Upper Extremities Conditions - Markham Ontario Chiropractor

Transcription

CONDITIONS OF THE
UPPER EXTREMITIES
FREQUENTLY SEEN AND
HELPED IN OUR OFFICE
CHIROPRACTIC CENTRE
134 Main Street North
Markham, Ontario, L3P 1Y3
Dr. H. Boehnke D.C.DIBAK
Thoracic Outlet Syndromes
1. Anterior Scalene Syndrome
2. Costoclavicular Syndrome
3. Pectoralis Minor Syndrome
Anterior Scalene Syndrome
q This is caused by compression of the
brachial plexus etc., between the anterior
scalene, the medial scalene and the first
rib.
q Symptoms are often numbness in the
hand and fingers radiating up into the
forearm. It can also cause a cold hand and
shoulder pain similar to Raynaud’s
phenomenon.
1. Patient supine with
head elevated as if
to test the scalene
muscles
2. Test the wrist
extensors or other
muscles of the hand
while the patient is in
this position.
Diagnosis and Treatment
1. Patient supine have him or her elevate
the head as if to test the scalene
muscles
2. Test the wrist extensors or other muscles
of the hand while the patient is in the
above position. If the tested muscle
which was strong initially now tests
weak, a scalene syndrome is present.
3. Test for the need of TP therapy or SCS
4. Check for underlying problems such as
weakness of the posterior neck
extensors which would correlate with a
sacral fixation. This could also correlate
with a gluteus maximus weakness sitting
which would result in a hypertonic
piriformis resulting in the sacral fixation
5. Check any other factors that could be
associated and correct them.
Costoclavicular Syndrome
q This is entrapment of the brachial plexus
and blood vessels as they go beneath the
clavicle and over the 1st rib.
q Symptoms are usually transient and
similar to the anterior scalene syndrome.
The patient complains of numbness in the
hand and fingers radiating up the forearm.
Sometimes shoulder pain and cold hands
q The patient is put in a
position that places
the shoulder rotated
posterior with the arm
extended 30°
q The patient is asked
to inspire and finger
muscles are tested for
weakening
1. Patient is put in shoulder rotated
posterior with the arm extended 30°
position or the patient is instructed to
elevate their arm to 140° of flexion.
2. The patient is asked to inspire fully
3. Test hand muscles, if a weakness results
the syndrome is present.
4. Treat subluxations of the clavicle and or
muscle weakness of the subclavius
5. Treatment of other factors which might
contribute to this problem. Possibilities
are a Category I pelvis, a Sacroiliac
misalignment, dorsolumbar fixations etc.
Pectoralis Minor Syndrome
Hyperabduction Syndrome
q In this syndrome the brachial plexus and
vascular structures as well as the
subclavian vein can occur between the
fibers of the pectoralis minor muscle, it’s
tendon and the head of the humerus,
coracoid process and anterior rib cage.
q Symptoms are transient numbness of the
hands and fingers radiating into the
forearm
1. The arm muscles
test weak in the
neutral anatomic
position or a
pectoralis minor
contraction position
2. The arm is then fully
abducted and the
former weak
muscles test strong.
1. Arm or hand muscles test weak in the
neutral anatomic position and or a
contracted pectoralis minor position
2. Often there will be trigger points in the
belly of the pectoralis minor muscle.
These will be dramatically relieved by
pushing the shoulder gently inferior and
posterior. If so it is likely from a weak
latissimus dorsi.
3. Test for and correct if found weakness in
the ipsilateral latissimus dorsi, rhomboid,
anterior serratus and posterior deltoid.
4. Look for any other factor which may
contribute to the syndrome such as dural
torque etc.
q This syndrome relates to neurovascular
compression between the pectoralis minor
muscle and the rib cage.
q Symptoms:
§ An abnormal sensation, as of burning,
prickling, throughout the arm and or hand
§ Diminished arterial supply and venous
return
§ The insertion of the pectoralis minor on the
coracoid process is usually very tender.
