Date post: | 07-Feb-2018 |
Category: |
Documents |
Upload: | truongmien |
View: | 227 times |
Download: | 2 times |
Anatomy and KinesiologyShoulder and Elbow
Kim Kraft, PT, DPT, CHT
St Louis MOApril 7, 2017
Objectives
• Identify clinically relevant boney anatomy and soft tissue structures
• Understand how anatomy and kinesiology interrelate to create motion
• Consider how muscles work together to move joints
• Begin to relate the characteristics of structure to clinical concepts
2
Outline
Shoulder and Elbow1. Bones (osteology)
2. Joints (arthrology)3. Joint motion (kinesiology)4. Static stability (ligaments)
5. Neural relationships
OsteologyShoulder Girdle
The Shoulder Girdle
1. Clavicle
2. Scapula3. Humerus
Retrieved on 03/08/13 from: http://upload.wikimedia.org/wikipedia/commons/thumb/4/49/Human_arm_bones_diagram.svg/683px‐Human_arm_bones_diagram.svg.png
• Connects axial skeleton and upper limb• Protects the neurovascular bundle from neck
to arm• Crank-Shaped: Convex medially/concave
laterally• Acts as a strut holding arm away from body
Bones: Clavicle
Right
ClaviclePopular Insertion Site
Left
7Photo retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f0/Gray201.png
Bones: Scapula• Lies over ribs 2-7• Scapular Spine is the landmark for T4
Spinous Process• 30 anterior to the coronal plane, 10 on
the frontal tilt.• “Plane of the scapula”
Anterior Scapula Landmarks
1.Acromion2.Coracoid Process
3.Subscapular Fossa
Gaunt & McCluskey 2012
Posterior Scapula Landmarks
1. Superior angle2. Supraspinous fossa3. Scapular notch4. Scapular spine5. Axillary border6. Vertebral border7. Infraspinous fossa
Gaunt & McCluskey 2012
Bones: HumerusLandmarks
• Greater tubercle: insertion for supraspinatus, infraspinatus, teres minor
• Lesser tubercle: insertion for subscapularis
• Surgical neck• Anatomical neck• Shaft• epicondyles
Right
Gaunt & McCluskey 2012
Clinical ApplicationProximal Humerus Fractures
Gaunt & McCluskey 2012
Bicipital Groove Palpation
Side to Side Palpation
• Fingers proximal anterior humerus
• Rotate at forearm
Karreigis
Joints Shoulder Girdle
Shoulder Girdle Joints
Play along
1. Sternoclavicular2. Acromioclavicular3. Scapulothoracic
4. Glenohumeral
1. Sternoclavicular Joint (SC)• Proximal clavicle and sternum• Only articulation between the axial skeleton
and the upper limb
• Movement: protraction, retraction, rotation, elevation and depression
• Articular disc
• True synovial joint with capsule & articular disc
2. Acromioclavicular (AC) joint
TC
• Diarthrodial joint with meniscus
• A/P Glide of acromion with pro/retraction
• Allows up to 20⁰ rotation of clavicle with arm elevation
• Stressed with cross-body adduction
• Compressed with arm elevation
• Frequent site of DJD
3. Scapulothoracic (ST) Joint• Formed between the scapula and the thoracic
wall
• Not a "true" articulation
• Movement: protraction, retraction, elevation, depression, upward & downward rotation
• Stabilized by muscles
• Provides a stable base for glenohumeral mobility and stability; shoulder movement depends on it
5 ST Functions
1. Increase glenohumeral stability (Orients glenoid up 5 degrees)
2. Increases arm elevation ROM3. Serves as muscle attachment4. Absorbs forces from the arm5. Maintains the subacromial space
4. Glenohumeral Joint• Glenoid fossa of the scapula and the head of
the humerus• Ball and socket joint that sacrifices stability for
mobility• Movement: flexion, extension, abduction,
adduction, external and internal rotation• Static stability
• Ligaments, Bony architecture, capsule, labrum
• Dynamic stability• muscles
Glenohumeral JointIncludes:
• RC tendons• Long head of biceps• Sub-acromial – sub-deltoid bursa• Subscapularis bursa• Subcoracoid bursa• Coracohumeral ligament
