2017 htrc anatomy & kinesiology shoulder & elbow marik therapy review course uc irvine...

Hand Therapy Review CourseUC Irvine Medical Center

Orange, CAFebruary 24‐26, 2017

Shoulder & Elbow Anatomy

Tambra Marik, OTD/L, CHT

Marik HTRC ASHT 2017 1

Objectives

• Integrate functional movement to the shoulder anatomy and relate movement to muscular recruitment

• Identify key boney landmarks and muscular locations

• Organize muscle groups for learning

• Utilize anatomy to think like a clinician


Agenda

• Why do hand therapy practitioners need to learn the shoulder girdle and elbow anatomy?

• Osteology

• Joints

• Kinesiology

• Ligaments

• Glenohumeral & Elbow: static & dynamic stabilizers

• Muscular & Peripheral Nerve Innervations


Centennial Vision Statement

“We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs.”(AOTA, 2006)


Conceptual FrameworkOutcome for Shoulder Pathology

Figure retrieved from: Goldhahn et al 2014

Person Factors

Shoulder Impingement

i.e. ROM, strength, pain

i.e. unable to lift items shoulder level, unable to play water polo

i.e. leisure and home roles, inability to work

i.e. compensation i.e. comorbidities, personal demands


I. Shoulder Girdle Osteology

6Marik HTRC ASHT 2017

Shoulder GirdleOsteology

Wikipedia shoulder girdle from:http://upload.wikimedia.org/wikipedia/commons/thumb/4/49/Human_arm_bones_diagram.svg/683px‐Human_arm_bones_diagram.svg.png


CLAVICLE

Left Clavicle

Trapezius

Sternocleidomastiod

Pectoralis Major Deltoid

Subclavius

AcromionArticulation/lateral

Sternal Articulation/medial

Caudal side(top)

Cephal side(bottom)

Clavicle Wikipedia from http://upload.wikimedia.org/wikipedia/commons/f/f0/Gray201.png 8Marik HTRC ASHT 2017

SCAPULA

Scapula Wikipedica from http://upload.wikimedia.org/wikipedia/commons/thumb/e/ed/Scapula_ant_numbered.png/476px‐Scapula_ant_numbered.png

9

Volar

Dorsal

Glenoid fossa

Acromion

Coracoid process

Superior angle

Lateral border

Medial border

Inferior angle

Acromion

Supraspinatus fossa

Infraspinatus fossa

Superior angle

Inferior angle

Medial borderLateral border

Subscapularis fossa

Marik HTRC ASHT 2017

Humerus

Intertubercle Groove

Humerus, Wikipedia fromhttp://upload.wikimedia.org/wikipedia/commons/thumb/e/ee/HumerusBack.png/311px‐HumerusBack.png

Spiral Groove

Humerus Wikipedia fromhttp://upload.wikimedia.org/wikipedia/commons/thumb/e/e2/Gray818.png/280px‐Gray818.png


II. Shoulder GirdleJoints


Joints of the Shoulder Girdle

• Scapulothoracic

• Sternoclavicular

• Acromioclavicular

• Glenohumeral

12http://upload.wikimedia.org/wikipedia/commons/thumb/0/02/Scapula_‐_posterior_view2.png/600px‐Scapula_‐_posterior_view2.png

http://upload.wikimedia.org/wikipedia/commons/thumb/8/82/Clavicle_‐_anterior_view.png/250px‐Clavicle_‐_anterior_view.png

SaddleJoint

Ball & Socket Joint

PlaneSynovialJoint


GLENOHUMERAL STABILIZERS

STATIC

• Ligaments/Capsule

• Geometry of GH joint

• Glenoid Labrum

• Negative intra‐articular pressures

DYNAMIC

• Muscles

– Scapular Stabilizers

– Rotator Cuff Muscles

– Long head of the biceps

13

Finnoff J, Doucette S, Hicken G. Glenohumeral instability and dislocation. Phys Med and Rebab Clinics of N Amer, 2004;15:575‐605.Marik HTRC ASHT 2017

III. Shoulder GirdleLigaments


Ligaments of the Shoulder Girdle

• Sternoclavicular (SC)

• Acromio‐clavicular (AC)

• Coracoclavicular

• Coracoacomion

• Coracohumeral ligament (CHL)

• Glenohumeral ligament (superior, middle, inferior)15

http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png


Sternoclavicular Ligaments


– Anterior/Posterior

– Interclavicular

17


Ligaments of the Sternoclavicular Joint

Wikipedia acromioclavicular joint from http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png


Static Stabilizers of Clavicle & Scapula

• Acromio‐clavicular– Acromio‐clavicular ligament

• Coracoacromial– Coracoacromion ligament

• Coracoclavicular– Conoid

– Trapzoid ligament

18

Wikipedia acromioclavicular joint from http://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png

Wikipedia acromioclavicular joint from http://upload.wikimedia.org/wikipedia/commo/3/3b/Gray326.pngMarik HTRC ASHT 2017

Glenohumeral Ligaments


Glenohumeral Static Stabilizers

• Ligaments

• Capsule

• Labrum

• Boney Architect

http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Study_99/shoulder/edited/glenoid_fossa.jpeg


Ligaments of the Glenohumeral Joint/(SGHL, MGHL, IGHL)

• Coracohumeral ligament (CHL)

• Superior glenohumeral ligament (SGHL)

• Middle glenohumeral ligament (MGHL)

• Inferior glenohumeral ligament (IGHL)

• Posterior band glenohumeral ligament


Axillary Pouch

SGHL

MGHL

IGHL

21

CHL


Multidirectional Instability (MDI)Inferior translation restrained by

coracohumeral and superior glenohumeral ligaments

Positive Test:Visible sulcus sign.

(Hawkins & Mohtadi 1991)

Inferior translation,November 2010. Courtesy Blaydes Chun


0 to 30 degrees

45 to 60 degrees

90 degrees

Glide antero-medial direction

Anterior translation, November 2010. Courtesty Blaydes Chun.



