The Shoulder Complex - Upper Extremities PDF

Upper Extremities Functional B Lecturer: Beáta Seregély assistant lecturer; [email protected] Semmelweis University Faculty of Health Sciences Department of Physiotherapy The free upper limb Main functions: reaching for, grabbing, holding, manipulating, rele...

Upper Extremities Functional B Lecturer: Beáta Seregély assistant lecturer; [email protected] Semmelweis University Faculty of Health Sciences Department of Physiotherapy The free upper limb Main functions: reaching for, grabbing, holding, manipulating, releasing an object supporting clinging Together with the visual system, is the most important tool of cognition. Functionally can be divided into two parts: the forming hand, which is the most complex part of the locomotor system from both motor and sensory aspects, and the arm, which most important function is to bring the hand to any point in space. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - mobility The almost limitless freedom of movement of the free upper limb is achieved through the shoulder-shoulder girdle complex, which connects the upper limb to the trunk and provides the trunk-arm-hand kinetic chain. The articular structures of the shoulder complex are designed primarily for mobility. Muscles provide the dynamic stability needed for free movement, while the same muscles also play an important role in generating movements. In the shoulder-shoulder girdle complex, the joint and its surrounding structures (capsule, ligaments) have a less stabilising role. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - mobility It is a free joint from an osteokinematic point of view. It has 3 degrees of freedom, and this allows orientation of the upper limb in the three planes of space that correspond to its three major axes: 1. The transverse axis, lying in the coronal plane, allows the movements of flexion (180°) and extension (45-50°) to occur in a sagittal plane. 2. The antero-posterior axis, lying in a sagittal plane, allows the movements of abduction (away from the body) (180°) and of adduction (moves towards the body) (~30° - in front of the body) to occur in a coronal (frontal) plane. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - mobility 3. The vertical axis, running through the intersection of the sagittal and coronal planes, controls the movements of flexion (horizontal adduction) (140°) and extension (horizontal abduction) (30°- 40°) , which take place in a horizontal plane with the arm abducted to 90°. The long axis of the humerus allows lateral (80°- 90°) and medial (70°-110°) rotation, it depends on the humerus position. The long axis of the humerus can coincide with any of the 3 axes or lie in any intermediate position, thereby permitting the movement of lateral or medial rotation in any place. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - mobility Circumduction combines the movements about the three cardinal axes up to their maximal ranges. The arm describes a conical surface in space. Its apex lies at the theoretical centre of the shoulcler and its side is equal to the length of the upper limb, but its base is far from being a regular circle, deformed as it is by the presence of the trunk. This cone demarcates in space a spherical sector of accessibility, wherein the hand can grasp objects and bring them to the mouth without displacement of the trunk and can reach all parts of the body. All this forms the anatomical base for the cross-body function of the arm. During work movements, the arm makes diagonal push and pull movements. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - components The segments of the shoulder complex are the clavicle, scapula and humerus, which are connected to the trunk through the sternum. These 3 segments are joined by 3 interdependent linkages: the sternoclavicular (SC) joint, the acromioclavicular (AC) joint, and the glenohumeral (GH) joint. The articulation between the scapula and the thorax is described as the scapulothoracic (ST) “joint,” although it does not have the characteristics of a synovial joint. The ST joint is frequently described in the literature as a “functional” joint. An additional functional articulation that is considered to be part of the shoulder complex is the subacromial (or suprahumeral) “functional joint”, is formed by movement of the head of the humerus below the coracoacromial arch, refer to it as the subacromial (suprahumeral) space and consider it a component of the GH joint. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder complex - components The shoulder: 1. the glenohumeral (GH) joint (articulatio humeri), 2. the subacromial (SA) (or subdeltoid or suprahumeral) “functional joint”. The shoulder girdle: 3. the scapulothoracic (ST) “functional joint,” 4. the acromioclavicular (AC) joint (articulatio acromioclavicularis), 5. the sternoclavicular (SC) joint (articulatio sternoclavicularis), Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle The SC joint serves as the only structural attachment of the clavicle, scapula, and upper extremity to the axial skeleton. The majority of the muscles that generate the movements of the shoulder girdle are located on the trunk and move the scapula. These movements generate displacements of the clavicle through the tight acromioclavicular joint in the sternoclavicular joint. The osteokinematic movements of the shoulder girdle are performed in the sternoclavicular joint. These movements are observed through the displacements of the acromion and scapula. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – the function The main function of the shoulder girdle is to connect the trunk and the arm. Its own displacements serve two purposes: to increase the range of motion of the shoulder complex and to adjust the glenoid cavitas to the optimal position for shoulder joint movements. The shoulder joint forms a closed kinematic chain, any displacement of one of its joints ("real-osteokinematic", "functional-voluntary") generates movements in the whole system. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – sternum Osteologic Features Muscles that originate Manubrium Sternocleidomastoid Clavicular facets Pectoralis major Costal facets Subclavius Jugular notch (Body) (Xiphoid process) Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – clavicle Osteologic Features Shaft (S shaped) Muscles that originate (red) Sternal end Sternocleidomastoid Costal facet Pectoralis major Costal tuberosity Anterior deltoid Acromial end Muscles that insert (gray) Acromial facet Subclavius Conoid tubercle Upper trapezius Trapezoid line Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – scapula Osteologic Features Muscles that originate Angles: inferior, Supraspinatus superior, and lateral Infraspinatus Med. or vertebral border Lat. or axillary border Posterior deltoid Superior border Teres minor and major Supraspinous fossa (Latissimus dorsi) Infraspinous fossa Muscles that insert Spine Lower and middle trapezius Root of the spine Levator scapulae Acromion Rhomboid minor and major Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – scapula Osteologic Features Muscles that originate Clavicular facet Middle deltoid Glenoid fossa (6°-7° retroverted) Biceps short head Coracobrachialis Supraglenoid and infraglenoid tubercles Biceps long head Coracoid process Triceps long head Subscapularis Subscapular fossa Muscles that insert A Serratus anterior Pectoralis minor 7° Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. P The shoulder girdle – coracoid proces Muscles that originate Biceps short head Coracobrachialis Muscles that insert Pectoralis minor Ligaments that attach Coracohumeral Coracoacromial Coracoclavicular Conoid Trapezoid Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – humerus Osteologic Features of Muscles that originate the Proximal-to-Mid There is no any Head of the humerus (one third to one half of a Muscles that insert 3 cm sphere) Supraspinatus Anatomic neck (45° Subscapularis superiorly to the shaft) Lesser tubercle and crest Pectoralis major Greater tubercle and Latissimus dorsi crest Teres major Intertubercular (bicipital) Deltoid groove Deltoid tuberosity Coracobrachialis Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – humerus Osteologic Features of Muscles that originate the Proximal-to-Mid There is no any Humerus Muscles that insert Head of the humerus Teres minor Lesser tubercle Infraspinatus Greater tubercle Supraspinatus Upper, middle, and lower facets on the greater Subscapularis tubercle Intertubercular (bicipital) groove Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle – humerus Osteologic Features of Muscles that originate the Proximal-to-Mid Humerus Triceps brachii medial and lateral head (short heads) Head of the humerus Greater tubercle Muscles that insert Middle, and lower facets Teres minor on the greater tubercle Infraspinatus Radial groove The head faces medially and superiorly, forming an approximate 135° angle of inclination with the long axis of the humeral shaft. Relative to a M-L axis through the elbow, the humeral head is rotated posteriorly (retroverted) about 30° within the horizontal plane. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The shoulder girdle angulations Superior view The orientation of the clavicle deviated about 20°-30° posterior to the frontal plane. The orientation of the scapula (scapular plane) deviated about 30°–40° anterior to the frontal plane. Retroversion of the humeral head about 30°. ~ 60° between the scapula and the clavicle Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The scapula position on the chest wall It extends up and down from the 2nd to the 7th rib. Its supero-medial angle corresponds to the 1st thoracic spinous process or the 2nd rib. The medial tip of its spine lies at the level of the 3rd spinous process. Its medial border lies at a distance of 5- 6 cm from the interspinous line. Its inferior angle lies at a distance of 7 cm from the interspinous line and corresponds to the 7th rib. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. The scapula-thoracic “functional joint” It consists of two gliding planes. The serratus anterior, extending as a muscular sheet from the medial border of the scapula to the lateral thoracic wall, which gives rise to two gliding spaces: the space between the scapula padded by the subscapularis and the serratus anterior (1) the space between the thoracic wall and the serratus anterior (2). Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Misalignments of the scapula Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Scapula mobility on the chest wall The primary movements at the scapulothoracic joint must be defined. These movements are Elevation and depression, Protraction (abduction) and retraction (adduction), Upward and downward rotation. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Terminology Describing the Primary Movements at the Scapulothoracic Joint Elevation - the scapula slides superiorly on the thorax, as when “shrugging of the shoulders”. Depression - the scapula slides inferiorly on the thorax. In range 10-12 cm Both are translatory motions, and occurs through elevation of the clavicle at the SC joint. Requires a small, subtle adjustments in anterior/posterior tipping and internal/external rotation at the AC joint to maintain the scapula in contact with the thorax. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Terminology Describing the Primary Movements at the Scapulothoracic Joint Protraction - The medial border of the scapula slides anteriorlaterally on the thorax away from the midline, the glenoid fossa facing anteriorly as when maximizing forward reach. Retraction - The medial border of the scapula slides posteriormedially on the thorax toward the midline, as when “pinching” of the “shoulder blades” together. The clavicle assumes a more oblique direction posteriorly and the angle between the scapula and the clavicle increases to 70°. The angle of the scapula closed by the frontal plane is less than 30° In range 10-12 cm Both are translatory motions Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Terminology Describing the Primary Movements at the Scapulothoracic Joint Upward rotation - the inferior angle of the scapula rotates in a superior-lateral direction, facing the glenoid fossa upward. Natural component of raising the arm upward. Downward rotation - the inferior angle of the scapula rotates in an inferior-medial direction, facing the glenoid fossa downward. Natural component of lowering the arm down to the side. Occurs around an axis perpendicular to the plane of the scapula passing through close to its superolateral angle, beneath the spine of the scapula. The range is 45-60°.The displacement of the inferior angle is 10-12 cm, and that of the superolateral angle is 5-6 cm. Most important is the change in the orientation of the glenoid cavity, which plays an essential role in the movements of the shoulder. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Accessory motions of the Scapula The motions at the AC joint are kinesiologically important, as they optimize the mobility and fit between the scapula and thorax, and ultimately the glenohumeral joint. The motions of the AC joint are described by the movement of the scapula relative to the lateral end of the clavicle. Defined 3 degrees of freedom The primary is the upward and downward rotation. Secondary motions – rotational adjustment motions - fine-tune the position of the scapula, in both the horizontal and the sagittal planes. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Accessory motions of the Scapula Upward/downward rotation of the scapula at the AC joint occurs as the scapula (the acromion or the glenoid fossa) “swings upwardly and outwardly”/”downwardly and inwardly” relative to the lateral end of the clavicle in the frontal (or in the scapular) plain. This motion occurs as a natural component of abduction or flexion of the shoulder, up to 30° at the AC joint occur as the arm is raised fully over the head. Its AP axis passing by between the joint and the coracoclavicular ligament. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Accessory motions of the Scapula Horizontal plane adjustments at the AC joint occur around a vertical axis, evident as the medial border of the scapula pivots away and toward the posterior surface of the thorax. These motions are the internal and external rotation/winging, defined by the direction of rotation of the glenoid fossa. Internal/external rotation of the scapula on the thorax should normally accompany protraction/retraction of the clavicle at the SC joint, to follow the curved rib cage. Internal rotation of the scapula on the thorax that is isolated to (or occurs excessively at) the AC joint results in prominence of the vertebral border of the scapula as a result of loss of contact with the thorax. This is clinically the scapular “winging”, may be indicative of pathology or poor neuromuscular control of the ST muscles. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Motions of the Scapula Sagittal plane adjustments at the AC joint occur around a near medial-lateral axis, evident as the inferior angle pivots away or toward the posterior surface of the thorax. The terms anterior tilting/tipping and posterior tilting/tipping describe the direction of this rotation, based on the direction of rotation of the glenoid fossa. Anterior/posterior tipping of the scapula on the thorax occurs at the AC joint and normally accompany anterior/posterior rotation of the clavicle at the SC joint. Anterior tipping that is isolated to or occurs excessively at the AC joint result in prominence of the inferior angle of the scapula. An anteriorly tipped scapula may occur in pathologic situations (poor neuromuscular control) or in abnormal posture. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Scapula stability on the chest wall During movements, the scapula is attached to the chest by the interaction of several factors: atmospheric pressure, the integrated stability of the acromioclavicular and sternoclavicular joints, the muscles connecting the scapula to the chest. Szervezeti egység neve, Dr. Minta Mihály, SU-FoHS Department ha hosszabbofa Physiotherapy sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular (SC) Joint a complex articulation, involving the medial end of the clavicle, the clavicular facet on the sternum, and the superior border of the cartilage of the first rib. functions as the basilar joint of the entire upper extremity, linking the appendicular skeleton with the axial skeleton. firmly attached while simultaneously allowing considerable range of movement. it has an irregular saddle-shaped articular surface, the medial end of the clavicle is usually convex along its longitudinal diameter and slightly concave along its transverse diameter. The sternal end of the clavicle and the manubrium are incongruent; there is little contact between the articular surfaces. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint stability - the disc The superior portion of the medial clavicle does not contact the manubrium at all; instead it serves as the attachment for the SC joint disk and the interclavicular ligament. The upper portion is attached to the posterosuperior clavicle. The lower portion is attached to the manubrium and first costal cartilage, the anterior and posterior aspects to the fibrous capsule. The disc serves an important stability function by increasing joint congruence and absorbing forces transmitted along the clavicle from its lateral end. Its diagonal attachment check medial movement of the clavicle that might otherwise cause the large medial articular surface of the clavicle to override the shallow manubrial facet, dissipate the medially directed forces that would otherwise cause high pressure at the small manubrial facet. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint stability - capsule and ligaments The joint surrounded by a strong fibrous capsule but depend on three ligaments for the majority of its support. The sternoclavicular ligaments (anterior and posterior), reinforce the capsule and check anterior and posterior translator movement of the medial end of the clavicle. the very strong costoclavicular ligament, found between the clavicle and the first rib. It has two segments: The anterior lamina has fibers directed laterally, the fibers of the posterior lamina are directed medially from the first rib to the clavicle. Both check elevation of the lateral end of the clavicle and, when the limits of the ligament are reached, may contribute to the inferior gliding of the medial clavicle that occurs with clavicular elevation. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint stability - capsule and ligaments The interclavicular ligament resists excessive depression of the distal clavicle and superior glide of the medial end of the clavicle. The limitation to clavicular depression is critical to protecting structures such as the brachial plexus and subclavian artery that pass under the clavicle and over the first rib. In fact, when the clavicle is depressed the tension in the interclavicular ligament can support the weight of the upper extremity or external loads. Tissues That Stabilize the Sternoclavicular Joint - summary Anterior and posterior sternoclavicular joint ligaments Interclavicular ligament Costoclavicular ligament Articular disc Sternocleidomastoid, sternothyroid, sternohyoid, and subclavius muscles. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint mobility The motions are elevation (35–45 °) and depression (10-15 °) in a near frontal plane, around a near anterior-posterior axis of rotation. Elevation and depression of the clavicle produce a similar path of movement of the scapula on the thorax. Elevation - the clavicle’s convex articular surface rolls superiorly and simultaneously slides inferiorly on the concavity of the sternum. The stretched costoclavicular ligament limit the motion as well as stabilize the clavicle. Depression - the clavicle’s convex surface rolling inferiorly and sliding superiorly. It elongates and stretches the interclavicular ligament and the superior portion of the capsular ligaments. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint mobility Protraction and retraction (both 15-30°) in a near horizontal plane, around a vertical axis of rotation, theoretically intersecting the sternum (others say the CCL). Retraction - the concave articular surface of the clavicle rolls and slides posteriorly on the convex surface of the sternum. The end ranges of retraction elongate the anterior bundles of the costoclavicular ligament and the anterior capsular ligaments. Arthrokinematics of protraction - the clavicle rolls and slides anteriorly on the convex surface of the sternum. The extremes of protraction occur during maximal forward reach. Excessive tightness in the posterior bundle of the costoclavicular ligament, the posterior capsular ligament, and the scapular retractor muscles limits the extremes of clavicular protraction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Sternoclavicular joint mobility Posterior clavicular rotation (30-45°) in a near sagittal plane, around the bone’s longitudinal axis, intersecting the SC and AC joints. Raises the arm overhead (i.e., during shoulder abduction or flexion), a point on the superior aspect of the clavicle rotates posteriorly 20–35 degrees. As the arm is returned to the side, the clavicle rotates back to its original position. The arthrokinematics of clavicular rotation involve a spin of its sternal end relative to the lateral surface of the articular disc. Axial rotation of the clavicle is mechanically linked with the overall kinematics of abduction or flexion of the shoulder and cannot be independently performed. SC joint close packed position when the clavicle is maximally (posteriorly) rotated - maximum arm elevation. While the resting position occurs when the arm is resting by the side. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Acromioclavicular (AC) Joint is the articulation between the lateral end of the clavicle (convex - if) and the acromion (concave - if) of the scapula. The clavicular facet on the acromion faces medially and slightly superiorly, providing a point of attachment with the corresponding acromial facet on the clavicle. An articular disc of varying form is present in most AC joints. The AC joint is a gliding or plane joint. Joint surfaces vary, however, from flat to slightly convex or concave. Because of the predominantly flat joint surfaces, roll-and-slide arthrokinematics are not described. Close packed position: 90 ° abduction Resting position: when the arm is resting by the side. