Muscle Test of the Shoulder Joint Part II PDF

Muscle Test of the Shoulder Joint Part II Dr/ Mohamed Naeem Lecturer of Physical Therapy  Shoulder Horizontal Abduction Deltoid (posterior portion)  Factors Limiting Motion: 1-Tension of anterior fibers of capsule of glenohumeral joint 2- Tension of Pectoralis major and Deltoid...

Muscle Test of the Shoulder Joint Part II Dr/ Mohamed Naeem Lecturer of Physical Therapy  Shoulder Horizontal Abduction Deltoid (posterior portion)  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.  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 C5-C6  Normal & Good Patient Position: Prone with shoulder abducted to 90º, upper arm resting on table and forearm off edge of table with elbow flexed. Therapist Position and Grasps: Therapist stands beside the table, proximal hand is placed on the shoulder, and distal hand is placed proximal to elbow joint to give resistance. Resistance : Is given proximal to elbow. Motion takes place primarily at glenohumeral joint and not between scapula and thorax  Resistance: Grade 4: Moderate leading resistance is given in a form of pressing the upper arm down directly opposing line of raising the upper arm up. Grade 5: Maximum resistance is applied throughout the range of motion plus a "hold" position is kept at the end of the range. Instruction to patient: "Pull your upper arm up ---- Relax".  Fair Patient Position: Prone with shoulder abducted to 90 degrees, upper arm resting on table and lower arm hanging vertically over edge. Therapist Position: He stands beside the table, proximal hand is placed on the shoulder, and distal hand on the lateral border of scapula to stabilize it. Command: "Pull your upper arm up ----  Poor Patient Position: Short sitting with arm supported on table (smooth surface) in 90° of abduction Therapist Position and Grasps: Therapist stands behind the patient, proximal hand is placed on the shoulder, the distal is placed on the lateral border of scapula to stabilize it Command: "Slide your arm backward- Relax".  Trace & Zero Therapist Position and Grasps: Palpate the fibers of the posterior deltoid below and lateral to the spine of the scapula and on the posterior aspect of the proximal arm adjacent to the axilla. Command: "Try to move your arm backward ---- Relax".  Note Effect of Weakness Weakness of deltoid muscle posterior fibers will results in inability to perform horizontal abduction of the shoulder against gravity. Substitution: 1- Adduction of scapula with Trapezius. Caution !!!!! 2- Long head of the triceps. 3- Teres Major 4- Latissimus to some extend Shoulder Horizontal Adduction Upper pectoralis major Lower pectoralis major Range of motion 0o- 90o  Muscles contribute to Shoulder Horizontal Adduction Upper pectoralis major Origin: Medial half of anterior surface of clavicle Insertion: Intertubercle groove of humerus Action: Shoulder Horizontal Adduction Nerve supply: Lateral pectoral nerve: C5, C6, C7  Muscles contribute to Shoulder Horizontal Adduction Lower pectoralis major Origin: Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum Oponeurosis of the obliqus externus abdominis Insertion: Intertubercle groove of humerus Action: Shoulder Horizontal Adduction Nerve supply: Lateral and medial pectoral nerve: C6, C7, C8, Tl  Normal & Good Patient Position: Supine. Shoulder abducted to 90° and elbow flexed to 90° Therapist Position and Grasps: Therapist stands near the edge of the table, the proximal hand is placed under the shoulder to stabilize the scapula. but the distal hand grasps the upper arm proximal to elbow joint to give resistance Resistance: Is given proximal to elbow joint.  Resistance: Grade 4: Moderate loading resistance is given in a form of pressing down the upper arm directly opposing line of raising. Grade 5: Maximal resistance is given throughout the range of motion plus a "hold" position is kept at the end of the range. Command: "Raise your arm up to vertical position ---- Relax".  Fair Patient Position: Supine with arm abducted to 90º. Therapist Position and Grasps: Therapist stands near the edge of the table, the proximal hand is placed under the shoulder to stabilize the scapula. Command: "Raise your arm up to vertical position ---- Relax.  Poor Patient Position: Sitting on stool with arm resting on table in 90º of abduction. Therapist Position and Grasps: Therapist stands behind the patient, proximal hand is placed on the shoulder to stabilize the trunk. Command: "Pull your arm forward ---- Relax".  