The Shoulder

Origin and insertion of scalenes.

*Anterior* = C3-6 → R1 *Middle* = C2-7 → R1 *Posterior* = C5-7 → R2

What are ways to challenge tissue capacity?

- Be careful. - Expand neuropathways and movement patterns. - Eccentrics, increasing load, complexity and speed over time. - Mindful movements.

What are the benefits of myofascial release (MFR)?

- Brings awareness of chronically tight areas. - Brings nervous system's attention to areas that are sleepy, dormant, weak. - Creates pathway between brain and body. - Increases circulation and blood flow. - Clears out neurologic static. - Hydrates tissues. - Helps tissues glide.

What are ways to strengthen neurocircuitry and tissue adaptations?

- Create new neuropathways and movement patterns. - Create stability in static positions, then efficiently control joint in movement, then repeate to create new neuro patterns. - Isometrics (slow, simple, low load, mindful). - AROM (slow, with increasing isometric resistance).

When sequencing, what are the main 3 things we want to do?

- Prepare the tissues. - Challenge the tissues. - Balance the tissues.

What does PNF do?

- Resets nervous system. - Sparks neurologic control. - Helps clear neurologic static.

Why test Active ROM (AROM)?

- Test so student can control how far they go with their own muscles. - Tests motor control and neurologic control.

What is PROM testing?

- Tests the lengthening muscle. - Tests tissue limitations.

What are ways we can help clients turn on weak or inhibited areas in their shoulders?

-Create neuromuscular connection with body awareness and visualizations. Feel muscles. -Use small, non-weight bearing movements to initiate proper engagement. -Slowly increase challenge with focus on alignment to avoid compensation. -Use myofascial work before strength work if inhibited. Allows client to feel and connect to those tissues before they strengthen.

What are some general ways we can help clients release shoulder tissue tension?

-Engage antagonists to inhibit and create circulation. -Release with PNF or help postures. -Myofascial release (MFR). -Yin held postures. -Look for patterns of guarding.

What are common problems in chaturanga?

-Forward carriage of head. -Scapula winging. -Tendency to lay in the shoulder joint. Increases pressure on the biceps tendon and rotator cuff. -Tension in pec minor contributes to winging and difficulty stabilizing. - Serratus anterior is commonly weak; is an inefficient scapular stabilizer. -Shoulders drop to or below elbow height.

What areas should you focus on to achieve the 4 function aims/issues and make sure shoulder joint is functioning well?

-Humeral head stability (rotator cuff) - tight/weak. Want it to be stabile in weight bearing positions. -Scapular stability (serratus) - weak. Work on stability when weight bearing. -Scapular mobility. Barrier to humeral head stability and scapular stability. If scapula is stuck, difficult to achieve stability through shoulder blades and good weight bearing position for the head of the humerus. -Mobility of surrounding tissues. Barrier to humeral head stability and scapular stability. If tissues are tight, glued, adhered, they will prevent us from finding that good position.

What does "guarding" mean?

-Is an involuntary response of the muscles to protect body from pain. -Muscles rapidly learn habits of guarding that often outlast the injury. -Begin with relaxation, breathing, body awareness.

When assessing scapular and humeral stability, what are you looking for?

-Look for differences from side to side. -Winging (scapular stabilizers) -Humeral position (rotator cuff). Can humeral head stay centered in the socket or does it round forward/down? -Don't want: tailbone lifting or belly dropping. Maintain plumbline. -Thoracic spine should life above scapular when push into floor in scapular pushups. -Watch/ask for pain, ask to point where. -Watch for compensation, tension, weakness, facial expression, winging. -Is one side weaker than the other?

If chaturanga is too difficult for a client, what are some other options?

-Skip chaturanga and do scapular pushups. -Chaturanga with knees on mat. -Don't lower as far. -Arms wider with fingers turning slightly inward/outward. Recruits pecs. -Vasisthasana/side plank.

What often goes along with anterior shoulder carriage?

-Strained erectors - having to hold us up against gravity/chronically stretched; constantly working eccentrically. -Weak external rotators posterior shoulder and scapular stabilizers. -Might be adhesions in the tissues. -Poor stabilization => tight posterior rotators => tight posterior capsule.

What are the 3 reason to do intake?

-To be more effective in teaching. -To track progress and help motivate client. -Inform healthcare/insurance providers.

What problems can happen in chaturanga when shoulders drop to or below elbow height?

-Triceps are less efficient. -Biceps tendon pulls on labrum/capsule as round and lean into front of shoulders. -Often with hyperextend neck. -Often with loss of core/legs/bandhas.

What does -itis mean?

-itis means inflammation.

What does -osis mean?

-osis means there are no inflammatory markers but there is a lack of healing--degenerative issue; thinning of collagen fibers.

What are the 5 steps of therapeutic progression?

1. Able to move joint (PROM). Want to regain PROM before moving on. 2. Stabilize joint in static positions. - Hug down into joint; Push forward; Isometric hug hands in; Braden clavicles. 3. Efficiently control joint in movement. 4. Repeat to create new neuro patterns. 5. Increase load, complexity, and challenge.f

What are the 6 steps of assessing function and their CC (chief complaint)?

1. Ask - When, where, how. (efficient to give them an intake form ahead of time.) 2. Observe static posture. 3. Observe movement - AROM, RROM. 4. PROM and palpation. 5. Yoga assessment and application. 6. Re-evaluate and record.

What are the 4 aims/issues to make sure shoulder joints are functioning well?

1. Flexibility of tissues (stretch). Want to release tight/tense muscles so allow joints to move. 2. Movement of joint (thoracic/cervical). Restricted movement from influence of thoracic spine. Hyperkyphotic posture limits options for shoulder blades, glenohumeral joints, head and neck as try to keep eyes level. 3. Control of joint (strengthen). Look for weak muscles and give them opportunities to strengthen. Want tissues to be strong enough to move bones in place. 4. Optimal joint position (align). Fine tuning. Connect to mindfulness muscles like the rotator cuff. Subtlety of aligning bones with good biomechanics.

Observing static posture from the side, what main areas do I look at?

1. Front to back head and shoulder position. Is chin jutting forward? Back? Is head stacked over rib cage? Look at both sides.

What 4 steps stabilize the shoulder?

1. Hug head of humerus down and into the glenoid fossa. Imagine a pine diagonally hugging the head of the humerus down and in. 2. Push forward. Push floor away. Protract shoulder blades. 3. Isometric hug hands in toward each other. Like squeezing a pillow between arms. Like wrinkling mat between hands. 4. Broaden clavicles with slight external rotation. Shine sternum forward. Depending on the pose, may accentuate one step more than another.

What are the cues to get into chaturanga?

1. Push the floor away. Turn on the serratus anterior. 2. Sternum forward. Like headlight forward. 3. Come to very tips of toes = turns core and quads on. 4. Bend elbows. Do not need to lower to 90°.

What are the 3 steps to create durability?

1. Recapture diminished ROM. 2. Strengthen neurocircuitry and tissue adaptations. 3. Challenge tissue capacity.

What are the 4 keys (steps) to healthy shoulder function?

1. Scapula position. 2. Humeral position and rotation. 3. Core and shoulder coordination. 4. Head and neck alignment.

Observing static posture from the front, what main areas do I look at?

1. Shoulder height 2. Anterior tilt or rotation of head of humerus. 3. Neck/ear position + Any asymmetries. Lengths of side body might be different. Hands might hang differently.

Observing static posture from the back, what main areas do I look at?

1. Shoulder height. 2. Scapular position. 3. Neck/ear position. + Any asymmetries. Spine of scapula is usually about level with T3. Bottom tips of scapula are usually about level with T7

What is the normal range of movement for abduction?

180°

What is the normal range of movement for flexion?

180°

What is the normal range of movement for extension?

40-50°

What is the normal range of movement for adduction?

50-75°

How long does it take for fascia to change?

6-24 months. Long term changes in connective tissue happen slowly.

What is the normal range of movement for internal rotation?

60°

What is the normal range of movement for external rotation?

90°

How do you perform Empty Can Test?

90° abduction, horizontal, turn hand down 30-45° thumb down. Give the outside (pinky) edge of client's hand a bit of downward pressure. Make sure you can see their scapula. Can they meet that downward pressure without their scapula winging off their back? Is there any pain?

How do you perform O'brien's test?

90° flexion and horizontal, add with thumb down. Give the outside (pinky) edge of client's hand a bit of downward pressure.

What is a trigger point?

A point that triggers pain. Trigger points in one area refer to another area of the body. Trigger points are stiffer and have more fluid in them. More viscous. Reduces capacity to transmit vibration. In connective tissue.

Action of lateral deltoid

Abduction (arms out to side). Works with supraspinatus.