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Acromioclavicular Joint The AC joint is surrounded by a capsule that is directly reinforced by superior and inferior ligaments. The superior capsular ligament is reinforced through attachments from the deltoid and trapezius muscles. The coracoclavicular ligament (CCL) provides an important extrinsic source of stability to the AC joint and consists of two parts: the trapezoid (laterally) - extends obliquely in a superior-lateral direction, more in the sagittal plane, provides of resistance to posterior translatory forces applied to the distal clavicle, and the conoid ligament (medially) - extends almost vertically, more in the frontal plane, restraint for the AC joint in the superior and inferior directions. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Acromioclavicular Joint - stability The CCL as a whole, it is stronger and absorbs more energy than most other ligaments of the shoulder, provide horizontal and superior stability and prevent the superior dislocation of the clavicle. The CCL limit upward rotation of the scapula at the AC joint. The medial displacement of the scapula’s acromion on the clavicle is prevented by tension in and the strength of the coracoclavicular ligament (trapezoid portion) that transfer the force to the clavicle, and then on to the strong SC joint. One of the most critical roles played by the coracoclavicular ligament, is in coupling the posterior rotation of the clavicle to scapula rotation during elevation of the upper extremity. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Acromioclavicular Joint - mobility Distinct differences exist in the functions of the SC and AC joints. The SC joint permits extensive motion of the clavicle, which guides the general path of the scapula. The AC joint, permits more subtle movements between the scapula and lateral end of the clavicle. The accessory motions, described before (slide 28-31), at the AC joint optimize the mobility and fit between the scapula and thorax, and ultimately the glenohumeral joint. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Muscle of the shoulder girdle – Brachial plexus Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01. Muscle of the shoulder girdle – Brachial plexus Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder Most of the muscles of the shoulder complex fall into one of two functional categories: proximal stabilizers or distal mobilizers. The proximal stabilizers are muscles that originate on the spine, ribs, and cranium and insert on the scapula and clavicle, such as trapezius or serratus anterior. The distal mobilizers are muscles that originate on the scapula and clavicle and insert on the humerus or the forearm, such as the deltoid or biceps brachii. An important theme is that optimal function of the shoulder complex requires a coordinated, kinetic interaction between and among these two sets of muscles. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder girdle ELEVATORS (Pectoralis minor) Upper trapezius RETRACTORS (Adductors) Levator scapulae Middle and lower trapezius Rhomboids (major and minor) Rhomboids (major and minor) (Serratus anterior upper part) DEPRESSORS UPWARD ROTATORS Lower trapezius Serratus anterior both part (Latissimus dorsi) Upper and lower trapezius Pectoralis minor DOWNWARD ROTATORS Subclavius Rhomboids (Serratus anterior lower part) Pectoralis minor PROTRACTORS (Abductors) (Levator scapulae) Serratus anterior both part Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder girdle Elevators - posterior aspect: Trapezius – 3 parts Upper trapezius (1) – elevate the shoulder girdle, rotates the scapula laterally and superiorly Middle trapezius (1’) – adduct the scapula Lower trapezius (1”) – depress the scapula and when elevation occurs rotates the scapula laterally and superiorly. Rhomboids (major and minor) (2) – adduct and elevate the scapula and rotates medially and inferiorly, so that the glenoid cavity faces inferiorly, fix the inferior angle against the ribs Levator scapulae (3) - elevate the scapula and rotates medially and inferiorly. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder girdle depressors – posterior aspect: Lower trapezius (1”) – depress the scapula and when elevation occurs rotates the scapula laterally and superiorly Latissimus dorsi - depresses the shoulder girdle indirectly, primarily by pulling the humerus inferiorly ventral aspect: Pectoralis minor (5) - depresses the shoulder girdle and rotates medially and inferiorly. Pulls the scapula laterally and anteriorly so that its posterior edge is pulled off the thorax. Subclavius - depresses the clavicle, so indirectly the shoulder girdle, fix the clavicle to the first rib and presses the medial extremity of the clavicle against the manubrium sterni and thus ensures the coaptation of the articular surfaces of the sterno-costo-clavicular joint. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder girdle The lateral aspect - protractor: Serratus anterior – lying on the deep surface of the scapula and spreading over the postero-lateral wall of the thorax two part upper part (4), running horizontally and anteriorly, draws the scapula anteriorly and laterally (abduction), slightly elevates and superiorly rotates it. Stabilizes the medial border of the scapula on the chest wall. The lower part(4'), running obliquely, anteriody and inferiody, tilts the scapula superiody by pulling its inferior angle laterally and causing the glenoid cavity to face superiody. It is active in flexion and abduction of the arm, and in the carrying of loads, only when the arm is already abducted beyond 30°. Stabilizes the angulus inferior on the chest wall. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions of the shoulder girdle The lateral aspect - retractors: Contracting synergistically, the middle trapezius, rhomboids, and the lower trapezius function as primary retractors of the scapula. Of the three muscles, however, the middle trapezius has the most optimal line of force for this action. As a group, the three muscles dynamically anchor the scapula to the axial skeleton. This proximal stabilization is essential for pulling activities, such as climbing and rowing. The rhomboids and the lower trapezius show how two muscles can share similar actions (such as retraction), but also function as direct antagonists to one another. During a vigorous retraction, the elevation tendency of the rhomboids is neutralized by the depression tendency of the lower trapezius. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Misalignments of the scapula It can be caused Downwards rotated Short m.levator scapulae and rhomboids; and lengthened upper by postural trapezius (serratus ant.) abnormalities - Depressed lengthened upper trapezius and short, or over working latissimus increased dorsi, pectoralis major kyphosis of the Elevated Short levator scapulae, upper trapezius, (rhomboids) back, scoliosis, Adducted Short rhomboids and trapezius; and lengthened serratus ant. flat back and Abducted Short serratus ant., pectoralis major (and short lateral rotators of various muscle the glenohumeral joint) imbalances Tilted Short pectoralis minor, (biceps brachii short head, anterior deltoid, associated or and coracobrachialis) unrelated to Depressed and tilted combination these conditions. Abducted and tilted combination Winged Weak serratus ant., háti szakasz deformity of the back, hypertrophy of the subscapularis Upwards rotated Short upper Szervezeti trapezius egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The glenohumeral (shoulder) joint The GH joint is a typical ball-and-socket synovial joint with three rotational and three translational degrees of freedom. The articulation is composed of the large biconvex head of the humerus and the shallow biconcave glenoid fossa. Main motions (lot of contradiction): Flexion (120° (100°)) – extension (50-60°) in the sagittal plane (without any scapular motion (60-90°) Abduction (90-120°) - adduction in the frontal plane (without any scapular motion ~60°) Internal (70-85°) – external (60-90°) rotation around the longitudinal axis of the shaft of the humerus, depends on the placement of the joint Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The Codman’s “paradox” From the position, the upper limb hangs down vertically alongside the trunk, with the thumb facing anteriorly and the palm of the hand medially. The limb is then abducted to +180°. From this position with the palm facing laterally the limb is extended -180° in the sagittal plane. It is now back alongside the body, except that the palm now faces laterally and the thumb posteriorly. In reality, it is due to an automatic medial rotation of the limb on its long axis, also called conjunct rotation, and typically seen in joints with 2 axes and 2 degrees of freedom. Codman's 'paradox'is seen only when the shoulder is used as a biaxial joint, where the adjunct rotation does not offset the conjunct rotation. So the Coclman's paradox is a false paradox, and it is easy to understand why the joints at the roots of limbs have three degrees of freedom so that their movements are not limited by conjunct rotation during moving in the space. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The glenohumeral (shoulder) joint The head of the humerus facing superiorly, medially and posteriorly, this corresponds to a third of a sphere with a radius of 3 cm. Its axis forms an angle of 135° (the angle of inclination) with the axis of the humeral shaft and an angle of 30° (the retroversion angle) with the coronal plane. It is separated from the humerus by the anatomical neck, which makes an angle of 45° with the horizontal plane (the angle of declination). It is flanked by two tuberosities,which receive the insertions of the periarticular muscles: the lesser tuberosity, pointing anteriody, the greater tuberosity, pointing laterally. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The glenohumeral (shoulder) joint The glenoid cavity of the scapula lies at the supero- lateral angle of the scapula and points laterally, anteriorly and slightly superiorly. It is biconcave vertically and transversely, but its concavity is less marked than the convexity of the humeral head. It is much smaller than the humeral head. Typically the longitudinal diameter of the humeral head is about 1.9 times larger than the longitudinal diameter of the glenoid fossa. The transverse diameter of the humeral head is about 2.3 times larger than the opposing transverse diameter of the glenoid fossa. The glenoid labrum is a ring of fibrocartilage attached to the margin of the glenoid cavity. It deepens the glenoid cavity so as to make the articular surfaces more congruent. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The glenoid labrum (right shoulder) 12 hours: origin of long head of biceps, 3 hours: anterior part, between 9-3 hours: loosely attached, between 2-3 hours (superiorly): may not be fixed, the inferior portion is firmly attached and relatively immobile, the glenoid labrum also serves as the attachment site for the glenohumeral ligaments, removal of the labrum increases the chance of instability, the labrum deepens the articular groove by up to 50%, Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Incongruency Incongruent articular surfaces Sternoclavicular joint - there is little contact between their articular surfaces - disc Acromioclacicular joint - vary in configuration - disc Glenohumeral joint - the convex humeral head is a substantially larger surface and a different radius of curvature than the shallow concave fossa. The bony surfaces alone cannot maintain joint contact in the dependent position – labrum Strong capsuls and ligaments Muscles Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Glenohumeral Capsule and Ligaments The entire GH joint is surrounded by a large, loose capsule that is taut superiorly and slack anteriorly and inferiorly (axillary pouch) when arm hanging aside. The relative laxity of the GH capsule is necessary for the free movements but provides little stability without the reinforcement of ligaments and muscles. The capsule is reinforced by the coracohumeral ligament, and the glenohumeral ligaments. The tendon of the long head of the biceps brachii inserts into the supraglenoid tubercle of the scapula and contribute to the glenoid labrum. This tendon is thus intracapsular. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The coracohumeral ligament Originates from the coracoid process and having 2 bands. The first (posterior) inserts into the edge of the supraspinatus and onto the greater tubercle, where it joins the superior GH ligament; the other band (anterior) inserts into the subscapularis and lesser tubercle. The location and interconnections of the ligament imply a complex function. As part of the rotator interval capsule, it appears to be most important in limiting inferior translation of the humeral head in the dependent arm, assist preventing superior translation, when the rotator cuff muscles impaired. In addition, the coracohumeral ligament is usually reported as resisting humeral external rotation below 60° abduction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The glenohumeral ligaments It consist from 3 parts: the supraglenoid suprahumeral superior (1), the supraglenoid prehumeral middle (10) band and the preglenoid subhumeral inferior (11) band complex has 3 components: an anterior band, a posterior band, and a sheet of tissue connecting these bands known as an axillary pouch. This complex forms a roughly Z spread over the anterior aspect of the capsule. Between these bands there are 2 points of weakness: the foramen of Weitbrecht (12) and the foramen of Rouviere (13). Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The superior glenohumeral ligament Its proximal attachment near the supraglenoid tubercle (about 1 o’clock), just anterior to the long head of the biceps and with adjacent capsule, attaches near the anatomic neck of the humerus above the lesser tubercle. With the coracohumeral ligament surround the tendon of the long head of the biceps brachii. The ligament is slightly taut in and near the anatomic position, capable of resisting external rotation and inferior and anterior translations of the humeral head. As the GH joint is abducted beyond 35–45 degrees, the superior GH ligament slackens significantly. It may taut in the and of adduction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The middle glenohumeral ligament It has a wide proximal attachment to the superior and middle aspects of the anterior rim of the glenoid fossa (about 2-4 o’clock). The ligament blends with the anterior capsule and broad tendon of the subscapularis muscle, then attaches along the anterior aspect of the anatomic neck. It provides at least a modest stabilizing tension to most movements of the shoulder. Most notably, the broad ligament provides substantial anterior restraint to the GH joint, especially in a position of 45–90° of abduction. Based on its location, the middle GH ligament is very effective at limiting the extremes of external rotation; the ligament readily slackens upon internal rotation. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The inferior glenohumeral ligament It attaches proximally along the anterior-inferior rim of the glenoid fossa, and the labrum (at 4-8 o’clock). Distally the inferior GH ligament attaches as a broad sheet to the anterior-inferior and posterior-inferior margins of the anatomic neck as forms a "hammock". The axillary pouch and the surrounding inferior capsular ligaments become most taut in about 90 degrees of GH joint abduction. Acting as a sling, it supports the suspended humeral head and provides a cradling effect that resists inferior and anterior, posterior translations. In this abducted position, the anterior band becomes further taut at the extremes of external and posterior band in internal rotation. The anterior band—the strongest and thickest part of the entire capsule—is particularly important, as it furnishes the primary ligamentous restraint to anterior translation of the humeral head, both in an abducted and in a neutral position. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The coracoacromial arch It is formed by the coracoid process, the acromion, and the coracoacromial ligament that spans the 2 bony projections. It is the functional “roof ” of the GH joint. The very clinically relevant subacromial space contains: the supraspinatus muscle and tendon, the subacromial bursa, the long head of the biceps, and part of the superior capsule. It prevents the head of the humerus from dislocating superiorly. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The bursae Multiple separate bursa exist around the shoulder. Some of them are direct extensions of the synovial membrane of the GH joint, such as the subscapular (SS) bursa, whereas others are separate structures. All situated in regions where significant frictional forces develop, such as between tendons, capsule and bone, muscle and ligament, or two adjacent muscles and reduce the frictional forces between structures. The 2 most important are the subacromial (SbA) - protects the relatively soft and vulnerable supraspinatus muscle and tendon from the rigid undersurface of the acromion, and subdeltoid bursa (SD) - limiting frictional forces between the deltoid and the underlying supraspinatus tendon and humeral head. Also exist the subcoracoid (SC), coracoclavicular (CC), and supraacromial (SpA) Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  The physiological alignment of the humerus… … if the posture of the dorsal spine and scapula is physiological. Neutral rotational position, Olecranon facing backwards, Palms facing body, but shortening of m.flexor digitorum brevis should be excluded Less than 1/3 of the humeral head can be in front of the acromion, Humerus upper and lower part in a vertical straight line Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Static stabilization of the GH joint in neutral position The gravity acts on the humerus parallel to the shaft in a downward direction (caudally directed translatory force). The mechanism of joint stabilization is passive. The line of gravity (LoG) creates a downward force on the humerus and given the magnitude of passive tension in the structures of the rotator interval capsule (superior capsule, superior GH ligament, and coracohumeral ligament) that are taut when the arm is at the side, the resultant pull of both forces creates a line of force that compresses the humeral head into the lower portion of the glenoid fossa. Two other mechanisms help provide static stability of the dependent arm: In a healthy GH joint, there is a negative intra-articular pressure. The degree of glenoid inclination. If there is a slight upward tilt either anatomically in the structure or through scapular upward rotation, the tilt of the fossa produce a bony block against humeral inferior translation. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Static stabilization of the GH joint in neutral position When the available passive forces are inadequate for static stabilization, as may occur in the heavily loaded arm, activity of the supraspinatus is recruited. This is not surprising, given that the supraspinatus tendon has attachments to the rotator interval capsule. Although the subscapularis muscle may also, through its connections to the rotator interval, provide some support to those structures. When extreme vertical load pull down the arm, muscles that have upward directed translatory force component, such as the deltoid, supraspinatus, or the long heads of the biceps brachii and triceps brachii may help the stability. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - osteokinematics (in 53rd slide) The GH joint rotates in all 3 planes and therefore it has three degrees of freedom. The primary rotational movements at the GH joint are: flexion and extension in the sagittal plane around ML axis, abduction and adduction in the frontal (or scaption) plane around AP axis, and internal and external rotation in the horizontal plane around the longitudinal axis the shaft of the humerus. A 4th motion is defined at the GH joint: horizontal adduction and abduction. The motion occurs from a starting position of 90° of abduction. The humerus moves around a vertical axis of rotation: anteriorly during horizontal adduction and posteriorly during horizontal abduction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - arthrokinematics The term spin refers to a rotation of the movable component, as when a top spins. Spin is a pure rotatory motion. The same points remain in contact on both the moving and stationary components. Rolling, combine of translation and rotation, when different point of the rolling object meet a different point of the surface. Sliding/gliding, which is a pure translatory motion, refers to the gliding of one component over another, as when a braked wheel skids. The point of contact changes in the fixed component as the sliding component moves over it. (Glide is effortless i.e. in air, slide on some surface. In our case, they are synonyms) Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - arthrokinematics Abduction: the convex head of the humerus rolling superiorly while simultaneously sliding inferiorly. Roll-and-slide arthrokinematics occur along, or close to, the longitudinal diameter of the glenoid fossa. Adduction: the reverse motion, the convex head of the humerus rolling inferiorly while simultaneously sliding superiorly. If the humeral head is a sphere with a circumference of 16.3 cm, it would translate upward 1 cm after a superior roll (abduction) of only 22°. This translation would cause the humeral head to press against the contents of the subacromial space. So the abduction without a concurrent inferior slide causes the humeral head to impinge against the arch and block further abduction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - arthrokinematics