anatomy and kinesiology shoulder and elbow kim kraft, · pdf fileanatomy and kinesiology...

Anatomy and KinesiologyShoulder and Elbow

Kim Kraft, PT, DPT, CHT

St Louis MOApril 7, 2017

Objectives

• Identify clinically relevant boney anatomy and soft tissue structures

• Understand how anatomy and kinesiology interrelate to create motion

• Consider how muscles work together to move joints

• Begin to relate the characteristics of structure to clinical concepts

2

Outline

Shoulder and Elbow1. Bones (osteology)

2. Joints (arthrology)3. Joint motion (kinesiology)4. Static stability (ligaments)

5. Neural relationships

OsteologyShoulder Girdle

The Shoulder Girdle

1. Clavicle

2. Scapula3. Humerus

Retrieved on 03/08/13 from: http://upload.wikimedia.org/wikipedia/commons/thumb/4/49/Human_arm_bones_diagram.svg/683px‐Human_arm_bones_diagram.svg.png

• Connects axial skeleton and upper limb• Protects the neurovascular bundle from neck

to arm• Crank-Shaped: Convex medially/concave

laterally• Acts as a strut holding arm away from body

Bones: Clavicle

Right

ClaviclePopular Insertion Site

Left

7Photo retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f0/Gray201.png

Bones: Scapula• Lies over ribs 2-7• Scapular Spine is the landmark for T4

Spinous Process• 30 anterior to the coronal plane, 10 on

the frontal tilt.• “Plane of the scapula”

Anterior Scapula Landmarks

1.Acromion2.Coracoid Process

3.Subscapular Fossa

Gaunt & McCluskey 2012

Posterior Scapula Landmarks

1. Superior angle2. Supraspinous fossa3. Scapular notch4. Scapular spine5. Axillary border6. Vertebral border7. Infraspinous fossa


Bones: HumerusLandmarks

• Greater tubercle: insertion for supraspinatus, infraspinatus, teres minor

• Lesser tubercle: insertion for subscapularis

• Surgical neck• Anatomical neck• Shaft• epicondyles

Right


Clinical ApplicationProximal Humerus Fractures


Bicipital Groove Palpation

Side to Side Palpation

• Fingers proximal anterior humerus

• Rotate at forearm

Karreigis

Joints Shoulder Girdle

Shoulder Girdle Joints

Play along

1. Sternoclavicular2. Acromioclavicular3. Scapulothoracic

4. Glenohumeral

1. Sternoclavicular Joint (SC)• Proximal clavicle and sternum• Only articulation between the axial skeleton

and the upper limb

• Movement: protraction, retraction, rotation, elevation and depression

• Articular disc

• True synovial joint with capsule & articular disc

2. Acromioclavicular (AC) joint

TC

• Diarthrodial joint with meniscus

• A/P Glide of acromion with pro/retraction

• Allows up to 20⁰ rotation of clavicle with arm elevation

• Stressed with cross-body adduction

• Compressed with arm elevation

• Frequent site of DJD

3. Scapulothoracic (ST) Joint• Formed between the scapula and the thoracic

wall

• Not a "true" articulation

• Movement: protraction, retraction, elevation, depression, upward & downward rotation

• Stabilized by muscles

• Provides a stable base for glenohumeral mobility and stability; shoulder movement depends on it

5 ST Functions

1. Increase glenohumeral stability (Orients glenoid up 5 degrees)

2. Increases arm elevation ROM3. Serves as muscle attachment4. Absorbs forces from the arm5. Maintains the subacromial space

4. Glenohumeral Joint• Glenoid fossa of the scapula and the head of

the humerus• Ball and socket joint that sacrifices stability for

mobility• Movement: flexion, extension, abduction,

adduction, external and internal rotation• Static stability

• Ligaments, Bony architecture, capsule, labrum

• Dynamic stability• muscles

Glenohumeral JointIncludes:

• RC tendons• Long head of biceps• Sub-acromial – sub-deltoid bursa• Subscapularis bursa• Subcoracoid bursa• Coracohumeral ligament

