Osteology Shoulder Girdle

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Objectives Anatomy and Kinesiology Shoulder and Elbow Kim Kraft, PT, DPT, CHT St

tissue structures Understand how anatomy and kinesiology interrelate to create

characteristics of structure to clinical concepts and pathology 2 Outline

neurovascular bundle from neck to arm Crank-Shaped: Convex medially/concave

1 Objectives Anatomy and Kinesiology Shoulder and Elbow Kim Kraft, PT, DPT, CHT St Louis MO April 27-29, 2018 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 and pathology 2 Outline Shoulder and Elbow 1. Bones (osteology) 2. Joints (arthrology) 3. Joint motion (kinesiology) 4. Static stability (ligaments) Osteology Shoulder Girdle The Shoulder Girdle 1. Clavicle 2. Scapula 3. Humerus Bones: Clavicle 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 Right Retrieved on 03/08/13 from: Human_arm_bones_diagram.svg.png Gaunt & McCluskey 2012

Clavicle Popular Insertion Site Left Bones: Scapula Lies over ribs 2-7 Scapular Spine is the landmark for T4

Plane of the scapula Photo retrieved from: http://upload.wikimedia.org/wikipedia/commons/f/f0/gray201.

Subscapular Fossa Posterior Scapula Landmarks 1. Superior angle 2. Supraspinous fossa 3. Scapular notch 4.

Infraspinous fossa Gaunt & McCluskey 2012 Gaunt & McCluskey 2012 Bones: Humerus Landmarks Greater tubercle:

2 Clavicle Popular Insertion Site Left 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 Photo retrieved from: 7 Anterior Scapula Landmarks 1.Acromion 2.Coracoid Process 3.Subscapular Fossa Posterior Scapula Landmarks 1. Superior angle 2. Supraspinous fossa 3. Scapular notch 4. Scapular spine 5. Axillary border 6. Vertebral border 7. Infraspinous fossa Gaunt & McCluskey 2012 Gaunt & McCluskey 2012 Bones: Humerus Landmarks Greater tubercle: insertion for supraspinatus, infraspinatus, teres minor Lesser tubercle: insertion for subscapularis Surgical neck Anatomical neck Shaft epicondyles Right Clinical Application Proximal Humerus Fractures Gaunt & McCluskey 2012 Gaunt & McCluskey 2012

Bicipital Groove Palpation Side to Side Palpation Fingers proximal anterior humerus Rotate at forearm Joints Shoulder Girdle Karreigis Shoulder Girdle Joints Play along 1.

Sternoclavicular Joint (SC) Proximal clavicle and sternum Only articulation between the axial skeleton and the upper limb Movement: protraction, retraction, rotation, elevation

Acromioclavicular (AC) joint Diarthrodial joint with meniscus T A/P Glide of acromion with pro/retractionc Allows up to 20⁰ rotation of clavicle with arm elevation Stressed with

3 Bicipital Groove Palpation Side to Side Palpation Fingers proximal anterior humerus Rotate at forearm Joints Shoulder Girdle Karreigis Shoulder Girdle Joints Play along 1. Sternoclavicular 2. Acromioclavicular 3. 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 Diarthrodial joint with meniscus T A/P Glide of acromion with pro/retractionc 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

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,

Increase glenohumeral stability (Orients glenoid up 5 degrees) 2. Increases arm elevation ROM 3. Serves as muscle attachment 4. Absorbs forces from the arm 5.

4 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 5 ST Functions 1. Increase glenohumeral stability (Orients glenoid up 5 degrees) 2. Increases arm elevation ROM 3. Serves as muscle attachment 4. Absorbs forces from the arm 5. Maintains the subacromial space Glenohumeral Joint Includes: RC tendons Long head of biceps Sub-acromial sub-deltoid bursa Subscapularis bursa Subcoracoid bursa Coracohumeral ligament Key Feature Coracoacromial Arch Subacromial space between acromion, coracoacromial ligament, coracoid process and the superior humeral head Contents:subacromial bursa, 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 intraarticular pressure Dynamic Muscles Scapular Stabilizers (scapular dumping) Rotator Cuff Muscles?Long Head biceps Capsule and Ligaments Shoulder Girdle

Static Stabilizers Glenohumeral Joint 1. Labrum 2. Capsule 3. Sternoclavicular (SC) 4. Acromioclavicular (AC) 5. Coracoclavicular Conoid Trapezoid 6. Coracoacromial 7. Coracohumeral 8.