Shoulder capsule, ORIF from:http://www.eorif.com/Shoulderarm/Shoulder%20anat/Images/Shoulder‐ligaments.jpg


IV. KINESIOLOGYPRECISE TIMING

Clavicle Force Couples

Scapular Force Couples

Glenohumeral Force Couples


SCAPULOHUMERAL RHYTHM

Illustration retrieved on 12/28/14 from: http://www.geocities.ws/ptexas9/angles.jpg

3 Phases of Motion (Scapula contribution varies, Scibek & Carcia, 2012)

Phase I 0º to 60º

Phase II 60º to 120º

Phase III 120º to 180º

90º sagittal plane flexion30º scapula and 60º glenohumeral 25Marik HTRC ASHT 2017

Framework for Teaching2° of humeral motion1° degree scapula motion

Retrieved from:http://www.zimmer.com/web/enUS/images/products/joints/shoulders/bigliani_flatlow_shoulder2.jpg on 02/22/09

Video Movement Patterns


3 Dimensional Motions of Scapula

27

Retrieved on 06/07/09: http://www.flzine.com/wp-content/uploads/2009/03/rotator.gif

Upward Rotation

Posterior Tilt

From Int. Rot.

Towards Ext. Rot.


AXIOSCAPULAR MUSCLESSCAPULAR FORCE COUPLE MUSCLES

• Serratus Anterior

• Trapezius (upper, middle, lower)

28Scapula force couples, Nov. 12, 2012 courtesy of Kathy Wilson


29

Upper Trapezius (UT) and

Serratus Anterior (SA)provide

rotatory force early needed for

Upward Rotation.

Picture adapted from: Donatelli, R. (1997).

Scapulo‐thoracic MotionPhase 1 & 2


Phase I & II0‐60°60° to 120°

30

Picture adapted from: Donatelli, R. (1997).


Phase III120‐180°

3 Dimensional Motions of the Clavicle

31

Elevate

RetractPosterior Rotate

Photo retrieved from: http://upload.wikimedia.org/wikipedia/commons/8/82/Clavicle_‐_anterior_view.png

Mechanical coupling at acromioclavicular (AC) joint and sternoclavicular (SC) joint


SCAPULAR MOTIONRelative to the

Acromio‐clavicular Joint

Phase I: SC elevation and AC posterior tilt = 16°scapula upward rotation

Phase II & III: SC elevation & posterior rotation = 2°scapula posterior tilt

Phase II & III:SC retraction and AC internal rotation = 2° scapula external rotation.

32

Illustration from: Ludewig P, Braman J. Shoulder impingement: Biomechanical considerations in rehabilitation. Manual Ther, 2011;16:33‐39


Teece, R., Lunden, J., Lloyd, A., Kaiser, A., Cieminski, C., Ludewig, P. (2008). Three‐dimensional acromioclavicular jointmotions during elevation of the arm. Jour of Orthop Sports Phys Ther, 38: 181‐190.

33

Three Dimensional Motions of the Glenohumeral Joint

Superior / Inferior Glide

Retrieved on 2/21/10 from:http://www.ithaca.edu/faculty/lahr/LE2000/UE_Ind_Study_99/shoulder/edited/glenoid_fossa.jpeg

Spins, Rolls & Glides

External RotationLudewig et al 2009


Glenohumeral Motions: Anterior and Posterior Balance Forces

Phase I (0°‐60°):0.7 to 2.7mm of anterior translationPhase II (60°‐120°):0‐1.5mm of posterior translationPhase III (120°‐180°): 4.5mm posterior translationLudewig & Cook, 2002.rieved on 08/02/09 from:

http://www.bosshin.com/owners_manual_instability/


SCAPULOHUMERAL MUSCLESGLENOHUMERAL FORCE COUPLE

MUSCLES

35Rotator cuff, Dreamstime from: http://www.dreamstime.com/stock‐illustration‐shoulder‐anatomy‐medically‐accurate‐illustration‐image57248638#res13544998">The Shoulder Anatomy Photo</a>

Deltoid. Wikipedia from: https://upload.wikimedia.org/wikipedia/commons/9/93/Deltoideus.png

S.I.T.SSupraspinatusInfraspinatusTeres minorSubscapularis

Deltoids


DELTOID AND SUPRASPINATUS

Donatelli, R. (1997). Physical Therapy of shoulder. Philadelphia, PA: Chruchill Livingstone

Retrieved and adapted on 06/07/09 from:http://img.tfd.com/dorland/thumbs/bursa_subacromialis.jpg


SCAPULOHUMERAL RHYTHM

First Phase 0 to 60 Degrees GH ForcesSetting Phase

37

The deltoid provides a shearing force between 60 to 100 degrees of arm elevation and the rotator cuff provides a compressive force.

SCAPULOHUMERAL RHYTHMSecond Phase GH 60 to 120 Degrees

Retrieved and adapted on 06/08/09 from:http://www.chiroandosteo.com/content/13/1/20 Marik HTRC ASHT 2017 38

2nd Phase 60 to 120 DegreesBalance Forces Needed Between Subscapularis and Infraspinatus to Keep the Glenohumeral

Joint Centered

Albert, M. (2008). Evaluation and Treatment of Shoulder Biomechanics .

Ratio of posteriorto anterior forces

60% to 70%.ER/IR ratio ~ 66%


39

SCAPULOHUMERAL RHYTHMFinal GH Phase 120 to 180 Degrees

• The humerus must disengage from the scapula!

Retrieved from:http://www.zimmer.com/web/enUS/images/products/

joints/shoulders/bigliani_flatlow_shoulder2.jpg on 02/22/09


Scapulothoracic joint moves ~ 60 degrees

Glenohumeral joint moves ~ 120 degrees

Total Motion ~ 180 degrees

GH 120

ST 60Retrieved on 06/08/09 adaptedFrom:http://www.goodbyepain.biz/images/gallery_3.jpg

Total 180

SH Rhythm1 degree scapularmovement for 2 degrees humeral

movement


Video SH Rhythm

Marik HTRC ASHT 2017 41 Marik HTRC ASHT 2017 42

Movement Pattern Video


V. MUSCLES OF THE SHOULDER GIRDLE


SHOULDER GIRDLE MUSCLE ANATOMY

AxioscapularOriginate: Axio‐skeletonInsert: Scapula

ScapulohumeralOriginate: ScapulaInsert: Humerus

Axiohumeral:Originate: Axio‐skeletonInsert: Humerus

Wikapedia glenohumeral muscles from:http://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Pectoralis_major.png/250px‐Pectoralis_major.png


Axio‐scapularAnterior

• Serratus Anterior (originates anterior/inserts posterior)