Key FeatureCoracoacromial Arch• Subacromial space

between acromion, coracoacromial ligament, coracoid process and the superior humeral head

• Contents:subacromialbursa, long head biceps tendon, supraspinatus tendon

Impingement*

Glenohumeral Stabilizers(Stability Sacrificed for Mobility)

Static

• Ligament/Capsule

• Geometry (ball much larger than socket)

• Glenoid labrum

• Negative intra-articular pressure

Dynamic

• Muscles• Scapular Stabilizers

(scapular dumping)• Rotator Cuff Muscles• ?Long Head biceps

Capsule and LigamentsShoulder Girdle

Glenohumeral Static Stability Movie

• Relationships between boney, glenoid, capsular, and ligamentous structures

• Multidirectional instability (joint laxity)

• Traumatic instability

Static StabilizersGlenohumeral Joint

1. Labrum2. Capsule3. Sternoclavicular (SC)4. Acromioclavicular (AC)5. Coracoclavicular

• Conoid• Trapezoid

6. Coracoacromial7. Coracohumeral8. Glenohumeral Ligaments

• Superior (SGHL)• Middle (MGHL)• Inferior (IGHL)

Glenoid Labrum

Labrum

1. Narrow at the top, wide at the bottom (inverted comma)

2. Hyaline cartilage lining is thinnest at the center where OA may develop

3. Attachment for ligaments


“ All portions of the joint capsule are responsible for stabilizing the humerus in the glenoid fossa.”

Warren & Hawkins

CapsuleBlends with Labrum, Ligaments


Sternoclavicular Ligaments

• Very stout, very stable• Incorporate meniscus

• Allow bucket-handle motion of elevation/posterior rotation

Meniscus/Capsule can become painful or stiff

Sternoclavicular (SC) Joint Ligaments

Interclavicular Ligament

First Rib

Anterior Sternoclavicular Ligament

Articular Disc

Costoclavicular Ligament


Acromioclavicular & Coracoclavicular Ligaments• Conoid & Trapezoid• Prevent inferior translation of the acromion

on the distal clavicle

• Stabilizes horizontal adduction of the forearm

Trapezoid

CoracoacromialLigament

AcromioclavicularLigament Conoid

Acromioclavicular (AC) and Coracoclavicular Joint LigamentsC

oraco

clavicu

lar Lig

amen

ts


Passive (Static) Restraints3 Glenohumeral LigamentsSuperior, Middle, Inferior

GH-Ligaments

SuperiorLimits inferior glide

fromanatomical position

Superior GlenohumeralLigament (SGHL)

GH-Ligaments

MiddleLimits anterior glide

from partial abduction

Middle Glenohumeral Ligament(MGHL)

GH-LigamentsInferior; 3 PartsAnterior Band

Axillary Pouch

Posterior Band

Inferior Glenohumeral Ligament(IGHL)

Acts as a sling to protect against anterior and inferior instability

Inferior GlenohumeralLigament


Coracohumeral Ligament

Strongest supportive ligamentReinforces RC Interval

Limits inferior GH Glide from 00-500

Limits Extremes of GH ERGaunt & McCluskey 2012

Ligaments of the Scapula

• Superior transverse ligament forms the suprascapular foreamen by closing the scapular notch

• Passage way for the suprascpular nerve

• (to supraspinatus & infraspinatus)

Arthrology & Kinesiology Shoulder Girdle

1. Joints

2. Muscle Force Couples

Described as effects on the distal clavicle

• Elevation/depression

• Protraction/retraction

• Posterior rotation

Sternoclavicular (SC) Joint SC Joint MotionsInferior glide + Posterior spin

Instructions: Back to Front Palpation

Acromioclavicular Joint

• Small amount of glide anterior/posterior

• Accommodates motions of the scapulothoracicjoint

• Back to front Palpation right shoulder:

1. Right index finger on acromion

2. Left hand distal clavicle

Scaption = Elevation• 30-45 anterior to the

frontal plane because of the angle of the ribs

• “True” plane of movement of the shoulder allowing the greatest range of motion

• AAOS “raise your arm”