§ Weakness of upper extremity muscles
q Symptoms (continued)
§ numbness in the hand radiating up into the
forearm
§ Pain from the shoulder to the hand
§ Cold hands
§ Sensory symptoms on the little finger side
of the hand
Brachial
plexus
Pectoralis
Minor
muscle
Pectoralis minor syndrome
q This syndrome results from weakness of
the muscles which do the opposite action
of the pectoralis minor which allows the
pectoralis minor to get hypertonic.
q The muscles which may be weak causing
this syndrome are, the rhomboids, the
middle trapezius, the latissimus dorsi and
or the lower trapezius.
Treatment
q To treat the causes of the muscle
weaknesses which allow the pectoralis
minor to act unapposed and compress the
nerves of the brachial plexus.
q In this office we carefully examine the
possible causes and correct them to give
welcome relief to the symptoms of this
syndrome.
Dorsal Scapular Nerve
Syndrome
q In this syndrome a nerve called the dorsal
scapular nerve gets entrapped by a
hypertonic (tense) scalene muscle which
disturbs the function of the rhomboid and
or levator scapula muscle.
q This causes the shoulder blade (scapula)
to drop inferior and lateral creating an
unstable shoulder blade (scapula).
Syndrome
q This unstable shoulder blade (scapula)
can result in a number of shoulder
dysfunctions, such as stretching of the
suprascapular nerve when the armshoulder is moved forward causing a
stretch on that nerve.
q That results in weakness of one or more
muscles of the rotator cuff
Syndrome
Syndrome
q Symptoms: (according to Walther)
Syndrome
§ Pain along the medial border of the
scapula which radiates to the lateral
surface of the arm and forearm.
Syndrome
§ The pain is a dull ache or generalized pain
characteristic of a motor nerve.
Syndrome
§ The pain is a dull ache or generalized pain
characteristic of a motor nerve.
§ If chronic, atrophy of the rhomboid
muscles and possible the levator scapula
muscle is present
Syndrome
Syndrome
Syndrome
§ The musculature, rhomboids and levator
scapula will likely be tender to deep
palpation.
Syndrome
palpation.
§ There will be tenderness of the lower
aspect of the scalenus medius muscle.
Syndrome
palpation.
§ There will be tenderness of the lower
aspect of the scalenus medius muscle.
§ Palpatory pressure at this area may cause
increased pain in the rhomboid and levator
scapula muscles and in the arm
Dorsal scapular
nerve
Syndrome
Dorsal scapular
nerve
Levator scapula
Rhomboid minor
Rhomboid major
Syndrome
Levator scapula
Rhomboid minor
Rhomboid major
Syndrome
Levator scapula
Rhomboid minor
Rhomboid major
q Entrapment of the
dorsal scapular nerve
by the scalenus
medius usually
involves pain along
the medial scapula
and into the lateral
surface of the arm
and forearm
Syndrome
Syndrome
q Signs and symptoms:
Syndrome
§ Instability of the scapula – if you watch the
patient abduct both arms, the inferior
angle of the scapula on the involved side
will frequently move laterally into the mid
axillary line. If it does not do that then
having the patient extend their neck and
repeating the abduction of the arms will
cause execcive movement of the scapula
Syndrome
Syndrome
q The rhomboid on the affected side will
frequently test weak in the clear, but if not,
have the patient extend his neck and
retest the muscle, it will now almost
always test weak if the syndrome is
present.
Syndrome
q The rhomboid on the affected side will
frequently test weak in the clear, but if not,
have the patient extend his neck and
retest the muscle, it will now almost
always test weak if the syndrome is
present.
q The scalenus medius muscle will most
frequently palpate tense and somewhat
fibrotic and will need a myofascial release
Syndrome
Syndrome
q It will result in an unstable scapula and will
frequently be the cause of a suprascapular
nerve syndrome which will be corrected
when the dorsal scapular nerve syndrome
is corrected.