• Pectoralis Minor

Posterior

• Trapezius

• Rhomboids (Minor & Major)

• Levator Scapulae


Anterior

Serratus Anterior

Pectoralis Minor

Wikapedia: Pectoralis Minor from http://openphysio.co.za/images/thumb/5/5d/Levator_scapulae.jpg/150px‐Levator_scapulae.jpg

Wikapedia: Serratus Anterior from http://openphysio.co.za/images/thumb/5/5d/Levator_scapulae.jpg/150px‐Levator_scapulae.jpg

Axioscapular Anterior


Serratus Anterior

Origin: First 8 to 9 ribs

Insertion: Medial border of scapula

Innervation: Long thoracic nerve (C5, C6, C7)

Cadaver photo courtesy of Ithaca University,http://ect.downstate.edu/courseware/haonline/imgs/00000/0000/500/586.jpg. Courtesy of Dr. Stephan Lahr

Wika pedia: pectoralis minor from http://upload.wikimedia.org/wikipedia/commons/c/c9/Gray1215.png


Pectoralis Minor

Origin: Ribs 3, 4, & 5

Insertion: Coracoid Process

Innervations: Medial pectoral nerve (C8, T1)

Action: Draws scapula anteriorly and inferiorly.

Wikapedia pectoralis minor:http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

49



Pectoralis Minor

Action of Pectoralis Minor with origin fixed:

Tilts scapula anterior and downward.

Anterior

Posterior

50

Images by human anatomy basics from http://hippie.nu/~unicorn/tut/img/basics/humananatomy/scapula.jpeg

Pectoralis minor assessment, October 2012. Courtesty Tambra Marik


Posterior

Trapezius

Rhomboids

Levator Scapulae

Upper, Middle

& Lower

Minor

Major

Axioscapular Posterior


Trapezius

• Upper trapezius (UT)

• Middle trapezius(MT)

• Lower trapezius (LT)Wikipedia Trapezius: http://upload.wikimedia.org/

wikipedia/commons/a/aa/Trapezius_animation_small2.gif

UT

MT

LT

52



Upper Trapezius Fibers

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

Insertion: Posterior lateral third of clavicle, acromion

Innervations: Spinal accessory nerve (motor) & C 3, C4 (sensory/proprioceptive)

Wikipedia trapezius 2/10/13 from: http://upload.wikimedia.org/wikipedia/commons/6/60/Trapezius.png

Wikipedia Trapezius: http://upload.wikimedia.org/wikipedia/commons/a/aa/Trapezius_animation_small2.gif


Upper Trapezius Fibers

Action of U.T. on Scapula: Scapula & clavicle elevation, clavicle retraction and assists with scapular upward rotation. *Excessive elevation contributes to scapular anterior tilt

Action of U.T. on Cervical Spine: Unilateral extension, assists same side lateral flexion and rotation of head to opposite side. 54

Scapular elevation, August 8, 2012. Courtesy Blaydes Chun

Scapula force couple, October 2012. Courtesy Kathy Wilson


Middle Trapezius FibersOrigin: Spinous process

C7 – T3

Insertion: Medial acromion process and spine of scapula

Innervation: Spinal accessory nerve (motor) & cervical spinal nerves (motor & sensory) C 3, C4

Wikapedia trapezius from 2/10/13 http://upload.wikimedia.org/wikipedia/commons/2/2d/Trapezius_Gray409.PNG


Lower Trapezius FibersOrigin: Spinous process T4 to T12

Insertion: Inferior portion of spine of scapula

Innervations: Spinal accessory nerve (motor) & cervical spinal nerves (motor & sensory)

C 3, C4

Photos retrieved on 2/10/13 from: http://upload.wikimedia.org/wikipedia/commons/6/60/Trapezius.png

Spinal Accessory nerve injury from:http://electrodiagnosis.net/NewsResearch/EandRNewsletter/Vol_4_Issue_2_Differential%20Diagnosis

%20and%20Treatment%20of%20Winging%20Scapul


Middle &Lower Trapezius Fibers

Action of LT: Scapular depression and adduction, assists with scapula upward rotation and assists with scapular external rotation.

Wikipedia trapezius from 2/10/13 from:http://upload.wikimedia.org/wikipedia/commons/2/2d/Trapezius_Gray409.PNG

57

Scapula force couple, October 2012. Courtesy Kathy Wilson


Rhomboid major/minor

58

Innervations: Dorsal scapular nerveC4, C5

Wikepedia rhomboids from: http://upload.wikimedia.org/wikipedia/commons/7/70/Rhomboid_muscles_animation_small.gif

Kendall et al 2005


R. Minor

R. Major

Action: Scapular adduction/retraction, elevation, downward rotation and resist lateral translation of serratus anterior


Levator Scapulae (L.S.)Action of Levator Scapulae on Scapula:

Scapular elevation and assists with scapula downward rotation

Action Levator Scapulae on Cervical: Same side cervical flexion and rotation. Assists with cervical extension

Innervations: Dorsal scapular nerve (C5) and ventral primary rami of C3 and C4


Wikipedia levator scapulae on 2/10/13 from:http://upload.wikimedia.org/wikipedia/commons/thumb/2/2c/Muscle_%C3%A9l%C3%A9vateur_de_la_scapula.png/636px‐Muscle_%C3%A9l%C3%A9vateur_de_la_scapula.png

L.S.


Scapulohumeral Muscles

60

Anterior

Anterior & Middle Deltoids

Subscapularis

Corcobrachialis

Posterior

Posterior & Middle Deltoids

Supraspinatus

Infraspinatus

Teres minor

Teres major

Wikipedia posterior cuffi from:from:http://images.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedi

Wikipedia anterior deltoid, corcobrachialis, subscapularis from : http://openphysio.co.za/index.php?title=Muscles_that_move_the_shoulder_girdle


DELTOID MUSCLE

• Anterior deltoids

• Middle deltoids

Image cadaver deltoidsIthaca College Physical Therapy DepartmentGross Anatomy – Joints website:http://www.ithaca.edu/faculty/lahr/LE2000/LE_index.html“. Courtesy Stephan Lahr


Action of Anterior Deltoid Fibers:

Flex shoulder and contribute to medial/internal rotation when supine

Action of Middle Deltoid Fibers: Shoulder abduction

Innervations: Axillary nerve (C5, C6)

