Scapular Muscle PDF

Course Title: Test and Measurement Course Code: [FM203] Faculty of Physical Therapy Department: Basic Sciences Scapular Muscles Manual muscle test and R O M Measurement Dr.Peter Ramzy Scapular Movements Protraction (Abduction) Retraction...

Course Title: Test and Measurement Course Code: [FM203] Faculty of Physical Therapy Department: Basic Sciences Scapular Muscles Manual muscle test and R O M Measurement Dr.Peter Ramzy Scapular Movements Protraction (Abduction) Retraction (Adduction) Abduction &Upward rotation Adduction &Downward rotation Elevation Depression Scapular Abduction and Upward Rotation Serratus Anterior Origin:  Outer surfaces and superior borders of upper eight or nine ribs. The fibers run obliquely (to varying degrees) between these septa, forming a multipennate muscle architecture. Insertion  It inserts on the front of medial border of the scapula.  The muscle is divided into three parts :  Upper / Superior : 1st to 2nd rib → superior angle of scapula.  Middle / Intermedius : 2nd to 3rd rib → medial border of scapula.  Lower / Inferior : 4th to 9th rib → medial border and inferior angle of scapula. It is the most powerful and prominent part. Nerve supply Long thoracic nerve C5, C6, C7. Action or function of serratus anterior  The main actions are protraction and upward rotation of the scapulothoracic joint. , which allows for overhead arm movement.  The serratus anterior, also known as the “boxer’s muscle,” is largely responsible for the protraction of the scapula, a movement that occurs when throwing a punch.  It’s also a key scapular stabilizer, keeping the shoulder blades against the ribcage. in addition the lower fibers may depress the scapula and the upper fiber may elevates it slightly.  When the shoulder girdle is fixed, all three parts of the serratus anterior muscle work together to lift the ribs, assisting with forced inspiration.  Range of Motion: In general, the abduction displacement of the scapula is approximately equivalent to the space of 3 to 4 fingers. This Range of Motion may be limited by: 1- Tension of trapezoid ligament (limits upward rotation of scapula upon clavicle). 2. Tension of Trapezius and Rhomboids major and minor. Effect of Weakness of the Serratus Anterior Muscle The main sign of weakness of the serratus anterior muscle will be the winging of the scapula. A subject with a paralyses serratus muscle will not be able to raise the arm overhead. The Paralysis result from Long thoracic nerve injury which result from direct trauma (scapular or clavicular fractures) or repetitive carrying heavy backpack Test of scapular winging The patient is pushing against the wall the scapular medial border and inferior angle will be prominent Grade 3 "Fair Strength" 1.Patient Starting Position: supinelying with arm flexed to 90° and scapula resting on table. 2.Therapist Position and Grasps: Therapist standing beside the treatment table at the level of the patient hips. The proximal hand is fixing the thorax sideway just below the scapula. 3.Command: Push your arm in front of you as if you want to reach the ceiling ---- relax. Grades 4 and 5 "Good and Normal Strength" 1.Patient Starting Position: Same as for "Grade 3" 2.Therapist position and grasp: Therapist is standing sideway beside the treatment table at the level of the patient's head. The arm of the patient is in front of him. The proximal hand grasps around the patient's elbow and the distal hand grasps around the patient's wrist and forearm. 3.Resistance: Grade 4: A moderate leading resistance is given in a form of pressing down directly opposing the line of raising. Grade 5: A maximum leading resistance is given throughout the range of motion plus a "Hold" Position is kept at the end of the range. 4.Command: Same as for "Grade 3," Plus "Hold" when testing for "Grade 5". Grade 2: "Poor Strength" 1.Patient Starting Position: Sitting with arm flexed at 90° and arm resting on a table. 2.Therapist Position and Grasps: Therapist stands behind the patient and stabilizes the thorax with Proximal hand placed over the shoulder. 3.Command: "Push your arm forward sliding it on the table ---- Relax". Grade 1 and 0 "Trace and Zero Strength" 1.Patient Starting Position: Same as for "Grade 2" or sitting with his arm flexed at 90° without the table support. 2.Therapist Position and Grasps: Therapist is standing facing the affected shoulder. The proximal hand is placed on the outer surface of the ribs to palpate contraction and the distal hand grasps the patient arm forcing it slightly backward to stimulate a contraction of Serratus Anterior Muscle. Scapular Elevation Upper fiber of Trapezius Levator Scapulae Accessory Muscles: Rhomboids Major and Minor Upper fiber of Trapezius Origin: External occipital protuberance Medial 1/3 of superior nuchal line Nuchal ligament Spinous process of 7th cervical vertebra Insertion: Lateral 1/3 of clavicle Acromion process of scapula  Ventral ramus Cranial root Nerve Supply: Accessory nerve and ventral ramus: C2, C3, C4.  Action:  The trapezius upper fibers elevate the scapula.  With the insertion fixed and acting Unilaterall: The upper fibers extension, laterally flex and rotate the head and joints of the cervical vertebrae toward the opposite side.  With the insertions fixed and acting Bilaterally: the upper trapezius extends the head and neck.  Levator Scapulae: Origin: Transverse processes of first four cervical vertebrae. Insertion: Medial border of scapula between superior angle and root of spine. Nerve Supply: Dorsal Scapular Nerve: C3, C4, C5 C3, C4, C5 Action: Elevates the scapula and assists in down ward rotation.  