Key FeatureCoracoacromial Arch• Subacromial space
between acromion, coracoacromial ligament, coracoid process and the superior humeral head
• Contents:subacromialbursa, long head biceps tendon, supraspinatus tendon
Impingement*
Glenohumeral Stabilizers(Stability Sacrificed for Mobility)
Static
• Ligament/Capsule
• Geometry (ball much larger than socket)
• Glenoid labrum
• Negative intra-articular pressure
Dynamic
• Muscles• Scapular Stabilizers
(scapular dumping)• Rotator Cuff Muscles• ?Long Head biceps
Capsule and LigamentsShoulder Girdle
Glenohumeral Static Stability Movie
• Relationships between boney, glenoid, capsular, and ligamentous structures
• Multidirectional instability (joint laxity)
• Traumatic instability
Static StabilizersGlenohumeral Joint
1. Labrum2. Capsule3. Sternoclavicular (SC)4. Acromioclavicular (AC)5. Coracoclavicular
• Conoid• Trapezoid
6. Coracoacromial7. Coracohumeral8. Glenohumeral Ligaments
• Superior (SGHL)• Middle (MGHL)• Inferior (IGHL)
Glenoid Labrum
Labrum
1. Narrow at the top, wide at the bottom (inverted comma)
2. Hyaline cartilage lining is thinnest at the center where OA may develop
3. Attachment for ligaments
Gaunt & McCluskey 2012
“ All portions of the joint capsule are responsible for stabilizing the humerus in the glenoid fossa.”
Warren & Hawkins
CapsuleBlends with Labrum, Ligaments
Gaunt & McCluskey 2012
Sternoclavicular Ligaments
• Very stout, very stable• Incorporate meniscus
• Allow bucket-handle motion of elevation/posterior rotation
Meniscus/Capsule can become painful or stiff
Sternoclavicular (SC) Joint Ligaments
Interclavicular Ligament
First Rib
Anterior Sternoclavicular Ligament
Articular Disc
Costoclavicular Ligament
Gaunt & McCluskey 2012
Acromioclavicular & Coracoclavicular Ligaments• Conoid & Trapezoid• Prevent inferior translation of the acromion
on the distal clavicle
• Stabilizes horizontal adduction of the forearm
Trapezoid
CoracoacromialLigament
AcromioclavicularLigament Conoid
Acromioclavicular (AC) and Coracoclavicular Joint LigamentsC
oraco
clavicu
lar Lig
amen
ts
Gaunt & McCluskey 2012
Passive (Static) Restraints3 Glenohumeral LigamentsSuperior, Middle, Inferior
GH-Ligaments
SuperiorLimits inferior glide
fromanatomical position
Superior GlenohumeralLigament (SGHL)
GH-Ligaments
MiddleLimits anterior glide
from partial abduction
Middle Glenohumeral Ligament(MGHL)
GH-LigamentsInferior; 3 PartsAnterior Band
Axillary Pouch
Posterior Band
Inferior Glenohumeral Ligament(IGHL)
Acts as a sling to protect against anterior and inferior instability
Inferior GlenohumeralLigament
Gaunt & McCluskey 2012
Coracohumeral Ligament
Strongest supportive ligamentReinforces RC Interval
Limits inferior GH Glide from 00-500
Limits Extremes of GH ERGaunt & McCluskey 2012
Ligaments of the Scapula
• Superior transverse ligament forms the suprascapular foreamen by closing the scapular notch
• Passage way for the suprascpular nerve
• (to supraspinatus & infraspinatus)
Arthrology & Kinesiology Shoulder Girdle
1. Joints
2. Muscle Force Couples
Described as effects on the distal clavicle
• Elevation/depression
• Protraction/retraction
• Posterior rotation
Sternoclavicular (SC) Joint SC Joint MotionsInferior glide + Posterior spin
Instructions: Back to Front Palpation
Acromioclavicular Joint
• Small amount of glide anterior/posterior
• Accommodates motions of the scapulothoracicjoint
• Back to front Palpation right shoulder:
1. Right index finger on acromion
2. Left hand distal clavicle
Scaption = Elevation• 30-45 anterior to the
frontal plane because of the angle of the ribs
• “True” plane of movement of the shoulder allowing the greatest range of motion
