MMT Shoulder Muscles PDF

Testing the Muscles of the Upper Extremity Prof. Dr. Amir N Wadee Shoulder Joint Shoulder Horizontal Adduction Upper pectoralis major Lower pectoralis major  Range of motion 0 degrees to 90 degrees from neutral 0 degrees to 135 degrees from a fully ho...

Testing the Muscles of the Upper Extremity Prof. Dr. Amir N Wadee Shoulder Joint Shoulder Horizontal Adduction Upper pectoralis major Lower pectoralis major  Range of motion 0 degrees to 90 degrees from neutral 0 degrees to 135 degrees from a fully horizontally abducted position  Preferred starting position: The subject should be sitting with the shoulder in neutral rotation. The shoulder joint is flexed to 90 degrees and the elbow is flexed to 90 degrees. End position: The shoulder should be in a position of maximal horizontal adduction at the end of the movement.  Goniometric alignment: Axis: The superior aspect of the acromion process of the scapula, 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. Goniometric alignment:  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 & medial Pectoral nerve Palpation site: - Upper fibers (clavicular portion): inferior to the medial end of clavicle  Muscles contribute to Shoulder Horizontal Adduction Lower pectoralis major Origin: Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum Insertion: Intertubercle groove of humerus Action: Shoulder Horizontal Adduction Nerve supply: Lateral & medial Pectoral nerve Palpation site: Lower fibers (sternal portion): anterior axillary fold  Secondary Movers Anterior deltoid, coracobarchialis and biceps  Normal & Good Position: Supine with arm abducted to 90 degrees. Stabilization: Stabilize scapula to prevent abduction of the scapula. Palpation: Below and near the origin at sternal end of the clavicle. Palpation Desired Motion: Patient adducts arm through range of motion. Resistance: Is given proximal to elbow joint.  Fair Position: Supine with arm abducted to 90º. Stabilization: Stabilize scapula to prevent abduction of the scapula. Palpation: Below and near the origin at sternal end of the clavicle. Desired motion: Patient adducts arm to vertical position.  Poor Position: Sitting with arm resting on table in 90º of abduction. Stabilization: Stabilize trunk. Palpation: Below and near the origin at sternal end of the clavicle. Desired motion: Patient brings arm forward through ROM.  Trace & Zero Examiner 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 thoracic.  Note Factor limiting Motion: Tension of shoulder extensor muscles (Tension of latissimus dorsi, posterior deltoid and teres major) Contact of arm with trunk. Fixation: In forceful horizontal adduction, contraction of Obliquus externus abdominus muscle on same side. Substitution: 1-Anterior portion of deltoid 2-Coracobrachialis 3- Short Head of biceps. 4- Trunk rotation  N.B: When testing the upper fibers (clavicular portion) : Put the arm below 90 degree. When testing the Lower fibers (sternal portion) : Put the arm above 90 degree  Effect of weakness: 1- Upper fibers (clavicular portion): - Difficulty to bring the arm to opposite shoulder - Decrease strength of shoulder flexion and medial rotation 2- Lower fibers (sternal portion) : - Difficulty to bring the arm to opposite hip - From a supine position, if the subject’s arm is placed diagonally overhead, he will find it difficult to lift the arm from the table. - He will also have difficulty holding any large or heavy object in both hands at or near waist level. Shoulder External Rotation Teres Minor Infraspinatus  Lateral (External) Rotation Patient Instructions: Ask the patient to rotate their arm up toward their head as far as they can. Starting and Ending Position Supine with 90º of shoulder abduction and 90º of elbow flexion. The table should not support the elbow. (Refer to above picture) Fulcrum on the olecranon process. The moving arm should be aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor. Ending Position: Same as before Shoulder External Rotation Teres Minor Infraspinatus  Range of motion: 0 degrees to 90 degrees. Preferred starting position: The subject should be in supine, with the shoulder joint positioned in 90 degrees of abduction. The forearm is placed in mid position between supination and pronation. The elbow is flexed in 90 degrees. The humerus is placed level with the acromion process by placing a pad under the upper arm.  