Axillary nerve injury from: https://www.google.com/search?site=&tbm=isch&source=hp&biw=1280&bih=687&q=axillary+nerve+injury&oq=axillary+nerve+injury&gs_l=img.3..0j0i24l9.1584.4971.0.5338.21.14.0.7.7.0.109.1173.13j1.14.0....0...1ac.1.64.img..0.21.1217.Yc_hh87ohmU#imgrc=i2ACRTjOZA3U5M%3A

Marik, T. Actions of anterior deltoid, August 2012. Courtesy Tambra Marik

Wikapedia deltoids from:http://openphysio.co.za/index.php?title=Muscles_that_move_the_shoulder_girdle


Scapulohumeral Anterior Muscles

• Anterior/Middle Deltoid

• Subscapularis

• Coracobrachialis

Subscapularis

Wikapedia subscapularis from: http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png63

Wikapedia subscapularis from:http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png


Subscapularis (located anterior)

Action of Subscapularis: Contributes to medial/internal rotation of the shoulder and compression of the humeral head in the glenoid fossa during joint movements

Innervation: Upper and lower subscapular nerve (C6, C7)

Image retrieved from http://upload.wikimedia.org/wikipedia/commons/thumb/6/61/Subscapularis_muscle_frontal.png/250px‐Subscapularis_muscle_frontal.png


Coracobrachialis(located anterior)

Action of Coracobrachialis: Flexes and adducts the shoulder

Innervation: Musculocutaneous (C6, C7)

Wikapedia coracobrachialis from: http://upload.wikimedia.org/wikipedia/commons/thumb/6/61/Subscapularis_muscle_frontal.png/250px‐Subscapularis_muscle_frontal.png

Coracobrachialis


Scapulohumeral Posterior Muscles

• Posterior/Middle Deltoid

• Supraspinatus

• Infraspinatus

• Teres minor

• Teres major

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

Image provided by the Ithaca College Physical Therapy DepartmentGross Anatomy – Joints website:http://www.ithaca.edu/faculty/lahr/LE2000/LE_index.html“

Courtesy Stephan Lahr.

Supra.

Infra.

T. Minor

T. Major

Post. Deltoid


Posterior Deltoid

Action of Posterior Deltoid Fibers: Shoulder extension and contributes to lateral/external rotation in the prone position

Innervations: Axillary nerve (C5, C6)

67

Marik, T. Actions of anterior deltoid, August 2012. Courtesy Tambra Marik

Posterior deltoid, Wikipedia from https://upload.wikimedia.org/wikipedia/commons/thumb/9/93/Deltoideus.png/250px‐Deltoideus.png


Supraspinatus

Action of Supraspinatus: Abducts and externally/laterally rotates the humerus. Compression/stabilization of humeral head in the glenoid fossa during shoulder movements

Innervation: Suprascapular nerve (C4, C5, C6)

Wikapedia suparspinatus from: http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

AbductionER

68

Marik, T. Supraspinatus actions, August 2012. Courtesy Tambra Marik.


Infraspinatus

Action of Infraspinatus: External rotation of the shoulder. Compression/stabilization of humeral head in glenoid fossa during shoulder movements.

Innervation: Suprascapular nerve (C4, C5, C6)

Wikapedia infraspinatus from http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

ER

69

Marik, T. External rotation, August 2012. Courtesy Tambra MarikImage retrieved from: https://encrypted‐tbn3.google.com/images?q=tbn:ANd9GcRbiPKCRKCFS4HfJrg42Jv3hTzf7jsQtGY708tf20xgvvxfld2q


Teres Minor

Action of Teres Minor: External rotation of the shoulder. Compression/stabilization of humeral head in glenoid fossa during shoulder movements.

Innervation: Axillary Nerve (C5, C6)

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

ER

70

Marik, T. External rotation, August 2012. Courtesy Tambra Marik


Palpation: Infraspinatus & Teres Minor

71

Infra. & Teres Minor


Teres Major

Action of Teres Major: Medial/internal rotation of the humerus and extends humerus.

Innervation: Lower subscapular nerve (C5, C6, C7)

Wikapedia teres major Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png

IR

Ext.

72

Marik, T. Teres major actions, August, 2012. Courtesy Tambra Marik

Image retrieved from: http://upload.

wikimedia.org/wikipedia/commons/f/f2/Gray411.png


Rotator Cuff (S.I.T.S.)

• Supraspinatus

• Infraspinatus

• Teres Minor

• Subscapularis

Image retrieved and modified from:Retrieved on 06/07/09from:http://www.bartleby.com/107/Images/small/image410.jpg

S.I.T.S.Compress/concavity to stabilize and center the humeral head during shoulder motions.

Image provided by the Ithaca College Physical Therapy DepartmentGross Anatomy – Joints website:http://www.ithaca.edu/faculty/lahr/LE2000/LE_index.html Courtesy Stephan Lahr


Axiohumeral Muscles

74

Anterior

Pectoralis Major

Posterior

Latissimus

Dorsi

Wikipediat pectoralis major from: http://images.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedi

Wikipedia latissimus dorsi from:from:http://images.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedi


Pectoralis Major Middle (Clavicular) & Lower (Sternal) Fibers

Innervation: Lateral pectoral nerve and medial pectoral nerve (C7, C8 & T1)

Cadaver mage retrieved from:http://ect.downstate.edu/courseware/haonline/simgs/00000/0000/500/575.jpgDrawing pect. major retrieve from:from:http://images.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedi

75


Wikipedia pectoralis major from:http://images.google.com/Imgres?imgurl=http://upload.wikimedia.org/wikipedi


Pectoralis MajorAction of Clavicular Head (upper fibers): Horizontal adduction, medial/internal rotation and forward flexion of the humerus

Actions of Sternal Head (lower fibers): Oblique adduction towards opposite hip, medial rotation, and depresses the shoulder girdle

Combined Actions of Sternal & Clavicular Head: Humeral flexion, horizontal adduction, and medial rotation

Marik, T. Pectoralis major muscle actions, August 2012. Courtesy: Tambra Marik

Horz. Add.


77

Pectoralis Major

• Short muscle fiber exists when the extended arm does not drop down to the mat.

Kendall, F.(2005). MUSCLES TESTING AND FUNCTION WITH POSTURE AND PAIN. Baltimore, MD: Lippincott Williams & Wilkins.