Abducting the shoulder in the scapular plane (~ 30° anterior to the frontal plane) is a more natural movement than abducting in the pure frontal plane. In this case impingement is avoided because the apex of the greater tubercle placed under the relatively high point of the coracoacromial arch; and also the naturally retroverted humeral head to be oriented more directly into the glenoid fossa, and the attachments of the supraspinatus muscle are also placed along a straight line. For completion of frontal plane abduction, must be combined with external rotation of the humerus. This ensures that the prominent greater tubercle clears the posterior edge of the undersurface of the acromion. Horizontal abduction: the head of the humerus rolling posteriorly while simultaneously sliding anteriorly. Horizontal adduction: the reverse motion Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - arthrokinematics Flexion: primarily a spinning motion of the humeral head in the glenoid fossa which draws most of the surrounding capsular structures taut. Tension within the stretched posterior capsule may cause a slight anterior translation of the humerus at the extremes of flexion. Extention: the reverse motion, extremes of this motion stretch the capsular ligaments, causing a slight anterior tilting of the scapula. External rotation: the humeral head simultaneously rolls posteriorly and slides anteriorly on the glenoid fossa. Internal rotation: are similar, except the directions are reversed. From anatomic position, internal and external rotation are associated with roll-and-slide. Rotation of the GH joint from a position of about 90° of abduction, however, requires primarily a spinning. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Mobility - arthrokinematics We can provoke anterior translation with: abduction external rotation horizontal abduction. And posterior translation with: flexion internal rotation (horizontal) adduction The stability by passive elements of the shoulder joint (capsule, ligaments) is weakest from the ventral direction, and therefore can luxate in an extreme abduction, external rotation. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint Dynamic stability refers to the stability achieved while the joint is moving. Activated muscle forces combine with the passive forces from stretched capsular ligaments to maintain the humeral head in proper position on the glenoid fossa. Dynamic stability at the GH joint relies on the interaction of these active and passive forces because of the lack of bony containment of the joint. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint – static stabilizators Glenohumeral ligaments: during abduction the middle and inferior bands become taut, while the superior band and the coraco- humeral ligament relax. Thus in abduction the ligaments are maximally stretched and the articular surfaces maximal contact. Hence full abduction with external rotation corresponds to the close-packed position. during adduction the superior band become taut, during latetal rotation stretches all 3 bands of the GHL. during medial rotation relaxes them. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint – static stabilizators Coracohumeral ligament (in neutral rotational position): during extension the anterior (lesser tub.) band become taut. during flexion tension develops in the posterior (greater tub.) band. latetal rotation stretches the anterior (lesser tub.) band. medial rotation streches the posterior (greater tub.) band. during abduction both 2 band is relaxed, but it changes during the range of motion (end external rotation). during adduction both 2 band become taut (depending of the rotational position). Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint – dynamic stabilizators Stabilisation of the humeral head in the glenoid cavity is a result of coordinated muscular action during movement. The deltoid muscle is a prime mover (along with the supraspinatus) for GH abduction. The anterior deltoid is also considered the prime mover in GH flexion. Both abduction and flexion are elevation activities with many biomechanical similarities. Now we analyse the abduction. When the muscle action line (FD) is resolved into its parallel (Fx) and perpendicular (Fy) components in relation to the long axis of the humerus, the translational component directly cephalad (superiorly) is by far the larger of the two components, only a small proportion of force is perpendicular to the humerus and directly contributes to rotation (abduction) of the humerus. The large superiorly directed force, if unopposed, would cause the humeral head to impact the coracoacromial arch before much abduction had occurred. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint – dynamic stabilizators Another set of forces must be introduced for the deltoid to work effectively. This is the role of the rotator cuff muscles, which proved dynamic stabilization of the head of the humerus. These muscles are blended with and reinforce the GH capsule and referred to by the acronym SITS: the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. Although the infraspinatus, teres minor, and subscapularis are important GH joint compressors, equally (or more) critical to the stabilizing function with the inferior (caudal) translatory pull (Fx) of the muscles. The sum of the inferior translator components of these 3 muscles offsets the superior translatory force of the deltoid muscle. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint – dynamic stabilizators The teres minor (4) and infraspinatus (3) muscles, in addition to their stabilizing role, contribute to abduction of the arm by providing the external rotation. The medial (subscapularis) and lateral rotatory forces also help center the humeral head in an anterior/posterior direction. The equal and opposite forces for the deltoid and these 3 rotator cuff muscles provide an almost perfect (pure) spinning of the humeral head around a relatively stable axis of rotation. The long head of the biceps brachii (5), because of its position and connections to structures of the rotator interval capsule is sometimes considered to be part of the rotator cuff of the GH joint. It appears to contribute to GH stabilization by centering the head in the fossa and by reducing vertical (superior and inferior) and anterior translations. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Dynamic stabilization of the GH Joint dynamic stabilizators Although the supraspinatus (1) muscle is part of the rotator cuff, the action line of the muscle has a superior (cephalad) translatory component. The supraspinatus is an effective stabilizer of the GH joint. The supraspinatus has a large enough moment arm that it is capable of independently producing a full range of GH joint abduction while simultaneously stabilizing the joint. Gravity acts as a stabilizing synergist to the supraspinatus by offsetting the small upward translatory pull of the muscle. It also has a small amounts of medial or lateral rotation torque. The subscapular provide anterior, the infraspinatus and the teres minor posterior stability of the GH joint. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Scapulohumeral Rhythm After ~30° of (frontal plane) abduction this rhythm remained remarkably constant, occurring at a ratio of 2:1, 2° by GH joint abduction and 1° degree by scapulothoracic joint upward rotation. The first kinematic principle of shoulder abduction states that a full arc 180 ° of abduction is the result of a simultaneous 120° of GH joint abduction and 60° of scapulothoracic upward rotation. The aim of the SH rhythm: distributes the motion between the joints, permitting a large ROM with less compromise of stability maintains the glenoid fossa in an optimal position in relation to the head of the humerus, increasing joint congruency while decreasing shear forces and permits muscles to maintain a good length-tension relation while minimizing or preventing active insufficiency of them. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Scapulohumeral Rhythm Phase 1: 30° Humerus abduction; Minimal movement of the Scapula (setting phase); 0° to 5° Clavicle elevation Phase 2: 40° Humerus abduction; 20-30° Scapula rotation, minimal protraction or elevation; 15° Clavicle elevation Phase 3: 60° Humerus abduction, 90° lateral rotation; 30° Scapula rotation; 30° to 50° posterior Clavicle rotation, after the elevation up to 15° (The serratus anterior rotates the scapula upward, the coracoclavicular ligament is drawn taut and the stretched ligament rotates the crank-shaped clavicle in a posterior direction, allowing the AC joint to allow full upward rotation). Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes A simple movement requires several muscle groups to work together, which can be classify according to their role in movement: prime mover (agonist) is a muscle whose role is to produce a desired motion at a joint. The muscles that are directly opposite to the desired motion are the antagonists. secondary mover is a muscle help perform a desired action across the full or the partial RoM. synergist is a muscle contract when a desired action performed. may assist the agonist (assisting synergist), neutralize unwanted motions or stabilize the proximal attachment site. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – elevation The term “elevation” of the arm describes the active movement of bringing the arm overhead without specifying the exact plane of the motion. Elevation of the arm is performed by muscles that typically fall into 3 groups: muscles that elevate (abduct or flex) the humerus at the GH joint; Anterior and middle deltoid Supraspinatus Coracobrachialis Biceps brachii scapular muscles that control the upward rotation of the scapulothoracic joint; Serratus anterior Trapezius rotator cuff - control the dynamic stability and arthrokinematics at the GH joint. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – abduction 0-180° Across abduction the humerus abduct, externally rotate, the scapula rotate outwardly and superiorly, the clavicle elevate and rotate posteriorly. The prime muscles that abduct the GH joint are middle deltoid, and supraspinatus, secondary movers (synegists) are anterior and posterior deltoid (assist and neutralize), biceps brachii (assist when arm laterally rotated), stabilizing synergists are infraspinatus, teres minor and the subscalularis antagonists are latissimus dorsi, teres major, long head of the triceps and pectoralis major. The end of the RoM the contralateral paravertebral muscles also contract. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – abduction 0-180° The prime muscles that externally rotate the GH joint are the the infraspinatus, teres minor, secondary mover (synegist) is the posterior deltoid, antagonists are the subscapularis, pectoralis major, latissimus dorsi, teres major, and anterior deltoid. The primary upward rotator muscles of the scapula are in the early phase the serratus anterior and the trapezius upper fibers and in the late phase the lower fibers of serratus anterior and the trapezius. neutralizing synergist the middle trapezius and the rhomboids antagonist could be the subclavius. If agonists of any of these motions are shortened, they limit the RoM and the patients compensate with lateral flexion. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – flexion 0-180° The prime muscles of the flexion the anterior deltoid, coracobrachialis, and the biceps brachii, secondary mover (synegist) is the pectoralis major clavicular fibers, antagonists are the teres minor, teres major, and infraspinatus. The motions and muscle actions of the scapula are the same as in abduction. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – adduction 180-0° Backward movement from 180° elevated position while standing is performed by muscles listed at abduction, with isotonic eccentric action. The primary adductor muscles of the shoulder are the latissimus dorsi, teres major, and sternocostal head of the pectoralis major work only with resistance. secondary mover (assisting synegist) is the posterior deltoid (below 90°), infraspinate, (coracobrachialis, teres minor) and long head of the triceps brachii (also stabilizing). antagonist are the supraspinate and mid. deltoid. With the humerus held stable, contraction of the latissimus dorsi can raise the pelvis upward. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – adduction 180-0° Five of the seven adductor-extensor muscles have their primary proximal attachments on the inherently unstable scapula. The rhomboids are primary qualified the stabilization by to combine the actions of downward rotation and retraction of the scapula, secondary mover (assisting synergist) levator scapule, pectoralis minor and the latissimus dorsi (60-30°), lower trapezius (30-0°), stabilizing synergist is the middle trapezius, antagonist are the upper trapezius and serratus anterior. The primary internal rotators of the humerus the latissimus dorsi, pectoralis major and the subscapularis. secondary mover (assisting synergist) is the anterior deltoid antagonist are the infraspinate and teres minor. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Muscle actions by planes – extention 180-0° Backward movement from 180° elevated position while standing is performed by muscles listed at flexion, with isotonic eccentric action. The primary extensor muscles of the shoulder are the latissimus dorsi, teres major and teres minor work only with resistance. secondary mover (assisting synegist) is the posterior deltoid and long head of the triceps brachii (also stabilizing). antagonist are the anterior deltoid, coracobrachialis, and the biceps brachii. The motions and muscle actions of the scapula are the same as in abduction. The internal and external rotation is described above. Primary the subclavius rotates back the clavicule to the neutral position Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Summary muscles acting on the GH joint Muscles that abduct the arm: posterior deltoid, middle, anterior (posterior) deltoid triceps brachii long head supraspinatus infraspinatus, Muscles that flex the arm: teres minor anterior deltoid, Muscles that extend the arm: coracobrachialis, and latissimus dorsi, long head of the biceps teres major Muscles that adduct the arm: posterior deltoid, latissimus dorsi, triceps brachii long head teres major teres minor pectoralis major sternocostal head Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.  Summary muscles acting on the GH joint Muscles that internally rotate the arm: Muscles that externally rotate the arm: subscapularis, infraspinatus, pectoralis major, teres minor, and latissimus dorsi, posterior deltoid. teres major, and anterior deltoid. Szervezeti egység neve, Dr. Minta Mihály, SE-ETK Department of Physiotherapy ha hosszabb a sor két sorba tördelve Beáta Seregély titulus 2024. 09.01.