ANATOMICAL REVIEW

T h e e n t i r e s h o u l d e r g i r d l e w i t h its m u s c u l a r a n d l i g a m e n t o u s attachments should be included in considering structural dysfunction of the upper extremity. This extends the consideration to the entire span of the trapezius, latissimus dorsi and pectoral muscles proximally and distally to the h a n d . Associated structural lesions m a y be found from the spinal area within t h e origins of the trapezius (occiput to T-12) and latissimus dorsi (T-7 to the sacrum), to the shoulder girdle proper, consisting of the clavicle, m a n u b r i u m , first rib a n d scapula, and t h e n on to the proximal and distal h u m e r u s , the elbow joint, the proximal a n d distal radio-ulnar joints a n d finally to the carpals a n d metacarpals. Mid- a n d u p p e r thoracic lesions, as well as t h e m o r e apparent cervical lesions, affect the neurocirculatory condition of the h a n d s . T h e fact t h a t dorsal lesions affect t h e wrist a n d h a n d is frequently not understood and is overlooked.

T h e sternoclavicular joint, t h e acromioclavicular joint a n d t h e g l e n o h u m e r a l j o i n t s h o u l d b e t e s t e d for d y s f u n c t i o n . I n j o i n t dysfunction there is periarticular soft tissue c h a n g e - usually e d e m a , t e n d e r n e s s a n d altered joint motion with some d e g r e e of palpatory pain.

levator scapulae rhomboideus minor

rhomboideus major

trapezius

sternocleidomastoideus

subclavius

pectoralis minor pectoralis major

serratus anterior

latissimus dorsi

Figure 9.1 Muscular attachments of the shoulder girdle

Figure 9.1 depicts the m u s c u l a r a t t a c h m e n t s of the shoulder to the t h o r a x a n d c e n t r a l a x i s . T h e m u s c l e s s h o w n a r e t h e s t e r n o -cleidomastoideus, splenius cervicis, levator scapulae, rhomboideus minor, rhomboideus major, trapezius, latissimus dorsi, pectoralis major a n d pectoralis minor.

CLAVICLE

T h e clavicle articulates medially at the sternum with a ball and socket joint c o n t a i n i n g a disc, w h i l e laterally t h e a r t i c u l a t i o n w i t h t h e acromion process of the scapula is by an overlying bevel contiguously fixed by l i g a m e n t s w h i c h allows a riding-with-shoulder motion. The

costoclavicular

articular disc trapezoid conoid acromioclavicular

coracoacromial

clavicle is the only bony connection b e t w e e n the u p p e r extremity a n d the t r u n k or central axis of the body.

Clavicular ligaments

The sternoclavicular ligaments (Figure 9.2) are the capsular, anterior and posterior sternoclavicular, interclavicular a n d costoclavicular ligaments and the articular disc. The acromioclavicular ligaments are the capsular, superior and inferior acromio-clavicular, coracoclavicular (trapezoid and conoid) ligaments a n d the articular disc (sometimes).

Sternoclavicular joint testing

The operator, behind the patient, palpates the sternoclavicular joint with one h a n d and circumducts the ipsilateral (adjacent) extremity into extension and abduction.

Method 1

(1) With the patient sitting, or lying down, t h e p h y s i c i a n s t a n d s behind the patient (Figure 9.3).

(2) The physician's t h u m b and index finger are u s e d to p a l p a t e for joint motion at the sternoclavicular joint.

(3) The physician's t h u m b is placed over the m e d i a l third of t h e clavicle.

(4) The physician uses the other hand to grasp the patient's forearm or elbow and moves it by circumduction up, out a n d b a c k w a r d s .

sternoclavicular interclavicular

Figure 9.2 Ligamentous attachments of clavicle to sternum, first rib and scapula (anterior view)

Figure 9.3 Testing and correction of the sternoclavicular joint

Figure 9.4 Sternoclavicular joint testing using the shoulder action. If not adequate, the forearm and arm can be circumducted in a similar fashion to the sitting technique Method 2

The operator stands facing the standing or sitting patient. The patient m o v e s b o t h s h o u l d e r s forward w h i l e t h e o p e r a t o r p a l p a t e s b o t h sternoclavicular joints and compares the set, congestion, tenderness and motion of the joints.