Sternal fibers assess with horizontal abduction at 145°

Marik, T. Assess pectoralis major clavicular fibers,December, 2009. Courtesy Tambra Marik


Assess Length of Pectoralis MajorAssess Length of Pectoralis Major

• Short muscle fibers exist when the arm can not drop down to the mat.


Clavicular Fibers assess with horizontal abduction at 90°

Marik, T. Assess pectoralis major clavicular fibers,December, 2009. Courtesy Tambra Marik


Latissimus Dorsi

Action of Latissimus with the origin fixed:medial/internal rotation, adduction, and extension. Contributes to scapular depression.

Innervation: Thoracodorsal Nerve C6, C7, C8

IR

EXT

DEPRESSION

79

Retrieved from: from:http://images.google.coimgres?imgurl=http://upload.wikimedia.org/wikiped


Assess Length of Latissimus DorsiAssess Length of Latissimus Dorsi

• Shortness exists when the patient is unable to reach arms overhead to the mat.


Marik, T. Latissimus Dorsi assessment, December 2009. Courtesy Tambra Marik


XI. Elbow & Forearm Muscles


LONG ARM MUSCLES & ELBOW FLEXORS/EXTENSORS

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/7/77/Gray1232.png


Long Arm Muscles

Anterior

• Biceps short head

• Biceps long head

Posterior

• Triceps lateral head

• Triceps long head

• Triceps medial head

Image provided by the Ithaca College Physical Therapy DepartmentGross Anatomy – Joints website:http://www.ithaca.edu/faculty/lahr/LE2000/LE_index.html


Biceps (Anterior)

Origin Short Head: Coracoid process of scapula

Origin Long Head: Supra‐glenoid tubercle of scapula

Insertion: Tuberosity of radius


Short head

Long head

Image retrieved from:http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png


Biceps

Action of both Head of Biceps: Elbow flexion and supination

Action of Short Head of Biceps: Assists with shoulder adduction

Action of Long Head of the Biceps: Assists with shoulder abduction.


SUPINATION

ELBOW FLEXION


Triceps (Posterior)

Origin Long Head: Infraglenoid tubercle of scapulaOrigin Lateral Head: Lateral posterior humerus & lateral

intermuscular septumOrigin Medial Head: Medial posterior humerus and medial

intermuscular septum

Insertion: Posterior OlecranonInnervation: Radial (C6, C7, C8)


Long Head Lateral Head Lateral Head


Triceps

Action of Triceps: Extends elbow

Action of Long Head of Triceps: Contributes to shoulder extension and shoulder adduction.



Elbow Extensors: Anconeus (Posterior)

Photo retrieved from: http://upload.wikimedia.org/wikipedia/commons/thumb/d/d1/Slide1TTTT.JPG/800px‐Slide1TTTT.JPG

88

Assists with elbow extension


Range of Motion

Normal Arc: Elbow 0º to 140º; forearm 0º to 85º

Functional Arc: 30º to 130º (Bryce & Armstrong, 2008)


Elbow Flexors & ExtensorsElbow Flexors (anterior)

• Biceps Brachii (short & long heads)

• Brachialis

• Brachioradialis

Elbow Extensors (posterior)

• Triceps, (long, lateral & medial heads)

• AnconeusImage provided by the Ithaca College Physical Therapy DepartmentGross Anatomy – Joints website:http://www.ithaca.edu/faculty/lahr/LE2000/LE_index.html


Elbow Flexors: Biceps (Anterior)

Origin Short Head: Coracoid process of scapula

Origin Long Head: Supra‐glenoid tubercle of scapula

Insertion: Tuberosity of radius


Short head

Long head




Elbow Flexors: Biceps

Action of both Head of Biceps: Elbow flexion and supination

Action of Short Head of Biceps: Assists with shoulder adduction

Action of Long Head of the Biceps: Assists with shoulder abduction.


SUPINATION

ELBOW FLEXION


Elbow Flexors: Brachialis (Anterior)

Origin: Distal half of anterior humerusInsertion: Coronoid process and tuberosity of the ulnaInnervation: Musculcutaneous & small branch from radial nerve (C5, C6)

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/thumb/3/33/Slide6yyy.JPG/800px‐Slide6yyy.JPG


Elbow Flexors: Brachialis

Action: Flexes the elbow



Elbow Flexors: Brachioradialis (Anterior)

Origin: Lateral supracondylar ridge of the humerus

Insertion: Lateral side of styloid process

Innervation: Radial Nerve (C5, C6)

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/0/09/Brachioradialis.png

Cadaver retrieved From: http://ect.downstate.edu/courseware/haonline/imgs/00000/0000/700/734.jpg


Elbow Flexors: Brachioradialis

Action: Flexes the elbow. Assists with forearm rotation when there is resistance to elbow flexion.



Elbow Extensors:Triceps (Posterior)

Origin Long Head: Infraglenoid tubercle of scapulaOrigin Lateral Head: Lateral posterior humerus & lateral

intermuscular septumOrigin Medial Head: Medial posterior humerus and medial

intermuscular septum

Insertion: Posterior OlecranonInnervation: Radial (C6, C7, C8)


Long Head Lateral Head Lateral Head


Elbow Extensors: Triceps (Posterior)

Action of Triceps: Extends elbow

Action of Long Head of Triceps: Contributes to shoulder extension and shoulder adduction.