Goniometric alignment: Axis: Over the olecranon process of the ulna Stationary arm: Align perpendicular to the floor Moving arm: Align with the shaft of the ulna, siting the styloid process of the ulna. Goniometric alignment:  N.B: (Alternate position) The subject is in the prone position with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees over the edge of the table.  Muscles contribute to Shoulder External Rotation Origin: Teres Minor Posteriorly on upper & middle aspect of lateral border of scapula Insertion: Posterior surface of greater tubercle of the humerus Action: Shoulder Extension Nerve supply: Axillary Nerve: C5, C6. - Palpation site: - Lateral border of the scapula superior to the inferior angle of the scapula  Muscles contribute to Shoulder External Rotation Origin: Infraspinatus Posteriorly on upper & middle aspect of lateral border of scapula Insertion: Posterior surface of greater tubercle of the humerus Action: Shoulder Extension Nerve supply: Suprascapular Nerve: C4, C5, C6. - Palpation site: - Inferior to the spine of the scapula (body of scapula)  Secondary Movers Posterior deltoid  Normal & Good Position: Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge. Stabilization: Stabilize scapula with hand and forearm, but allow freedom for rotation. Palpation point: None Desired motion: Patient swings lower arm forward and upward and 'laterally rotates shoulder through range of motion. Resistance: Is given above wrist on forearm.  Fair Position: Prone with shoulder abducted to 90º, upper arm supported on table and lower arm hanging vertically over edge. Stabilization: Stabilize scapula and place hand against anterior surface of arm to prevent abduction (without interfering with motion). Palpation: None Desired motion: Patient swings lower arm forward and upward and laterally rotates shoulder through ROM.  Poor Position: Prone with entire arm over edge table in medially rotated positron. Stabilization: Stabilize scapula. Palpation: None Desired Motion: Patient laterally rotates arm through range of motion. (supination of the forearm should not be allowed to substitute for full range in lateral rotation.)  Trace & Zero The Teres minor may be palpated on axillary border of scapula, and Infraspinatus over body of scapula below the spine.  Note Factors Limiting Motion: a- Tension of superior portion of capsular ligament. and coracohumeral ligament. b- Tension of lateral rotator muscles of shoulder. (subscapularis, pectoralis major, teres major and latissimus dorsi) Fixation: a- Weight of trunk. b- Contraction of Trapezius and Rhomboid major and minor muscles to fix scapula Substitutions: 1. Wrist extensors 2. Roll the shoulder backwards.  Effect of weakness: Difficulty in some activities as: Using a screwdriver Installing a lightbulb into a socket on the ceiling. Shoulder Internal Rotation Subscapularis U. Pectoralis Major L. Pectoralis Major Latissimus Dorsi Medial (Internal) Rotation Patient Instructions: Ask the patient to rotate their arm down as far as they can. Starting Position Supine with 90º of shoulder abduction and the elbow is in 90º of flexion. The table should not support the elbow. The fulcrum centered over the olecranon process. The moving arm is aligned with the ulnar styloid and the stationary arm should be perpendicular to the floor. Ending Position Same as above Normal ROM is 60-70˚; the patient is in 68º of internal rotation. 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: Suprascapular Nerve: C4, C5, C6. - Palpation site: - Deep in the axilla  Secondary Movers Pectoralis major Teres major Latissimus dorsi  Muscles contribute to Shoulder Internal Rotation Upper pectoralis major Origin: Medial half of anterior surface of clavicle Insertion: Intertubercle groove of humerus Action: Shoulder Internal Rotation Nerve supply: Lateral & medial Pectoral nerve Palpation site: - Upper fibers (clavicular portion): inferior to the medial end of clavicle  Muscles contribute to Shoulder Internal Rotation Lower pectoralis major Origin: Anterior surface of costal cartilage of first six ribs, adjacent portion of sternum Insertion: Intertubercle groove of humerus Action: Shoulder Internal Rotation Nerve supply: Lateral & medial Pectoral nerve Palpation site: Lower fibers (sternal portion): anterior axillary fold  Muscles contribute to Shoulder Internal Rotation Origin: Latissimus dorsi 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 Internal Rotation Nerve supply: Thoracodorsal nerve C6-C8 - Palpation site: - Along the midaxillary line on the trunk.  