Hyaline cartilage lining is thinnest at the center where OA may develop 3.

elevation/posterior rotation All portions of the joint capsule are responsible for stabilizing the humerus in the glenoid fossa.

5 Static Stabilizers Glenohumeral Joint 1. Labrum 2. Capsule 3. Sternoclavicular (SC) 4. Acromioclavicular (AC) 5. Coracoclavicular Conoid Trapezoid 6. Coracoacromial 7. Coracohumeral 8. 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 Gaunt & McCluskey 2012 Capsule Blends with Labrum, Ligaments Sternoclavicular Ligaments Very stout, very stable Incorporate meniscus Allow bucket-handle motion of elevation/posterior rotation All portions of the joint capsule are responsible for stabilizing the humerus in the glenoid fossa. Warren & Hawkins Gaunt & McCluskey 2012 Sternoclavicular (SC) Joint Ligaments First Rib Articular Disc Interclavicular Ligament Costoclavicular Ligament Anterior Sternoclavicular Ligament Meniscus/Capsule can become painful or stiff Gaunt & McCluskey 2012 Acromioclavicular & Coracoclavicular Ligaments Conoid & Trapezoid Prevent inferior translation of the acromion on the distal clavicle Stabilizes horizontal adduction of the forearm

Acromioclavicular (AC) and Coracoclavicular Joint Trapezoid Acromioclavicular Conoid Ligament

Coracoacromial Ligament Gaunt & McCluskey 2012 Superior Glenohumeral Ligament (SGHL) GH-Ligaments Superior Limits

glide from partial abduction Inferior Glenohumeral Ligament (IGHL) Inferior Glenohumeral Ligament GH-Ligaments

6 Acromioclavicular (AC) and Coracoclavicular Joint Trapezoid Acromioclavicular Conoid Ligament LigamentsCoracoclavicular Ligaments Passive (Static) Restraints 3 Glenohumeral Ligaments Superior, Middle, Inferior Coracoacromial Ligament Gaunt & McCluskey 2012 Superior Glenohumeral Ligament (SGHL) GH-Ligaments Superior Limits inferior glide from anatomical position Middle Glenohumeral Ligament (MGHL) GH-Ligaments Middle Limits anterior glide from partial abduction Inferior Glenohumeral Ligament (IGHL) Inferior Glenohumeral Ligament GH-Ligaments Inferior; 3 Parts Anterior Band Axillary Pouch Posterior Band Acts as a sling to protect against anterior and inferior instability Gaunt & McCluskey 2012

Coracohumeral Ligament Ligaments of the Scapula Strongest supportive ligament

Gaunt & McCluskey 2012, Kraft Superior transverse ligament forms the suprascapular

supraspinatus & infraspinatus) Sternoclavicular (SC) Joint Arthrology & Kinesiology

Protraction/retraction Posterior rotation 1. Joints 2.

Joint Small amount of glide anterior/posterior Accommodates motions of the

7 Coracohumeral Ligament Ligaments of the Scapula Strongest supportive ligament Reinforces RC Interval Limits inferior GH Glide from Limits Extremes of GH ER Gaunt & McCluskey 2012, Kraft Superior transverse ligament forms the suprascapular foreamen by closing the scapular notch Passage way for the suprascapular nerve (to supraspinatus & infraspinatus) Sternoclavicular (SC) Joint Arthrology & Kinesiology Shoulder Girdle Described as effects on the distal clavicle Elevation/depression Protraction/retraction Posterior rotation 1. Joints 2. Muscle Force Couples SC Joint Motions Inferior glide + Posterior spin Acromioclavicular Joint Small amount of glide anterior/posterior Accommodates motions of the scapulothoracic joint Back to front Palpation right shoulder: 1. Right index finger on acromion 2. Left hand distal clavicle Instructions: Back to Front Palpation

Scapulothoracic Joint Plane of the Scapula Scaption = Elevation 30-45 anterior to the frontal plane because of the angle of the ribs True plane

Elevation=Plane of the scapula Functional Biomechanics Plane of the Scapula Elevation Shoulder abductors and rotators are at optimum

tubercle is at high point of coracoacromial arch Most comfortable for patients to gain Glenohumeral ROM and strength in this plane Three

Upwards rotation: Upper trapezius, middle trapezium, Serratus Anterior Downwards rotation: Rhomboids, Pectoralis minor Elevation: Levator