What are 4 common postural deviations in the shoulder?

Abduction of scapula. Anterior tilt of the shoulder complex. Internal rotation of the humerus. Elevation of the scapula.

action of pectoralis minor

Accessory muscle for breathing. Lifts ribs up. Helps repiratory diaphragm. Stabilizes front of shoulder by pulling scapula down and forward toward front ribs. Postural muscle. Especially important when weight bearing.

What can cause a labral tear?

Acute fall/pull or repetitive movements can cause a labral tear.

action of pectoralis major

Adduction. Drawing arm to midline especially with arm in front of body. Horizontal adduction. Internal rotation of humerus. Flexion. Upper part of pecs create flexion and lower portion of pecs do opposite, pulling upper arm back down to its anatomical position. Important postural muscle. Tight pecs can close off chest similar to lats. Tightness makes it difficult to take a full free breath. Pecs are commonly short and tight.

What are characteristics of frozen shoulder?

Adhesions in/around shoulder capsule that significantly decrease ALL ranges of motion. Spontaneous or from injury. Passive and active ROM limited with stabilize scapula. Soft end feel due to fibrosis. Mild to severe decrease ROM with or without pain. A lot of times, no pain at all. Important for client to work with physical therapist. Timeliness is essential. The more aggressive can be at the onset, the better the outcome will be.

What is another name for frozen shoulder?

Adhesive Capsulitis

what are the roles of muscle

Agonist - prime mover; primary muscle that's moving Antagonist - opposite action to prime mover Synergist - assists the prime mover/agonist

Primary function of rotator cuff muscles

Anchor and stabilize head of humerus in socket. Position head of humerus.

Antagonist to lateral deltoids

Anterior deltoid Posterior deltoid

Poses that strengthen deltoids

Anterior deltoids: Lifting arms in front and overhead Lateral deltoids: Lifting arms out to side Posterior deltoids: Reverse tabletop

Poses that stretch deltoids

Anterior deltoids: Reach arms behind, clasp hands, lift. Lateral deltoids: cross arms in front of body; Eagle Posterior deltoids: Arms in front and overhead

What is O'brien's test testing for?

Anterior pain = AC joint Deep pain = Labrum Labrum = usually no pain with palm up

What common injury might anterior shoulder carriage cause?

Anterior shoulder carriage can cause rotator cuff tendonitis, tendinosis, tear Can cause bursitis/Impingement. Labral tear..

Tight lats/teres major contribute to what shoulder postural deviations?

Anterior tilt Internal rotation

Poses that strengthen subscapularis

Any time bearing weight on arms Rotator cuff muscles work together to strengthen muscles and hold head of humerus in place.

Poses that strengthen rhomboids

Anything pulls shoulder blades back Camel Backbends where arms are along sides Dhanurasana Natarajasana Bridge Reverse tabletop Cactus arms

Poses that stretch rhomboids

Anything that stretches skin between shoulder blades Eagle Cat Crow Rhomboids are often in a chronically stretched position.

humerus or shoulder flexion

Arms in front and overhead Anterior deltoid Upper portion of pects Biceps are weak shoulder flexors

humerus or shoulder extension

Arms move straight back/behind latissimus dorsi, posterior deltoid, teres major Triceps are weak shoulder extensors

What is an easy tests to check whether lats are tight?

Arms will bend in down dog. Lay on back. Bring arms overhead in flexion. Upper arms should be pretty close to the floor. If widen arms and arms get closer to floor, lats are a potential source of tension. Watch for flaring ribs--compensation to get arms closer to floor.

types of cartilage

Articular (hyaline) Fibrocartilage; i.e. labrum Elastic

scapular upward rotation

As shoulder blade rotates down and forward, glenoid fossa turns up upper and lower trapezius, serratus anterior

scapular downward rotation

As shoulder blade turns forward and down, glenoid fossa turns down Mainly assisted by gravity to return arms to anatomical position. rhomboids, levator scapulae, pectoralis minor

What are the 3 key signs in assessing movement function?

Ask - when and where do they feel pain, limitation, stretch? Watch - ROM, facial expressions, asymmetry. Feel - strength, muscle firing, palpation.

What are movements are we assessing with PROM?

Assessing scapular vs humeral movement.

When observing posture and movement, what should I watch for?

Asymmetries (lean, favor, twist, torque) Clenching, bunching tissues or clothes. Any differences side to side. Stand back, unfocus eyes a bit, and wait for things to stand out.

what is the muscle origin?

Attachment site that does not move when the muscle contracts. Usually proximal (closer to midline)

what is the muscle insertion point?

Attachment site that moves when muscle contracts. Usually distal (farther away from midline)

What are the 2 types of labral tears?

Bankart tear--inferior team. A lot less common. Often happens when dislocate shoulder or other acute injury. SLAP tear--Common. Where bicep tendon connects to tendon. Can be acute or chronic jury.

What is the best way to work with joint and capsule ROM?

Best way to work with joint and capsule is through rotational work.

What is the Speed Test testing for?

Bicep tendon Labrum (SLAP) Irritation in the bicep tendon will feel tender to client.

Which parts of the shoulder are commonly irritated?

Bicep tendon Supraspinatus tendon Subacromial bursa Labrum Cartilage

What are the 5 possible bicep tendon injuries?

Bicep tendonitis Bicep tendinosis Bicep Tear Bicep Rupture Bicep Subluxation (tendon can pop out of the bicipital groove).

Biotensegrity

Bones, being load bearing structures, provide the solid component to the body's tensegrity. The myofascial element is the tensile component providing additional stability to the joints and absorbing outside forces. All parts are important. It is an unranked system. Every part is influencing every other part of the system. Every part is part of another part.

Which areas of the shoulder are common "victims"?

Bursa Labrum Supraspinatus Bicep tendon Degeneration from osteoarthritis

What activities can cause bursitis or impingement?

Bursitis: Repetitive motion. Impingement: Decreased space. Impingement: Irritated supraspinatus, can be with bursitis.

When observing external rotation, how are arms and palms positioned?

Cactus arms with palms down and forearms parallel to the floor at the start.

When observing internal rotation, how are arms and palms positioned?

Cactus arms with palms down and forearms parallel to the floor at the start.

What can help thoracic outlet syndrome?

Can do myofascial release of scalenes. Can teach diaphragmatic breathing while supine. Release scalenes and pecs. Check for proper scapular and humeral position and stability with movement.

What are characteristics of trigger points?

Can happen in any muscle. Fibrous tissue can adhere to nerve, blood vessels, lymph=numb, tingle, radiate, swelling. Can shorten muscle belly--tendonitis/tendinosis. Trigger point would be tender to touch but the referral pattern would not be tender to the touch.

Where can myofascial release help in the Cumulative Injury Cycle?

Can help release tension in weak/tight muscles. Allows nervous system to relate to tissues in a fresh new way. Can help with decreased circulation and edema. Can help release lighter adhesions.

What's a good method for working on trigger points?

Can press a myofascial ball in at trigger points. Working with trigger points gives quick, positive feedback to clients.

How to observe movement if client pain is moderate (limits function and/or ROM

Can work a little more intensely than with strong pain. Do AROM, may do PROM and or RROM. Ask them to stop before pain when doing evaluation and practice. Watch for: -Asymmetries (lean, favor, twist, torque). -Compensation, favor, guarding. -Clenching, bunching tissues or clothes. -Any differences side to side.

Poses that stretch supraspinatus

Can't really feel a lot of stretching in stabilizing muscles. May feel a small stretch if take arms together and behind back. Bit of a stretch in lower arm in gomukhasana.

Poses that strengthen serratus anterior

Cat Crow Eagle

Reference points of the shoulder

Clavicle AC joint (acromioclavicular joint) Scapula (shoulder blade) Coracoid process Acromion process Spine of scapula Supraspinous fossa Infraspinous fossa

What are the 3 parts of pec major?

Clavicular part Sternocostal part Abdominal part

How to observe movement if client pain is strong (significantly limits function and ROM)

Clients in this group need to be seeing a healthcare professional too especially if too painful to bear weight. Don't introduce too much at one time. Limit movement so not irritate more. No RROM, maybe no AROM if pain is severe. Ask them to stop before pain when doing evaluation and practice. Teach muscles to turn off and on without weigh bearing or gentle weight bearing (mindfulness sessions).

What is the structure of fascia?

Composed of: 1. Cells - mainly white blood cells & fibroblasts that perform certain functions. 2. Fibers - mainly collagen and elastin structure. 3. Ground substance - Viscous fluid or gel that surrounds the fibers and cells; conducts signals better. Gliding between tissues; becomes more fluid as we move.