Syndrome
Treatment
q In this office, the cause of the over
contracted medial scalene muscle is
treated. The cause is one of the following:
o A need for myofascial release of the
medial scalene muscle on the involved
side
o A need to correct a weakness of one or
more of the antagonist muscles
Syndrome
Treatment
q In this office we use treatments to the
muscles and spinal treatments which
balance the muscles responsible for the
syndrome.
q The result is improved shoulder blade
motion and function with reduced pain
Suprascapular Nerve Syndrome
q The suprascapular nerve, supplies the
supraspinatus and infraspinatus muscles.
It also supplies sensory fibers to
ligaments, bursa and the glenohumeral
joint. When entrapped or stretched, it can
cause shoulder dysfunction and pain
which over time can cause impingement
syndrome and rotator cuff tendon and
muscle tears.
q The main symptom pattern of suprascapular
nerve entrapment is deep diffuse pain that is
poorly localized in the posterior and lateral
aspects of the shoulder that may be referred to
the neck, into the arm or upper chest or localized
to the acromioclavicular joint.
q When the patient complains that shoulder
motion aggravates the pain, in this case, it
is scapular motion that aggravates the
pain but the patient cannot differentiate it
from glenohumeral motion.
q Suprascapular
nerve – this nerve
travels a long
distance and is
stretched if the
shoulder blade
moves excessively.
It controls the
following muscles
Infraspinatus
Muscle
Supraspinatus
Muscle
Infraspinatus Muscle
Supraspinatus Muscle
q Symptoms:
Deep diffuse pain that is poorly localized in
the posterior and lateral aspects of the
shoulder. The pain may be referred to the
neck, the upper arm, the upper chest, or
localized to the acromioclavicular joint.
q Causes:
§ Weakness of any of the shoulder blade
o
o
o
o
stabilizing muscles
Latissimus dorsi
Anterior serratus
Rhomboid
trapezius
q Treatment:
§ Any treatment that corrects the muscle
imbalances that lead to this syndrome.
§ This syndrome often resolves when other
treatments are made to correct for
weakness of the formerly mentioned
muscles.
Spinal Accessory Nerve
Syndrome
q The spinal accessory nerve (Cranial XI)
can be compressed or irritated at multiple
sites along its course from the base of the
skull, along the lateral side of the neck,
and to its termination in the region of the
trapezius muscle.
q Nerve compression alters the function of
the sternocleidomastoid muscle and the
trapezius muscle.
Syndrome
§ Weakness or inhibition of the trapezius
and sternocleidomastiod muscles.
§ In severe cases where the trapezius is
paralysed, the scapular alignment is
altered. The most impressive clinical sign
is a prominent inferior scapular tip. The
vertebral margin of the scapula and
inferior tip are no longer parallel to the --
Syndrome
q Signs and symptoms (continued)
§ --vertebral column but are obliquely
directed toward the mid-axillary line.
v D.D. This sign should not be mistaken for
scapular winging as seen in long thoracic
nerve palsy with loss of the anterior
serratus action.
Syndrome
q Because of the weak trapezius muscle, it
can result in impingement, rotator cuff
tendinitis, and or adhesive capsulitis
Spinal Accessory Nerve Syndrome
q Spinal accessory
nerve. It originates in
the spinal cord then
enters the skull
through the foramen
magnum and then
exits the skull again
through the jugular
foramen with other
cranial nerves
Upper
trapezius
Upper
trapezius
Upper
trapezius
q Upper Trapezius
Upper
trapezius
§ Palpate to determine
tension – tenderness
Upper
trapezius
§ Compare with deep
inspiration
Upper
trapezius
inspiration
expiration
Upper
trapezius
inspiration
expiration
§ Change in tension
indicates a cranial
motion disturbance
Sternocleidomastoid
muscle
Sternocleidomastoid
muscle
Sternocleidomastoid
muscle
q Sternocleidomastoid
Sternocleidomastoid
muscle
§ Palpate the SCM on
the left side as the
patient turns head
right
Sternocleidomastoid
muscle
patient turns head
right
the right side as the
patient turns head left
Sternocleidomastoid
muscle
patient turns head
right
the right side as the
patient turns head left
§ Note tone difference –
check against resp.
sternocleidomastoid
Upper trapezius
q Clinical signs and symptoms:
§ Weakness or paralysis of the trapezius
and sternocleidomastoid muscles
§ The trapezius is an important shoulder
elevator and weakness or paralysis alters
scapular alignment
§ The trapezius is an important shoulder
elevator and weakness or paralysis alters
scapular alignment
§ The most impressive clinical sign is a
prominent inferior scapular tip
Syndrome
q Impaired muscle function alters scapular
alignment, resulting in a more prominent
inferior scapular tip. Patients present with
weak shoulder elevation, scapular
instability, and a decreased ability to
smoothly elevate the arm.