With the insertion fixed Acting unilaterally, - it rotates to the other side and laterally flexed the cervical vertebrae to the same side  With the insertion fixed Acting bilaterally, - the levator scapulae may assist in extension of the cervical spine.  Range of motion With full range of motion the shoulder is brought upper with a distance of approximately 3 fingers separating it with the ear inferior lobe.  Scapular Elevation Range of Motion may be Limited By  Tension of Costoclavicular ligament  Pectoralis minor, Subclavius and Trapezius (lower fibers).  Test Procedures Grade 3 "Fair Strength" 1.Patient Starting Position: Sitting arms at sides. 2.Therapist Position: Therapist stand behind the patient. 3.Command: "Pull your shoulders upward as much as you can ---- relax". Grades 4 and 5 : "Good and Normal Strength" 1.Patient Position: Same as for "Grade 3". 2.Therapist Position and Grasps: Same as for "Grade 3" plus his two hands are placed over each shoulder to give resistance. 3.Resistance: Grade 4: A moderate leading resistance is given in a form of pressing down directly opposing the line of motion. Grade 5: A maximum resistance is given in the same manner as for "Grade 4" plus a "hold" position is kept at the end of the range of motion. 4.Command: Grade 4: Pull your shoulders up ---- relax. Grade 5: Pull your shoulders up ---- hold ---- relax. 1.Patient Starting Position: Prone lying position 2.Therapist Position and Grasps: Therapist stands beside the table at the level of the patient's waist. His two hands grasp each patient's shoulder to support them. 3.Command: "Pull your shoulders toward your ears ---- relax Grades 1 and 0 "Trace and Zero Strength" 1.Patient Starting: Same as for "Grade 2" 2.Therapist Position and Grasps: Same as for "Grade 2" but one hand is used to palpate the upper fibers of trapezius, parallel to cervical vertebrae and near their insertion above the clavicle. 3.Command: Same as for "Grade 2" Scapular Adduction Trapezius (middle fibers) Accessory Muscles:  Trapezius upper and lower fibers.  Rhomboid major and minor  Trapezius (middle fibers) Origin: Spinous processes and Supra spinous ligament of 1st to 5th thoracic vertebrae. Insertion: Medial acromion margin and superior lip of spine of scapula. Nerve Supply: Accessory ventral ramus: C2, C3, C4. Action:  Responsible for the scapula adduction.  They also maintain a stabilization role during the scapula downward rotation.  Range of Motion: From the abduction position to the adduction position, the scapula travels a distance equivalent to the space formed by 3 to 4 fingers. This range of motion may be limited by the following factors:  Tension of the conoid ligament (limits backward rotation of scapula upon clavicle).  Tension of Pectoralis major and minor and serratus anterior muscles.  Contact of vertebral border of scapula with spinal musculature.  Test Procedures Grade 3 "Fair Strength" 1.Patient Starting Position: Prone lying with arm abducted to 90° and laterally rotated, elbow flexed to a right angle. 2. Therapist Position and Grasps: Therapist stands beside the table at the level of the patient's waist. The proximal hand is placed over the thorax below the scapula to stabilize the thorax. 3. Command: Raise your arm up (in horizontal abduction) and adduct the scapula relax. Grades 4 and 5 "Good and Normal Strength" 1.Patient Starting Position: Same as for "Grade 3" 2.Therapist Position and Grasps: Same as for "Grade 3". The proximal hand is used to stabilize the thorax and the distal hand applies resistance on the lateral angle of the scapula. (no pressure is placed on the humerus). 3.Resistance: Grade 4: Moderate leading resistance is given directly opposing the line of motion. Grade 5: Maximum leading resistance is given throughout the range of motion plus a "hold" position is kept at the end of the range. 4. Command: Same as for "Grade 3" plus "hold" (at the end of the range) when testing for "grade 5". Grade 2 "Poor Strength" 1.Patient Starting Position: Sitting with affected arm resting on a table in a position midway between horizontal adduction and abduction. 2. Therapist Position and Grasps: Therapist stands in front of the patient, with one hand placed over the opposite shoulder to stabilize the thorax. 3.Command: "Pull your arm slightly backward and bring your scapula back and in ---- relax." Grade 1 and 0 "Trace and Zero Strength" 1. Patient Starting Position: Same as for "Grade 2" 2. Therapist position and grasps: Therapist stands beside the opposite shoulder. The distal hand is placed over the opposite shoulder to stabilize the thorax. The proximal hand palpate the muscles contraction between the root of spine of scapula and the vertebral column. 3. Command. Same as in "Grade 2"  Rhomboids weakness (inferior angle lateral displaced) Trapezius weakness (superior angle lateral displaced)  Comparison between scapular winging types Medial winging Lateral winging Injured nerve Long Thoracic Spinal Accessory Dorsal scapular Muscle palsy Serratus Anterior Trapezius Rhomboids Physical exam Arm Flexion push Arm abduction: Arm extension up against a wall external rotation against resistance against resistance while patient’s hands on the hips Position of scapula Entire medial Superior angle Inferior angle related to the scapula displaced more laterally laterally displaced normal displaced