Functions of fascia

Connection - Attach, separate (creates compartments of separation), support organs, scaffolding framework for whole body's structure, fill space, communication, force transmission. Protection - Enclose, store fat, fight infections, repair tissue damage, insulate, lubricate/hydration. Communication - fascia houses sensory nerves and is a communication system. Acts as an information highway through mechanotransduction. Fascia is a strain-distributing machine. 250 million nerve endings in fascia.

Potentially vulnerable spots with biceps

Connection point is a potential weak point where labrum could become compromised. Bicipital groove is a potential vulnerable spot--both the tendon on the head of the humerus and the insertion into the labrum, especially in poses like chaturanga.

Characteristics of fascia

Connective tissue. Flexible and strong One continuous interconnected system that exists from head to toe without interruption. Living interconnective communication system. Body-wide intelligence system--living, fibrous, liquid.

Characteristics of capsule joint

Connects one bone to another. Form of fibrous connective tissue. Can stretch, bend, and move with connective tissue. Deepest connection between two bones. One continuous structure going all around joint like top part of a tube sock. One edge is around the glenoid fossa and the other edge is around head of humerus. Surrounds/encapsulates joint. Creates one connective membrane bone to bone 2 distinct layers: liquid inner membrane (synovial layer); fibrous outer membrane. Deeper layer is synovial layer. Secretes synovial fluid, like an oil can, to lubricate the joint. Highly vascular and is import part of health of joint. Fibrous outer layer is poorly vascularized, very little blood flow to the outer layer, so heals very slowly. Fibrous outer layer is richly innervated--has a lot of good nerve innervation telling us a lot about what's happening in the joint and how it's moving.

What are characteristics of a bicep tendon injury?

Could be slight limitation for months or a sudden snap followed by swelling (acute rupture). Capsular tear and tearing of transverse ligament--subluxation of tendon. Anterior shoulder pain at bicep tendon. Tendinosis--pain/weak with speeds test; tender over bicipital groove. Sublux--pain/weak with speeds test, tender over bicipital groove, pop/click, palpable inflammation, refer out. Tendon rupture--Visible bulge or hollow increases with speeds test, weak, refer out.

What are symptoms of a labral tear?

Decrease in stability/strength/ROM. Pain with overhead movement Pop/lock/catching/grinding. Occasional night pain. Hard to see and diagnose.

problems from chronic muscle contraction

Decreases blood circulation Can cause inflammation (hypoxia) Can cause buildup of fibrous (scar) tissue

What are the characteristics of deep fascia?

Dense fibrous connective tissue. Incredibly strong. Interpenetrates and surrounds muscles, bones, nerves, and blood vessels. Surrounds individual muscles, divides groups of muscles into compartments or connects muscles into chains. Transmits force applied to muscle. Lubricates to allow tissues to glide and slide. If tissues are too dry, tissues stick together ("fuzz"). Keeps bones and tissues connected and upright. Contains myofibroblasts with the capacity to contract (slowly over time) and contribute to wound healing. Can also restrict length of fascia causing shortening and instability. Connects superficial fascia to deep fascia.

Poses that stretch biceps

Don't really feel a stretch in biceps. A little bit of stretch in extension or abduction. Dhanurasana.

Poses that strengthen latissimus dorsi

Downdog to high plank Updog (lats help lift and puff up chest) Reverse tabletop (lift and puff up chest) Not a lot of yoga moves strengthen lats.

What is one of the main function of pec minor?

Draw scapula forward.

Action of lower trapezius

Draw shoulder blades down and away from ears/depresses shoulder blades. Upward rotation of scapula. Tend to under-recruit.

what is concentric muscle contraction

Dynamic contraction where muscle gets shorter as it contracts i.e. deltoids concentrically contract when lift arm for Warrior 2

Poses that stretch middle trapezius

Eagle arms.

Poses that strengthen triceps

Eccentric contraction as lower into chaturanga Eccentric contraction in dolphin Eccentric contraction in arm balances

How do you perform RROM internal rotation test?

Elbow at 90° or hand behind back. Resist internal rotation as forearm moves toward body.

action of lavator scapulae

Elevates and downward rotation of scapula. Raises shoulder toward ears.

What is Thoracic Outlet Syndrome?

Entrapment of the brachial plexus as it exits the neck between the anterior and middle scalenes, under the clavicle or under the pectoralis minor.

Inadequate shoulder stability can lead to...

Excess impact/shearing forces through the joint impingement. Tension or weakness around the joint. All leading to joint damage and wear.

How do you perform PROM prone test?

Extension (40-50°): laying on belly, forehead on the ground. Palm turns in toward midline.

Action of posterior deltoid

Extension. Works with lats and triceps.

What is the progression sequence for AROM circles?

External rotation (palm out) Adduction (arm straight and across the front of body) Flexion (palm toward midline) Internal rotation (palm away from midline) Abduction Extension

Action of infraspinatus

External rotation of humerus; stabilize humeral head. Makes a little more room in the joint between humerus and acromion as it rotates head of humerus down and back. Reduces potential for impingement and soft tissues being compressed in bony space.

Action of teres minor and infraspinatus

External rotation; Stabilize humeral head.

characteristics of ligaments

Fiberous connective tissue that connects bone to bone. Reinforces capsule. Denser bands of connective tissue. Supports and reinforces shoulder capsule. Comprised of mainly of collagen. Small amount of elastin allows very minimal stretching. Have sensory nerves that protect joints and keep from over-stretching. Also collects mechanical information about the joint. Very little blood supply; heal slowly but can heal and repair. Good at: dynamic loading (stabilize with movement); controlling end range movements; proprioceptive feedback (awareness of body position, balance & movement in space). Has "creep effect" because of their viscoelastic properties (think gummy worm stretching then going back to original shape). Capacity to stretch/adapt to the stretch, but more importantly to bounce back over to time. Temporary deformation of connective tissues. Critical to passive stability of joints. Passive stability decreases over time in static positions. 3 stages when stretching connective tissue: 1-stretches out the crimp in the fascia; 2-stretches and deforms a bit; 3-plastic region where can tear, more permanent deformation of tissues. Muscular activity required to support prolonged gravitational loading. Movement is important for healing--getting blood flow to the surrounding tissues. Ligaments are functional in all positions rather than specific ones.

characteristics of tendons

Fibrous connective tissue that connects muscle to bone periosteum; connective tissue of the muscle fibers Very little elasticity; even less than ligaments Can be overstretched or torn away from attachments Can become inflamed from repetitive motions of muscles leading to tendonitis Very little blood supply; heal slowly like ligaments. Movement is important for healing--getting blood flow to the surrounding tissues.

Poses that stretch triceps

Flex elbow and flex shoulder. Puppy pose with elbows bent Top arm of gomukhasana

What tests check AROM?

Flexion Extension Abduction Adduction External Rotation Internal Rotation Scapular Protraction Scapular Retraction Scapular Elevation Scapular Depression Scapular Upward Rotation Scapular Downward Rotation Apley's scratch test Apley's bra test Arm drop

How do you perform PROM supine tests?

Flexion (180°): palm turns toward midline. Look for ribs popping up, elbow bending, arm turning/internally rotating. External rotation (90°): starting position is cactus arms with fingers pointing up and elbows on the floor (forearms perpendicular to the floor). Test on back and on belly. Hold client's elbow and wrist. Do not hold shoulder. Internal rotation (60°): starting position is cactus arms with fingers pointing up and elbows on the floor (forearms perpendicular to the floor). Hold client's elbow and wrist. Do not hold shoulder.

If client has had a dislocated shoulder, what would you focus on?

Focus on stability. Strengthen humeral stabilizers. Strengthen scapular stabilizers. Slowly add load to weight--connective tissue responds to loading.

How can you assess/test humeral stability?

From pushup or chaturanga position, bend elbows - at wall, plank knees down, plank knees up, chaturanga

How do you perform PROM seated tests?

Gently press down on top of shoulder as client raises arms. Hold wrist and shoulder Abduction (180°): Externally rotate as you go so palms turn toward midline at the top. Adduction (50-75°): Start at 90° of flexion with palm up throughout.

What is important to get before starting a plan of action for AC joint separation?

Get an ok from client's doctor to bear weight.

What is important to get before starting a plan of action for a fracture?

Get an ok from client's doctor to bear weight.

Joints of the shoulder

Glenohumeral (GH) Acromioclavicular (AC) Sternoclavicular (SC) Scapulothoracic

What 4 things do you do through AROM circles?

Go both directions, backward and forward Go slow to see ROM deficits Engage arm, shoulder, chest, and core prior and maintain throughout to help limit compensation. Have client use opposite hand to hold their rib cage.

