Deltoid
Anterior Division: Anterior border and superior surface of the lateral third of clavicle |
Middle Division: Superior surface of the acromion |
Posterior: Lower Edge of the crest of the scapular spine |
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Insertion: Deltoid Tubercle @ Midshaft of humerus |
Nerve: Axillary Nerve (C5-6) |
Movement: All fibres vertical abduct the arm, medial rotation and flexion (agonist of pec maj - anterior division), lateral rotation and extension (agnoist of lats + teres major- posterior) |
- Antagonist to Lats
- Suspectable to tears, fatty atrophy + enthesopathy (acromial = seronegative spondy)
- Prevents posterior dislocation of the humeral head when a person carries heavy loads
Trigger Points of Anterior
Trigger Points of Posterior
Supraspinatous
Origin: Medial 2/3 of the supraspinatous Fossa |
Insertion: Superior facet of the Greater Tubercle of the Humerus |
Nerve Supply: Suprascapular Nerve (C5-C6) |
Action: Abducts and stabilises Humeral Head |
- Prevents head of the humerus slipping inferiorly
- Tears (high- riding humeral head + acromiohumeral distance <7mm)
Supraspinatous - Palpation
Infraspinatous
Origin: Medial 2/3 of the Infraspinatous fossa |
Insertion: Middle Facet of the Greater Tubercle of the Humerus |
Nerve: Suprascapular Nerve C5-C6 |
Action: Lateral rotation + stabilisation of the Humerus |
- Synergists (working together) are teres minor + deltoid
Infraspinatus - Palpation
Belly Trps
Patient complains of a deep shoulder ache - can be mistaken for GH joint problems
Teres Minor
Origin: Upper 2/3 of the dorsal surface of the scapula |
Insertion: Lower facet of greater Tuberosity of Humerus |
Nerve: Axillary Nerve (C5-6) |
Action: Lateral rotation, Weak adduction + stabilisation of the Humerus |
- Prevents humeral head from sliding upwards as arm is abducted
- Atrophy of this muscle can be caused by rotator cuff tears
Teres Major
Origin: Oval Area on the Dorsal Surface of the inferior scapular angle |
Insertion:Medial Lip of the intertubercular sulcus |
Nerve: Lower Subscapular Nerve (C5-C7) |
Action: Extension and medial rotation of the humerus |
- Injuries of this muscle are rare - usually in professional and high level athletes (baseball pitchers)
- Assists the Lats in moving a raised humerus downwards and backwards
Teres Major Trp
- Hyperabduction may be restricted
Subscapularis
Origin: Medial 2/3 of the Subscapular Fossa |
Insertion: Lesser Tubercle of the Humurus |
Nerve: Upper and Lower Subscapular Nerves C5-C6 |
Action: Medial rotation of the humerus and stabilisation of the GH Joint |
- Prevents displacement of the head of the humerus
Subscapularis Trps
- Uncomfortable and unpleasant feeling in shoulder, hard to localise. Cannot get comfortable.
Subscapularis - Palpation
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Serratus Anterior
Origin: Fleshy digitations from the outer surfaces of upper 8-9 ribs - lower 4 external oblique) |
Insertion: Costal surface of the inferior angle of the scapula |
Nerve: Long thoracic nerve of Bell (C5-C7) |
Action: Works with Pec minor to protract the scapula in pushing movemments, upper fibres suspend scapular, lower fibres works with the traps to pull the inferior angle forward (upward rotation) |
- Antagonist - Rhomboid Major + Minor, Traps
- Serrare = to saw
- Nerve of Bell suspectable to certain surgeries (lymph node clearance from the axilla)
SA Trp
- Activated by prolonged/vigorous running, push-ups , overhead lifting or severe cough
Lats
Origin: Lower six tx vertebrae, thoracolumbar fascia, posterior part of iliac crest, lower 3 or 4 ribs, inferior angle of scapula
Insertion: Floor of intertubercular groove of the humurus
Nerve: Thoracodorsal Nerve (C6-C8)
Action: Adduction, Extension and Medial Rotation of the humurus - deep inspiration + forced expiration
Lats Trp
- Infrascapular pain usually not aggravated by movements
- Bra straps can activate Trps
- Associated with SIJ Dysfunction, chronic shoulder and back pain, GH problems
- PseudoTOS - (Lats, Teres major, Pecs major, Subscapularis)
- Used for breast reconstruction + Cardiac surgery (cardiomyoplasty)
Pec Major
Origin:
Clavicular Anterior surface of medial half of the clavicle
Sternal: Anterior surface of sternum, 6th-7th costal cartilage, 6th rib, aponeurosis of external oblique |
Insertion: Lateral lip of the unterrubercular sulcus of the humurus |
Nerves:
Clavicular: C5-6
Sternal: C6-T1 |
Action: Adducts and medially rotation of the humerus |
- Antagonist = Deltoid
- Pectus = breast
