Shoulder Anatomy and Palpation PDF

SHOULDER: ANTERIOR STRUCTURES Biceps Brachii Short Head Tendon Biceps brachii (long head) Biceps brachii (short head) Brachioradialis Brachialis Pronator teres The biceps brachii short head tendon originates from the apex of the coracoid process and traverses inferiorly next to the long head merg...

SHOULDER: ANTERIOR STRUCTURES Biceps Brachii Short Head Tendon Biceps brachii (long head) Biceps brachii (short head) Brachioradialis Brachialis Pronator teres The biceps brachii short head tendon originates from the apex of the coracoid process and traverses inferiorly next to the long head merging distally to form the bicipital aponeurosis. Unlike the long head of the biceps, the short head does not play a major role in the stabilization of the humeral head with deltoid contraction. Typically, the coracoid process is sensitive to palpation; therefore, light palpation of the tendon’s origin is necessary to limit guarding from overpressure. Origin: Coracoid process of the scapula Insertion: Radial tuberosity, bicipital aponeurosis Action: Elbow flexion and supination Innervation: C5-C6 (musculocutaneous nerve) Anterior Palpation Procedure • Place the patient supine with the elbow flexed and forearm supported. E6296/Speicher/Fig. 09.05/532252/JG/R1 • Locate the clavicle and trace it over to the anterior crease of the shoulder. The coracoid process is just below the inferior margin of the clavicle, just medial to the anterior crease of the shoulder. • Lightly apply a circular pressure to feel the coracoid process. • Move distally off the coracoid process, orienting your fingers perpendicular to the short head tendon of the biceps brachii. • Strum lightly over the short head tendon, which is medial to the long head tendon. • Resistive elbow flexion with supination will make the tendon under palpation more prominent. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient supine. • With your far hand, grasp the patient’s elbow, positioning it at 90°, then move the arm into approximately 90 to 100° of shoulder flexion. • Using your far hand, move the arm into a 90/90 horizontal adduction position, then rotate the forearm into a supinated position. • Apply humeral distraction and compression using your far hand or your torso if just applying compression. 210 Biceps brachii (short head tendon) palpation procedure. Biceps brachii (short head tendon) PRT clinician procedure. • Apply humeral and forearm rotation for finetuning with the far hand. • Corollary tissues treated: Biceps brachii, brachialis, anterior and middle deltoids T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES Subscapularis Greater tubercle Supraspinatus The subscapularis is the largest of the rotator cuff muscles, covering the anterior surface of the scapulae. It is also the only rotator cuff muscle to medially rotate the arm because of its insertion site at the lesser tubercle of the humerus. Origin: Scapular fossa Insertion: Lesser tubercle of the humerus, glenohumeral joint capsule Subscapularis Teres minor Action: Shoulder internal rotation, glenohumeral joint stabilization Innervation: C5-C6 (upper and lower subscapular nerves) Anterior Palpation Procedure • Place the patient in a side-lying position. • Flex the shoulder to approximately 70 to 90° and apply distraction anteriorly to pull the 09.07/532259/JG/R1 scapulaE6296/Speicher/Fig. off the chest wall. • While holding the arm, use your thumb or fingers to explore the inferior lateral margin of the scapula. While attempting to locate the inferior lateral surface of the scapulae, move under the latissimus dorsi and teres major during palpation. • Once your fingers or thumb are on the subscapular fossa, instruct the patient to internally rotate the arm to accentuate the subscapularis for palpation. Only the inferior margin of the subscapularis will be accessible to palpation. • Alternately, the patient can be palpated supine. When palpating supine, the arm and elbow should be in a supported 90/90 flexed position; apply slight distraction at the elbow. • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient supine. • With your far hand, grasp the arm above the elbow. • Using your far hand, move the shoulder into approximately 30° of extension and abduction. Subscapularis palpation procedure. Subscapularis PRT clinician procedure. • Apply humeral internal rotation with your far hand. • Using your far hand, apply humeral distraction or compression. • Corollary tissues treated: Latissimus dorsi, serratus anterior, teres major T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 211 SHOULDER: ANTERIOR STRUCTURES