Scapulothoracic JointPlane of the Scapula

Shoulder Planes

• Flexion to the front• Abduction to the side

• Elevation=Plane of the scapula

Functional BiomechanicsPlane of the Scapula Elevation

• Shoulder abductors and rotators are at optimum length-tension ratio

• Joint capsule is relaxed or untwisted• Improved joint congruity of GH joint• Less likely to impinge as apex of greater

tubercle is at high point of coracoacromial arch• Most comfortable for patients to gain

Glenohumeral ROM and strength in this plane

Three Dimensional Motions Scapula

• Internal/External Rotation

• Tilting

• Upward/Downward Rotation

Scapulothoracic Motion Muscle Force Couples

• Upwards rotation: Upper trapezius, middle trapezium, Serratus Anterior

• Downwards rotation: Rhomboids, Pectoralis minor

• Elevation: Levator Scapula, Upper traps, Rhomboid

Motion of the scapula is accompanied by simultaneous motion at the sternoclavicular (SC)

joint and gliding at the acromioclavicular (AC) joint

Neumann 2010

50Neumann, 2010

Scapulohumeral RhythmPhases of Motion• Phase I : 0-60

(Setting) • Phase II: 60-120

(Critical)• Phase III: 120-180

(Final)Total: 60 degrees scapulothoracic120 degrees glenohumeral

ArthrokinematicsShoulder Elevation

ICF - Inferior capsular ligament

SCF - Superior capsular ligament

With arm elevation, it is necessary to have a upward roll and a downward glide of the humerus on GH fossa.

Neumann, 2010

Force Couple:Scapular Upward Rotation

Muscles involved:

a. Serratus Anterior

b. Upper trapezius

c. Lower trapezius

Action:

• Rotate scapula upward

• Stabilize scapula

Force Couple

Greene, 2005

a

b

c

Muscles Shoulder Girdle

Shoulder ComplexMuscles• Axio-Scapular

TrapeziusRhomboidsLevator ScapulaSerratus anteriorPectoralis minor

• Axio - humeralLatissimus dorsiPectoralis Major

• Scapulo-humeralDeltoidBiceps brachiiTriceps brachii• Rotator Cuff

(SITS)Supraspinatus,Infraspinatus,Teres minorSubscapularis

Serratus Anterior

Action• Upward rotation and

protraction of the scapula.

• Assists with scapular posterior tilt and external rotation.

• Origin: First 8 ribs• Insertion: Medial border

of the scapula• Innervation: Long

thoracic nerve (C5,C6, C7)

55Creative Commons

Serratus AnteriorStrengthening Interventions

1. Dynamic Hug

2. Protraction

3. “Plus”

Scapular Adductors Axioscapular muscle

Rhomboids

Trapezius

Upper fibers (UT)

Middle fibers (MT)

Lower fibers (LT)

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MT

LT

Middle Trapezius and Lower Trapezius• Scapular Adduction,

Depression • Middle: Origin spinous

process C7-T3• Lower: Origin spinous

process T4-T12• Both insert on spine of

scapula• Innervation: Spinal

accessory (C3, C4)

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Middle/Lower Trapezius

Strengthening Interventions

1. Prone “T”

2. Prone “Y”

3. Scapular adduction

Scapula ElevatorsAxioscapular muscles

• Upper trapeziusInnervation: Accessory nerve, & C 2-C4

• Levator scapulaInnervations: Dorsal scapular nerve (C4 & C5)

• Rhomboids

Neumann 2010

Upper Trapezius

• Sidebending cervical spina, scapula elevation and upward rotation

• Origin: Occipital protuberance, nuchal ligament, spinous process of C7-T1

• Insertion: Lateral third of clavicle, acromion

• Innervation: Spinal Accessory nerve, C3, C4

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Levator Scapula

• Scapular elevation and downward rotation

• Cervical spine side bending and rotation

• Insertion: Superior angle of scapula

• Innervation: Dorsal scapular nerve (C5, ventral rami C3,C4)

Creative Commons

Scapular Depressors

• Gravity

• Weight carried by arm

• Lower trapezius

• Latissimus dorsi

• Pectoralis minor

Neumann 2010

Latissimus DorsiStrengthening

Interventions• Prone “I”

• Medial/internal rotation, adduction, and extension.