• AAOS “raise your arm”
Scapulothoracic JointPlane of the Scapula
Shoulder Planes
• Flexion to the front• Abduction to the side
• Elevation=Plane of the scapula
Functional BiomechanicsPlane of the Scapula Elevation
• Shoulder abductors and rotators are at optimum length-tension ratio
• Joint capsule is relaxed or untwisted• Improved joint congruity of GH joint• Less likely to impinge as apex of greater
tubercle is at high point of coracoacromial arch• Most comfortable for patients to gain
Glenohumeral ROM and strength in this plane
Three Dimensional Motions Scapula
• Internal/External Rotation
• Tilting
• Upward/Downward Rotation
Scapulothoracic Motion Muscle Force Couples
• Upwards rotation: Upper trapezius, middle trapezium, Serratus Anterior
• Downwards rotation: Rhomboids, Pectoralis minor
• Elevation: Levator Scapula, Upper traps, Rhomboid
Motion of the scapula is accompanied by simultaneous motion at the sternoclavicular (SC)
joint and gliding at the acromioclavicular (AC) joint
Neumann 2010
50Neumann, 2010
Scapulohumeral RhythmPhases of Motion• Phase I : 0-60
(Setting) • Phase II: 60-120
(Critical)• Phase III: 120-180
(Final)Total: 60 degrees scapulothoracic120 degrees glenohumeral
ArthrokinematicsShoulder Elevation
ICF - Inferior capsular ligament
SCF - Superior capsular ligament
With arm elevation, it is necessary to have a upward roll and a downward glide of the humerus on GH fossa.
Neumann, 2010
Force Couple:Scapular Upward Rotation
Muscles involved:
a. Serratus Anterior
b. Upper trapezius
c. Lower trapezius
Action:
• Rotate scapula upward
• Stabilize scapula
Force Couple
Greene, 2005
a
b
c
Muscles Shoulder Girdle
Shoulder ComplexMuscles• Axio-Scapular
TrapeziusRhomboidsLevator ScapulaSerratus anteriorPectoralis minor
• Axio - humeralLatissimus dorsiPectoralis Major
• Scapulo-humeralDeltoidBiceps brachiiTriceps brachii• Rotator Cuff
(SITS)Supraspinatus,Infraspinatus,Teres minorSubscapularis
Serratus Anterior
Action• Upward rotation and
protraction of the scapula.
• Assists with scapular posterior tilt and external rotation.
• Origin: First 8 ribs• Insertion: Medial border
of the scapula• Innervation: Long
thoracic nerve (C5,C6, C7)
55Creative Commons
Serratus AnteriorStrengthening Interventions
1. Dynamic Hug
2. Protraction
3. “Plus”
Scapular Adductors Axioscapular muscle
Rhomboids
Trapezius
Upper fibers (UT)
Middle fibers (MT)
Lower fibers (LT)
57
MT
LT
Middle Trapezius and Lower Trapezius• Scapular Adduction,
Depression • Middle: Origin spinous
process C7-T3• Lower: Origin spinous
process T4-T12• Both insert on spine of
scapula• Innervation: Spinal
accessory (C3, C4)
Creative Commons
Middle/Lower Trapezius
Strengthening Interventions
1. Prone “T”
2. Prone “Y”
3. Scapular adduction
Scapula ElevatorsAxioscapular muscles
• Upper trapeziusInnervation: Accessory nerve, & C 2-C4
• Levator scapulaInnervations: Dorsal scapular nerve (C4 & C5)
• Rhomboids
Neumann 2010
Upper Trapezius
• Sidebending cervical spina, scapula elevation and upward rotation
• Origin: Occipital protuberance, nuchal ligament, spinous process of C7-T1
• Insertion: Lateral third of clavicle, acromion
• Innervation: Spinal Accessory nerve, C3, C4
Creative Commons
Levator Scapula
• Scapular elevation and downward rotation
• Cervical spine side bending and rotation
• Insertion: Superior angle of scapula
• Innervation: Dorsal scapular nerve (C5, ventral rami C3,C4)
Creative Commons
Scapular Depressors
• Gravity
• Weight carried by arm
• Lower trapezius
• Latissimus dorsi
• Pectoralis minor
Neumann 2010
Latissimus DorsiStrengthening
Interventions• Prone “I”
• Medial/internal rotation, adduction, and extension.
