Upper Extremity Techniques Flashcards
What muscles make up the rotator cuff?
- Supraspinatus
- Insfraspinatus
- Teres Minor
- Subscapularis
Rotator Cuff Muscle Actions
- Supraspinatus
~ Shoulder Abduction - Insfraspinatus
~ Shoulder ER - Teres Minor
~ Shoulder ER - Subscapularis
~ Shoulder IR
Rotator Cuff Function
- Muscles work together to stabilize the shoulder by maintaining articulation between the humeral head and glenoid
~ Humeral head compression and
depression during shoulder
movements
If the Rotator Cuff is not the primary mover of the shoulder, who is?
- Pec major
- Teres major
- Latissimus dorsi
- Deltoids
- Biceps
How is the Rotator Cuff traditionally rehabbed?
- In Isolation!
~ Asking the group to internally rotate,
externally rotate and abduct the
shoulder.
> Does this make sense when
considering functional or end
stage rehabilitation? NO
> Does this make sense when
considering the size of the
muscles involved? NO
How should the rotator cuff be rehabbed to enhance function?
- Ask it to do what it does
~ Cooperate
> IR, ER, Abduct along with other
movement patterns
~ Move the shoulder in functional
movement patterns
> Anytime you move the shoulder,
the cuff works (especially away
from body to train it to stabilize)
~ Work in a diverse way
> Concentrically, eccentrically, and
isometrically
~ Remember Integrated Isolation
> Move shoulder in conjunction
with the core and LE
What makes the rotator cuff unhappy?
- Overuse
- Impingement: cuff tendon against AC ligament or acromion
- Mechanical problem down the chain asks the muscles of the shoulder to work harder including the cuff.
Link between the hip and shoulder
- The most efficient upper extremity movements utilize loading and unloading by the lower extremity (especially the hip) to more efficiently load and unload the upper extremity.
~ Efficient because
> Loading involves eccentric
contraction, lengthening of
muscle, and activation of MS
> Loading of the LE creates high
momentum (momentum
transferred to UE through the core)
Sagittal Plane Loading Patterns for Shoulder
- Shoulder Flexion
~ Same side hip flexion
~ Loads same side hip extensors and
shoulder flexors - Shoulder Extension
~ Opposite side hip flexion
~ Loads opposite side hip extensors
and shoulder extensors
Frontal Plane Loading Patterns for Shoulder
- Shoulder Abduction
~ Opposite side hip adduction
~ Loads opposite side hip abductors
and shoulder abductors - Shoulder Adduction
~ Same side hip adduction
~ Loads same side hip abductors and
shoulder adductors
Transverse Frontal Plane for Shoulder
- Shoulder ER
~ Opposite side hip IR
~ Loads opposite side hip external
rotators and shoulder external
rotators - Shoulder IR
~ Same side hip IR
~ Loads same side hip external rotators
and shoulder internal rotators
Link Between Hip and Shoulder in Sports
- Since we are most successful at movements in the transverse plane understanding and applying the transverse plane loading patterns is
important.
~ Abnormalities in the mechanics
down the chain can cause transverse
plane compensations and injury.
What would make the anterior shoulder unhappy?
Bad same side LE (especially hip)
What would make the posterior shoulder unhappy?
Bad opposite side LE (especially hip)
Characteristics of Functional Movement: Scapula and Humerus
- Scapula acts as a base for movement of the humerus.
- As the humerus moves the scapula must follow.
- Scapulothoracic Rhythm: for every 2 degrees of humeral elevation there’s 1 degree of scapular upward rotation
~ Scapula needs to move symmetrically
with the humerus
What limits scapular motion?
- Muscle Tightness/Imbalance/ Diminished NMC.
- Pain associated with injury.
- Immobilization
What else needs to move properly to allow for normal shoulder function?
- Thoracic cage, especially with motions occurring in the transverse plane
What happens when the scapula is not moving properly? And how do you fix it?
- Impingement
~ Humerus is banging against the
acromion because scapula is not
getting out of the way of the
humerus. - Fix it by enhancing scapula and thoracic cage mobility and/or NMC.
What else causes impingement?
- Anatomic Variation
~ Bony alignment that’s abnormal - Chronic Inflammation
- Capsular Limitation
~ Beware of the throwing athlete with
a tight posterior/inferior capsule.
> Forces humeral head anterior/
superior when the opposite
should be happening - Tight muscles/joint capsule can pull on the humerus causing it to move in the wrong direction leading to impingement which can result in rupture
How to determine impingement: GIRD (Glenohumeral Internal Rotation Deficit) vs. Total Motion
- Sometimes patients appear to have a deficit in IR rotation when they do not.
- When assessed, internal rotation is limited, but ER is excessive.
~ True GIRD would show diminished
IR, but ER would be normal - As long as total motion is 150-190 degrees GIRD is not likely.
- Possible that the shape of the humerus has been changed by forceful, overhead activities.