• Scapular depression.

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IR

EXT

DEPRESSION

Pectoralis Major

Sternal: rotates scapula & draws inferior angle laterally forwardClavicular: lowers the raised armInnervation: Lateral

pectoral nerve, medial pectoral nerve

(C5, C6, C7, C8 & T1)

Force CoupleScapular Downward Rotation

Gravity

Rhomboids (against resistance)

Levator Scapulae

Rhomboid Major/Minor

• Axioscapular muscles

• Scapular adduction, elevation, downward rotation and stabilization

• Innervation: Dorsal scapular nerve

67Retrieved on 06/07/09 from: http:// openphysio.co.za/images/thumb/5/5d/Levator_scapulae.jpg/150px‐Levatorscapulae.jpg

Force CoupleRetraction

Axioscapular Muscles• Middle trapezius

• Rhomboids• Lower trapezius

Neumann 2010

Four Muscles of the Rotator CuffSupraspinatus, Infraspinatus, Teres Minor,

Subscapularis (SITS)

http://handsport.us/patient‐education/shoulder‐anatomy/

Rotator Cuff Muscles

• S.I.T.S. Provides a compressive force between humeral head and glenoid fossa

• Supraspinatus

• Infraspinatus

• Teres Minor

• Subscapularis

Supraspinatus

• Origin: Supraspinous fossa to superior facet of greater tuberosity

• Function: Initiates & asstists deltoid in ABD

• Nerve: Suprascapular N

• Blood supply: Suprascapular artery

Infraspinatus

• Origin:Infraspinatus fossa to middle facet of greater tuberosity

• Function: ER of arm and supports head of humerus in glenoid

• Nerve: Suprascapular nerve

• Blood supply : Suprascapular and Circumflex arteries

Teres Minor

• Origin: Superior part of lateral border of scapula to inferior facet of greater tuberosity

• Function: ER arm and helps stabilize humeral head in glenoid

• Nerve: Axillary nerve (C5-C6)

• Blood supply: subscapular & circumflex scapular arteries

Subscapularis

• Origin: Subscapular fossa to lesser tuberosty

• Function: IR and Adduction

• Nerve: Upper and lower subscapular nerves

• Blood supply: subscapular artery

Deltoidscapulohumeral muscle

• Posterior deltoid: Provides external rotation and assist with horizontal Abduction

• Anterior deltoid: Initiates flexion and provides horizontal Adduction

• Middle Deltoid: initiates Abduction primarily to 90 degrees while producing upward shear of the humeral head

Early in abduction the deltoid pulls superiorly (upward shear force) while the supraspinatus gets abduction started. As the arm is abducted to 90°, the direction of pull of the deltoid becomes similar to the pull of the supraspinatus.

Elevation Force Couple

Internal Rotation

Strengthening Interventions

Can vary elevation

1. Isometric

2. Theraband IR

3. Dumb bell

4. Cable column

Teres Major

• Origin: Inferior angle of scapula

• Insertion: Crest of lesser tuberosity humerus

• Function: IR, Adduction. extension

• Nerve: Thoracodorsalnerve

Force Couple External Rotation• ER: infraspinatus,

teres minor & posterior deltoid

• Small total mass and isometric torque

External Rotation

Strengthening

Can vary elevation

1. Isometric

2. Side lying or prone dumb bell

3. Theraband

Force CoupleInternal Rotation• IR: suscapularis,

anterior deltoid, pect major, latissimus dorsi & teres major

• IR larger mass than ER

Neumann 2010

Anterior deltoid,CoracobrachialisLong head biceps

(weak)

Lateral view

Neumann 2010

Force CoupleGlenohumeral Forward Flexion

Coracobrachialis

• Flexes and adducts the shoulder

• Innervation: Musculocutaneous (C6,C7)