• Scapular depression.
64
IR
EXT
DEPRESSION
Pectoralis Major
Sternal: rotates scapula & draws inferior angle laterally forwardClavicular: lowers the raised armInnervation: Lateral
pectoral nerve, medial pectoral nerve
(C5, C6, C7, C8 & T1)
Force CoupleScapular Downward Rotation
Gravity
Rhomboids (against resistance)
Levator Scapulae
Rhomboid Major/Minor
• Axioscapular muscles
• Scapular adduction, elevation, downward rotation and stabilization
• Innervation: Dorsal scapular nerve
67Retrieved on 06/07/09 from: http:// openphysio.co.za/images/thumb/5/5d/Levator_scapulae.jpg/150px‐Levatorscapulae.jpg
Force CoupleRetraction
Axioscapular Muscles• Middle trapezius
• Rhomboids• Lower trapezius
Neumann 2010
Four Muscles of the Rotator CuffSupraspinatus, Infraspinatus, Teres Minor,
Subscapularis (SITS)
http://handsport.us/patient‐education/shoulder‐anatomy/
Rotator Cuff Muscles
• S.I.T.S. Provides a compressive force between humeral head and glenoid fossa
• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis
Supraspinatus
• Origin: Supraspinous fossa to superior facet of greater tuberosity
• Function: Initiates & asstists deltoid in ABD
• Nerve: Suprascapular N
• Blood supply: Suprascapular artery
Infraspinatus
• Origin:Infraspinatus fossa to middle facet of greater tuberosity
• Function: ER of arm and supports head of humerus in glenoid
• Nerve: Suprascapular nerve
• Blood supply : Suprascapular and Circumflex arteries
Teres Minor
• Origin: Superior part of lateral border of scapula to inferior facet of greater tuberosity
• Function: ER arm and helps stabilize humeral head in glenoid
• Nerve: Axillary nerve (C5-C6)
• Blood supply: subscapular & circumflex scapular arteries
Subscapularis
• Origin: Subscapular fossa to lesser tuberosty
• Function: IR and Adduction
• Nerve: Upper and lower subscapular nerves
• Blood supply: subscapular artery
Deltoidscapulohumeral muscle
• Posterior deltoid: Provides external rotation and assist with horizontal Abduction
• Anterior deltoid: Initiates flexion and provides horizontal Adduction
• Middle Deltoid: initiates Abduction primarily to 90 degrees while producing upward shear of the humeral head
Early in abduction the deltoid pulls superiorly (upward shear force) while the supraspinatus gets abduction started. As the arm is abducted to 90°, the direction of pull of the deltoid becomes similar to the pull of the supraspinatus.
