humeral shaft, siting the lateral epicondyle of the humerus.  Stabilization: The thorax must be stabilized against the back of a chair to prevent trunk rotation. Substitutions: The subject may attempt to rotate the trunk to gain more movement. Elbow extension and scapular elevation.  Muscles contribute to Shoulder Horizontal Abduction Deltoid (posterior portion) Origin: Inferior edge of the scapular spine Insertion: Deltoid tuberosity on the lateral humerus Action: Shoulder Horizontal Abduction Nerve supply: Axillary nerve c5-c6 - Palpation site: - Inferior and lateral to the spine of the scapula  Secondary Movers Long head of the triceps brachii  Position: Normal & Good Prone with shoulder abducted to 90º, upper arm resting on table and lower arm hanging vertically over edge. Stabilize: scapula in adduction. Palpation point: Below the spine of the scapula. Desired motion: Horizontal abduction of humerus to the level of the table 90º. Subject directive: “Lift your elbow up toward the ceiling and hold it. Do not let me push it down.” Resistance : Is given proximal to elbow. Motion takes place primarily at glenohumeral joint and not between scapula and thorax  Fair Position: Prone with shoulder abducted to 90 degrees, upper arm resting on table and lower arm hanging vertically over edge. Stabilization: Stabilize scapula. Desired motion: Patient abducts upper arm through range of motion Subject directive: “Lift your elbow up toward the ceiling and hold it. Do not let me push it down.”  Poor Position: Sitting with arm supported in a position of 90º of flexion. Stabilization: Stabilize scapula. Desired Motion: Patient horizontally abducts arm through range of motion.  Trace & Zero Muscle fibers of posterior portion of Deltoid are palpated on posterior aspect of shoulder joint.  Note Factors Limiting Motion: 1-Tension of anterior fibers of capsule of glenohumeral joint 2- Tension of Pectoralis major and Deltoid (anterior fibers) Fixation: Contraction of Rhomboid major and minor and Trapezius (primarily) middle and lower fibers) Substitution: 1- Adduction of scapula with Trapezius. Caution !!!!! 2- Long head of the triceps. 3- Teres Major 4- Latissimus to some extend Caution !!!!!  Evidence- Based Practice for Therapeutic Exercise