Creative COmmons

Scapulohumeral MusclesAnteriorSide to Side Palpation

• Anterior & Middle Deltoid

• Subscapularis

• Coracobrachialis

Scapulohumeral MusclesPosteriorSide to side palpation

• Posterior/ middle deltoid

• Supraspinatus

• Infraspinatus

• Teres Minor

• Teres Major

Assessing Muscle Tightness

Play along

• Pectoralis Minor

• Latissimus Dorsi

• Biceps Brachialis

THE ELBOW

•Elbow Osteology

•Elbow joints, ligaments & kinesiology

•Static stabilizers of the elbow

•Elbow Muscles

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Bones of the Elbow

• Distal Humerus• Proximal Ulna

• Radial Head

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Elbow Joints

1. Humeroulnar Joint

Hinge-joint that flexes and extends

2. Radiohumeral Joint

Hinge-joint that flexes and extends

3. Proximal Radioulnar Joint

Pronation and supination

89Creative Commons

Bony Anatomy Distal Humerus

Which side is this?

• Shaft inclines anteriorly 30°

• Articular surfaces and joint axis anterior to shaft

• Creates room for soft tissue and greater flexion

• Shaft widens for medial and lateral support pillars

• Aids in maintenance of strength

Carrying Angle Radius

• Rotates around ulna• Becomes "shorter"

In pronation

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Radial Tuberosity

SupinatorInsertion

Brachio‐radialisInsertion

Pronator QuadratusInsertion

Radial Head• A secondary

stabilizer to both varus and valgus forces if the MCL and LCL are intact

• If MCL or LCL is deficient, then radial head becomes a primary stabilizer

•Radial head is cylindrical and concave proximally

Bony Anatomy Ulna

• Trochlear notch is anterior to shaft and directed anterosuperiorly

• Axis anterior to shaft

• Arc of notch less than 180 degrees

ULNA

95

Coronoid Process

Supinator origin

Brachialis insertion Radial Notch

Pronator QuadratusOrigin

Retrieved from:http://upload.wikimedia.org/wikipedia/commons/thumb/f/f2/Slide1bgbg.JPG/800px‐Slide1bgbg.JPG

Photo retrieved from:http://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Gray214.png/250px‐Gray214.png

Proximal Ulna

• The major determinant of elbow stability

• Ulno-humeral integrity is key to stability

• ~30% of articular surface must be intact

• Coronoid is key to prevent posterior subluxation

Coronoid

• ~50% of coronoid must be present for the elbow to function

• Deficient coronoid will result in posterior instability

Stabilizers of the Elbow

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Elbow Stability

• A complex interaction among the bones and ligaments to resist physiologic stress applied to the elbow

• A deficiency in one area can be compensated for by other intact structures (ie radial head and MCL in valgus force)

• Soft tissues that contribute to the stability include the collateral ligaments and the capsule both anteriorly and posteriorly. Dynamic stability is also provided by the actions of the muscles crossing the joint.

Rehab of the Hand, 6th ed

Elbow Bony Stability

• Olecranon Process-30% of articulation required for stability

• Coranoid- Critical as an anterior buttress for posteriorly directed forces. Approximately 50% required for stability.

• Radial Head -Contributes 30% to valgus stability with intact MCL and 75% with deficient MCL. Bears 60% of axial load in extension

Creative commons

Elbow Capsule• Encloses elbow and proximal

radioulnar joints ( 3 sets of articular surfaces)

• Small contributor as a passive soft tissue stabilizer (questionable)

• Most lax at 80 degrees of flexion • Assumes position of comfort after

injury• Risk of flexion contracture• Typical hinge joint relationships:

anterior & posterior portions taut only at end range

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Elbow Ligaments

The ligaments are secondary stabilizers when bones are intact.Ulnar Medial Collateral ligament (MCL)

• from medial epicondyle to ulna• Anterior band most important part• Resists valgus forcesRadial Lateral Collateral• Lateral epicondyle to ulna and annular ligament• Maintains relationship of forearm to trochlea and capitellum• Resists posterior lateral rotatory instabilityAnnular Ligament• Secures radial head to ulna

Annular Ligament

• Attaches to anterior and posterior edges of radial notch and surrounds radial head

• Holds head in notch and allows head to spin

• Resists distraction of radius

Ulnar (Medial) Collateral Ligament (MCL)

• Includes: anterior bundle, posterior bundle, transverse ligament

• MCL is a primary stabilizer for the elbow

• Anterior bundle is major stabilizer to valgus stress.