8 Scapulothoracic Joint Plane of the Scapula Scaption = Elevation 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 Shoulder Planes Flexion to the front Abduction to the side Elevation=Plane of the scapula Functional Biomechanics Plane 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 Higgins Scapulothoracic Motion Muscle Force Couples Upwards rotation: Upper trapezius, middle trapezium, Serratus Anterior Downwards rotation: Rhomboids, Pectoralis minor Elevation: Levator Scapula, Upper traps, Rhomboid Neumann 2010 Motion of the scapula is accompanied by simultaneous motion at the sternoclavicular (SC) joint and gliding at the acromioclavicular (AC) joint

Scapulohumeral Rhythm Phases of Motion Phase I : 0-60 (Setting) Phase II: 60-120 (Critical) Phase III: 120-180 (Final) Total: 60 degrees

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

Lower trapezius Action: Rotate scapula a upward Stabilize scapula Force Couple b c Muscles Shoulder Girdle Greene, 2005 Shoulder Complex Muscles

Major Scapulo-humeral Deltoid Biceps brachii Triceps brachii Rotator Cuff (SITS) Supraspinatus, Infraspinatus, Teres minor Subscapularis Action

9 Scapulohumeral Rhythm Phases of Motion Phase I : 0-60 (Setting) Phase II: (Critical) Phase III: (Final) Total: 60 degrees scapulothoracic 120 degrees glenohumeral Neumann, Arthrokinematics Shoulder 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 a upward Stabilize scapula Force Couple b c Muscles Shoulder Girdle Greene, 2005 Shoulder Complex Muscles Serratus Anterior Axio-Scapular Trapezius Rhomboids Levator Scapula Serratus anterior Pectoralis minor Axio - humeral Latissimus dorsi Pectoralis Major Scapulo-humeral Deltoid Biceps brachii Triceps brachii Rotator Cuff (SITS) Supraspinatus, Infraspinatus, Teres minor Subscapularis 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) 54

Serratus Anterior Strengthening Interventions 1. Dynamic Hug 2. Protraction 3.

(LT) Higgins 56 Middle Trapezius and Lower Trapezius Scapular Adduction, Depression Middle: Origin spinous process

Middle/Lower Trapezius Strengthening Interventions 1. Prone T 2. Prone Y 3.

C4 Levator scapula Innervations: Dorsal scapular nerve (C4 & C5) Rhomboids Neumann 2010 Upper Trapezius Side bending

10 Serratus Anterior Strengthening Interventions 1. Dynamic Hug 2. Protraction 3. Plus MT LT Scapular Adductors Axioscapular muscle Rhomboids Trapezius Upper fibers (UT) Middle fibers (MT) Lower fibers (LT) Higgins 56 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) Middle/Lower Trapezius Strengthening Interventions 1. Prone T 2. Prone Y 3. Scapular adduction Higgins Scapula Elevators Axioscapular muscles Upper trapezius Innervation: Accessory nerve, & C 2- C4 Levator scapula Innervations: Dorsal scapular nerve (C4 & C5) Rhomboids Neumann 2010 Upper Trapezius Side bending 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

Levator Scapula Scapular elevation and downward rotation Cervical spine side bending and rotation

Scapular Depressors Gravity Weight carried by arm Lower trapezius Latissimus dorsi Pectoralis minor

adduction, and extension. Scapular depression.

Clavicular: lowers the raised arm Innervation: Lateral pectoral nerve, medial pectoral nerve (C5, C6,

Levator Scapulae Rhomboid Major/Minor Axioscapular muscles Scapular adduction, elevation, downward

11 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) Scapular Depressors Gravity Weight carried by arm Lower trapezius Latissimus dorsi Pectoralis minor Neumann 2010 Latissimus Dorsi Strengthening Interventions Prone I Medial/internal rotation, adduction, and extension. Scapular depression. IR EXT DEPRESSION Pectoralis Major Sternal: rotates scapula & draws inferior angle laterally forward Clavicular: lowers the raised arm Innervation: Lateral pectoral nerve, medial pectoral nerve (C5, C6, C7, C8 & T1) 63 Force Couple Scapular Downward Rotation Gravity Rhomboids (against resistance) Levator Scapulae Rhomboid Major/Minor Axioscapular muscles Scapular adduction, elevation, downward rotation and stabilization Innervation: Dorsal scapular nerve Retrieved on 06/07/09 from: openphysio.co.za/images/ thumb/5/5d/levator_scapulae.jpg/150px Levatorscapulae.jpg 66

Force Couple Retraction Axioscapular Muscles Middle trapezius Rhomboids Lower trapezius Four Muscles of

http://handsport.us/patient education/shoulder anatomy/ Rotator Cuff Muscles S.