What is the grade rating for rotator cuff tendonitis/tendinosis/tear and bicep tendonitis/tendinosis/team/rupture/subluxation?

Grade I - minor pain/weak Grade II - pain, moderate limitation - probably see this the most. Grade III - pain, severe limitation (inability to abduct shoulder actively through ROM, possible atrophy)

Antagonist to upper trapezius

Gravity. Lower traps.

How to observe movement if client pain is mild or none (limited function or ROM)

Harder to work with. Use RROM to assess bilateral differences; may do AROM and/or PROM, too. Look for any differences side to side or on opposite sides of the joint. Watch for: -Asymmetries (lean, favor, twist, torque) -Compensation, favor, guarding -Clenching, bunching tissues or clothes -Any differences side to side

synovial joints

Has a joint capsule Secretes synovial fluid that is like consistency of egg white. All shoulder joints are synovial joints except for the scapula.

How do you perform Speed Test?

Have them resist shoulder flexion with their arm at 90° flexion, palm up. You press on their palm.

types of synovial joints

Hinge - i.e. knee Gliding - joints that create a little gliding movement, i.e. AC joint Ball and socket - i.e. hip; shoulder

characteristics of articular cartilage

Hyaline cartilage - type of cartilage Articular cartilage - location of cartilage Covers ends of bones in synovial joints i.e. labrum; meniscus Absorb shock (kind of rubbery) Glide (like surface of skating rink) Decreases friction No nerve innervations No direct blood flow In shoulder, covers the glenoid fossa

What is the Model of Repetitive Motion?

I = NF / AR I = Insult to the tissues--Injury, Irritation, Inflammation N = Number of repetitions F = Force or tension of each repetition as a percentage of maximum muscle strength. Heavy load or level of tension in muscles A = Amplitude of each repetition. The bigger the movement. R = Relaxation of time between repetitions (lack of pressure or tension on the tissue involved). Rest, relax, give tissues a chance to recover.

If client has issues with their rotator cuff, where else might be an issue?

If have issues with rotator cuff, also want to look upstream to scapular stabilizers.

What is the "magic" test for the levator scapulae?

If person is feeling pinching at the top of the shoulder by the acromion, push firmly on the medial part of the spine of the scapula as person raises arm. This forces muscles use upward rotation. Muscles in neck aren't able to block the normal movement of the scapula.

What areas would you work on if there is pain under the acromion?

If there is pain here, can't always differentiate between supraspinatus and infraspinatus. Work on both of these as well as scapular stabilizers.

What would you focus on with a client if ROM isn't an issue?

If this isn't an issue, focus on stability.

Poses that strengthen pectoralis major

Important for stabilizing front of shoulder in poses like plank, chaturanga, and pushups.

What is Apley's Bra Test testing for?

Infraspinatus

What muscle is tested in RROM external rotation test?

Infraspinatus and teres minor.

Antagonist to subscapularis and supraspinatus

Infraspinatus and teres minor. Gravity. Together, they juggle the head of the humerus front to back in the socket.

What muscle is the issue if there is pain with resisted external rotation?

Infraspinatus can cause pain with resisted external rotation.

Action of supraspinatus

Initiates abduction (5-15 degrees to begin to lift arm up, then deltoids take over); not a major lifter of arm; Stabilizes humeral head in relation to gravity, in an up and down relationship. Works to lift head of humerus up as gravity pulls it down. Stabilizer more than mover.

Action of subscapularis

Internal rotator; little bit of abduction. Hugs head of humerus into socket; Stabilizer; smaller, more refined actions. Of all the rotator cuff muscles, is closest to the middle of the rib cage and helps connect head of humerus to the center of the socket.

supraspinus fossa

Inward divot superior to (above) spine of scapula; Proximal/medial attachment of supraspinatus; above scapular spine

How do you perform RROM external rotation test?

Keep client's upper arm still by gently holding it against their torso. Elbow at 90°. Gently press against the back of their hand while client moves forearm away from their body.

Which muscles are commonly tight?

Lats Pec major Pec minor Triceps/lats/teres Levator scapulae Infraspinatus Upper traps Subscapularis Supraspinatus Posterior capsule

What are the 4 muscles that can adhere/velcro each other and create pain or limited overhead ROM?

Lats Teres major Triceps Infraspinatus

What is the key to get from up dog to chaturanga?

Length of stance is key. Measure stance from stacking shoulders over wrists in up dog, then rolling over toes to plank. When rock forward to chaturanga, should be on very tip toes. To move from chaturanga to up dog, push from tips of toes.

How do you perform Arm Drop test?

Lift clients arms into abduction (arms overhead by ears), then ask them to lower their arms back down. See if they have difficulty slowly lowering their arm from 180°.

Poses that strengthen supraspinatus

Lifting arms Weight bearing poses on arms.

scapular elevation

Lifting/shrugging shoulders Muscles that create action: upper trapezius, levator scapulae Muscles that potentially inhibit the action: tight levator, upper rhomboids, and upper traps.

layers of synovial joint

Listed from deepest layer to most superficial layer: Bone - deepest layer Cartilage Capsule Ligaments Tendons Muscles

What muscles would you look at with AC joint separation or a fracture?

Look at humeral and scapular stability.

If rotator cuff isn't working well, what else should we look at?

Look at scapular stabilizers too.

What are indicators or rotator cuff tendonitis, tendonosis, tear?

Loss of normal shoulder rhythm on abduction or flexion. Positive Apley's Bra Test and/or Scratch Test, Arm Drop, Empty Can Test, pain with AROM and RROM in abduction. For full tears, refer client out.

How do you perform Apley's Bra Test?

Lower arm in gomukhasana. Want hand to be at lease waist height. See how each side compares.

What is good alignment for side plank?

Lower arm is in external rotation. Eye of elbow toward long edge of mat. Lift rib cage away from mat. Bottom hand energetically "turns" away from thumb side--externally rotates.

What is the antagonist to pec minor?

Lower traps.

scapular depression

Lowering shoulders latissimus dorsi, pectoralis major, pectoralis minor, lower trapezius

What can we do to slow down the process of osteoarthritis?

Lubricate the connective tissues--myofascial release, gentle movement. Look at what muscles are tight. Look at what muscles are weak. Look at neck. Look at midback. Look at kyphosis and posture.

What are 2 main functions of the serratus anterior?

Main functions are to protect shoulder blades and upwardly rotate shoulder blades.

What are guidelines for assessing function with PROM?

Make sure client is completely relaxed Use as needed for specific, painful ROM Go slow and ask if is painful Feel for "hard end" (bone meeting bone) vs "soft end" (bouncing feel) Seated, side lying, prone, or supine depending on test. Maybe easier to use a massage table for side lying and supine.

When observing adduction, how are arms and palms positioned?

Measure horizontally. Start at 90 degress of flexion with palms up throughout.

Why assess function with PROM?

Mostly testing areas that had restriction in AROM. Not every test is useful for every client. See ROM capacity without guard/compensate.

How does movement help fascia?

Movement helps take ground substance in fascia from more viscous/tick to more fluid quality.

adduction of arm at shoulder

Movement toward the midline of the body Pectoralis major. Coracobrachialis.

Poses that stretch pectoralis major

Moves that abduct arms/shoulders Shoulder stretch on belly with arm out to side Cactus arms, drawing arms back. Any time arms are out to the side and retracting scapula Dhanurasana Ustrasana Natarajasana With really tight pecs, lower muscle fibers stretch when bring arms overhead. Pecs are commonly short and tight.

Why test Resisted ROM (RROM)?

Muscle firing test. For more functional pain, performance, or neurologic.

How long does it take muscle strength to change in most people?

Muscle strength changes take 5-8 weeks for most people.

AROM tests are what kind of tests?

Muscle tests

How can tight/weak muscles cause irritations?

Muscles that are tight and weal can affect our biomechanics, can change the way our bones relate to one another. That's where common irritations start to appear.

What can you do to help areas that were limited in AROM?

Myofascial release can give some changes in the tissues right away and help ROM.

What does impingement mean?

Narrowing of space; pinching.

What are ways to recapture diminished ROM?

Need PROM as prerequisite for AROM. Create potential for movement. PROM/yin, PNF, MFR, CNS/restorative.

What do you need to have active stability of shoulder girdle?

Need to stabilize scapula and humerus Important scapular stabilizers: serratus anterior; rhomboids. When both fire at the same time, they hold scapula in one position, stable and still in relation to rib cage. Having stabile fixed position of shoulder blade is more important for stabilizing shoulder than rotator cuff. Shoulder blade is closer to axial skeleton. Pay attention to how we support and articulate shoulder. Want balance of scapular and humeral stability. With those 2 together, we create integrity and stability of whole shoulder complex. Because we have less passive stability in the shoulder joint, active stability becomes more crucial.