Ulnar (Medial)Collateral Ligament (MCL)

• Pathology• Chronic

attenuation• Fall• Medial

epicondylectomy with cubital tunnel

Radial (Lateral) Collateral Ligament (LCL)• Extends from lateral

epicondyle to annular ligament for common insertion to ulna

• Lateral laxity allows prox FA to sublux away from humerus when loaded in supination.

• Challenged with any varus stretch or load and more unstable in supination.

Radial (Lateral) Collateral Ligament Complex

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Ulna

• Radial collateral ligament• Connects lateral epicondyle and annular

ligament

• Annular ligament• Encircles the radial head attaching at the

radial notch posterior & anterior

• Lateral ulnar collateral ligament (LUCL)• Connects lateral epicondyle and supinator

crest of ulna• Provides stability to posterolateral

rotation

• Accessory lateral collateral ligament• Connects inferior annular ligament to

supinator crest

3/3/14 Retrieved from: http://www.orthoverse.com/posterolateralrotatoryinstabilityelbow.asp

Radius

Posterolateral rotatory instability

• Radius & ulna, as a unit, externally rotate away from distal humerus, so radial head displaces posterior to capitellum

• Cause• LUCL injured with Supinated compressive force with

valgus stress- usually at 20-40 degrees ext and reduces in flex

• Stable • Full pronation and some flexion

Interosseous Membrane (IOM)

• At the wrist most load is carried by radius

• At the elbow most load is carried by ulna

• IOM transfers part of the load at the distal radius to the proximal ulna.

• Fibers run medially and distally from radius to ulna.

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Elbow Stabilizers“Other”

• Radial head most important and provides 30% of valgus stability

• Posterior Capsule is primary restraint to distraction in full ext

• Lateral Capsule secondary stabilizer to varus stress

• Anconeous also secondary stabilizer to varus stress

Elbow Muscles

Pronator Teres• Origin:medial epicondyle and coronoid process

• Insertion: middle of lateral surface of radius

• Action: Pronates and flexes

• Innervation:Median nerve (C6,C7)

• Arterial supply: Ulnar artery, anterior recurrent ulnar artery

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Biceps Brachii

• Origin: • Short head: tip of coracoid process of

scapula; • Long head: supraglenoid tubercle of scapula

• Insertion: Tuberosity of radius and fascia of forearm via bicipital aponeurosis(lacertus fibrosus)

• Action: Supinates forearm, flexes forearm

• Innervation: Musculocutaneous nerve (C5 and C6 )

• Arterial Supply: Muscular branches of brachial artery

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Anconeus• Origin: Lateral epicondyle of humerus

• Insertion: Lateral surface of olecranon and superior part of posterior surface of ulna

• Action: Assists triceps in extending forearm; stabilizes elbow joint; abducts ulna during pronation

• Innervation: Radial nerve (C7, C8, T1)

• Arterial Supply: Middle collateral branch of deep brachial artery; Recurrent interosseous artery

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Brachialis

• Origin: Distal half of anterior surface of humerusInsertion: Coronoid process and tuberosity of ulna

• Action: Major flexor of forearm -- flexes forearm in all positions

• Innervation: Musculocutaneous nerve (C5, C6)

• Arterial Supply: Muscular branches of brachial artery, recurrent radial artery

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Supinator

• Origin: Lateral epicondyle of humerus, radial collateral and annular ligaments, supinator fossa and crest of ulna

• Insertion: Lateral, posterior and anterior surfaces of proximal 1/3 of radius

• Action: Supinates forearm (i.e., rotates radius to turn palm anteriorly)