Serratus Anterior The majority of the serratus anterior is not accessible to palpation because of its coverage by the scapulae, latissimus dorsi, and pectoralis major. However, as its fibers extend anteriorly around the thorax, its axillary fibers are accessible to palpation. Traditionally in therapy, the serratus anterior is dubbed the punching muscle because it assists in the protraction of the scapula when reaching forward. It also stabilizes the scapula against the chest wall to prevent winging and works with the upper and lower trapezius in a force couple to facilitate upward scapular rotation. Subclavius Origin: Ribs 1 through 8 (often 9 and 10 also) Pectoralis minor Coracobrachialis Serratus anterior Insertion: Scapula (ventral surface at vertebral border) Action: Scapular abduction, upward rotation, and depression; stabilizes the scapulae against the thoracic wall Innervation: C5-C7 (long thoracic nerve) Palpation Procedure • Place the patient supine or in a seated position. • The axillary fibers of the serratus anterior are located between the margins of the pectoralis E6296/Speicher/Fig. 09.02/532242/JG/R1 major and latissimus dorsi. • Place your fingers within the axillary region on the rib cage, just underneath the lower margin of the pectoralis major. • Orient your fingers perpendicular to the fibers of the serratus anterior or lay them across the ribs, pointing toward the head. • The serratus anterior musculature has a soft speed-bump feel as you strum across their fibers. • To accentuate palpation of the muscle, have the patient punch the arm toward the ceiling against your resistance while palpating. • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Serratus anterior palpation procedure. PRT Clinician Procedure • The patient is supine with the knees bolstered. • While palpating the serratus anterior with the near hand, grasp the patient’s wrist with your far hand and move the arm into approximately 20 degrees of shoulder flexion. 212 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES • Using the far hand, move the arm through adduction and abduction. Typically, the treatment position of the arm is found either at the side of the patient’s torso or in slight adduction over the ipsilateral anterior hip. • With the far hand, apply marked distraction of the arm downwards towards to the ipsilateral hip. • With the far hand, apply internal rotation to the arm. • Fine-tune with application of wrist extension or flexion with the far hand. • Corollary tissues treated: Teres major, latissimus dorsi, obliques, diaphragm, intercostals See video 9.3 for the serratus anterior PRT procedure. Serratus anterior PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 213 SHOULDER: ANTERIOR STRUCTURES Pectoralis Minor The pectoralis minor lies on the upper thorax underneath the pectoralis major. The fibers of the pectoralis minor are oriented perpendicular to those of the pectoralis major and course inferiorly from the coracoid process to their rib attachments to form the anterior wall of the axillary region. Because the neurovascular bundle of the neck and shoulder pass under the pectoralis minor, lesions of the pectoralis minor can result in neurovascular compression, which may facilitate the development of thoracic outlet syndrome. Subclavius Origin: Ribs 3 through 5 Pectoralis minor Coracobrachialis Serratus anterior Insertion: Coracoid process of the scapulae (medial and superior surface) Action: Scapular protraction and abduction, rib elevation during forced inspiration (when scapula is fixed), scapular depression Innervation: C5-T1 (medial and lateral pectoral nerves) Palpation Procedure • Position the patient supine. • The pectoralis minor can be palpated indirectly throughE6296/Speicher/Fig. application of deep palpation across its 09.02/532242/JG/R1 fibers, but over and through the anterior aspect of the pectoralis major. This palpation procedure is less painful than accessing the pectoralis minor under the pectoralis major which is also detailed below. • To palpate the pectoralis minor directly, abduct the arm to expose the axillary region. • Gently slide your fingers under the lateral border of the pectoralis minor and onto the anterior chest wall. • While palpating inward, you will feel the lateral border of the pectoralis minor. Move your fingers inward and down in a strumming fashion to feel the fibers of the pectoralis minor. Be careful to use gentle pressure when utilizing this palpation method because it is often very painful. • To accentuate palpation of the muscle, ask the patient to depress the shoulder during palpation. • Patients with a large amount of breast tissue can be positioned in a side-lying position to move the tissue and the pectoralis major off the anterior chest wall. The palpation procedure in this position is the same as described earlier. • Note the location of any tender points or fasciculatory response at the muscle. 