Normal & Good Position: Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge. Stabilization: Stabilize scapula with hand and forearm, but allow freedom for rotation. Palpation: None Desired Motion: Patient swings lower arm backward and up- ward and medially rotates shoulder through range of motion. Resistance: Is proximal to wrist on forearm.  Fair Position: Prone with shoulder abducted to 90 degrees, upper arm supported on table and lower arm hanging vertically over edge. Stabilization: Stabilize scapula. Palpation: None Desired Motion: Patient swings lower arm backward and upward and medially rotates shoulder through range of motion.  Poor Position: Prone with arm over edge of table in lateral rotation. Stabilization: Stabilize scapula. Palpation: None Desired Motion: Patient medially rotates arm through range of motion. (Pronation of the forearm should not be allowed to substitute for full range in medial rotation.)  Trace & Zero Fibers of Subscapularis may be palpated deep in axilla near insertion.  Factors Limiting Motion: Tension of capsular ligament Tension of infraspinatus and teres minor Fixation: Weight of arm  Effect of weakness: Difficulty when lifting the hand away from the back as: Tucking a shirt into a pair of pants (in males) Hooking a bra (in females)  N.B: The subject may be placed in the prone position with the shoulder in 90 degrees abduction and the elbow flexed to 90 degrees over the edge of the table. Shoulder Abduction to 90º Middle Deltoid Supraspinatus  Abduction Patient Instructions: Have the patient bring their arm out to their side and as close to their head as they can. Make sure that their palm faces upward throughout the motion. Starting Position The patient is supine with arm at side; the palm should be facing interiorly. The fulcrum is placed at the acromion process. The stationary and moving arms are aligned with the anterior midline of the humerus. Ending Position The stationary arm should remain still and parallel to the sternum. The moving arm should still be resting at the anterior midline of the humerus. Normal ROM between 160 and 180º; the patient in the picture is in 174º of abduction Shoulder Abduction to 90º Middle Deltoid Supraspinatus  Muscles contribute to Shoulder Abduction to 90º Middle Deltoid Origin: Acromion process Insertion: Deltoid tuberosity on the lateral humerus Action: Shoulder Abduction to 90º Nerve supply: Axillary nerve c5-c6 - Palpation site: - Lateral/inferior to the acromion process.  Muscles contribute to Shoulder Abduction to 90º Supraspinatus Origin: Supraspinatus fossa Insertion: Greater tubercle of the humerus Action: Shoulder Abduction to 90º Nerve supply: Suprascapular nerve C5-C6  Secondary Movers Anterior & Posterior deltoid  Note Factors Limiting Motion: Stiffness of shoulder joint. Tension of latissimus dorsi and teres major. Fixation: Contraction of Trapezius and Serratus anterior muscles. Serratus anterior and upper fibers of trapezius assist in upward rotation of scapula as well as in fixation.  Substitution: Shoulder elevation Lateral flexion (side bend) the trunk NB: Although the deltoid is a strong abductor, it is the supraspinatus, not the deltoid, that initiates the movement  Normal & Good Position: Sitting with arm at side in mid-position between medial and lateral rotation. Elbow flexed a few decrees. Stabilization: Stabilize scapula. Palpation: Just below the acromion process of the scapula. Desired Motion: Patient abducts the humerus to 90º(palm down). Resistance : Is given proximal to elbow  Fair Position: Sitting with arm at side in midposition between medial and lateral rotation. Elbow flexed a few degrees. Stabilization: Stabilize scapula. Palpation: Just below the acromion process. Desired Motion: Patient abducts arm to 90º (palm down).  Poor Position: Supine with arm at side in midposition between medial and lateral rotation. Elbow slightly flexed. Stabilization: Stabilize scapula over acromion. Alternate Desired Motion: Patient abducts arm to 90º without Lateral rotation at shoulder joint  Trace & Zero Examiner palpates middle section of Deltoid on lateral surface of upper third of arm  Note Patient may laterally rotate arm and attempt to substitute Biceps brachii during abduction. Arm should be kept in midposition between medial and lateral rotation. Although the deltoid is a strong abductor, it is the supraspinatus, not the deltoid, that initiates the movement  Note Range of Motion: 0° TO 90° Factors Limiting Motion: Tension of expansions of extensor tendons of fingers. Fixation: Weight of arm  Evidence- Based Practice for Therapeutic Exercise