• Innervation: Deep branch of radial nerve (C5 and C6) (C5, C6)

• Arterial Supply: Recurrent interosseous artery

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Brachioradialis

• Origin: Proximal 2/3 of lateral supracondyle ridge of humerus

• Insertion: Lateral surface of distal end of radius

• Action: Flexes forearm

• Innervation: Radial nerve (C5, C6, C7)

• Arterial Supply: Radial recurrent artery

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Triceps• Origin:

• Long head: infraglenoid tubercle of scapula;

• Lateral head: posterior surface of humerus, superior to radial groove;

• Medial head: posterior surface of humerus, inferior to radial groove

• Insertion: Proximal end of olecranon process of ulna and fascia of forearm

• Action: Chief extensor of forearm; long head steadies head of abducted humerus

• Innervation: Radial nerve (C6, C7, C8)• Arterial Supply: Branches of deep

brachial artery

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Shoulder / ElbowCommon Nerve Compression

Sites

Cervical Radiculopathy

• Neck can be a source of compression

• Spinal nerves exit foramen

• Small amounts of compression can amplify distal symptoms

Sammut

Peripheral Nerves

• Brachial Plexus(C7-T1 spinal nerves)• Dorsal Scapular• Long Thoracic• Suprascapular• Upper and Lower

Subscapular• Medial and lateral

pectoral• Thoracodorsal

• Musculocutaneous• Axillary• Radial-with motor

branch PIN• Median-with motor

branch AIN• Ulnar• Medial brachial and

antebrachial• Nerve to subclavius

Thoracic Outlet

• Neurovscularbundle passes over first rib/under clavicle

Sammut

Brachial Plexus

Sammut

Axillary Nerve CompressionQuadrangular Space• Quadrangular

• Between Teresminor, teres major, long head of triceps and humeral shaft.

• Contains axillary nerve and posterior humeral circumflex artery

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Mix and Match

Sammut

Where They Are

Where It Comes Out Musculocutaneous Nerve

Sammut

Sammut

Musculocutaneous Nerve Course

Sammut

Posterior Cord

Sammut

Radial Nerve

Radial Nerve Course

• Arises from C5-8, T1• Travels posterior on medial

side of arm• Winds around spiral groove• Pierces lateral

intermuscular septum (in proximal lat epi)

• Divides into sensory and motor branches (prox. edge of supinator)

• Sensory branch follows radius

• Motor branch pierces supinator

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Radial Nerve CompressionSupinator Arch: Arcade of Frohse

• Sometimes called the supinator arch

• Fibrous arch over the posterior interosseous nerve

• Common site for compression and paralysis

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Radial Tunnel Syndrome

• Primarily a pain syndrome

• Compression of radial nerve as it passes between the radial head & the supinator muscle

• Deep, burning pain in forearm extensor muscle mass (4-5 cm distal to lateral epicondyle)

Sammut, Left

Sammut

Median Nerve

Median Nerve Course

• Arises from C5-8, T1• Courses with brachial

artery in arm• Medial to biceps• Enters cubital fossa• Anterior Interosseous

(AIN) branch at FDS• Travels b/w FDS & FDP• Enters hand at carpal

tunnel (common site of compression)

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Sammut

Median Nerve Compression

Pronator Syndrome

Anterior Interosseous Syn.

Proximal forearm pain volarly

Proximal forearm pain volarly

Numbness/tingling volar index, long and ring

Sensory distubances absent

Thumb, index, and long finger weakness

Thumb IP weakness and FDP weakness index

Symptoms reproduced with palpation pronator

No symptoms with palpation of pronator

139Marik HTRC ASHT 2017 Sammut

Ulnar Nerve

Ulnar Nerve Course

• Arises from C8 and T1

• B/w coracobrachialis & medial head of triceps

• ~3in prox. medial epicondyle enters Arcade of Struthers

• Enters medial intramuscular septum

• Enters cubital tunnel

• Passes 2 heads of FCU

• Penetrates flexor/pronator mass & lies b/w FDS and FDP

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Ulnar NerveCompression Sites

1. Medial Intramuscular Septum (Triceps)2. Arcade of Struthers (under ligament, 8 cm

proximal to medial epicondyle)

3. Cubital Tunnel4. Deep Flexor Pronator Aponeurosis5. Guyon’s Canal

Sammut, Left

Ulnar Nerve CompressionArcade of Struthers• The arcade is a thin

aponeurotic band extending from the medial head of the triceps to the medial intramuscular septum.