§ Pecina
q In spinal accessory
paralysis (trapezius
muscle) the vertebral
margin of the scapula
and the inferior
scapular tip are
obliquely directed
toward the midaxillary line
§ Patient can lose the ability to shrug the
shoulder on the involved side.
§ Patients often complain of a dull ache in
the shoulder extending down the arm
§ Patients often complain of a dull ache in
the shoulder extending down the arm
§ The disturbed biomechanics can result in
secondary effects such as shoulder
impingement, rotator cuff tendinitis and
adhesive capsulitis
Syndrome
q Treatment:
§ In this office we direct treatment to both
the spinal aspect and the cranial aspect of
this nerve by both spinal and cranial
treatments as needed.
Syndrome
q Results of treatment:
§ Better shoulder motion and stabilization
§ Improved neck rotation
§ Reduced pain in the upper trapezius
muscle on the involved side.
Lateral Axillary Hiatus
Syndrome
Syndrome
§ In this syndrome, first described by
Bateman in 1955, the axillary nerve can be
compressed while passing through the
lateral axillary hiatus (quadrilateral
foramen) in the shoulder region.
Syndrome
§ In this syndrome, first described by
Bateman in 1955, the axillary nerve can be
compressed while passing through the
lateral axillary hiatus (quadrilateral
foramen) in the shoulder region.
§ It is also named Quadrangular or
Quadrilateral Space Syndrome
Lateral Axillary
Hiatus
Quadrangular Space Syndrome
Lateral Axillary
Hiatus
Quadrangular Space Syndrome
q The long head of the
Lateral Axillary
Hiatus
triceps divides the
space created by the
teres major and
minor, the humerus,
and the scapula into
two spaces, the
medial and lateral
axillary hiatus
Syndrome
Syndrome
q The axillary nerve and
the posterior
circumflex artery pass
through the lateral
opening. It enters
from its position over
the subscapularis
muscle and passes to
the deltoid muscle
Syndrome
Syndrome
q When the arm is
extended as in
sleeping with the arm
up, or abducting the
arm above 90° the
hiatus narrows.
Syndrome
§ Paresthesias or hypesthesias around the
shoulder and upper arm
§ Deltoid atrophy – contour changes around
the shoulder
§ In a functional sense, the deltoid may test
strong in a normal test position but tests
weak when hyperabducted.
Syndrome
§ Compensatory activity of the
supraspinatus as well as the long head of
the biceps is frequently present to diminish
the functional disability found with deltoid
atrophy.
§ Tenderness over the lateral axillary hiatus
space
§ Decreased shoulder abduction is frequent
Syndrome
q Treatment:
§ Myofascial release of any of the involved
muscles at the location of this syndrome.
§ Release of any adhesions that may be in
this location.
q Result:
§ Improved deltoid muscle strength when
hyperabducted
Musculocutaneous nerve
syndrome
Musculocutaneous
Nerve
Coracobrachialis
Muscle
syndrome
Musculocutaneous
Nerve
Coracobrachialis
Muscle
syndrome
q Musculocutaneous
nerve branches from
the lateral cord close
to the inferior border
of the pectoralis minor
Musculocutaneous
Nerve
Coracobrachialis
Muscle
syndrome
Musculocutaneous
Nerve
Coracobrachialis
Muscle
nerve branches from
q Supplies the
coracobrachalis
muscle, often piercing
it to supply the biceps
and brachalis
muscles
syndrome
Sensory
area
nerve branches from
q Supplies the
coracobrachalis
muscle, often piercing
it to supply the biceps
and brachalis
muscles
syndrome
syndrome
q This syndrome is relatively rare, however
several factors are consistently found:
syndrome
§ Patients are young and active performing
demanding work with flexion of the
shoulder and repetitive flexion of the
elbow with pronation of the arm
syndrome
§ Patients are young and active performing
demanding work with flexion of the
shoulder and repetitive flexion of the
elbow with pronation of the arm
§ The majority present following repetitive
high-demand activities
syndrome
syndrome
§ Some authors suggest compression
occurs with hypertrophy of the
coracobrachalis muscle or excessive
pressure generated by the
coracobrachialis muscle.