Elbow Extensor: Anconeus (Posterior)

Origin: Posterior lateral epicondyle

Insertion: Olecranon and upper posterior ulna

Innervation: Radial Nerve (C7, C8)

Images retrieved from: http://upload.wikimedia.org/wikipedia/commons/thumb/d/d1/Slide1TTTT.JPG/800px‐Slide1TTTT.JPG


Elbow Extensor: Anconeus (Posterior)

Action: Contributes to elbow extension



Forearm Rotation Muscles

Supinators & Pronators


Forearm Supinator: Supinator

Origin: Lateral epicondyle, radial collateral ligament, annular ligament, and supinator crest of ulnaInsertion: Lateral 1/3 of radius covering anterior and posteriorInnervation: Radial Nerve (C5, C6)

Images retrieved from: http://upload.wikimedia.org/wikipedia/commons/c/c6/Gray420.png


Forearm Supinator: Supinator Muscle

Action: Supinates the forearm


Palm Up


Forearm Pronators: Pronator Teres

Origin: Proximal medial epicondyle and common flexor tendonInsertion: Mid‐lateral surface of the radiusInnervation: Median Nerve (C6, C7)

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/d/de/Muscles_of_forearm.jpg


Forearm Pronators: Pronator Teres

Action: Pronates the forearm and assists with elbow flexion

Image retrieved from: http://upload.wikimedia.org/wikipedia/commons/d/de/Muscles_of_forearm.jpg

Palm Down


Forearm Pronators: Pronator Quadratus Quadratus

Origin: Anterior distal ulna

Insertion: Anterior distal radius

Innervation: Median Nerve (C7, C8, T1)

Images retrieved from: http://upload.wikimedia.org/wikipedia/commons/thumb/b/b4/Slide2VVVV.JPG/800px‐Slide2VVVV.JPG


Forearm Pronators: Pronator Quadratus

Action: Forearm pronation

Images retrieved from: http://upload.wikimedia.org/wikipedia/commons/thumb/b/b4/Slide2VVVV.JPG/800px‐Slide2VVVV.JPG

Palm Down


XII. Important Soft Tissue Regions of the Elbow


IMPORTANT SOFT TISSUE AREAS

• Potential nerve compression sites of arm, elbow & forearm

– Ulnar Nerve

– Median Nerve

– Radial Nerve

http://upload.wikimedia.org/wikipedia/commons/7/75/Gray413_color.png


Potential Soft Tissue Sites of Ulnar Nerve Compression

Ulnar Nerve Compression Sites:

• Arcade of Struthers

• Medial intramuscular septum

• Condylar groove

• Cubital tunnel retinaculum

• Deep flexor pronator aponeurosis

.

UlnarNerve

Proximal to ElbowUlnar Nerve

Arcade Struthers

Medial Intermuscular

Septum

Arcade StruthersArcade Struthers

Ulnar Nerve

Image from: http://upload.wikimedia.org/wikipedia/commons/e/e7/Gray528.png 110Marik HTRC ASHT 2017

Special Tests: Medial ElbowCubital Tunnel Syndrome

TinelsSensitivity:54% to 70%

Modified Shoulder Internal Rotation TestSensitivity: 87% (5 second)Specificity: 97% Ochi et al 2012

Scratch CollapseSensitivity: 69%Spec.: 99%


Potential Soft Tissue Sites of Median Nerve Compression

• Median Nerve (Pronator Syndrome)

• Anterior Interosseous Nerve (branch of median nerve)

http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Nerves_of_the_left_upper_extremity.gif/314px‐Nerves_of_the_left_upper_extremity.gif



• Median Nerve (Pronator Syndrome)

Possible Compression Sites• Pronator teres(most common site)

• Arch for flexor digitorum superficialis (FDS)

• Ligament of Struthers(located at supracondylar process)

• Lacertus fibrosis (bicipital aponeurous)

http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Nerves_of_the_left_upper_extremity.gif/314px‐Nerves_of_the_left_upper_extr

FDS

Pronator Teres



• Anterior Interosseous Nerve (branch of median nerve)

Possible Compression Sites

• Fibrous bands from deep PT

• Flexor digitorum superficialis arch

• Gantzer muscle (FPL accessory)

• Flexor carpi radialis

• Palmaris longus

http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Nerves_of_the_left_upper_extremity.gif/314px‐Nerves_of_the_left_upper_extremity.gif

PronatorTeres


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


Potential Soft Tissue Sites of Radial Nerve Compression

• Intermuscular Septum (spiral groove b/w triceps & brachiallis)

• Edge for ECRB• Radio‐capitellar joint due to arthrosis (b/w brach. & BR)

• Ligament of Frosche• Between 2 heads of supinator

• Exit under brachioradiallis

Brachialis

Triceps

Radial Nerve

ECRB

http://upload.wikimedia.org/wikipedia/commons/7/75/Gray413_color.pngRetrieved on 4/3/11 from:http://upload.wikimedia.org/wikipedia/commons/c/c6/Gray420.png

Supinator

Radial Nerve


Radial Nerve Signs/Symptoms• Compression proximal elbow present with weakness of wrist and digit extensors

• Compression distal to elbow can present with weak finger ext. and normal wrist ext. strength (PIN)

• Compression proximal ligament Froshe can present with sensation disturbance.

Retrieved on 4/3/11 from:http://upload.wikimedia.org/wikipedia/commons/c/c6/Gray420.png


THANK YOU!


REFERENCES1. Ahmad Z, Siddiqui N, Malik SS, Abdus‐Samee M, Tytherweigh‐Strong G, Ruston M. (2013). Lateral epicondylitis. A review

of pathology and management. Bone & Joint Surgery;95(9):1158‐1164.2. Bryce CD, ArmstrHariri S, Safran MR. (2010). Ulnar collateral ligament injury in overhead athlete. Clin Sports

Med.;29(4):619e644. 3. Chong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39(2):141e154.4. Devereaux, M. W., & ElMaraghy, A. W. (2013). Improving the Rapid and Reliable Diagnosis of Complete Distal Biceps Tendon

Rupture A Nuanced Approach to the Clinical Examination. The American journal of sports medicine, 0363546513493383.5. Hart D, Carmichael S. Biomechanics of the shoulder. Jour of Ortho and Sports Phys Ther, 1985;6(4):229‐234.6. Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical

examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta‐analysis of individual tests. British journal of sports medicine, bjsports‐2012.