Poses that stretch pectoralis minor

Needs more restorative poses where it can rest and stay. Won't really feel a stretch in pec minor. Need to hold soft, open chest position long enough for tight pattern to stretch/dissolve. For most people, this is a tight, short muscle. Hard to stretch.

Poses that stretch upper trapezius

Needs more stretch and release. Cue to drop/relax shoulders. Ear to shoulder stretch with arm behind back. Cues and arm positioning are important to stretching.

characteristics of cartilage

No direct blood supply No direct nerve supply, so doesn't transmit pain signals. Capacity to heal or regenerate is significantly impaired. Receives nutrition from tissues, fluids, and bone around joint. Strong and dense to provide smooth joint surface and absorb shock. Primarily composed of collagen.

Poses that strengthen pectoralis minor

None listed

Poses that stretch lower trapezius

None listed.

Poses that strengthen upper trapezius

Not an area that we typically need to strengthen.

What are symptoms of thoracic outlet syndrome?

Numbness/tingling in the arm and/or fingers. Symptom pattern can be different from person to person. Can be vascular symptoms. Can be neurological symptoms. Can have pain. Can be in different parts of the arm, down to fingers, etc.

Origin and insertion of serratus anterior

ORIGIN: Attaches to lateral surface of the top 8 or 9 ribs INSERTION: Goes between scapula and rib cage to insert on medial border of scapula

Origin and insertion of teres minor

ORIGIN: Comes from the lateral border of the scapula INSERTION: Inserts on the back side of the greater tuberosity.

Origin and insertion of coracobrachialis

ORIGIN: Coracoid process INSERTION: Middle of medial margin of shaft of humerus

Origin and insertion of pectoralis major

ORIGIN: Covers about 2/3 of medial part of clavicle coming down sternum. Connects to fascia of external obliques (top of oblique X). INSERTION: Covers chest all the way over lateral to bicipital groove on head of humerus.

Origin and insertion of triceps

ORIGIN: Long head - crosses shoulder to insert on Infraglenoid tubercle just opposite of bicep insertion Lateral and medial heads connect to humerus. INSERTION: Crosses elbow and attaches to Olecranon process of ulna (pointy part of elbow)

Origin and insertion of supraspinatus

ORIGIN: Originates in supraspinous fossa on scapula. INSERTION: Goes under the acromion to attach to the top of the greater tuberosity of humerus. Potential pinch point between acromion and head of humerus.

Origin and insertion of pectoralis minor

ORIGIN: Ribs 3-5 INSERTION: Coracoid process or scapula

Origin and insertion of biceps

ORIGIN: Short head tendon-Coracoid process Long head sits in bicipital groove then slots over head of humerus to connect to supraglenoid tubercle (little bony prominence superior to glenoid fossa). Also connects to labrum at top of glenoid fossa. INSERTION: Both long and short heads cross elbow to insure on radius/forearm (radial tuberosity)

Origin and insertion of trapezius

ORIGIN: Spinous process of C1 - T12 INSERTION: V at top of shoulder--lateral spine of scapula, acromion process, and lateral 1/3 of clavicle.

Origin and insertion of infraspinatus

ORIGIN: Starts in infraspinous fossa on scapula and covers majority of posterior part of scapula. INSERTION: Attaches more to the back part of the greater tuberosity on head of humerus.

Origin and insertion of latissimus dorsi

ORIGIN: T7 down to L5. Connects to thoracolumbar fascia then to top of iliac crest. Also attaches a bit to lower ribs and lower tip of scapula. INSERTION: Humerus front, medial to bicipital groove--the floor of the bicipital groove. Goes from the back part of the shoulder, under the arm to front of humerus. Connects arms to pelvis. Thin sheet of muscle.

Origin and insertion of lavator scapulae

ORIGIN: Transverse processes of the C1-C4 INSERTION: Medial border of the scapula between spine and superior angle.

Origin and insertion of deltoids

ORIGIN: V at top of shoulder--lateral 1/3 of clavical, acromion, and lateral spine of scapula INSERTION: Deltoid tuberosity (a very small bony prominence) on the lateral side of humerus about 1/2 way down humerus. Fits like cap sleeves. Covers tendinous insertions of rotator cuff, pec major, and lat.

Origin and insertion of subscapularis

ORIGIN: front of scapula. Covers the whole front part of scapula. Subscapular fossa (anterior scapula) INSERTION: Inserts on the lesser tuberosity or humerus.

Origin and insertion of rhomboids

ORIGIN: spinous processes of C7-T5 INSERTION: medial border of scapula, pretty much where serratus anterior stops.

What is osteoarthritis in the shoulder?

Osteoarthritis is a degenerative joint disease. Can be genetic, movement, or age related. Wearing away of the hyaline/articular cartilage. Bone spurs start to develop in more progressed osteoarthritis.

What is our goal with osteoarthritis?

Our goal is to slow down the process. Can't reverse damage but if optimize biomechanics, can slow it down and can optimize tissues are the area that are causing pain and discomfort.

What motion is a prerequisite to AROM?

PROM is a prerequisite.

What type of stretch is better for long term ROM gains?

PROM/yin stretches are better for long term ROM gains. Good for hydrating tissues.

How do clients often describe a labral tear?

Pain is usually vague, like a really deep joint pain. May say that it feels unstable. Might feel like it's catching.

Where does pain from subscapularis end to show up (refer)?

Pain tends to refer more to wrist -- dull, achy wrist pain.

Where does pain from infraspinatus generally show up (refer)?

Pain tends to refer to front of shoulder. Common for infraspinatus pain to radiate down the arm. People have pain here when sleeping on their sides.

What might indicate impingement?

Pain with abduction.

What daily activities could cause pain with supraspinatus?

Pain with blow drying hair, pulling shirt on over head, overhead movements.

What daily activity could cause pain with infraspinatus?

Pain with hooking bra.

When observing extension, how are palms positioned?

Palm turns in toward midline throughout.

When observing flexion, how are palms positioned?

Palms turn toward the midline throughout.

What tight muscle can cause scapula winging?

Pecs

Which muscles create internal rotation?

Pecs Lats Subscapularis

What 3 muscles attach to coracoid process?

Pectoralis major, coracobrachialis, and short head of bicep

What causes thoracic outlet syndrome?

Poor respiratory mechanics (hypertonic scalenes, SCM, pec minor) Postural changes (upper cross syndrome=tight pecs, weak deep neck flexors, tight suboccipitals, weak posterior shoulder). Tight scalenes and/or pec minor. Sleeping with arm over/under head. Computer work/repetitive stress. Exercises that induce forward carriage of the head, shoulders and/or trunk (bench press, dips, cycling).

What muscles can contribute to rotator cuff tendonitis, tendonosis, tear?

Poor scapular stability - weak serratus anterior and lower traps Imbalance in rotator cuff muscles Tight levator scapulae Tight posterior capsule Poor humeral stabilizers Tight levator and rhomboids inhibiting upward rotation

Poses that stretch subscapularis

Poses that externally rotate arm. Upper arm with gomukhasana.

What tests would be good to check for rotator cuff tendonitis, tendonosis, tear?

Positive Apley's Bra Test and/or Scratch Test, Arm Drop, Empty Can Test, pain with AROM and RROM in abduction.

What might indicate bursitis?

Positive squeeze test. Decreased active and passive ROM.

What happens to the head of the humerus when there is posterior capsule tension?

Posterior capsule tension a lot of times comes from tightness and restriction of infraspinatus. Capsule gets tight and pushes head of humerus forward. Infranspinatus can influence the posterior capsule, putting pressure on the back of the synovial capsule and driving the shoulder complex forward toward chest.

Action of biceps

Powerful elbow flexor; Weaker shoulder flexor. Biceps help anterior deltoids and pecs create shoulder flexion. Supinate forearm.

Action of triceps

Powerful extend forearm, long head. Also extends shoulder, though weak. Extends elbow. Triceps are important in weight bearing as bend elbows to help articulate and coordinate stability of shoulders and elbow. Lattice work of muscles with triceps, teres minor, and teres major. Free up any adhesion by mobilizing triceps and mobilizing lats.

What is the primary function of the rotator cuff muscles?

Primary function is to stabilize head of humerus in socket

Characteristics of superficial shoulder muscles

Primary function is torque production=movement Control shoulder in weight bearing. Too much activity here can be detrimental to joint. Generally much bigger Usually a lot more powerful Closer to the surface of the body Prime movers Can see, palpate Create visible movements Examples: deltoids, traps, pec major, lats.