syndrome
§ Some authors suggest compression
occurs with hypertrophy of the
coracobrachalis muscle or excessive
pressure generated by the
coracobrachialis muscle.
§ Some authors suggest a traction such as
caused by surgical positioning in
abduction and external rotation
syndrome
syndrome
q Symptoms and signs:
syndrome
§ Biceps muscle weakness and wasting
syndrome
§ Sensory complaints to the lateral side of
the forearm.
syndrome
§ Sensory complaints to the lateral side of
the forearm.
§ Biceps brachii and brachialis muscle
weakness typically follows intensive
activity with a flexed arm, elbow flexionextension and a pronated forearm
syndrome
syndrome
q Symtoms and signs:
syndrome
§ Biceps reflex is often absent
syndrome
§ Decreased biceps tone
syndrome
§ Decreased biceps tone
§ Hypesthesia and paresthesias on the
lateral aspect of the forearm.
syndrome
q Treatment:
§ If the cause is from a shortened
coracobrachialis or an adhesion in the
coricobrachialis, it can be helped by a
specific myofascial release.
§ If there is a more severe cause, it would
need to be seen by an orthopedic surgeon
Ulnar sulcus syndrome
q The ulnar nerve passes through a tunnel
of tissue (the cubital tunnel) behind the
inside of the elbow. Here you can feel the
nerve through the skin. It is commonly
called the " funny bone; see the figure on
the left in the next slide.
Compression at the elbow, ulnar
sulcus syndrome also known as
cubital tunnel syndrome, causes
numbness in the small finger (also
known as the "pinkie"), along the half
(lengthwise) of the ring finger closest
to the small finger, and the back half of
the hand over the small finger.
q The epicondylo-olecranon ligament
stabilizes the ulna and the humerus. It also
stabilizes the ulnar nerve at the sulcus and
prevents it from moving during forearm
movements.
q When the ligament is hypertrophied or
stretched, entrapment of the ulnar nerve
occurs
q When ulnar nerve entrapment happens it
§
§
§
§
can cause pain and parethesia over the
ulnar nerve distribution and can weaken
the following muscles:
Flexor carpi ulnaris
Ulnar portion of flexor digitorum profundus
Interossei and hyopthenar muscles
Adductor pollicis
q Treatment:
§ Any chronic misalignment correction
§ Correction of muscle imbalances such as
the necessity of stretching the long head
of the triceps
§ If dislocation or avulsion are present, it is a
medical orthopedic problem
Carpal Tunnel Syndrome
Carpal Tunnel Symptoms
q Pain, tingling or numbness in the thumb,
index, middle or ring fingers.
q A swollen or tight feeling in the hand or
wrist
q Hands and lower arms feel weak and you
may drop objects more than normal
q These symptoms are often worse at night
or when first getting up in the morning
Causes
q Trauma such as stopping a fall, forcing a
stuck window open, holding a heavy tray
over the shoulder as a waiter or waitress
q Reptitive motion such as typing, using
vibrating hand tools or instruments, or
knitting at home.
q Vitamin B-6 deficiency with resultant soft
tissue swelling.
q Toxic states with retention of fluid
Diagnosis
q Phalen’s Test
q Flex both wrists and approximate them to
each other. Hold for 60 seconds.