Elevation Force Couple
Internal Rotation
Strengthening Interventions
Can vary elevation
1. Isometric
2. Theraband IR
3. Dumb bell
4. Cable column
Teres Major
• Origin: Inferior angle of scapula
• Insertion: Crest of lesser tuberosity humerus
• Function: IR, Adduction. extension
• Nerve: Thoracodorsalnerve
Force Couple External Rotation• ER: infraspinatus,
teres minor & posterior deltoid
• Small total mass and isometric torque
External Rotation
Strengthening
Can vary elevation
1. Isometric
2. Side lying or prone dumb bell
3. Theraband
Force CoupleInternal Rotation• IR: suscapularis,
anterior deltoid, pect major, latissimus dorsi & teres major
• IR larger mass than ER
Neumann 2010
Anterior deltoid,CoracobrachialisLong head biceps
(weak)
Lateral view
Neumann 2010
Force CoupleGlenohumeral Forward Flexion
Coracobrachialis
• Flexes and adducts the shoulder
• Innervation: Musculocutaneous (C6,C7)
Creative COmmons
Scapulohumeral MusclesAnteriorSide to Side Palpation
• Anterior & Middle Deltoid
• Subscapularis
• Coracobrachialis
Scapulohumeral MusclesPosteriorSide to side palpation
• Posterior/ middle deltoid
• Supraspinatus
• Infraspinatus
• Teres Minor
• Teres Major
Assessing Muscle Tightness
Play along
• Pectoralis Minor
• Latissimus Dorsi
• Biceps Brachialis
THE ELBOW
•Elbow Osteology
•Elbow joints, ligaments & kinesiology
•Static stabilizers of the elbow
•Elbow Muscles
87
Bones of the Elbow
• Distal Humerus• Proximal Ulna
• Radial Head
Creative Commons
Elbow Joints
1. Humeroulnar Joint
Hinge-joint that flexes and extends
2. Radiohumeral Joint
Hinge-joint that flexes and extends
3. Proximal Radioulnar Joint
Pronation and supination
89Creative Commons
Bony Anatomy Distal Humerus
Which side is this?
• Shaft inclines anteriorly 30°
• Articular surfaces and joint axis anterior to shaft
• Creates room for soft tissue and greater flexion
• Shaft widens for medial and lateral support pillars
• Aids in maintenance of strength
Carrying Angle Radius
• Rotates around ulna• Becomes "shorter"
In pronation
92
Radial Tuberosity
SupinatorInsertion
Brachio‐radialisInsertion
Pronator QuadratusInsertion
Radial Head• A secondary
stabilizer to both varus and valgus forces if the MCL and LCL are intact
• If MCL or LCL is deficient, then radial head becomes a primary stabilizer
•Radial head is cylindrical and concave proximally
Bony Anatomy Ulna
• Trochlear notch is anterior to shaft and directed anterosuperiorly
• Axis anterior to shaft
• Arc of notch less than 180 degrees
ULNA
95
Coronoid Process
Supinator origin
Brachialis insertion Radial Notch
Pronator QuadratusOrigin
Retrieved from:http://upload.wikimedia.org/wikipedia/commons/thumb/f/f2/Slide1bgbg.JPG/800px‐Slide1bgbg.JPG
Photo retrieved from:http://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Gray214.png/250px‐Gray214.png
Proximal Ulna
• The major determinant of elbow stability
• Ulno-humeral integrity is key to stability
• ~30% of articular surface must be intact
• Coronoid is key to prevent posterior subluxation
Coronoid
• ~50% of coronoid must be present for the elbow to function
• Deficient coronoid will result in posterior instability
Stabilizers of the Elbow
98
Elbow Stability
• A complex interaction among the bones and ligaments to resist physiologic stress applied to the elbow
• A deficiency in one area can be compensated for by other intact structures (ie radial head and MCL in valgus force)
• Soft tissues that contribute to the stability include the collateral ligaments and the capsule both anteriorly and posteriorly. Dynamic stability is also provided by the actions of the muscles crossing the joint.
Rehab of the Hand, 6th ed
Elbow Bony Stability
• Olecranon Process-30% of articulation required for stability
• Coranoid- Critical as an anterior buttress for posteriorly directed forces. Approximately 50% required for stability.
• Radial Head -Contributes 30% to valgus stability with intact MCL and 75% with deficient MCL. Bears 60% of axial load in extension
Creative commons
Elbow Capsule• Encloses elbow and proximal
radioulnar joints ( 3 sets of articular surfaces)
• Small contributor as a passive soft tissue stabilizer (questionable)
• Most lax at 80 degrees of flexion • Assumes position of comfort after
injury• Risk of flexion contracture• Typical hinge joint relationships:
anterior & posterior portions taut only at end range
101
Elbow Ligaments
The ligaments are secondary stabilizers when bones are intact.Ulnar Medial Collateral ligament (MCL)
• from medial epicondyle to ulna• Anterior band most important part• Resists valgus forcesRadial Lateral Collateral• Lateral epicondyle to ulna and annular ligament• Maintains relationship of forearm to trochlea and capitellum• Resists posterior lateral rotatory instabilityAnnular Ligament• Secures radial head to ulna
Annular Ligament
• Attaches to anterior and posterior edges of radial notch and surrounds radial head
• Holds head in notch and allows head to spin
• Resists distraction of radius
Ulnar (Medial) Collateral Ligament (MCL)
• Includes: anterior bundle, posterior bundle, transverse ligament
• MCL is a primary stabilizer for the elbow
• Anterior bundle is major stabilizer to valgus stress.