Characteristics of deeper shoulder muscles

Primary functions are: (1) Control humeral head in glenoid fossa. (2) Stabilize shoulder. Stabilize joint and draw bones together. Proprioceptive role Smaller, more intrinsic muscles; smaller role in movement. Closer to the bones Deeper under skin "Mindfulness" muscles More subtle Create cohesion Activate first to stabilize/protect joint and create more efficient movement with superficial muscles. Examples: Rotator cuff (supraspinatus, subscapularis, infraspinatus, teres minor), serratus anterior, teres major, pec minor.

If there is pain in the closing angle of the joint, what area is being affected?

Problems here are usually because of issues in the Joint capsule and ligaments.

What is PNF?

Proprioceptive neuromuscular facilitation is a group of stretching procedures involving alternating contraction and relaxation of the muscles being stretched.

action of serratus anterior

Protracts shoulder blade, upward rotation of scapula; stabilize scapula; pulls scapula forward onto ribcage; keeps scapula from winging out away from ribcage. Upward rotation assists humerus on abduction. Used when "push floor away".

When observing movement, if client feels pain, what are 2 main areas to look at?

RROM - look at muscle(s) shortening/engaging/contracting PROM - look at tension in lengthening muscle(s) Pain can be coming from inside the joint, from compression.

What test can help discover labral tear?

RROM testing internal rotation. Check their chaturanga.

What is RROM testing?

RROM tests the muscle that is shortening. Look at differences from side to side.

action of coracobrachialis

Reinforces the bicep. Elbow flexion. Adduction and flexion at shoulder.

How can we intervene/help a client with friction, pressure, and tension in tissues?

Restorative yoga can help with friction, pressure, and tension in tissues. Can reset tissues.

Antagtonist to serratus anterior

Rhomboids

Poses that stretch serratus anterior

Rhomboids Reverse tabletop Dhanurasana Ustrasana (camel) Bridge

What are the characteristics of superficial fascia?

Right under the skin. Blends with the dermis. Continuous, head to toe body suit. Passageway for nerves and blood vessels. Houses cellulite and in some places superficial muscle. **Main function is to protect and support.** Anchors the skin to the underlying myofascia while providing a cushion. Primarily what we are influencing. Part of our range of motion.

What is the Arm Drop test testing for?

Rotator Cuff tear

What muscles actively stabilize humeral head?

Rotator cuff muscles: Subscapularis Supraspinatus Infraspinatus Teres Minor

What are the 3 possible rotator cuff injuries?

Rotator cuff tendonitis Rotator cuff tendonosis Rotator cuff tear

Anterior tilt of the shoulder complex - postural deviation

Rounded upper back Tight muscles - pec minor, posterior capsule, infraspinatus Weak muscles - lower traps, lower serratus anterior Will often see a divot at the collar bone and deltoid.

What are SOAP notes?

S: subjective experience--what client is experiencing O: objective--what you see A: assessment P: plan--protocol that you'll be using

What is a SLAP tear?

SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.

What are the 3 common dysfunction patterns in overhead movements?

Scapula moves up rather than around the ribcage. Winging on the way down. Trunk moves in contralateral lateral flexion (away from lifted arm).

How do you perform PROM side lying tests?

Scapular ROM is optional. See if the scapula is able to move. Move it around with your hand.

How can you assess/test scapular stability?

Scapular push ups seated with arms in front, at wall, in table top with straight arms, plank knees down, plank knees up, chaturanga/side plank, arm balancing/inversions. Intensity of exercises increases as progress through the list.

What is the foundation for humeral stability?

Scapular stability is the foundation.

What muscles could lead to bursitis/Impingement?

Scapular stabilizers Humeral stabilizers Lats Tight levator scapulae - use "magic" test to check. Tight lats maybe pushing head of humerus up. Tight lats maybe thicking inferior capsule.

What muscles stabilize scapula?

Serratus Anterior Rhomboids

If there is scapula winging what muscle needs to be strengthened?

Serratus anterior

Which muscles are commonly weak?

Serratus anterior Lower traps Infraspinatus Subscapularis

Muscles that can add to rounded shoulders

Serratus anterior Pectoralis major Pectoralis minor Lats Infraspinatus

What are the primary scapular stabilizers?

Serratus anterior and rhomboids are the primary stabilizers.

scapular protraction

Shoulder blades move apart serratus anterior, pectoralis minor

scapular retraction

Shoulder blades squeeze together middle trapezius, rhomboids

Abduction of the scapula - postural deviation

Shoulders round forward. Tight muscles: Anterior deltoid, pecs. Weak muscles: Rhomboids, middle traps. Can also be caused by kyphosis, large chest/breasts, long or heavy arms, muscley people. Need to position scapula first (as foundation of humeral position).

Poses that stretch latissimus dorsi

Side bends Puppy pose with head and elbows on floor, hands in prayer. External rotation stretches Reverse warrior with top hand pinky toward ground. Side bend janu sirsasana with pinky toward ground Important to let lats release.

Poses that strengthen infraspinatus

Side plank

Poses that strengthen teres minor and infraspinatus

Side plank

Action of middle trapezius

Similar to rhomboids--retracts scapula.

What muscle works with teres minor?

Smaller version of the infraspinatus. Pretty much same function. They work as a team.

What tests check RROM?

Speed test Empty can test O'brien's test Abduction External rotation Internal rotation

What 2 RROM tests test labrum?

Speed test O'brien's test

What test would help discover bicep tendon injury?

Speeds test Palpating front of shoulder

When observing arm abduction, what 3 areas should you look at?

Spine - No compensatory movement. Humerus - Same side to side with movement; Stays centered in socket. Scapula - Same side to side with movement; No winging.

what is the muscular function at shoulder?

Stabilize joint. Absorb and direct forces through joint. Create movement.

How do you perform RROM abduction test?

Start at 10° and stay pretty low. Clients hands toward midline. Gently press against back of hand while client lifts arms away from torso.

For people with tight hamstrings, what is a good way to get into down dog?

Start in tabletop. Tuck toes under and sit back on heels. Look at hands, chest is still up. Hug shoulders down into sockets. Push floor away Broaden clavicles. Hover knees. Keep belly close to thighs (can help to hold a block or blanket.) Hover/lift hips Drop the head. Straighten knees. Index or middle finger can point forward, whichever is more comfortable. Hands can be a little wider than shoulders (good if lats or pecs are really tight). Distribute weight evenly through the hand. Avoid laying in just one part of the hand. Don't overly engage any of the muscles.

When observing abduction, how are palms positioned?

Start with palms facing forward. Externally rotate as you go so palm turns toward the midline at the top.

What is a good rule of thumb with strength work and frozen shoulder?

Stay away from strength work until client gets all of their range of motion back.

What is BATHE and when it is used?

Step 1 of intake evaluation to assess client's CC (chief complaint). B - Background - OPQRST, diagnosis (Dx), treatments (Tx), surgery, medications, review of systems (heart, lungs, digestion, urine, reproductive, EENT), energy, sleep, water, diet, stress, job, family, emotions. A - Affect - How does it make you feel? T - Trouble - What troubles you most? H - Handle - How are you handling it? E - Empathy - Statement of empathy.

What is OPQRST and when is it used?

Step 1 of intake evaluation to assess client's CC (chief complaint/what is happening now?). O - Onset - When and how did it start? P - Palliation - What makes it better or worse? Get examples from the daily life--work, exercise, yoga. Q - Quality - What does it feel like? Dull, achy, sharp, pulling, stabbing, numb, tingling, radiating. If they feel severe, shooting pain recommend that they see a doctor. R - Region - Where do you feel it? Point to it with 1 finger. Note if they can't be specific. S - Severity - What is the pain on a scale of 0-10. 0=no pain & 10=worst imaginable. This is THEIR scale. T - Time - Is there a time of day when it feels worse or better?

SC joint

Sternoclavicular joint Where the clavicle connects to the sternum Moves, but not much Is a synovial joint--has a joint capsule and secretes synovial fluid. Is a gliding joint--small gliding movements to allow for scapular movement, though very little movement.

How can we intervene/help client with weak and tight muscles?

Strength work Myofascial release (releases tension and allows nervous system to relate to tissues in a fresh, new way.)

What do you do when you find a "weak" muscle with RROM (objective or subjective weakness)?

Strengthen Release if it feels tight. Neuromuscular re-education--clearing the path from the brain to the area. Is the tissue rigid, flaccid/atrophied, or unresponsive? Re-education can be through myofascial release, simple mindful movement, acupuncture, biofeedback, and many other techniques. Is it tension vs compression vs weakness?

What needs to be done if there is no external rotation of the humerus when lifting arms (to create room for the supraspinatus)?

Strengthen infraspinatus Release subscapularis Teach external rotation as a pattern/alignment

What needs to be done if there is decreased abduction and upward rotation of the scapula with lift arms?