7. Hutchinson RL, Rayan G. (2011). Diagnosis of cubital tunnel syndrome. Journal of Hand Surgery Am.;36(9):1519e1521.8. Jia, X., Petersen, S. A., Khosravi, A. H., Almareddi, V., Pannirselvam, V., & McFarland, E. G. (2009). Examination of the

shoulder: the past, the present, and the future. The Journal of Bone & Joint Surgery, 91(Supplement_6), 10‐18.9. Jobe C, Phipatanakul W, Coen M. Gross Anatomy of the Shoulder. In: Rockwook C, Matsen F, Wirth M, Lippitt S. The

Shoulder, 4th ed, Philadelphia, PA: Saunders Elsevier; 2009:33‐100.10. Kendall, F.(2005). MUSCLES TESTING AND FUNCTION WITH POSTURE AND PAIN. Baltimore, MD: Lippincott Williams &

Wilkins.11. Koo J, Szabo R. Compression neuropathies of the median nerve. JASHS, 2004;4(3):156‐175.12. Ludewig P, Cook T, Nawoczenski D. Three Dimensional Scapular Orientation and Muscle Activity at Selected Positions of

Humeral Elevation. JOSPT, 1996;24(2):57‐65. 13. Ludewig et al (2009). Motion of the Shoulder Complex during Multiplanar Humeral Elevation. Jour Bone & Joint Surg,

91:378‐8914. Nordin M, Frankel V. Basic Biomechanics of the Musculoskeletal System. 3rd ed, Baltimore, MD:Lippincott Williams &

Watkins;2001. 15. Ochi K, Horiuchi Y, Tenabe A, Waseda M, Kuneko Y, Koyanagi T. (2012) Shoulder internal rotation elbow flexion test for

diagnosing cubital tunnel syndrome. Journal of Shoulder Elbow Surgery;21(6):777e781.16. O’Driscoll SW, Lawton RL, Smith AM. (2005). The “moving valgus stress test” for medial collateral ligamnt tears of the eblwo.

American Journal of Sports Medicine;33(2):231‐239.17. Palastanga N, Field D, Soames R. The Upper Limb. Anatomy and Human Movement: Structure and Function. 4th ed.

Woburn, MA: Butterworth‐Heinnemann, 2002:41‐109.18. Regan W, Lapner PC.(2006). Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the

elbow. Journal Shoulder Elbow Surgery;15(3):344e346.19. Tosti R, Jennings J, Sewards JM. (2013). Lateral epicondylitis of the elbow. American Journal of Medicine;126(4):357.


SPECIAL THANKS FOR PHOTOS AND ILLUSTRATIONS PROVIDED BY:

Dr. Stephen Lahr

Ithaca CollegeDepartment of Physical TherapyHuman Anatomy Review Site

and

Suny Downstate University Medical Center


Conclusion

• Preparatory activities to reach occupation‐base goals

• Think function

• Organize muscular groups for learning

• Think like a clinician


THANK YOU

AMAZING VARIETIES OF FUNCTION OF

THE SHOULDERS &

ELBOWS


References• Ahmad Z, Siddiqui N, Malik SS, Abdus‐Samee M, Tytherweigh‐Strong G, Ruston M. (2013). Lateral epicondylitis. A review of pathology and

management. Bone & Joint Surgery;95(9):1158‐1164.• American Occupational Therapy Association (2006). AOTA’s Centennial Vision. Retrieved

from:http://www.aota.org/~/media/Corporate/Files/AboutAOTA/Centennial/Background/Vision1.ashx• Bryce CD, ArmstrHariri S, Safran MR. (2010). Ulnar collateral ligament injury in overhead athlete. Clin Sports Med.;29(4):619e644. • Chong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39(2):141e154.• Devereaux, M. W., & ElMaraghy, A. W. (2013). Improving the Rapid and Reliable Diagnosis of Complete Distal Biceps Tendon Rupture A Nuanced

Approach to the Clinical Examination. The American journal of sports medicine, 0363546513493383.• Hart D, Carmichael S. Biomechanics of the shoulder. Jour of Ortho and Sports Phys Ther, 1985;6(4):229‐234.• Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical examination tests provide

clinicians with the most value when examining the shoulder? Update of a systematic review with meta‐analysis of individual tests. Britishjournal of sports medicine, bjsports‐2012.

• Hutchinson RL, Rayan G. (2011). Diagnosis of cubital tunnel syndrome. Journal of Hand Surgery Am.;36(9):1519e1521.• Jia, X., Petersen, S. A., Khosravi, A. H., Almareddi, V., Pannirselvam, V., & McFarland, E. G. (2009). Examination of the shoulder: the past, the present,

and the future. The Journal of Bone & Joint Surgery, 91(Supplement_6), 10‐18.• Jobe C, Phipatanakul W, Coen M. Gross Anatomy of the Shoulder. In: Rockwook C, Matsen F, Wirth M, Lippitt S. The Shoulder, 4th ed, Philadelphia, PA:

Saunders Elsevier; 2009:33‐100.• Kendall, F.(2005). MUSCLES TESTING AND FUNCTION WITH POSTURE AND PAIN. Baltimore, MD: Lippincott Williams & Wilkins.• Koo J, Szabo R. Compression neuropathies of the median nerve. JASHS, 2004;4(3):156‐175.• Ludewig P, Cook T, Nawoczenski D. Three Dimensional Scapular Orientation and Muscle Activity at Selected Positions of Humeral Elevation. JOSPT,

1996;24(2):57‐65. • Ludewig et al (2009). Motion of the Shoulder Complex during Multiplanar Humeral Elevation. Jour Bone & Joint Surg, 91:378‐89• Nordin M, Frankel V. Basic Biomechanics of the Musculoskeletal System. 3rd ed, Baltimore, MD:Lippincott Williams & Watkins;2001. • Ochi K, Horiuchi Y, Tenabe A, Waseda M, Kuneko Y, Koyanagi T. (2012) Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel

syndrome. Journal of Shoulder Elbow Surgery;21(6):777e781.• O’Driscoll SW, Lawton RL, Smith AM. (2005). The “moving valgus stress test” for medial collateral ligamnt tears of the eblwo. American Journal of Sports

Medicine;33(2):231‐239.• Palastanga N, Field D, Soames R. The Upper Limb. Anatomy and Human Movement: Structure and Function. 4th ed. Woburn, MA: Butterworth‐Heinnemann, 2002:41

109.• Regan W, Lapner PC.(2006). Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow. Journal Shoulder Elbow

Surgery;15(3):344e346.• Scibek, J. S., & Carcia, C. R. (2012). Assessment of scapulohumeral rhythm for scapular plane shoulder elevation using a modified digital inclinometer. World journal of orthopedics, 3(6), 87

• Teece, R., Lunden, J., Lloyd, A., Kaiser, A., Cieminski, C., Ludewig, P. (2008). Three‐dimensional acromioclavicular joinmotions during elevation of the arm. Jour of Orthop Sports Phys Ther, 38: 181‐190.

• Tosti R, Jennings J, Sewards JM. (2013). Lateral epicondylitis of the elbow. American Journal of Medicine;126(4):357.