Trace & Zero Therapist Position and Grasps: Same as for "Grade 2", the distal hand palpates tendon of pectoralis major near insertion on anterior aspect of upper arm. Muscle fibers of both sternal and clavicular portions may be observed and palpated on upper anterior aspect of thorax. Command: "Try to move your arm forward ---- Relax"  Note Sternal and clavicular portions of pectoralis major may be isolated to some degree. In "Normal and Good Grade" test resistance is given in a direction opposite to the line of pull of the muscle fibers: Sternal or lower portion: upward and outward. - Clavicular or upper portion: downward and outward  Note In "Fair Grade" test, the arm is placed above 90 of abduction for testing the lower portion and below 90° of abduction for testing the upper portion. The patient is then asked to pull his arm to the vertical position for each direction of muscle fibers being tested.  Effects of Weakness Upper fibers: - Weakness of these fibers decreases the ability to draw the arm in horizontal adduction across the chest, making it difficult to touch the hand to the opposite shoulder. - Also it decreases strength of shoulder flexion and medial rotation.  Lower fibers: - Weakness of these fibers decreases the strength of medial rotation of the shoulder and adduction obliquely toward the opposite hip. - There is a loss of continuity of muscle action from the pectoralis major to external oblique and internal oblique on the opposite side with the result that the chopping or striking movements are difficult.  Shoulder External Rotation Teres Minor Infraspinatus R.O.M 90°  Muscles contribute to Shoulder External Rotation Teres Minor Origin: Upper 2/3, dorsal surface of lateral border of scapula Insertion: Lower facet of greater tubercle of the humerus, Shoulder joint capsule. Action: Laterally rotates the shoulder joint. Stabilizes the head of humerus in the glenoid cavity during movements of this joint. Nerve supply: Axillary Nerve: C5, C6.  Muscles contribute to Infraspinatus Origin: Medial 2/3 aspect of infraspinatus fossa of scapula Insertion: Medial facet of greater tubercle of the humerus, shoulder joint capscule Action: Laterally rotates the shoulder joint. Stabilizes the head of humerus in the glenoid cavity during movements of this joint. Nerve supply: Suprascapular nerve C4,C5,  Normal & Good Patient Position: Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge. Therapist Position and Grasps : Therapist stands beside table at the level of the patient's waist. The proximal hand and forearm is placed over the shoulder and scapula to stabilize it.  Resistance: It’s given in form of pressing down opposite line of motion. Grade 4: Moderate leading resistance is given in a form of pressing down directly opposite to the line of motion. Grade 5: Maximal resistance is given throughout the range of motion plus a "Hold", position is kept at the end of the range. Command: "Pull your hand up and toward your head ---- Relax".  Fair Position: Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge. Therapist Position and Grasps: Therapist stands beside table at the level of the patient's waist. The proximal hand and forearm is placed over the shoulder and scapula to stabilize it. The distal hand is placed over the arm above the elbow to prevent abduction to occur during the test. Command: "Pull your hand up and toward your head ---- Relax".  Poor Patient Position: Prone with entire arm over edge table in medially rotated position. Therapist Position and Grasps: Same as for the other grades but his two hands are placed. one over and one under the shoulder joint to stabilize the scapula. Command: "Turn your whole arm so that your palm and the inside of your elbow is facing you ---- Relax".  Trace & Zero Therapist Position and Grasps: Same as for "Grade 2" but one hand is palpating the muscle contraction of Teres Minor on the axillary border of scapula and infraspinatus over the body of scapula below the spine of scapula  Effect of weakness In case of weakness of these muscles the humerus assumes a position of medial rotation. Lateral rotation in anti-gravity positions is difficult or impossible.  Note Though for grading a weak lateral rotator group against gravity the prone position may be used, the supine position is preferred to eliminate the necessity of maximal trapezius fixation and decrease the assistance from deltoid posterior.  