Method 3

With the patient supine, the ipsilateral upper extremity is put in extension and abduction, rotating the arm externally or internally while palpating the sternoclavicular joint (Figure 9.4). Internal rotation moves the clavicle down: external rotation moves it up.

Testing a joint in lesion m a y be corrective, if the testing action exaggerates the motion. Corrections can be m a d e simply by stretching or stretching with a low velocity thrust.

Corrective techniques for sternoclavicular lesions Method 1

(1) T h e operator stands b e h i n d t h e sitting patient and palpates the joint w i t h t h e t h u m b a n d i n d e x finger by r e a c h i n g over t h e opposite shoulder and across the chest to the sternoclavicular joint, while t h e other h a n d grasps t h e arm or elbow (Figure 9.3).

(2) The operator places his thumb over the medial third of the clavicle.

(3) T h e o p e r a t o r u s e s h i s o t h e r h a n d t o t a k e u p s l a c k a n d exaggerates t h e extension and abduction of t h e extremity while the p r e s s u r e of t h e t h u m b is on t h e clavicle. This motion pulls the clavicle up a n d away from the sternoclavicular joint, giving a release a n d re-alignment to the norm.

Method 2

A non-specific shoulder m a n e u v e r is performed by the operator s t a n d i n g behind the patient and grasping both u p p e r extremities as illustrated in Figure 9.5. T h e patient's elbows are

Acromioclavicular joint motion can be tested by moving t h e palpat-ing fpalpat-ingers from the medial sternoclavicular joint laterally to t h e ac-romioclavicular joint. T h e patient's arm is circumducted to create motion in order for the palpating fingers to assess w h e t h e r t h e joint

a n c h o r i n g t h e c l a v i c l e w i t h h i s t h u m b a n d i n d e x finger w h i l e c i r c u m d u c t i o n of t h e p a t i e n t ' s p r o x i m a t e a r m is m a d e w i t h t h e o p e r a t o r ' s other h a n d .

Corrective technique for depressed lateral clavicle

(1) T h e operator stands b e h i n d the sitting patient (Figure 9.7).

(2) T h e operator places his first great index knuckle over the middle t h i r d of t h e clavicle b u t t h e h a n d is p o s t e r i o r so as to p u t p r e s s u r e d o w n w a r d s on t h e u p p e r part of the scapula.

(3) Circumduction of t h e a r m is started from an anterior position, b r i n g i n g t h e a r m up a n d finishing laterally a n d posteriorly.

T h e last part of this m a n e u v e r lifts a n d spreads the ribs a n d m a y be u s e d for anterior rib lesions.

SCAPULA

Anatomical review

T h e scapula forms t h e posterior part of the shoulder girdle a n d is a flat, t r i a n g u l a r b o n e with two surfaces, t h e ventral surface b e i n g broadly concave, a n d three borders. The dorsal surface is divided by

Figure 9.6 Elevated clavicle technique Figure 9.7 Depressed lateral clavicle technique

the scapular spine which separates t h e s u p r a s p i n a t o u s fossa from t h e infraspinatous fossa w h e r e the respectively n a m e d muscles arise. T h e spine is broad a n d flattened, e n d i n g laterally in t h e acromion that articulates with the clavicle. On t h e lateral a s p e c t of t h e superior scapular e d g e there is a notch, just lateral to w h i c h is t h e anteriorly projected coracoid process. Below this, on the lateral edge, is the broad glenoid cavity.

The scapula articulates with t h e clavicle a n d t h e h u m e r u s . T h e s c a p u l a i s a t t a c h e d a n d s u p p o r t e d i n position b y l i g a m e n t s a n d muscles without any bony a t t a c h m e n t to t h e trunk, except indirectly by the clavicle (Figure 9.8). Dorsal lesions affecting t h e myofascial support alter the position of t h e scapula. In c h e c k i n g t h e s c a p u l a r position, it should be compared with the sister scapula. T h e m u s c u l a r tension and ligamentous tone should be evaluated along with position, motion and restrictions.

Scapular ligaments

T h e s e are shown in Figure 9.2. T h e acromioclavicular, trapezoid, conoid, coracohumeral, glenoid capsular a n d glenoid l a b r u m are for b o n e s t r u c t u r a l s u p p o r t s . T h e s u p e r i o r t r a n s v e r s e a n d inferior transverse serve for n e u r a l p a s s a g e .