Strengthen serratus anterior and lateral traps Release rhomboids and levator.

Poses that strengthen middle trapezius

Strengthen with active shoulder blade retraction. Ustrasana Dhanurasana Dhanurasana Cactus arms

What helps restore shoulder function?

Stretch Strengthen Release (myofascial) Acupuncture, massage, physiotherapy, chiropractic, osteopathic, naturopathic, nutrition. Causative factors: biomechanics, repetitive motions. Limiting factors: nutrition, rest.

How can you stretch a tight posterior capsule?

Stretch using "prone shoulders" (laying on belly with arms crossed under chest).

Poses that stretch infraspinatus

Stretch with internal rotation. Lower arm of gomukhasana Reverse namaste Grabbing opposite elbows behind back Can feel pain in lower arm of gomukhasana if issues with muscle.

Poses that stretch teres minor and infraspinatus

Stretch with internal rotation. Lower arm of gomukhasana Reverse namaste Grabbing opposite elbows behind back.

How can you add force?

Stretch, loading, or posture.

action of latissimus dorsi

Strong extensor; Adduction; Internally rotates shoulders/arms, extend; Plays some role in rotating torso. Helps draw head of humerus in to shoulder girdle as move arm in to extension--think puffed chest of updog. Can take over and cause forward shoulder carriage. Connects upper body to spine. Fires best from an overhead position like in chip ups or pulling down on a weight bar.

Action of deltoids

Strong movers. 3 different fiber orientations each with different action.

RROM tests are what kind of tests?

Structural tests

What muscle is tested in RROM internal rotation test?

Subscapularis

What are the rotator cuff muscles (humeral stabilizers)

Subscapularis Supraspinatus Infraspinatus Teres minor Their tendons fuse together and cover about 70% of head of humerus. Barely cross over the shoulder joint. Overall, pretty weak.

Antagonist to infraspinatus

Subscapularis - together they juggle the position of the head of the humerus front to back in the socket. Supraspinatus.

What muscles commonly lock up around the T-spine?

Subscapularis and lats tend to lock up around this area.

internal rotation of shoulder

Subscapularis, pect major, teres major, lat dorsi

What are the main types of fascia?

Superficial fascia Deep fascia

Antagonist to teres minor and infraspinatus

Supraspinatus

What muscle is tested in RROM abduction test?

Supraspinatus

What is the Empty Can Test testing for?

Supraspinatus (Winging = Serratus)

What is Apley's Scratch Test testing for?

Supraspinatus Subscapularis Lats/Teres Major Triceps

What muscle is most likely to be implicated in a rotator cuff injury?

Supraspinatus Would feel pinching pain especially in positions like handstand or down dog.

If supraspinatus is tense or irritated, what areas would you focus on?

Supraspinatus is a victim. Not a big muscle. If there is tension or irritation, it is because of muscles around it. Focus on posture and postural muscles as well as scapular stabilizers and the rest of the rotator cuff. Focus on tight lats, tight levator.

What are the biggest potential obstacles to humeral stability and scapular mobility?

TIGHT: Lats Teres major Triceps Infraspinatus Levator Upper rhomboids Upper traps Pec minor Pec major Post capsule WEAK: Lower traps Post shoulder Serratus anterior Infraspinatus Thoracic/cervical movement is also important to look at.

What tight/weak muscles can cause anterior shoulder carriage?

TIGHT: Pec minor Pec major Infraspinatus (tight with lower arm gomukasana) Post capsule WEAK: Lower trap Post shoulder

Poses that strengthen lower trapezius

Tend to be weak. Want postures that actively draw scapula down Locust Cobra

What is tensegrity?

Tensegrity = tension & integrity. A net of continuous tension that creates stability without direct contact. It is a fluid and fibrous matrix. Balance between bones and myofascia. System responsible for managing tension and compression in a balanced and oppositional way. It is a passive tensional system. Bones do not directly contact, rather connect via soft tissues. Bones float in a sea of soft tissue. If the tension network becomes weak (it cannot support) tension elsewhere or pressure on joint/joint structures (maybe herniated disc; joint degeneration, etc.) When tension pushes and pulls, gives and takes, it is a win/win situation. Allows our bodies to move efficiently, without damage, and with minimal irritation. Allows us to absorb mechanical stress without distorting our shape or the structures themselves, using minimal energy to maintain shape.

What are the results of tight pecs?

Tension here effects posture (internal rotation and anterior tilt). Affects breathing and abdominal organs due to postural changes.

What do tight latissimus dorsi and teres major effect?

Tension here effects posture (internal rotation and anterior tilt). Postural effects limit breathing and place pressure on abdominal organs due to postural changes. If tension here, shoulder blade can stick out to the side (more than 1/2 inch). If internal rotation of the arm increases overhead ROM => tension here.

Why test Passive ROM (PROM)?

Test ROM and test stretch tolerance and structural changes for more significant pain to help limit compensation/tension. - Look at where head of humerus shifts, where there is pain, where ribs start to pop up.

Why test AROM first?

Test this first because it's something client can control. Feels safer to them. Can see where limitations are so am more sensitive to when doing PROM. Client needs to be able to control their own range of motion to be functionally beneficial.

What is a good way to test for tight lats?

Test this muscle by bringing arms overhead with external rotation.

What does proprioception mean?

The ability to tell where one's body is in space.

subscapular fossa

The front side of the shoulder blade that is closest to the ribs.

What is the brachial plexus?

The neurovascular bundle that innervates the entire arm. Comes from C5 to T1.

Glenoid fossa/Glenoid cavity

The part of the scapula that joins with the humeral head to form the glenohumeral joint. Covered in articular cartilage

glenohumeral joint

The synovial ball-and-socket joint of the shoulder Where humerus fits into glenoid fossa Is a ball and socket joint Allows for the most movement All movements except gliding On its own, does 2x as much movement as all the other 3 shoulder joints put together 50-80% of shoulder movement comes from glenohumeral joint..

What do nociceptors measure?

These measure extreme changes in pressure, temperature, or chemicals.

What do eccentric movements do?

These movement stimulate fibroblasts in the connective tissue to adapt and respond to demands (increasing collagen & hyaluronic acid).

What muscles can contribute to bicep tendon injury?

Thinking upstream--rotator cuff, scapular stabilizers, tightening on back of capsule pushing head of humerus forward. Look at subscapularis (limited external rotation) Look at pecs Look at infraspinatus Look at scapular stabilizers Look at lats.

What tight muscle creates limited PROM with internal rotation?

Tight infraspinatus creates limited PROM with internal rotation.

What are possible causes when scapula moves up rather than around the ribcage in overhead movements?

Tight levator Tight upper rhomboids Weak serratus anterior

Internal rotation of humerus - postural deviation

Tight muscles - pecs, teres major, lats, subscapularis Weak - external rotators, posterior deltoid Hands turn palms back.

Elevation of scapula - postural deviation

Tight muscles, medial/upper traps, levator, upper rhomboid Weak muscles - lower traps, lower serratus anterior

Tightening of what contributes to anterior carriage of shoulder?

Tightening of the posterior capsule pushes the head of the humerus forward and contributes to anterior carriage of shoulder.

What muscles can cause limited range of motion in upper arm of gomukhasana?

Tighter pecs and lats.

What are good ways to create more PROM?

To create more PROM, do more yin, myofascial release, and passively held postures.

Antagonist to biceps

Triceps

Injury concepts

Understand structure=understand function=understand dysfunction Stability is not a guarantee Weak = often tight somewhere else - think trampoline system Tight = often weak somewhere else - think trampoline system What's tight, what's weak, what's not moving, where's the poor alignment? All affect optimal joint position=affect muscle firing Community effect=minimize wear on the joint Look upstream Balance stability and mobility - IMPORTANT! Don't forget mind, spirit, perspective, education to pain and how they relate to pain.

What muscles help upwardly rotate scapula?

Upper and lower traps Serratus anterior help upward rotation.

How do you perform Apley's Scratch Test?

Upper arm in gomukhasana. Want hand to at least move behind head. See how each side compares.

Which muscles have a common attachment point at the V/top of the shoulder?

Upper traps and deltoids have common attachment point.

Action of upper trapezius

Upper traps: elevate shoulder/shoulder blade--raises shoulder toward base of skull. Upwardly rotating scapula so can lift arm overhead. Tend to over-recruit.

Action of trapezius

Upper, middle, and lower traps all have different functions depending on the angling of the muscle fiber orientation. Overall action is to elevate, depress, retract scapula.

What are the main components to alignment in downward dog?