- Trained by: barbell bench press, dumbbell bench press, machine bench
- Injured by powerlifting (US and MRI)
- Women less suspectable to pec injuries (more muscle elasticity, larger tendon to muscle diameter)
- Affected arm mobilised for 6-8weeks, then 2 months after surgery, rehab is introduced
- Return to sport usually at 6 months
Pec Minor
Origin: Upper margins and outer surfaces of 3-5th Ribs, near their cartilages + Fascia of external intercostals |
Insertion: Coracoid process of the scapula (Upper surface) |
Nerve: Medial and Lateral Pectoral Nerve (C5-T1) |
Action: Draws scapula forward with Serratus Anterior - Works with LS and Rhomboids to rotate the scapular |
Pec Minor Trp
- Mimics Cx radiculopathy - tight fibres can press on brachial plexus/axillary artery
- Mimics Cardiac ischaemia
Subclavius
Origin: First rib + costal cartilage |
Insertion: Middle third of the clavicle |
Nerve: Subclavian Branch of the Brachial Plexus (C5-C6) |
Action: Pulls point of shoulder down and forward - protects subclavian vessels when clavicle f# |
Subclavian Trps
- Mimics C6 radiculopathy
- Can cause Vascular TOS - When shortens, draws clavicle towards Subclavian artery + vein
Upper Traps
Origin: EOP, Superior nuchal lines, Supraspinous ligament, Spinous process C7-T12 |
Insertion: Lateral third of clavicle (superior), Medial acromial margin and superior lip of the crest of the scapular spine (medial), aponeurosis, medial end of the scapula spine |
Nerve: Spinal part of the accessory nerve, sensory branches from ventral rami C3-C4 |
Action: Ipsilateral lateral flexion of the head, Contralateral rotation of the head, Bilaterally extends the head, Bilaterally shrugs the shoulders |
- Antagonist = serratus Anterior, Lats, Pec Major
- Trained by: Elevation of shoulder - hang clean, shoulder shrug
- Traps Palsy - damage of spinal accessory nerve - difficulty with adduction and abduction of the arm , drooping shoulder and shoulder and neck pain
- Traps commonly affected in facioscapulohumeral muscular dystrophy (FSHD) - upper fibres spared until later
Upper Traps Trp
- Tight bra straps + heavy coats can activate these trps
- Gothic Shoulders (raised shoulders)
- Trps can overlap - SCM, Suboccipital, Temporalis
Middle and Lower Traps
Middle: T1-T5 Sps |
Lower: T6-T12 Sps |
Nerve: Spinal part of the accessory nerve, sensory branches from ventral rami C3-C4 |
Action: Scapular retraction and stabilisation |
- Trained by pulling shoulder blades together (middle)
- Trained by drawing shoulder blads downwards (Lower)
Mid + Lower traps - Palpation
Mid + Lower Traps Trp
- Trps in the Middle Traps can cause Trps in the Upper
- Middle traps are disinhibited when pec major is hypertonic (Antagonistic)
Dysfunctional Shoulder
Glenohumeral hypomobility with inhibition of the lower scapular stabilisers, stiff thoracic spine and possible fear avoidance behaviour |
Management: Spencer technique with humeral head kinematic release and subscapularis kinematic release if required
Facilitated stretching of hypertonic muscles involved in upper crossed posture / trigger point / kinetic release of overactive muscles +/- strengthening exercises of inhibited muscles
Brugger microbreak, thoracic adjustment, mobilisation, wall angel exercise etc for the thoracic stiffness
BQ for assessment of any psychosocial issues plus cognitive behavioural therapy, motivational interviewing and active listening |
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Scapular dyskinesis with reduced external rotation of the shoulder |
Management: Scapular dyskinesis managed by facilitated stretching of hypertonic muscles involved in upper crossed posture/ trigger point / kinetic release of overactive muscles followed by strengthening exercises of inhibited muscles
Scapulothoracic mobilisation with active arm movements may improve scapular tracking
Facilitated stretching of external rotators of the glenohumeral joint |
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Glenohumeral hypomobility, tight subscapularis with trigger point and referral pain from cervical manipulable lesions |
Management: Spencer technique with humeral head kinematic release and subscapularis kinematic release if required
Trigger point therapy to subscapularis
manipulable lesions may be treated with adjustment, mobilisation or facilitated stretching of the cervical spine (PIR) |
Core Treatment: Spencer technique
Scapular stabilsation with movement mobilisation
Subscapularis kinetic release
Humeral head kinetic release |
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