Scapular muscles

The muscles connecting the scapula to t h e anterior a n d lateral axial thorax are the pectoralis minor a n d serratus anterior. T h e m u s c l e s connecting t h e scapula to the vertebral column are t h e trapezius, latissimus dorsi, levator scapulae a n d r h o m b o i d e u s major a n d minor

(see Figure 9.1).

Scapular testing

The scapulae are tested by comparing symmetry. Is o n e anterior or posterior? T h e testing may be carried out with t h e patient sitting, standing or prone. The myofascial tension is tested by a p a l m i n g grasp of each scapula, simultaneously testing for motion a n d resistance.

W h e n t h e r e i s a s c a p u l a r l e s i o n , t h e a c r o m i o c l a v i c u l a r a n d sternoclavicular joints, a l o n g with t h e ribs, m u s t be c h e c k e d for lesions. The pectoralis minor, lying u n d e r the pectoralis major, arises from the 2 n d - 5 t h ribs anteriorly and inserts in t h e coracoid process (see Figure 9.13, p a g e 122). The serratus anterior arises from t h e first

superior

subscapularis

serratus

( A )

levator scapulae

minor rhomboideus

infraspinatus rhomboideus major

deltoideus

teres minor

teres major

Figure 9.8 Scapula showing anterior (A) and posterior (B) muscle attachments

n i n e ribs anterolaterally a n d inserts along the under-surface of the scapula at t h e vertebral e d g e . Both muscles pull the scapula forwards whilst w i n g i n g t h e s c a p u l a o u t w a r d s . W h e n t h e r e is an acromio-clavicular lesion t h e r e is p e r i a r t i c u l a r p a l p a t o r y p a i n w i t h s o m e alteration of articular approximation. Trigger-point t e n d e r n e s s may

pector minor biceps and coracobrachiolis

triceps

inferior

costal surface

supraspinatus

biceps trapezius

( B ) dorsal surface

be found in the medial aspect of the sternoclavicular joint. T h e gleno-h u m e r a l articulation m a y b e restricted, b e a r i n g i n m i n d t gleno-h a t t gleno-h e deltoid, s u p r a s p i n a t u s , infraspinatus, teres minor a n d major a n d the pectoralis major muscles attach to the proximal portion of the h u m e r u s .

Apart from the musculoskeletal t e c h n i q u e s already m e n t i o n e d for a c r o m i o c l a v i c u l a r l e s i o n s , t h e r e a r e m y o f a s c i a l o r soft t i s s u e treatments for scapular lesions. Treatment is performed most often with the patient in the lateral r e c u m b e n t position. T h e m e d i a l b o r d e r of the scapula is grasped with the finger tips w h i c h are worked u n d e r the scapula, drawing the scapular mass laterally in a repeated m a n n e r until the myofascial tension is felt to release (Figure 9.9).

Testing for joint or other structural motion or restriction and performing stretching maneuvers are similar techniques because in each of these procedures the operator applies his perceiving palpating h a n d a n d fingers over one area of examination after another, while the other hand activates the tissues under evaluation. For instance, in interscapular soft tissue manipulation with the patient lying in a lateral recumbent position, the operator anchors the patient's upper shoulder with one hand while the other hand grasps the myofascial soft tissues (thoracic sacrospinalis and rhomboids) in the fingers and draws them deeply from the spinalis muscle group laterally across to and under the vertebral e d g e of the scapula and continues the motion laterally. This creates a perpendicular type of traction against the muscle bundles, effects relaxation of the muscles and stimulates circulatory decongestion. While doing this, the palpating fingers discern the tissue qualities, such as tissue motion, restriction, congestion, contraction and temperature. grasping the interscapular myofascial tissues a n d drawing t h e m laterally to bring the fingers u n d e r the vertebral e d g e of scapula, laterally rotating the scapula over the chest wall.

A variation of subscapular soft tissue t r e a t m e n t is to r e a c h below the spine and work t h e t h u m b s u n d e r the lower scapula (Figure 9.10).

Figure 9.9 Scapular soft tissue manipulation of the dorsum

SHOULDER