214 Pectoralis minor palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The treatment is similar to that used for the subclavius, with the exception of often applying a greater amount of humeral distraction and internal rotation. • Place the patient in a supine position. • Grasp the patient’s wrist with the far hand and pull the involved limb across the body toward the opposite hip. • With the far hand, move the arm up and down the patient’s opposite flank while keeping the limb extended. • Apply significant limb distraction with marked internal limb rotation with the far hand. • Alternate position: Place patients who can’t tolerate limb distraction in a side-lying position. With the far hand, grasp the posterior shoulder and move it into a protracted, adducted position. Using the far hand, fine-tune with scapular depression or elevation and rotation. • Corollary tissues treated: Pectoralis major, subclavius, AC joint Pectoralis minor PRT clinician procedure. ○○ ○○ ○○ T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 215 SHOULDER: ANTERIOR STRUCTURES Pectoralis Major The fibers of the pectoralis major are separated into two major divisions: the clavicular (upper) portion and the sternocostal (middle and lower) portion. The two divisions form part of the anterior axillary wall. Fibers from both divisions converge into a common tendon to insert on the humerus. Origin: Clavicular fibers: Clavicle (sternal half) Pectoralis major (clavicular) Anterior deltoid Sternocostal fibers: Sternum (anterior surface), ribs 1 through 6, 2 through 6 rib cartilage, aponeurosis of obliquus externus abdominis Insertion: Greater tubercle of the humerus Middle deltoid Action: All fibers: Shoulder adduction, internal rotation, horizontal adduction; thorax elevation during forced inspiration (with both extremities fixed) Pectoralis major (sternal) Clavicular fibers: Shoulder internal rotation, flexion Sternocostal fibers: Shoulder extension Innervation: Clavicular fibers: C5-C7 (lateral pectoral nerve) E6296/Speicher/Fig. 09.04/532248/JG/R1 Sternocostal fibers: C6-T1 (medial and lateral pectoral nerves) Palpation Procedure When palpating the pectoralis major of women, it is advisable to palpate around the breast tissue, not directly through it. Because many women feel uncomfortable with palpation in this area, explain why palpation in this area is needed and how it will be done before proceeding. Most important, gain consent from the patient before performing the palpation procedure. The two methods for moving the breast tissue away from the chest wall to gain access to the pectoralis major and other chest wall muscles are to (1) place the patient in a side-lying position, which will facilitate the breast tissue to fall away from the chest wall, or (2) have the patient manually move the breast tissue medially. In the side-lying position: • Support the arm at the elbow while slightly flexing the shoulder upward. • Apply slight distraction to the shoulder at the elbow. • The pectoralis major can be grasped with the thumb underneath its inferior border while the fingers above are in position to strum across the clavicular and sternocostal fibers. • During palpation, passively flex and extend the shoulder to accentuate the upper and lower fibers. 216 Pectoralis major palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: ANTERIOR STRUCTURES In a supine position: • Slightly abduct the shoulder. • Locate the inferior medial clavicle and lateral surface of the sternum. From this location, drop your fingers off the bony structures and onto the clavicular fibers. • Orient your fingers perpendicular to the fibers and strum across them toward their common tendon at the coracoid process. • Continue to explore the middle and inferior sternocostal fibers in the same way you explored the clavicular fibers. • Ask the patient to internally rotate the shoulder to accentuate palpation of the muscle fibers. For both positions: • Note the location of any tender points or fasciculatory response at the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Pectoralis major PRT clinician procedure. PRT Clinician Procedure • Place the patient supine. • Using the far hand, grasp the patient’s wrist with your dominant hand. • For the clavicular fibers, pull the arm across the chest above the nipple line. • For the