Shoulder Internal Rotation Subscapularis U. Pectoralis Major L. Pectoralis Major Latissimus Dorsi  Muscles contribute to Shoulder Internal Rotation Subscapularis Origin: Anterior surface of subscapular fossa Insertion: Lesser tubercle of the humerus Action: Shoulder Internal Rotation Nerve supply: upper and lower subscapular nerve C5,C6  Pectoralis Major Origin: Anterior surface of sterna1 half of clavicle. Anterior surface of sternum. Cartilages of first six or seven ribs. Oponeurosis of the obliqus externus abdominis. Insertion: Lateral lip of intertubercular groove of humerus Nerve Supply: Upper Fibers: Lateral pectoral nerve: C5, C6, C7. Lower Fibers: Lateral and medial pectoral nerve: C6, C7, C8, Tl.  Action: Upper Fibers: Flex the shoulder joint and horizontally adduct the humerus toward the opposite shoulder. Lower Fibers: Depress the shoulder girdle by virtue of attachment on the humerus. Horizontally adduct the humerus toward the opposite iliac crest.  Muscles contribute to Shoulder Internal Rotation Teres Major Origin: Dorsal surfaces of inferior angle and lower third of lateral border of scapula Insertion: Crest of lesser tubercle of humerus Action: Medially rotates, adducts and extends the shoulder joints Nerve supply: Lower subscapular nerve: C5, C6, C7  Muscles contribute to Shoulder Internal Rotation Latissimus dorsi Origin: a- Spines of lower 6 thoracic vertebrae b-Through the thoracolumbar fascia from the lumbar and sacral c- Lower 3-4 ribs d- Inferior angle of scapula E- Posterior 1/3 of external lip of iliac crest. Insertion: Intertubercle groove of humerus  Nerve supply: Thoracodorsal nerve C6, C7,C8 Action: With the origin fixed, it medially rotates, adducts and extends the shoulder joint. By continued action, it depresses the shoulder girdle, and assists in lateral flexion of the trunk. With the insertion fixed, it assists in tilting the pelvis anteriorly and laterally. Acting bilaterally, this muscle assists in hyperextending the spine and anteriorly tilting the pelvis, or in flexing the spine depending upon its relation to the axes of motion.  This muscle is extremely important in relation to movements such as climbing, walking with crutches, or hoisting the body up on parallel bars. Forceful arm movements in swimming, rowing and chopping are largely dependent on the strength of this muscle. All shoulder adductors and medial rotators act in these strong movements but the latissimus dorsi is probably of major importance. The latissimus dorsi may act as an accessory muscle of respiration.  Normal & Good Patient Position: Prone with head turned toward test side. Shoulder is abducted to 90° with folded towel placed under distal arm and forearm hanging vertically over edge of table. Therapist Position and Grasps: Therapist stands beside the table, the proximal hand and forearm is placed on shoulder and scapula to stabilize it but allowing freedom for the shoulder rotation the distal hand is placed at the patient's wrist level to give resistance.  Resistance: Grade 4: Moderate leading resistance is given in a form of pressing down directly opposite to the line of motion. Grade 5: Maximal resistance is given throughout the range of motion plus a "Hold", position is kept at the end of the range. Command: "Pull your hand back and up keeping your upper arm on the table ---- Relax  Fair Patient Position: Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge. Therapist Position and Grasps: Therapist stands beside the table, the proximal hand and forearm is placed on shoulder and scapula to stabilize it but allowing freedom for the shoulder rotation Command:"Pull your hand back and up keeping your upper arm on the table ---- Relax.  Poor Patient Position: Prone lying with entire arm hanging over the edge of table in lateral rotation (Palm and interior of elbow facing the patient). Therapist Position and Grasps: Therapist stands beside the table, the proximal hand and forearm is placed on shoulder and scapula to stabilize it but allowing freedom for the shoulder rotation Command: "Turn your whole arm in so that your palm and the interior of your elbow face me ----  Trace & Zero Fibers of Subscapularis may be palpated deep in axilla near insertion.  Latissimus Dorsi palpation is described in the laboratory on "Shoulder extension muscles" and the pectoralis major palpation is described in the laboratory on "shoulder horizontal adduction". Command: “Try to turn your whole arm that your palm and the interior of your elbow face me ---- Relax".  Effect of Weakness In as much as the medial rotator muscles are also the strong shoulder adductor muscles, the ability to perform both medial rotation and adduction is decreased by the weakness of these muscles.