Paresthesias into fingers indicates median
nerve entrapment
q Opponens Pollicis muscle tests weak
especially in Phalen’s postion
q Palpable edema in the wrist
Opponens Pollicis Test
q Ask the patient to
approximate the
thumb and little finger
q Ask them to keep the
thumb where it is and
to relax the little finger
q Stabilize the hand
q Exert pressure
against the thumb to
separte it from the
hand
Treatment
q Adjust radius, ulna,
and carpals if needed
q This can be with an
adjustment and or
repositioning
q B-6 supplementation
may be necessary
q Rehabilitation
exercise
q Bracing may be
needed
Treatment
q In severe cases that do not respond to
conservative measures, surgery may be
necessary.
Ulnar Tunnel Syndrome
q The ulnar tunnel is bordered by the
pisiform and hamate, the transverse carpal
ligament and the flexor carpi ulnaris
muscle
q Weakness of the flexor digiti minimi and or
the opponens digiti minimi muscles with
normal strength of the flexor digtorum
profundus of the 4th and 5th fingers
Opponens Digiti Minimi Muscle
q Patient is asked to
approximate the
thumb and little finger
q The thumb is allowed
to relax
q Stabilize the hand
q Pressure is applied to
flatten the hand in the
direction to lengthen
the muscle
Flexor Digiti Minimi Muscle
q Patient is asked to
flex the little finger
while the
interphalangeal joints
are held in extension
q Stabilize the rest of
the hand
q Pressure is applied to
extend the proximal
phalanx .
Flexor Digitorum Profundus
q Patient flexes the
distal interphalangeal
joint of the finger to
be tested
q Stabilize the proximal
phalanges
q Force is applied to
extend the distal
phalanx
Ulnar Tunnel Syndrome
Treatment
q If weakness is found in the opponens digiti
minimi and or flexor digiti minimi muscle
pressure against the pisiform and or
hamate is done in various vectors until one
vector strengthens the muscle test.
q Adjustment is done to reposition the
pisiform and or hamate accordingly
q Stabization if necessary
DeQuervain’s Tenosynovitis
1. Finkelstein’s test. Have the patient tuck
their thumb into a closed fist and deviate
the wrist ulnarward. If it creates
considerable pain over the radial styloid
area it is a sign of possible
DeQuervain’s.
2. Subluxations of the radius, ulna and or
carpals especially the trapezium and or
scaphoid may be involved
3. Myofascial release of the abductor
pollicis longus and extensor pollicis
brevis and longus may be needed.
4. A check for stability or instability of the
carpals, radius and ulna and treat
accordingly with support if needed.
5. Avoidance of activities that can
aggravate the carpals and tendons in the
wrist
The Shoulder
q The shoulder is the most complicated joint
in the body.
q It is actually a complex of joints and
muscles working together.
q The only direct boney connection to the
skeleton is via the acromioclavicular joint
(the joint between the shoulder blade and
the collar bone.
The Shoulder
q The shoulder blade attaches to the collar
bone (clavicle) and the collar bone
(clavicle) attaches to the breast bone
(sternum), which in turn attaches to the
ribs, which in turn attach to the spine.
q The rest of the functional aspects of the
shoulder are via muscles and tendons.
q So the shoulder literally floats in a sea of
muscles with one direct boney attachment
Shoulder Joints Structures
q Five functional joints
1. Sternoclavicular
1. Sternoclavicular
2. Acromioclavicular
1. Sternoclavicular
3. Subacromial
1. Sternoclavicular
3. Subacromial
4. Glenohumeral
1. Sternoclavicular
3. Subacromial
4. Glenohumeral
5. Scapulothoracic
Shoulder 5 functional joints
The Sternoclavicular Joint
q Visual detection of a
subluxation
subluxation
1. The examiner puts
his index fingers on
the sternal aspect of
the clavicles
subluxation
1. The examiner puts
his index fingers on
the sternal aspect of
the clavicles
2. The examiner
determines if it is
superior, inferior, or
anterior
Sternoclavicular Joint
misalignment-elevated clavicle
The Acromioclavicular Joint
§ This is a common site
of separation.
§ This is a common site
of separation.