Provides a compressive force between humeral head and glenoid fossa Supraspinatus Infraspinatus Teres

Function: Initiates & assists deltoid in ABD Nerve: Suprascapular N Blood supply: Suprascapular artery

supports head of humerus in glenoid Nerve: Suprascapular nerve Blood supply : Suprascapular and

12 Force Couple Retraction Axioscapular Muscles Middle trapezius Rhomboids Lower trapezius Four Muscles of the Rotator Cuff Supraspinatus, Infraspinatus, Teres Minor, Subscapularis (SITS) Neumann 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 & assists 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

external rotation and assist with horizontal Abduction Anterior deltoid: Initiates flexion and provides

of the humeral head Elevation Force Couple Early in abduction the deltoid pulls superiorly (upward shear force)

As the arm is abducted to 90, the direction of pull of the deltoid becomes similar to the pull of the

13 Subscapularis Origin: Subscapular fossa to lesser tuberosty Function: IR and Adduction Nerve: Upper and lower subscapular nerves Blood supply: subscapular artery Deltoid scapulohumeral 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 Elevation Force Couple 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. Internal Rotation Strengthening Interventions Can vary elevation 1. Isometric 2. Theraband IR 3. Dumb bell 4. Cable column Higgins Teres Major Origin: Inferior angle of scapula Insertion: Crest of lesser tuberosity humerus Function: IR, Adduction. extension Nerve: Thoracodorsal nerve 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.

Theraband Force Couple Internal Rotation IR: subscapularis, anterior

Higgins Neumann 2010 Force Couple Glenohumeral Forward Flexion Anterior

Coracobrachialis Flexes and adducts the shoulder Innervation:

Muscles Anterior Side to Side Palpation Anterior & Middle Deltoid

14 External Rotation Strengthening Can vary elevation 1. Isometric 2. Side lying or prone dumb bell 3. Theraband Force Couple Internal Rotation IR: subscapularis, anterior deltoid, pect major, latissimus dorsi & teres major IR larger mass than ER Higgins Neumann 2010 Force Couple Glenohumeral Forward Flexion Anterior deltoid, Coracobrachialis Long head biceps (weak) Lateral view Coracobrachialis Flexes and adducts the shoulder Innervation: Musculocutaneous (C6,C7) Neumann 2010 Creative COmmons Scapulohumeral Muscles Anterior Side to Side Palpation Anterior & Middle Deltoid Subscapularis Coracobrachialis Scapulohumeral Muscles Posterior Side 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

radial ulnar 3x3x3 3 Ligaments Medial collateral Lateral collateral Annular Bony Alignment Carrying Angle Females 13⁰ -16⁰ Males 11⁰ -14⁰ Due to trochlea, functional for carrying and eating

15 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 86 Bones of the Elbow Humerus, Ulna, Radial Head Distal Humerus Proximal Ulna Radial Head Elbow Anatomy 3 Bones Distal humerus Proximal ulna Radial head 3 Joints Radiocapitellar Ulnohumeral Proximal radial ulnar 3x3x3 3 Ligaments Medial collateral Lateral collateral Annular Bony Alignment Carrying Angle Females 13⁰ -16⁰ Males 11⁰ -14⁰ Due to trochlea, functional for carrying and eating Epicondyles and Olecranon Form an equilateral triangle in 90 degrees elbow flexion Form a straight line in extension Most mechanically stable for intact joint: Humeroulnar: full extension Radioulnar: 5 degrees supination

Elbow Motion Humeroulnar joint has 1 degree of freedom: flexion 150⁰ /extension 0⁰ Radioulnar joints have 1 degree of freedom:

Functional ROM Activity Elbow Flexion Pronation Combing Hair 119 136 89 100 Perineal Care 35 55 12 20 Washing 100 110 25 30

Humerus Radius Radial Tuberosity Which side is this?

flexion Shaft widens for medial and lateral support pillars Aids in maintenance of strength Rotates around ulna Becomes

stabilizer to both varus and valgus forces if the MCL and LCL are intact If MCL or LCL is deficient, then radial head becomes

16 Elbow Motion Humeroulnar joint has 1 degree of freedom: flexion 150⁰ /extension 0⁰ Radioulnar joints have 1 degree of freedom: supination 90⁰ /pronation 80⁰ Elbow flexion normal is 145 (limited by biceps bulk) Function favors flexion/pronation Reported Functional ROM Activity Elbow Flexion Pronation Combing Hair Perineal Care Washing contralateral axilla Feeding self Mangermans et al 2005, Aizawa et al 2010, van Andel 2008 Bony Anatomy Distal Humerus Radius Radial Tuberosity 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 Rotates around ulna Becomes "shorter" In pronation Supinator Insertion Pronator Quadratus Insertion Brachioradialis 94 Insertion 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 Bony Anatomy Ulna Trochlear notch is anterior to shaft and directed anterosuperiorly Axis anterior to shaft Arc of notch less than 180 degrees Radial head is cylindrical and concave proximally