Ulnar (Medial)Collateral Ligament (MCL)
• Pathology• Chronic
attenuation• Fall• Medial
epicondylectomy with cubital tunnel
Radial (Lateral) Collateral Ligament (LCL)• Extends from lateral
epicondyle to annular ligament for common insertion to ulna
• Lateral laxity allows prox FA to sublux away from humerus when loaded in supination.
• Challenged with any varus stretch or load and more unstable in supination.
Radial (Lateral) Collateral Ligament Complex
107
Ulna
• Radial collateral ligament• Connects lateral epicondyle and annular
ligament
• Annular ligament• Encircles the radial head attaching at the
radial notch posterior & anterior
• Lateral ulnar collateral ligament (LUCL)• Connects lateral epicondyle and supinator
crest of ulna• Provides stability to posterolateral
rotation
• Accessory lateral collateral ligament• Connects inferior annular ligament to
supinator crest
3/3/14 Retrieved from: http://www.orthoverse.com/posterolateralrotatoryinstabilityelbow.asp
Radius
Posterolateral rotatory instability
• Radius & ulna, as a unit, externally rotate away from distal humerus, so radial head displaces posterior to capitellum
• Cause• LUCL injured with Supinated compressive force with
valgus stress- usually at 20-40 degrees ext and reduces in flex
• Stable • Full pronation and some flexion
Interosseous Membrane (IOM)
• At the wrist most load is carried by radius
• At the elbow most load is carried by ulna
• IOM transfers part of the load at the distal radius to the proximal ulna.
• Fibers run medially and distally from radius to ulna.
Creative Commons
Elbow Stabilizers“Other”
• Radial head most important and provides 30% of valgus stability
• Posterior Capsule is primary restraint to distraction in full ext
• Lateral Capsule secondary stabilizer to varus stress
• Anconeous also secondary stabilizer to varus stress
Elbow Muscles
Pronator Teres• Origin:medial epicondyle and coronoid process
• Insertion: middle of lateral surface of radius
• Action: Pronates and flexes
• Innervation:Median nerve (C6,C7)
• Arterial supply: Ulnar artery, anterior recurrent ulnar artery
Creative Commons
Biceps Brachii
• Origin: • Short head: tip of coracoid process of
scapula; • Long head: supraglenoid tubercle of scapula
• Insertion: Tuberosity of radius and fascia of forearm via bicipital aponeurosis(lacertus fibrosus)
• Action: Supinates forearm, flexes forearm
• Innervation: Musculocutaneous nerve (C5 and C6 )
• Arterial Supply: Muscular branches of brachial artery
Creative Commons
Anconeus• Origin: Lateral epicondyle of humerus
• Insertion: Lateral surface of olecranon and superior part of posterior surface of ulna
• Action: Assists triceps in extending forearm; stabilizes elbow joint; abducts ulna during pronation
• Innervation: Radial nerve (C7, C8, T1)
• Arterial Supply: Middle collateral branch of deep brachial artery; Recurrent interosseous artery
Creative Commons
Brachialis
• Origin: Distal half of anterior surface of humerusInsertion: Coronoid process and tuberosity of ulna
• Action: Major flexor of forearm -- flexes forearm in all positions
• Innervation: Musculocutaneous nerve (C5, C6)
• Arterial Supply: Muscular branches of brachial artery, recurrent radial artery
Creative Commons
Supinator
• Origin: Lateral epicondyle of humerus, radial collateral and annular ligaments, supinator fossa and crest of ulna
• Insertion: Lateral, posterior and anterior surfaces of proximal 1/3 of radius
• Action: Supinates forearm (i.e., rotates radius to turn palm anteriorly)
• Innervation: Deep branch of radial nerve (C5 and C6) (C5, C6)
• Arterial Supply: Recurrent interosseous artery
Creative Commons
Brachioradialis
• Origin: Proximal 2/3 of lateral supracondyle ridge of humerus
• Insertion: Lateral surface of distal end of radius