Shoulder Instability
- Laxity is a clinical sign and instability is a symptom
- Instability is a joint’s inability to function under the stresses on functional activity
- Glenohumeral Joint
~ Relatively Unstable Joint
> Small, Flat Glenoid v. Large,
Round Head
> Loose Capsule
> Allows for High Mobility
> Majority of Stability from Rotator
Cuff
How do you make the shoulder more stable?
- Make it move more functionally
- Only training IR and ER doesn’t result in a more stable shoulder
- Only training the scapula to stay still doesn’t result in a more stable shoulder
What type of muscle contraction is being used when the rotator cuff is stabilizing the shoulder?
Isometric
How can rotator cuff activity be characterized?
- Low resistance
- High reps
Labral Tears
- As with any shoulder repair follow physician protocols closely during early stages.
- Address obvious deficits.
- Train the Cuff for stabilization
- Avoid movements that will overly stress repair.
~ Remember shoulder kinematics. - Common with dislocations
Which way does the humerus translate during flexion, extension, abduction, IR, ER?
- Flexion: Posterior
- Extension: Anterior
- IR: Posterior
- ER: Anterior
- Abduction: Inferior
Muscles important at the elbow: Flexor/Pronator Group
- All originate at the medial epicondyle
~ Pronator Teres
~ Palmaris Longus
~ Flexor Carpi Radialis
~ Flexor Carpi Ulnaris
~ Flexor Digitorum Superficialis
~ Flexor Digitorum Profundus
What does the flexor/pronator group do?
- Flexes wrist and fingers.
- Pronates the forearm.
- Stabilizes the medial elbow.
If flexor/pronator group does not do its job what can result?
Sprain/rupture of UCL
How should the flexor/pronator group be rehabbed to enhance function?
- Move the UE in functional patterns.
~ Anytime you elevate the limb the
elbow groups work to stabilize
especially in overhead movements. - Work in a diverse way.
~ Concentrically, Eccentrically and
Isometrically/NM control activity. - Incorporate Integrated Isolation
Muscles Important at the elbow: Extensor/Supinator Group
- All originate at the lateral epicondyle
~ Extensor Carpi Radialis Longus
~ Extensor Carpi Radialis Brevis
~ Extensor Digitorum
~ Extensor Carpi Ulnaris
~ Supinator
What does the extensor/supinator group do?
- Extends wrist and fingers.
- Supinates the forearm.
- Stabilizes the lateral elbow
~ But less compared to the flexor/
pronator group
~ Resting position is always in valgus,
so it’s uncommon to injure the
lateral elbow
What makes the muscle groups of the elbow unhappy?
- Overuse
- Mechanical problems down the chain
- Same as the shoulder, efficient UE
movements utilize loading and
unloading of the LE
Transverse Plane Loading Patterns for Elbow
- Medial: Flexor/Pronator Group
~ Same side hip IR
~ Loads same side hip external
rotators and flexor/pronator group - Lateral: Extensor/Supinator
~ Opposite side hip IR
~ Loads opposite side hip external
rotators and external/supinator group
What would make the flexor/pronator group unhappy?
Bad same side LE (especially hip)
What would make the extensor/supinator group unhappy?
Bad opposite side LE (especially hip)
A bad same side LE may be a factor in which elbow conditions? (Medial epicondyle)
- Little leaguer’s elbow (apophysitis or fracture)
- Golfer’s elbow (medial epicondylitis)
- UCL sprain
A bad opposite side LE may be a factor in which elbow conditions? (Later epicondyle)
- Tennis Elbow (lateral epicondylitis)
~ extensor carpi radialis is most
commonly affected - Maybe: RCL sprain
Elbow ROM Concerns
- Elbow and finger ROM is especially difficult to obtain.
~ Especially Extension
> Normal resting position
> Ability to function in flexed
position
> Difficulty in passive range
> Pain = protected position
Fingers/Hand Rehab
- Rehab fingers like any other joint.
~ NMC
~ Mobility
> Swelling loves to stay in the
hands due to gravity
• Will commonly be at the
dorsal aspect due to a lack of
musculature
~ Function - Remember to ask the
fingers to do what they are designed
to do.
> Manipulate the envirnment
> Prehension
• Ability to apply force with
the hand to perform a task.
Types of Prehension (grips): Cylindrical
Used for a cylindrical object, such as for a hollow cylinder and coffee mug.
Types of Prehension (grips): Tip
Used to hold a small a sharp object, such as a nail or a piece of paper.
Types of Prehension (grips): Hook
Used for heavy objects
Types of Prehension (grips): Palmar
Used for a flat and relatively thick object
Types of Prehension (grips): Spherical
Used for a spherical object, such as a ball or an apple
Types of Prehension (grips): Lateral (key grip)
Used for a thin and flat object
Specific contributions to Grip Strength
- Thumb: 17%
- Index: 22%
- Middle: 31%
- Ringle and Little: 29%