§ The horizon sign is a
frequent finding. It is
a lump that shows up
when the A/C joint
separates with the
clavicle lifting up from
the acromion process
Horizon
sign
Horizon sign overview
Horizon
sign
Acromioclavicular Joint
§ A space of more than
1.3 cm. Between the
coracoid and clavicle
is a sign of a
coracoclavicular
ligamentous
disruption
Upper
Trapezius
Deltoid
Upper
Trapezius
Deltoid
q A/C joint separation
or sprain
Upper
Trapezius
Deltoid
or sprain
§ Often is associated
with upper trapezius
hypertonicity and
trigger points
Upper
Trapezius
Deltoid
or sprain
§ Often is associated
with upper trapezius
hypertonicity and
trigger points
§ Often associated with
middle and posterior
deltoid that test weak
Upper
Trapezius
Deltoid
q A/C joint separation or sprain - continued
§ then hold the patients acromioclavicular
joint in approximation and if it relieves the
tenderness it needs adjustment.
v The adjustment is a controlled act, best
done by a chiropractor
v The adjustment is a controlled act, best
done by a chiropractor
§ Follow adjustment by isometric exercise
for the anterior and posterior deltoid
Acromioclavicular stability
excercise
excercise
§ Anterior deltoid part
excercise
§ Anterior deltoid part
§ With the forearm in an
elevated position with
the angle such that
the belly of the
muscle rises push
isometrically against
an immovable object
excercise
excercise
§ Posterior deltoid part
excercise
§ Posterior deltoid part
§ With the patients arm
in a position with the
forearm pointing
inferior to an angle
which causes the
muscle belly to rise
do an isometric
contraction against an
immovable object
Normal Shoulder Abduction
Normal Shoulder Abduction
q In normal abduction
the patient is able to
bring the arms
together above the
head at a full 180°
without pain or
restriction.
Slouched Shoulder Abduction
q When the patient is in
a slouched position
with an increased
kyphosis, the
abduction is usually
restricted.
q When the patient is in
a slouched position
with an increased
kyphosis, the
abduction is usually
restricted.
q This is due to
impingement of the
greater tubercle of the
humerus against the
coraco-acromial lig.
Shoulder Abduction with Internal
Rotation
Rotation
q With the hands and
arms in internal
rotation, most patients
will have restricted
abduction.
Rotation
q With the hands and
arms in internal
rotation, most patients
will have restricted
abduction.
q This is due to
impingement of the
greater tubercle of the
humerus against the
coraco-acromial lig.
Shoulder Muscles (anterior)
Shoulder Muscles Anterior
Shoulder Muscles posterior
Shoulder Muscles Posterior
Biceps tendon slip
The biceps tendon
can slip out of its
groove in the
humerus.
In a medial slip the
tendon can be
palpated when the
elbow is flexed to 90
degrees and the
humerus is externally
rotated to 30 degrees
Biceps Tendon Medial Slip
Biceps Tendon Normal
Biceps Tendon
Medial Slip
q In my personal experience, I have found
that myofascial adhesions appear to occur
between the pectoralis major clavicular
division and the tendon of the long head of
the biceps which appear to put a medial
pull on the tendon. This I have often found
is associated with a painful restriction of
the Apley’s inferior test for the shoulder.
The release of the adhesions improves
the ROM
Biceps Tendon
Medial Slip
Pectoralis
Major
clavicular
Biceps
Tendon
Long head
Biceps tendon slip
q Lateral
§ Typically occurs
during a throwing type
motion.
Shoulder Impingement
q This is when passive or active abduction
results in an elevation of the humeral head
and restriction of abduction occurs usually
with discomfort or pain
q This is often due to an imbalance between
the muscles that pull the humerus
cephalad as opposed to those that pull it
caudad which results in the humeral head
not being seated properly in the
glenohumeral joint.
q This results in a situation where the
greater tubercle impinges against the
hood formed by the acromion process and
the coracoacromial ligaments compressing
the soft tissue structures between it.
These impinged structures are the
supraspinatus tendon and the subacromial
bursa
q This patient had
1. A-C Joint separation
2. Slipped biceps
tendon
3. Frozen subclavius
4. Weak external
rotator muscles

Upper Extremities Conditions - Markham Ontario Chiropractor

Transcription

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