• Action: Flexes forearm
• Innervation: Radial nerve (C5, C6, C7)
• Arterial Supply: Radial recurrent artery
Creative Commons
Triceps• Origin:
• Long head: infraglenoid tubercle of scapula;
• Lateral head: posterior surface of humerus, superior to radial groove;
• Medial head: posterior surface of humerus, inferior to radial groove
• Insertion: Proximal end of olecranon process of ulna and fascia of forearm
• Action: Chief extensor of forearm; long head steadies head of abducted humerus
• Innervation: Radial nerve (C6, C7, C8)• Arterial Supply: Branches of deep
brachial artery
Creative Commons
Shoulder / ElbowCommon Nerve Compression
Sites
Cervical Radiculopathy
• Neck can be a source of compression
• Spinal nerves exit foramen
• Small amounts of compression can amplify distal symptoms
Sammut
Peripheral Nerves
• Brachial Plexus(C7-T1 spinal nerves)• Dorsal Scapular• Long Thoracic• Suprascapular• Upper and Lower
Subscapular• Medial and lateral
pectoral• Thoracodorsal
• Musculocutaneous• Axillary• Radial-with motor
branch PIN• Median-with motor
branch AIN• Ulnar• Medial brachial and
antebrachial• Nerve to subclavius
Thoracic Outlet
• Neurovscularbundle passes over first rib/under clavicle
Sammut
Brachial Plexus
Sammut
Axillary Nerve CompressionQuadrangular Space• Quadrangular
• Between Teresminor, teres major, long head of triceps and humeral shaft.
• Contains axillary nerve and posterior humeral circumflex artery
Creative Commons
Mix and Match
Sammut
Where They Are
Where It Comes Out Musculocutaneous Nerve
Sammut
Sammut
Musculocutaneous Nerve Course
Sammut
Posterior Cord
Sammut
Radial Nerve
Radial Nerve Course
• Arises from C5-8, T1• Travels posterior on medial
side of arm• Winds around spiral groove• Pierces lateral
intermuscular septum (in proximal lat epi)
• Divides into sensory and motor branches (prox. edge of supinator)
• Sensory branch follows radius
• Motor branch pierces supinator
133
Radial Nerve CompressionSupinator Arch: Arcade of Frohse
• Sometimes called the supinator arch
• Fibrous arch over the posterior interosseous nerve
• Common site for compression and paralysis
Creative Commons
Radial Tunnel Syndrome
• Primarily a pain syndrome
• Compression of radial nerve as it passes between the radial head & the supinator muscle
• Deep, burning pain in forearm extensor muscle mass (4-5 cm distal to lateral epicondyle)
Sammut, Left
Sammut
Median Nerve
Median Nerve Course
• Arises from C5-8, T1• Courses with brachial
artery in arm• Medial to biceps• Enters cubital fossa• Anterior Interosseous
(AIN) branch at FDS• Travels b/w FDS & FDP• Enters hand at carpal
tunnel (common site of compression)
137
Sammut
Median Nerve Compression
Pronator Syndrome
Anterior Interosseous Syn.
Proximal forearm pain volarly
Proximal forearm pain volarly
Numbness/tingling volar index, long and ring
Sensory distubances absent
Thumb, index, and long finger weakness
Thumb IP weakness and FDP weakness index
Symptoms reproduced with palpation pronator
No symptoms with palpation of pronator
139Marik HTRC ASHT 2017 Sammut
Ulnar Nerve
Ulnar Nerve Course
• Arises from C8 and T1
• B/w coracobrachialis & medial head of triceps
• ~3in prox. medial epicondyle enters Arcade of Struthers
• Enters medial intramuscular septum
• Enters cubital tunnel
• Passes 2 heads of FCU
• Penetrates flexor/pronator mass & lies b/w FDS and FDP
141
Ulnar NerveCompression Sites
1. Medial Intramuscular Septum (Triceps)2. Arcade of Struthers (under ligament, 8 cm
proximal to medial epicondyle)
3. Cubital Tunnel4. Deep Flexor Pronator Aponeurosis5. Guyon’s Canal
Sammut, Left
Ulnar Nerve CompressionArcade of Struthers• The arcade is a thin
aponeurotic band extending from the medial head of the triceps to the medial intramuscular septum.