ULNA Brachialis insertion Coronoid Process Radial Notch Proximal Ulna Pronator Quadratus Origin Supinator origin Photo retrieved from: http://upload.

png The major determinant of elbow stability Ulno-humeral integrity is key to stability ~30% of articular surface must be intact Coronoid is key to

JPG 97 Coronoid ~50% of coronoid must be present for the elbow to function Deficient coronoid will result in posterior instability Stabilizers of the

) 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

Dynamic stability is also provided by the actions of the muscles crossing the joint.

17 ULNA Brachialis insertion Coronoid Process Radial Notch Proximal Ulna Pronator Quadratus Origin Supinator origin Photo retrieved from: commons/thumb/4/47/gray214.png /250px Gray214.png 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 Retrieved from: bgbg.jpg/800px Slide1bgbg.JPG 97 Coronoid ~50% of coronoid must be present for the elbow to function Deficient coronoid will result in posterior instability Stabilizers of the Elbow 100 Elbow Stability A complex interaction among the bones and ligaments to resist physiologic stress applied to the elbow (more tomorrow.) 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. 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 Rehab of the Hand, 6 th ed Creative commons

Elbow Capsule Anterior capsule is taut in extension; posterior capsule taut in extension Medial/Lateral

of comfort ) Intraarticular insults cause capsular fibrosis (flexion contracture) Annular Ligament Attaches

head to spin Resists distraction of radius Ulnar (Medial) Collateral Ligament (MCL) Includes: anterior

annular ligament Annular ligament Encircles the radial head attaching at the radial notch posterior &

Provides stability to posterolateral rotation Accessory lateral collateral ligament Connects inferior

com/posterolateralrotatoryinstabilityelbow.

Radial: blends with Annular ligament Ulnar: taut in flexion and extension Accessory Radial Collateral

18 Elbow Capsule Anterior capsule is taut in extension; posterior capsule taut in extension Medial/Lateral sides blend with collateral ligaments Most lax at degrees of flexion (allows the most edema, position of comfort ) Intraarticular insults cause capsular fibrosis (flexion contracture) 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. Radial (Lateral) Collateral Ligament Complex 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 Radius Ulna 3/3/14 Retrieved from: Lateral (Radial) Collateral Ligament Taut in supination 4 portions: AL: associated with PRUJ, supinator Radial: blends with Annular ligament Ulnar: taut in flexion and extension Accessory Radial Collateral Annular Lateral Ulnar Collateral LATERAL COLLATERAL LIGAMENT LUCL 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.

Pronator Teres Elbow Muscles Origin: medial epicondyle and coronoid process Insertion: middle of lateral surface of radius Action: Pronates and flexes

Long head: supraglenoid tubercle of scapula Insertion: Tuberosity of radius and fascia of forearm via bicipital aponeurosis(lacertus fibrosus) Action: Supinates

humerus Insertion: Lateral surface of olecranon and superior part of posterior surface of ulna Action: Assists triceps in extending forearm; stabilizes elbow joint;

Brachialis Origin: Distal half of anterior surface of humerus Insertion: Coronoid process and tuberosity of ulna Action: Major flexor of forearm -- flexes forearm in

epicondyle of humerus, radial collateral and annular ligaments, supinator fossa and crest of ulna Insertion: Lateral, posterior and anterior surfaces of proximal 1/3

19 Pronator Teres Elbow Muscles 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 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 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 Brachialis Origin: Distal half of anterior surface of humerus Insertion: 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 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

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

20 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 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 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): 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 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, 6 th 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 Lahr Ithaca College Department of Physical Therapy Human Anatomy Review Site & Suny Downstate University Medical Center

Elbow Elbow Anatomy. Flexion extension. Pronation Supination. Anatomy. Anatomy. Romina Astifidis, MS., PT., CHT

Elbow Elbow Anatomy. Flexion extension. Pronation Supination. Anatomy. Anatomy. Romina Astifidis, MS., PT., CHT Elbow Elbow Anatomy Romina Astifidis, MS., PT., CHT Curtis National Hand Center Baltimore, MD October 6-8, 2017 Link between the arm and forearm to position the hand in space Not just a hinge Elbow = 70%