Chapter 9-Shulder

Clinical Application 9-1

Postural Influences
With rounding of the shoulders, the scapula is pulled into a protracted position (see ​Fig. 5-17​).
This places the rhomboids and middle trapezius (scapular retractors) in a chronically
stretched position, and as dictated by the length-tension relationship, these muscles
become ​weak and overstretched.​ The pectoralis minor, however, is placed on slack as the
coracoid moves anteriorly toward the ribs, and over time it adaptively shortens (adopts a
shorter resting length).

Points to Remember
•​ The shoulder girdle has both linear and angular motions.
•​ The inferior angle is the point of reference for scapular rotation.
•​ Certain shoulder girdle and shoulder joint motions are connected.
•​ Scapulohumeral rhythm is shoulder girdle and shoulder combined motions of the joints.
•​ In the shoulder girdle there are force couples for both upward and downward rotation where
muscles pulling in different directions help to accomplish the same motion.
•​ Concentric and eccentric are accelerating and decelerating activities. With isometric activity
there is no joint motion.
•​ Kinetic chain movement depends on whether the distal segment is fixed (closed) or free to
move (open).
Chapter 10-Shoulder Joint
Clinical Application 10-1
Linking Osteokinematics & Arthrokinematics
Arthrokinematic motion coupled with osteokinematic motion creates normal joint motion. When
pathology such as capsular tightness interferes with joint motion, use of arthrokinematic
motion can assist in restoring that motion by stretching the joint capsule. Take adhesive
capsulitis as an example. With adhesive capsulitis, the following capsular pattern of range of
motion loss may be seen: Severe loss of lateral rotation, moderate loss of abduction, and
slight loss of medial rotation. Use of arthrokinematic motions (in the form of joint
mobilizations) are often used to restore range of motion. For example, gliding the head of the
humerus in the direction of restriction to stretch a particular part of the capsule, or by
performing a long axis distraction where the head of the humerus is gently pulled away from
the glenoid fossa, produces an effective stretch to the joint capsule as a whole. Specific
application of these arthrokinematic motions in the use of joint mobilization is beyond the
scope of this book.

Reverse Muscle Action During Crutch Walking

As described in ​Chapter 9​, the pectoralis minor and lower trapezius can elevate the pelvis when
the arms are stabilized (see ​Fig. 9-27​). This action occurs during crutch walking, when the
arms are stabilized on the crutch handles. The pectoralis major and latissimus dorsi (see
 figure below) perform much like the pectoralis minor and lower trapezius in elevating the rib
cage, sternum, and pelvis and allowing the body to swing through the crutches. This
closed-chain activity is a good example of “reverse muscle action,” where the origin moves
toward the insertion instead of the more common insertion moving toward the origin.

Common Shoulder Pathologies

● humeral neck fracture​ is another injury caused by a fall on the outstretched hand. It is
common in the elderly and usually results in an impacted fracture.
● Midhumeral fractures​ are often caused by a direct blow or a twisting force. Spiral
fractures in this region increase the risk of a ​radial nerve injury,​ as the nerve passes
next to the bone in the spiral groove.
● Pathological fractures​ of the humerus may be caused by benign tumors or metastatic
carcinoma from primary sites such as the lung, breast, kidney, and prostate.
● anterior shoulder dislocations.​ most common joint dislocations
A forced shoulder abduction and lateral rotation tends to be the dislocating motion
causing the humeral head to slide anteriorly out of the glenoid fossa.
● Glenohumeral subluxation​ is commonly seen in individuals who have hemiplegia,
usually from a cerebrovascular accident (stroke). Paralysis of the shoulder muscles
leaves them no longer able to hold the head of the humerus in the glenoid fossa. This
paralysis, combined with the pull of gravity and the weight of the arm, over time causes
this partial dislocation.
● Impingement syndrome​ is an overuse condition that involves compression between the
acromial arch, the humeral head, and soft tissue structures. A type of impingement
known as ​swimmer’s shoulder​ is common with swimmers specializing in freestyle,
butterfly, and backstroke.
● Adhesive capsulitis​ refers to the inflammation and fibrosis of the shoulder joint capsule,
which leads to pain and loss of shoulder range of motion. It is also known as ​frozen
shoulder.​
● torn rotator cuff​ involves the distal tendinous insertion of the supraspinatus,
infraspinatus, teres minor, and subscapularis on the greater/lesser tubercle area of the
humerus. Tears can be the result of acute trauma or gradual degeneration.
● ​labral tear​ involves damage to the glenoid labrum. It can have a degenerative or
traumatic etiology and results in pain and limited motion in the shoulder joint.
Chronic inflammation of the supraspinatus tendon can lead to an accumulation of mineral
deposits and can result in
 ● calcific tendonitis,​ Chronic inflammation of the supraspinatus tendon can lead to an
accumulation of mineral deposits, may be asymptomatic or quite painful.
● Bicipital tendonitis​ usually involves the long head of the biceps proximally as it
crosses the humeral head, changes direction, and descends into the bicipital groove. A
rupture of the biceps long head tendon commonly occurs during repetitive or forceful
overhead positions. Irritation as it slides in the groove can lead to ​subluxation of the
biceps tendon​ (long head). Overloading the muscle in an abducted and laterally
rotated position tends to be the force subluxation the tendon out of the bicipital
groove.
Clinical Application 10-3
Postural Influence on Latissimus Dorsi

