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Student ID: 1055468 Student Number 1055468 Name of lecturer Jim Odell Assignment Title “Evaluate the structure and function of the shoulder girdle with particular attention to essential movements that occur in lateral flexion of the arm and the role of various structures in enabling this movement. Discuss two shoulder pathologies of your choice. Outline the structures affected and appraise the impact this would have on lateral flexion of the arm and how a Chiropractor may help in management of your chosen pathologies”. Module Number/Name Year 2: Biomechanics Word Count Word Count 1,649 1

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Page 1: bodhisattvajedi.weebly.com€¦ · Web viewWord Count . Word Count 1,649. Introduction. This essay will examine the structures of the shoulder joint and girdle, ... Impingement Syndrome

Student ID: 1055468

Student Number 1055468

Name of lecturer Jim Odell

Assignment Title “Evaluate the structure and function of the shoulder girdle with particular attention to essential movements that occur in lateral flexion of the arm and the role of various structures in enabling this movement.Discuss two shoulder pathologies of your choice.Outline the structures affected and appraise the impact this would have on lateral flexion of the arm and how a Chiropractor may help in management of your chosen pathologies”.

Module Number/Name Year 2: Biomechanics

Word Count Word Count 1,649

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Student ID: 1055468

Introduction

This essay will examine the structures of the shoulder joint and girdle, and the

dynamics responsible for creating lateral flexion at the glenohumeral joint,

while briefly discussing the movements simultaneously occurring at other

related articulations. Two conditions that notably affect lateral flexion, the

symptoms and consequences of each, and how Chiropractic may possibly

assist in recovery will also be explored.

Structure and Function of Shoulder joint + Lateral flexion and its

components.

The shoulder is regarded as the most complex joint in the human body (Hall,

2012) largely because it includes five separate articulations: the glenohumeral

joint (GHJ), the sternoclavicular joint, the acromioclavicular joint, the

coracoclavicular joint, and the scapulothoracic joint. The biomechanical

interaction of these five joints, their associated muscles, ligaments, cartilage,

capsule and soft tissue, make up what is commonly referred to as the

‘shoulder girdle’.The glenohumeral joint (GHJ) - the articulation between the

head of the humerus and the glenoid fossa of the scapula (which is a ball and

socket synovial joint) - is typically considered the major shoulder joint (Hall,

2012). The GHJ is has the greatest range of motion of any joint in the body

(Sanderson & Odell, 2012, pp.45) (see Appendix 1). While it is considered as

a joint in its own right, the GHJ is intricately linked with the sternoclavicular

and acromioclavicular joints, which contribute to specific and overall arm

movement.

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Flexion describes the movement that occurs at the GHJ when the arm is

raised in an anterior (forward) or lateral (outward) direction, resulting in a

typical degree range of 120 degrees for anterior flexion and 150 degrees for

lateral flexion (McHardy, et al., 2008). “The muscles crossing the

glenohumeral joint anteriorly participate in flexion at the shoulder. The prime

flexors are the anterior deltoid and the clavicular portion of the pectoralis

major. The small coracobrachialis assists with flexion, as does the short head

of the biceps brachii” (Hall, 2012) (see Appendix 2) Additional movements that

also occur at the shoulder girdle in conjuction with the GHJ are elevation and

upward rotation (initiated by upper trapezius and levator scapula activation).

Lateral ‘flexion’ of the arm and shoulder involves the GHJ and several key

muscles, notably the middle portion of the deltoid, the upper trapezius, and

the supraspinatus, one of the four rotator cuff muscles (which is involved in

the first ten to fifteen degrees of abduction) (Ticker & Warner, 1997) (see

Appendix 3).

Because of the anatomical complexity of the shoulder muscles and ligaments

that support a multitude of articulations, a greater risk of trauma exists through

anatomical wear and tear of muscles and ligaments and / or injury. The

supraglenoid fossa in particular is an anatomical weak point in the shoulder .

Its vulnerability to pathology or dysfunction means a greater risk of

impingement syndrome or supraspinatus tears (Keener, et al, 2009) (see

Appendix 4).

Pathology 1)

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Shoulder Impingement Syndrome (SIS)

Shoulder Impingement Syndrome (SIS) is a very common cause of shoulder

pain in presenting patients (Souza, 2001). SIS occurs when there is

impingement of any structures (such as the supraspinatus tendon or sub

acromial bursa) that pass through the coraco-acromial arch (Will, 2005), the

passageway formed by the union between the acromion and the coracoid

processes. The causes are thought to be pathological variations in structure,

such as sub-acromial spurs, or traumatic events, e.g. resulting from repetitive

overhead movements in some job roles and in some sports (painting, lifting,

swimming, tennis), resulting in conditions such as tendinitis or strains of the

supraspinatus tendon (Ticker & Warner, 1997). Faulty mechanics of the

shoulder, often caused by muscle imbalances, are another contributing factor

(Hall, 2012).

There is often a painful ‘arc’, a portion of anterior and or lateral flexion of the

GHJ, which provokes symptoms due to the approximation of irritated

structures. Thus movement of the GHJ is notably reduced and the function of

the shoulder is compromised on many levels. Diagnostically, orthopedic tests

specific to shoulder impingement (Hawkins Kennedy test) can be performed

to alert the clinician to the possibility of the condition. Plain film radiographs

(x-rays) may be used to rule out concurrent conditions such as calcific

tendinitis, calcific bursitis, and degenerative changes of the glenohumeral and

acromio-clavicular articulations. However, neither of these options is as

definitive as an MRI scan where evidence of possible soft tissue involvement

and other contributing factors such as hypertrophy associated with Shoulder

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Impingement Syndrome (Morrison, Frogameni, & Woodworth, 1997) can be

analysed in greater detail. Imaging findings are also more sensitive in the

detection of anatomical impingement as compared to manual tests, although

history and physical examination are often sufficient to detect the presence of

functional pathology (McHardy, et al., 2008).