Upward rotation: Outer scapular toward hands or floor and inner scapular toward hips. Scapula position: Slight elevation and upward rotation. Humerus: Slight active external rotation. External rotation fo humerus then internal rotation from elbow to get palm down. Very hard for people with tight lats.

Why test with Palpation?

Use our hands to check clients for tender spots/inflammation/trigger points (TPs)

What cues are good for bringing awareness to serratus anterior?

Very easy for clients to overdo the action. -Puff up upper back. -Stretch between scapula. -Lift thoracic spine above scapula. -Wrap outer scapula around ribcage. -Outer edge of scapula forward. -"Turn on" side ribs. -Demo.

What exercises can help frozen shoulder?

Walking fingers up wht wall; relaxing the shoulder then walking fings up a little more. Internal rotation to really target capsule. Abduction. Sleeper stretch with some PNF (proprioceptive neuromuscular facilitation).

What causes anterior shoulder carriage?

We all have a bit of anterior shoulder carriage because glenoid fossa is oriented slightly toward the front of the body. -Rounded thoracic; chronically lengthens muscles at the top of the shoulder. -Tight pecs -Tight posterior capsule, Infraspinatus -Tight lats, teres major -Tight levator -Anterior head carriage.

What can put a lot of stress on the cervical spine?

Weak serratus anterior and loss of scapular stability.

Is it painful when cartilage begins to wear?

Wearing of cartilage isn't necessarily painful because there are no nerve endings in the cartilage.

What can create tight inferior capsule?

When lats get really tight (lats and teres minor interweave) and adhere to triceps can push the head of the humerus up in the socket. Creates more rubbing in the space under the acromion. Inferior part of capsule starts to thicken.

What happens when superficial shoulder muscles override deeper shoulder muscles?

When superficial muscles override the deeper muscles, we get more wear and tear in the joint. Cohesiveness and balance minimizes wear and tear on joint.

Can hands be a bit further apart in chaturanga?

Yes, some body types need hands wider apart in chaturanga. But they do still need to keep their elbows in. Index or middle finger can point forward whichever is more comfortable.

What is one of the best interventions for osteoarthritis?

Yoga is one of the best interventions for osteoarthritis.

Poses that strengthen biceps

Yoga poses don't vigorously engage biceps. Most poses work triceps. We use biceps a little when weight bearing. Plank to downdog works biceps a bit.

What movement most commonly reveals shoulder pain and restriction?

abduction followed secondly by internal rotation

AC joint

acromioclavicular joint (a joint in the shoulder); moves, but not much at all. Is a synovial joint--has a joint capsule and secretes synovial fluid. Is a gliding joint--small gliding movements to allow for scapular movement, though very little movement.

characteristics of cartilagenous joints

allow only slight movement and consist of bones connected entirely by cartilage; i.e. between sternum and ribs; vertebra

What muscles are engaged when in flexion?

anterior deltoid coracobrachialis pec major bicep

What joint allows for the most movement; all movement except gliding?

ball and socket joint

Antagonist to triceps

biceps

what muscles are elbow flexors

biceps, coracobrachialis

Bones of the shoulder complex

clavicle, scapula humerus Structure

What is the most abundant protein in the body?

collagen (60%)

types of muscle contractions

concentric eccentric isometric

characteristics of fibrous joints

consists of generally immovable layers of dense connective tissue, holds the bones tightly together; i.e. bones in skull; pelvic bones

What muscles are engaged when in abduction?

deltoid supraspinatus

characteristics of labrum

fibrocartilage cartilage that forms a rim/lip around most of the glenoid fossa. Increases passive stability by deepening the joint. Can tear. Seals the joint. Traps fluid=intercapular seal=absorb impact=prevent cartilage on cartilage contact. Helps prevent degeneration. Lubricates. No direct blood supply. No direct nerve supply, though a few nerves in some of the superficial layers. Not always the culprit of pain. Bicep tendon attaches right into labrum. Commonly injured w/throwing populations. Bicep tendon can pull on the labrum and pull labrum away from the bone.

acromion of scapula

flat part of spine of scapula; lateral end of spine of scapula; forms top of shoulder

action of Scalenes, Anterior/middle/Posterior

flexes and rotates neck, elevates ribs 1 and 2

Action of anterior deltoid

flexion, lifting arms in front and overhead; works with pecs.

What is a bursa?

fluid-filled sac that cushions and allows for easy movement of one part of a joint over another. Where muscles glide under bones of over bones. Lined on the inside with synovial membrane similar to capsule. Acts as buffers. Become irritated with tight muscles rubbing over them, small space between bone and muscle, or from repetitive motion. If there is pain, the bursa is not the problem.

What muscles might cause a labral tear?

humeral head stabilizers. scapular stabilizers. Positioning of the humeral head. Thickening of the inferior capsule Infraspinatus Lats Pec major Pec minor Look at the same things that looked at with bicep tendon SLAP tear.

characteristics of fibrocartilage

i.e. labrum; intervertebral discs in spinal cord Helps bones fit together better Creates a lip around joint; deepens divot/cup that head of bones fits in to Reduces friction Absorbs shock Slows down regeneration Contains fibrous bundles of collagen Increases stability Can tear. No direct nerve supply, but a few nerves in some of the superficial layers. Depending on where tear is, pain might not be from labrum. A little bit triangular shaped to wedge in and seal the joint.

What muscles are engaged when in external rotation?

infraspinatus teres minor posterior deltoid

external rotation of shoulder

infraspinatus, teres minor, posterior deltoid

infraspinous fossa

inward divot inferior to (below) spine of scapula; origin of infraspinatus muscle; below scapular spine

What muscles are engaged when in extension?

lats teres major posterior deltoid tricep lower fibers of pec major

What muscles are the antagonists to scapular upward rotation?

levator scapulae upper rhomboids antagonists to rotation.

coracoid process of scapula

located in the hollow under the clavicle by the shoulder; insertion of pectoralis minor

What other areas would you check with common injuries?

look for other things along the chain that could be having problems. Look at antagonists Look at synergists.

What muscles are engaged when in scapular depression?

lower trap pec minor lats (via humerus) subclavius (via clavicle)

what is eccentric muscle contraction

muscle lengthens as it contracts i.e. bending front knee in warrior 2, quads lengthen but also engage. i.e. In chaturanga, triceps contract eccentrically but also lengthen.

what is isometric muscle contraction

muscle tension without movement i.e. Holding triangle pose

What activities are more likely to cause rotator cuff tendonitis, tendonosis, tear?

overhead sports throwing sports reaching overhead

What muscles are engaged when in adduction?

pec major lats teres major subscapularis coracobrachialis

What are possible causes when scapula wings on the way down from overhead movement?

poor scapular stability weak serratus anterior

action of rhomboids

retract shoulder blades; stabilize scapula; tethers scapula to spin/axial skeleton.

What muscles are engaged when in scapular downward rotation?

rhomboids levator scapulae

What muscles are engaged when in scapular retraction?

rhomboids middle traps

ST joint

scapulothoracic joint; not a typical joint. Moves more than the SC or AC joints but less than the GH (glenohumeral) joint Is a synovial joint--has a joint capsule and secretes synovial fluid. Is a gliding joint--small gliding movements to allow for scapular movement, though very little movement.

Antagonist of rhomboids

serratus anterior

Antagonist to levator scapulae

serratus anterior

What muscles are engaged when in scapular protraction?

serratus anterior pecs

What muscles are engaged when in scapular upward rotation?

serratus anterior upper traps lower traps The 3 work in synergy

Parts of the scapula

shoulder blade Medial border: Inner edge of scapula closest to the spine. Lateral border: Outer edge of scapula cloer to humerus Superior angle: top inner corner of scapula. Inferior angle: Bottom corner of scapula

abduction of shoulder

side deltoid, supraspinatus Serratus anterior assists humerus on abduction

What muscles are engaged when in internal rotation?

subscapularis pec major teres major lats anterior deltoid

What is mechanotransduction?

the conversion of a mechanical stimulus into electrochemical activity that influences our senses--how we feel, our proprioception, balance, etc.

lesser tuberosity/tubercle

top of humerus; Anterior view: Provides attachment for subscapularis muscle. Medial to bicipital groove at the head of the humerus. Inner part of shoulder.

greater tuberosity/tubercle

top of humerus; Provides attachment for supraspinatus, infraspinatus, and teres minor muscles; Lateral to the bicipital groove at the head of the humerus. Outside of shoulder.

What are possible causes when trunk moves into contralateral lateral flexion (away from the lifted arm) in overhead movements?

traps hypertonic, so lean compensates

humerus

upper arm bone between shoulder and elbow. Internal and external rotation occurs at the head of humerus. We don't use internal shoulder rotation a lot in yoga.

What muscles are engaged when in scapular elevation?

upper trap levator scapulae