sternal fibers, pull the arm diagonally across the chest at or below the nipple line. • With your far hand, apply humeral distraction and internal rotation. • Corollary tissues treated: AC joint, pectoralis minor, sternalis, sternocostal joint, serratus anterior T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 217 SHOULDER: POSTERIOR STRUCTURES Supraspinatus Greater tubercle Supraspinatus Infraspinatus The supraspinatus is one of the four rotator cuff muscles, which form the acronym SITS (supraspinatus, infraspinatus, teres minor, subscapularis). The muscle occupies the entire supraspinous fossa, traversing under the acromion as a tendon to insert on the greater tubercle of the humerus. A common method to place more emphasis on the supraspinatus during muscle testing is to use the empty can orthopedic special test. Origin: Supraspinous fossa of the scapula Insertion: Humerus (greater tubercle) Action: Shoulder abduction, shoulder external rotation, humeral head stabilization in the glenoid fossa Teres minor Posterior Palpation Procedure • To promote relaxation of the shoulder girdle, palpate while the patient is in a supine position, but you can also perform the palpation with the patient seated if necessary. E6296/Speicher/Fig. 09.11/532271/JG/R1 • Locate the spine of the scapula, then, using one or two fingers, strum the fibers of the supraspinatus either against or away from it, demarcating the fibers of the supraspinatus that run parallel to the scapular plane. • Follow the belly of the supraspinatus as it courses under the acromion. When the tendinous aspect is reached, strum over the fibrous tendon. • To accentuate this muscle, instruct the patient to abduct or externally rotate the humerus (or do both) during palpation. • Note the location of any tender points or fasciculatory response at the muscle, the tendon, or the supraspinatus attachment at the humeral head. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient supine and, with your far hand, move the shoulder into flexion and abduction while supporting the elbow with your far hand or torso. • The supraspinatus is typically most relaxed at 120° of abduction, with a greater amount of horizontal adduction positioning needed than the infraspinatus PRT procedure. 218 Innervation: C5-C6 (suprascapular nerve) Supraspinatus palpation procedure. Supraspinatus PRT clinician procedure. • With your far hand, apply external rotation. • Apply humeral distraction or compression with your far hand or torso to promote relaxation. • If possible, use the thenar aspect of your near hand to apply an inferior glide to the humerus to facilitate further relaxation. • Corollary tissues treated: Infraspinatus, upper trapezius, middle deltoid, teres minor T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. SHOULDER: POSTERIOR STRUCTURES Infraspinatus Greater tubercle Supraspinatus Infraspinatus The infraspinatus, the I in the SITS acronym for the rotator cuff group, also assists the other rotator cuff muscles to stabilize the humeral head in the glenoid fossa, particularly during overhead movements. The infraspinatus is composed of three distinct muscle bellies that can be palpated individually. The infraspinatus occupies most of the infraspinous scapular fossa, but its tendon, unlike that of the supraspinatus, does not traverse under the acromion. Rather, it crosses over the lateral border of the scapular spine to attach to the humerus. Lesions of the infraspinatus are common when rotator cuff weakness or impingement is present. Origin: Scapula (infraspinous fossa) Teres minor Insertion: Humerus (greater tubercle) Posterior Action: Shoulder external rotation, humeral head stabilization in the glenoid fossa Innervation: C5-C6 (suprascapular nerve) Palpation Procedure • Place the patient prone or supine. • Locate the spine of the scapula. E6296/Speicher/Fig. 09.11/532271/JG/R1 • Using one or two fingers, strum the upper fibers of the infraspinatus upwards against the spine of the scapula and for the middle and inferior fibers, pin and strum them against the scapula. With the patient supine, gravity and the weight of the thorax can be used to facilitate palpation of the infraspinatus against the scapula. • Follow the belly of the infraspinatus as it courses over the lateral border of the scapula. • To accentuate this muscle, instruct the patient to externally rotate the humerus during palpation. • Note the location of any tender points or fasciculatory response at the muscle, the tendon, or its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Infraspinatus palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 219