Ulnar Nerve CompressionCubital Tunnel
• Site of ulnar nerve compression• Begins at the condylar groove between the medial
epicondyle and the olecranon.• Floor of the cubital tunnel: elbow capsule and MCL • Roof :FCU Fascia & arcuate ligament of Osborne
(cubital retinaculum)• Walls: medial epicondyle and olecranon • Capacity is greatest when the elbow is in extension
because the arcuate ligament is slack. • Changes from round shape to oval shape with
flexion- results in a 55% volume decrease in the canal.
Nerves at Post –Op RiskArthroscopy or Fracture/ORIFClose to Humerus
• Axillary nerve (Proximal; at risk with shoulder arthroscopy)
• Radial nerve (in radial groove, posterior humerus; at risk with mid humeral fractures and ORIF)
• Ulnar nerve (in cubital tunnel; at risk with distal humeral fractures and ORIF)
Sammut, 2 cm proximal to medial condyle humerus
Cross Section
Sammut, 2 cm proximal to medial epicondyle of humerus
Cross Section
Shoulder / ElbowVascular Structures
Arteries
• Subclavian• Axial• Brachial• Radial and Ulnar• Interosseus
• Superficial and deep arches
• Collaterals and recurrents
• Digital arteries
Veins
• Subclavian• Cephalic
• Basilic• Medial Cubital • Dorsal Venous
network
Circumflex Arteries
• Circumflex arteries to proximal humerus are delicate
• If disrupted by fracture, lose perfusion ….Nonunion
151
Triangular Space
• Triangular• Superior: Teres Minor• Inferior: Teres Major• Lateral: Long Head of
Tricep
• Contains: Scapular Circumflex Artery
• Visible: Radial nerve
References• Borich, M.R., Bright, J.M., Lorello D.J., Cieminski, C.J.,
Buisman, T., Ludewig, P.M., (2006) Scapular angular positioning at end range internal rotation in cases of glenohumeral internal rotation deficit. J Orth Sports PT. 36 (12): 926-34.
• Gaunt, B.W., McCluskey, G.M. (2012) A Systematic Approach to Shoulder Rehabilitation. Columbus GA: HPRC.
• Greene, D.P., Roberts, S. L., (2005) Kinesiology Movement in the context of activity. St. Louis: Elsevier Mosby.
• Kendall, F.(2005). Muscles testing and function with posture and pain. Baltimore, MD: Lippincott Williams & Wilkins.
• Neumann D., (2010) Kinesiology of the Musculoskeletal System. St Louis: Elsevier Mosby.
• Reinhold et al: Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. Journal of Orthopedic and Sports Physical Therapy. Volume 39(2); Feb 2009.
• Ross, L. M., Lamperti E. D. Schuenke, M., Schulte, E., Schumacher, U., (2006) Thieme atlas of anatomy; General anatomy & musculoskeletal system. New York: Thieme.
• Skirven, T. M., Osterman, A. L., Fedorczyk, J., and Amadio, P. C. (2011) Rehabilitation of the Hand and Upper Extremity, 6th ed. St Louis: Mosby.
• Sahrmann, S. (2002) Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby.
Acknowledgments–Susanne Higgins, OTD, MHS, OTR/L, CHT–Tambra Marik OTD, OTR/L, CHT–Romina Astifidis MS, PT, CHT–Kirk Turner OTR, CHT
• Special thanks for photos and illustrations provided by:
Dr. Stephen LahrIthaca CollegeDepartment of Physical TherapyHuman Anatomy Review Site & Suny Downstate University Medical Center