• Illustration retrieved on 12/28/14 from: http://www.geocities.ws/ptexas9/angles.jpg


Photo References• Clavicle movement Moon OUHSC from http://images.google.com/imgres?imgurl=http://moon.ouhsc.• Clavicle Wikipedia from http://upload.wikimedia.org/wikipedia/commons/f/f0/Gray201.png• Humerus, Wikipedia from http://upload.wikimedia.org/wikipedia/commons/thumb/e/ee/HumerusBack.png/311px‐HumerusBack.png• Chun, B., 2010. Inferior translation. Courtesy Blaydes Chun.• Chun, B., 2010. Anterior translations. Courtesty Blaydes Chun.• Hicker, R. (Photographer). (2011). Moss rain forest [Photograph]. Courtesy of Ronald Hicker. • Lahr, S. (2013). Cadaver photos. Courtesy Dr. Stephan Lahr.• Lower trapezius from http://www.exrx.net/Graphics/SerratusAnteriorPull.gif• Marik, T., 2012. Pectoralis minor assessment. Courtesy Tambra Marik.• Pectoral girdle: http://upload.wikimedia.org/wikipedia/commons/

thumb/2/22/Pectoral_girdle_front_diagram.svg/250px‐Pectoral_girdle_front_diagram.svg.png• Pectoral girdle: http://upload.wikimedia.org/wikipedia/commons/

thumb/2/22/Pectoral_girdle_front_diagram.svg/250px‐Pectoral_girdle_front_diagram.svg.pn• Pectoralis minor Wikapedia pectoralis minor from http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.png• Rotator cuff, Dreamstime from: http://www.dreamstime.com/stock‐illustration‐shoulder‐anatomy‐medically‐accurate‐illustration‐

image57248638#res13544998">The Shoulder Anatomy Photo</a>• Scapula: http://hippie.nu/~unicorn/tut/img/basics/humananatomy/scapula.jpeg• Scapula upward rotation from http://www.flzine.com/wp-content/uploads/2009/03/rotator.gif• Scapula Wikipedica from http://upload.wikimedia.org/wikipedia/• commons/thumb/e/ed/Scapula_ant_numbered.png/476px‐Scapula_• ant_numbered.png• Scapulojhumral rhythm geocities from: http://www.geocities.ws/ptexas9/angles.jpg• Shoulder capsule, ORIF from: http://www.eorif.com/Shoulderarm/Shoulder%20anat/Images/Shoulder‐ligaments.jpg• Shoulder girdle from http://upload.wikimedia.org/wikipedia/commons/thumb/4/49/Human_arm_bones_diagram.svg/683px‐

Human_arm_bones_diagram.svg.png• Superior scapula rib vector (2009). From:http://www.exrx.net/

• Images/SuperiorScapulaRibVectors.gif• Wilson, K. (2012). Shoulder flexion. Courtesy of Kathy Wilson.• Wilson, K. (2012). Scapula force couples. Courtesy of Kathy Wilson• Wilson, K., (2012) .Scapula upward rotation. Courtesy of Kathy Wilson.


Photo References• Anterior deltoid Wikapedia from http://openphysio.co.za/index.php?title=Muscles_that_move_the_shoulder_girdle

• Clavicle Wikipedia from http://upload.wikimedia.org/wikipedia/commons/f/f0/Gray201.png• Humerus, Wikipedia from http://upload.wikimedia.org/wikipedia/commons/thumb/e/ee/HumerusBack.png/311px‐HumerusBack.png• Chun, B., 2010. Inferior translation. Courtesy Blaydes Chun.• Chun, B., 2010. Anterior translations. Courtesty Blaydes Chun.• Glenohumeral muscles, Wikapedia from: http://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Pectoralis_major.png/250px‐Pectoralis_major.png• Hicker, R. (Photographer). (2011). Moss rain forest [Photograph]. Courtesy of Ronald Hicker. • Lahr, S. (2013). Cadaver photos. Courtesy Dr. Stephan Lahr.• Levator scapula from Wikipedia: fromhttp:// openphysio.co.za/images/thumb/5/5d/Levator_scapulae.jpg/150px‐Levatorscapulae.jpg• Lower trapezius from http://www.exrx.net/Graphics/SerratusAnteriorPull.gif• MaRIK, T., 2009. Latissimus Dorsi assessment. Courtesy Tambra Marik.• Marik, T., 2009. Pectoralis Major assessment. Courtesy Tambra Marik.• Marik, T., 2012. Pectoralis minor assessment. Courtesy Tambra Marik.• Marik, T. Pectoralis major muscle actions, August 2012. Courtesy: Tambra Marik• Pectoral girdle: http://upload.wikimedia.org/wikipedia/commons/

thumb/2/22/Pectoral_girdle_front_diagram.svg/250px‐Pectoral_girdle_front_diagram.svg.png• Pectoral girdle: http://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Pectoral_girdle_front_diagram.svg/250pxPectoral_girdle_front_diagram.svg.pn• Pectoralis minor Wikapedia pectoralis minor from http://upload.wikimedia.org/wikipedia/commons/f/f2/Gray411.pn• Posterior cuff muscles Wikapedia from: from:http://images.google.com/• imgres?imgurl=http://• upload.wikimedia.org/wikipedi

• Scapula: http://hippie.nu/~unicorn/tut/img/basics/humananatomy/scapula.jpeg• Scapula upward rotation from http://www.flzine.com/wp-content/uploads/2009/03/rotator.gif• Scapula Wikipedica from http://upload.wikimedia.org/wikipedia/• commons/thumb/e/ed/Scapula_ant_numbered.png/476px‐Scapula_• ant_numbered.png• Shoulder girdle from http://upload.wikimedia.org/wikipedia/commons/thumb/4/49/Human_arm_bones_diagram.svg/683px‐Human_arm_bones_diagram.svg.png• Superior scapula rib vector (2009). From:http://www.exrx.net/

• Images/SuperiorScapulaRibVectors.gif• Wilson, K. (2012). Shoulder flexion. Courtesy of Kathy Wilson.• Wilson, K. (2012). Scapula force couples. Courtesy of Kathy Wilson• Wilson, K., (2012) .Scapula upward rotation. Courtesy of Kathy Wilson.


2017 htrc anatomy & kinesiology shoulder & elbow marik therapy review course uc irvine...

Documents