Ulnar Nerve CompressionCubital Tunnel

• Site of ulnar nerve compression• Begins at the condylar groove between the medial

epicondyle and the olecranon.• Floor of the cubital tunnel: elbow capsule and MCL • Roof :FCU Fascia & arcuate ligament of Osborne

(cubital retinaculum)• Walls: medial epicondyle and olecranon • Capacity is greatest when the elbow is in extension

because the arcuate ligament is slack. • Changes from round shape to oval shape with

flexion- results in a 55% volume decrease in the canal.

Nerves at Post –Op RiskArthroscopy or Fracture/ORIFClose to Humerus

• Axillary nerve (Proximal; at risk with shoulder arthroscopy)

• Radial nerve (in radial groove, posterior humerus; at risk with mid humeral fractures and ORIF)

• Ulnar nerve (in cubital tunnel; at risk with distal humeral fractures and ORIF)

Sammut, 2 cm proximal to medial condyle humerus

Cross Section

Sammut, 2 cm proximal to medial epicondyle of humerus

Cross Section

Shoulder / ElbowVascular Structures

Arteries

• Subclavian• Axial• Brachial• Radial and Ulnar• Interosseus

• Superficial and deep arches

• Collaterals and recurrents

• Digital arteries

Veins

• Subclavian• Cephalic

• Basilic• Medial Cubital • Dorsal Venous

network

Circumflex Arteries

• Circumflex arteries to proximal humerus are delicate

• If disrupted by fracture, lose perfusion ….Nonunion

151

Triangular Space

• Triangular• Superior: Teres Minor• Inferior: Teres Major• Lateral: Long Head of

Tricep

• Contains: Scapular Circumflex Artery

• Visible: Radial nerve

References• Borich, M.R., Bright, J.M., Lorello D.J., Cieminski, C.J.,

Buisman, T., Ludewig, P.M., (2006) Scapular angular positioning at end range internal rotation in cases of glenohumeral internal rotation deficit. J Orth Sports PT. 36 (12): 926-34.

• Gaunt, B.W., McCluskey, G.M. (2012) A Systematic Approach to Shoulder Rehabilitation. Columbus GA: HPRC.

• Greene, D.P., Roberts, S. L., (2005) Kinesiology Movement in the context of activity. St. Louis: Elsevier Mosby.

• Kendall, F.(2005). Muscles testing and function with posture and pain. Baltimore, MD: Lippincott Williams & Wilkins.

• Neumann D., (2010) Kinesiology of the Musculoskeletal System. St Louis: Elsevier Mosby.

• Reinhold et al: Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. Journal of Orthopedic and Sports Physical Therapy. Volume 39(2); Feb 2009.

• Ross, L. M., Lamperti E. D. Schuenke, M., Schulte, E., Schumacher, U., (2006) Thieme atlas of anatomy; General anatomy & musculoskeletal system. New York: Thieme.

• Skirven, T. M., Osterman, A. L., Fedorczyk, J., and Amadio, P. C. (2011) Rehabilitation of the Hand and Upper Extremity, 6th ed. St Louis: Mosby.

• Sahrmann, S. (2002) Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby.

Acknowledgments–Susanne Higgins, OTD, MHS, OTR/L, CHT–Tambra Marik OTD, OTR/L, CHT–Romina Astifidis MS, PT, CHT–Kirk Turner OTR, CHT

• Special thanks for photos and illustrations provided by:

Dr. Stephen LahrIthaca CollegeDepartment of Physical TherapyHuman Anatomy Review Site & Suny Downstate University Medical Center

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