With a slouched posture, the latissimus dorsi can become adaptively shortened. Two things happen at
the glenohumeral joint when you slouch: (1) The humerus medially rotates slightly, and (2) the trunk
flexes. These positional changes move the origin and insertion of the latissimus dorsi closer together,
placing the muscle on slack. Over time this muscle will adaptively shorten, leading to muscle tightness
and limited shoulder flexion. Passively moving the shoulder into flexion stretches the latissimus dorsi,
which can help restore normal upper body posture. Before the stretch is performed, the thoracolumbar
fascia (part of the muscle origin) must be stabilized so it does not move upward during the stretch. This
can be achieved by lying supine with the knees flexed and feet flat on the floor.

Points to Remember
• The shoulder is a triaxial ball-and-socket joint.
• Scaption is a specific type of glenohumeral joint elevation that happens in the plane of the scapula (30
degrees anterior to the frontal plane).

• The glenohumeral joint demonstrates convex on concave joint surface motion where the head of the
humerus moves in the opposite direction from the distal end of the humerus.
• The rotator cuff and deltoid muscles form a force couple that allows them to pull in different
directions to achieve the same motion.
• In addition to their individual motions, the rotator cuff muscles work collectively to stabilize the head
of the humerus by holding it against the glenoid fossa.

• Most shoulders dislocate in an anterior direction.

Chapter 11-Elbow Joint

Clinical Application 11-1
Elbow Flexion Strength Testing
The forearm is placed in different positions when testing strength generated by the various elbow
flexors. Due to their insertions on the radius, the biceps and brachioradialis can move both
the elbow and the forearm and must be allowed to perform actions at both joints
simultaneously. Before testing elbow flexion, the forearm is positioned according to the
supination/pronation action of that muscle. When testing biceps strength, the forearm is
placed in supination, and when testing brachioradialis strength, the forearm is placed in a
neutral position (midposition). These positions allow the muscles to direct their strength
toward elbow flexion rather than rotating the forearm while also allowing the radial insertion
points to “face” their respective origins, giving the muscles a straight line of pull for elbow
flexion. Testing brachialis strength is performed with the forearm in the pronated position,
not because it favors this position, but because the pronated position of the forearm puts the
other two flexors (biceps and brachioradialis) at a disadvantage, thus isolating the effect of
the brachialis to the greatest extent possible.

Clinical Application 11-2

Mechanics of Pushing and Pulling
Shoulder flexors and extensors work synergistically with the biceps and triceps to exert great
force at the elbow during pushing and pulling activities. The shoulder muscles (see ​Table
10-1​) are one-joint muscles acting only on the shoulder. The biceps and triceps, being
two-joint muscles, can exert force at both joints. They are assistive at the shoulder and very
strong at the elbow. As with all multijoint muscles, they simultaneously ​lengthen​ over one
joint (shoulder) while ​shortening​ over the other (elbow) to maintain an optimal
length-tension relationship and exert a constant contractile force throughout the activity. So,
while the shoulder muscles are strongest at moving the shoulder joint, the biceps and triceps
are strongest at moving the elbow. The figure below shows each person’s starting position
for the activity. The person on the left is preparing to push. The shoulder flexors and elbow
extensors are lengthened, preparing to contract (shorten). The person on the right is in the
opposite position, preparing to pull. As each person moves through the motion, the shoulder
muscles are performing their respective action while the biceps and triceps are able to exert a
strong elbow contraction (shortening) by simultaneously being lengthened over the shoulder.
In summary, the biceps and triceps are able to exert a strong force at the elbow because the
shoulder muscles are exerting a strong force at the shoulder. The respective motion at the
shoulders lengthens the biceps and triceps.
Points to Remember
•​ Synovial joint shapes can be irregular (plane), hinge, pivot, condyloid, saddle, or
ball-and-socket.
•​ Synovial joints can have zero to three axes.
•​ When a muscle has contracted (shortened) over all of its joints as far as it can, it has become
actively insufficient.
•​ When a muscle has elongated (stretched) over all of its joints as far as possible, it has become
passively insufficient.
•​ An activity can be an open- or closed-kinetic-chain movement, depending on whether the distal
segment is fixed.
•​ The concave-convex rule has the convex joint surface moving in a direction opposite to the
movement of the body segment and the concave joint surfacing moving in the same direction
as the body segment.
Chapter 12-wrist Joint
Clinical Application 12-1
Dual Role of Wrist Muscles
Most wrist muscles have more than one action and therefore are not capable of creating motion
in a cardinal plane when they contract alone. For example, the flexor carpi radialis will
always pull the wrist obliquely into a combined flexion and radial deviation motion, and
cannot, by itself, perform a cardinal plane motion of either flexion or radial deviation (see
figure below). When cardinal plane motions are desired, the wrist muscles act as neutralizers
to one another and agonists with each other. For example, when flexion is desired, the flexor
carpi ulnaris needs to contract along with the flexor carpi radialis. The radial and ulnar
deviation actions of these muscles cancel one another out (neutralize), and the muscles work
as agonists to create the desired motion of flexion. Similarly, if a pure ulnar deviation motion
is needed, the extensor carpi ulnaris will contract at the same time as the flexor carpi ulnaris.
The flexion and extension components of these concurrent forces will cancel one another
out, and the resultant force will move the wrist into ulnar deviation.

Dual role of wrist muscles. For motion to occur in a cardinal plane (blue lines), muscle actions (red lines)
must have their unwanted motions neutralized.

Clinical Application 12-2

Joint positioning for Stretching the Wrist Flexors and Extensors
The wrist flexors and extensors are two joint muscles that cross both the wrist and elbow. The
wrist flexors all cross anterior to the axis of rotation for the elbow so when they contract
(shorten), the elbow and wrist both move into flexion. To stretch (lengthen) these muscles,
the elbow and wrist joints must be moved into extension (opposite of the contracting action).
The wrist extensors have a slightly more complex arrangement in that the extensor carpi
radialis longus and brevis produce elbow flexion and wrist extension, whereas the extensor
carpi ulnaris creates wrist and elbow extension when it contracts (shortens). To stretch the
extensor carpi radialis longus, the elbow is placed in extension while the wrist is moved into
 a flexed position. To stretch the extensor carpi ulnaris, the elbow and wrist are both placed in
flexion.

Clinical Application 12-3

Lever Systems at the Wrist
The wrist muscles are set up as a third-class lever system with a very short force arm running
from the wrist joint axis to the point where the wrist muscles attach and a resistance arm
running to the center of gravity of the hand (​Fig. A​). With a longer resistance arm and
shorter force arm, these muscles are suited to produce large amounts of speed and/or range of
motion in response to a small shortening of the muscle, but as a trade-off, the muscle
will need to produce a relatively large amount of force to create this movement. When
holding an object flat in one’s hand, such as passing a heavy platter across the dinner table,
the center of gravity moves distally due to the weight of the platter (​Fig. B​). This increase in
the resistance arm requires the wrist muscles to produce even more force to maintain the
 wrist in a neutral position.

Levers. ​(A)​ When FA is less than RA, great force in needed to create movement. ​(B)​ When RA is
increased, even greater force is needed (to hold platter).

Points to Remember
•​ An isometric contraction has relatively no joint motion.
•​ The muscle attachments move closer together with a concentric contraction.
•​ An eccentric contraction is a deceleration activity.
•​ A mnemonic to help remember the order of the wrist bones:
“​S​ally ​L​ikes ​T​o ​P​ush ​T​he ​T​oy ​C​ar ​H​ard”
= ​s​caphoid, ​l​unate, ​t​riquetrum, ​p​isiform, ​t​rapezium, ​t​rapezoid, ​c​apitate, and ​h​amate.
•​ When using a longer resistance arm, more force is needed. Conversely, when using a shorter
resistance arm, less force is needed.
•​ Working against gravity requires more work than working with gravity or with gravity
eliminated.
Chapter 13-hand
Clinical Application 13-1
Functional Position of the Hand
There is a biomechanical reason why slight wrist hyperextension is part of the functional position
for the hand. When the wrist extensors hold the wrist in hyperextension, this allows the long
finger flexors to be lengthened over the anterior wrist as they contract (shorten) over the
finger joints. This creates an optimal length-tension relationship (contractility potential), and
grip strength is maximized.
When wrist immobilization is necessary, a cock-up splint is often used. (See figure below).
There are many variations of this type of splint available. What they have in common is that
the wrist is maintained in slight hyperextension while the fingers and thumb are able to
move. This “functional position” allows for optimal finger function (grip strength), even
though the wrist is not moving.

Cock-up wrist splint.

Clinical Application 13-2

Adaptation of Ignition Key with Impaired Lateral Prehension
Certain inflammatory or degenerative conditions, such as rheumatoid or osteoarthritis at the
CMC joint, can limit or prevent lateral prehension. Because this motion is required to turn
the key in an automobile ignition or door lock, an individual with this impairment may have
difficulty with or be unable to complete this task. By placing a fitted block or cylinder over
the key to expand its diameter and/or extend its lever arm, an individual can instead use a
cylindrical grip, or even a cylindrical grip variation to grasp the block, then use wrist flexion
and/or forearm supination to turn the key.
Points to Remember
•​ Isometric contractions are used to stabilize or hold a body part in position.
•​ Cylindrical, spherical, and hook grips are used for power hand movements.
•​ Pad-to-pad, pinch, tripod grasp, tip-to-tip, pad-to-side, side-to-side, and lumbrical grips are
used for precision hand movements.
•​ A convex joint surface glides in the opposite direction of the body segment’s movement.
•​ A concave joint surface glides in the same direction as the body segment’s movement.
•​ In anatomical position, the sagittal plane divides the body into right and left parts. The frontal
plane divides the body into front and back parts. The transverse plane divides the body into top
and bottom parts.