Pathology 2

Rotator Cuff Tear (Supraspinatus)

Muscle tears (strains) are divided into three categories based on the severity

of damage sustained. Grade one involves pain and minimal tearing of muscle

fibres, grade two involves substantial pain and significant tearing of muscle

fibres, and grade three is a complete rupture (Fongemie, Buss & Rolnick,

1998). The rotator cuff is a group of four muscles (supraspinatus,

infraspinatus, teres minor, and subscapularis) that connect the humerus to the

scapula and articulate its movements(Ticker & Warner, 1997). The

supraspinatus, so termed as it is found above (supra) the ‘spine’ (bony

prominence) located on the posterior aspect of the scapula, is the most

frequently torn of the four (Ticker & Warner, 1997). Activities that involve

forceful hyperextension or external rotation of an adducted arm are thought to

cause this pathology (Ticker & Warner, 1997). These may include repeated

overhead movements such as those found in tennis, badminton, or squash

(Ticker & Warner, 1997). Other mechanisms that may lead to a supraspinatus

tear include loading the muscle beyond its limit, or creating explosive

movement under strain, e.g. in performing shoulder shrugs with excessive

dumb-bell weight in the hands. The pain pattern is persistent and present in

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the arm in both lower and higher ranges of shoulder abduction (Ticker &

Warner, 1997).

Effect on lateral flexion and how this may be assisted with chiropractic

treatment.

“Studies indicate conservative management of shoulder impingement

syndrome results in resolution of symptoms in 70-90% of patients (Morrison,

Frogameni & Woodworth, 1997). Conservative clinical management in

chiropractic may include the use of ice or cold packs (cryotherapy),

adjustments, soft tissue work, and muscular rehabilitation. Over 3 quarters of

Chiropractors use full spine and extremity manipulation management

protocols, highlighting the presence of treatment techniques for peripheral

joint problems (McHardy, et al., 2008).

Impingement syndrome results in limited anterior and lateral flexion capability

due to the irritation of either subacromial bursa and / or an inflamed

supraspinatus tendon, thus reducing the range from typically 120° anteriorly

and 150° laterally to becoming painful between 60° to 120° anteriorly and 60°

to 90° laterally (Warner et al, 1992). Tears of the supraspinatus are not as

limiting as shoulder impingement syndrome because the supraspinatus’s

primary role is to initiate the first ten to fifteen degrees of abduction, after

which the deltoid and other synergistic shoulder muscles take over (Ticker &

Warner, 1997).

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Chiropractors may utilise ice or cold packs as part of the clinical management

of patients with shoulder inflammation to assist pain relief and reduction in

swelling. Typical application time of cold packs to the affected area is in a

range of 10 to 15 minutes, with a gap of at least an equivalent time after use

to allow ordinary blood-flow to re-establish before again applying a cold pack

(Fongemie & Rolnick, 1998). When evaluating the shoulder, the emphasis

must always be on the whole shoulder girdle complex and not simply on the

‘shoulder’ or the glenohumeral joint (Sanderson & Odell, 2012). Therefore, the

entire shoulder girdle (including the upper rib cage) should be evaluated.

Dysfunctions through the costovertebral joints (ribs) can be responsible for

faulty scapula movement patterns due to muscular cross-links, and therefore

must be checked (Warner et al, 1992). Subluxations in the lower cervical and

upper thoracic region, by inference, may also have an effect on the patient’s

ability to laterally flex (abduct) the arm, and should be corrected by

chiropractic adjustive techniques (Souza, 2001). Additionally, the nerves from

the cervical region (or neck) innervate the shoulder muscles. Chiropractic

treatment of cervical subluxations and their potential neurological interference

is essential to ensuring proper musculoskeletal function of the shoulder girdle

(McHardy, et al., 2008). Shoulder mobilisations are thought to be effective in

both impingement syndrome and supraspinatus tears. Mobility of the shoulder

is crucial to initiating the rehabilitation process. Shoulder mobilizations that

increase the subacromial space may be helpful in shoulder impingement

(longitudinal traction), whereas those that reduce faulty anterior positioning of

the GHJ in response to protective muscle spasm patterns (notably as anterior

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deltoid and pecs) (Keener, et al, 2009) such as anterior to posterior

movements may be helpful in supraspinatus tears.

Shoulder rehabilitation is absolutely essential in correcting an impingement

syndrome and in returning damaged muscle fibers of a supraspinatus muscle

to relative flexibility and strength. The primary causes of both these problems

need to be corrected and this correction facilitated through the rehabilitation

process. Rehabilitation focuses on strengthening the shoulder and back

muscles (rhomboids, external rotators, middle fibers of trapezius, post deltoid,

back extensors) (Morrison et al., 1997) increasing flexibility in the neck

(through soft tissue and adjustive methods), chest and arm muscles (though

targeted stretches), evaluating and correcting any breathing or respiratory

dysfunctions (through postural retraining), and working on re-establishing

normality in the neurological component of the shoulder girdle (through

movement alteration exercises). Impingement syndrome involving

pathological components (i.e. bone spurs), or in cases involving extensive

damage, then the supraspinatus may require surgical intervention in place of

conservative care.

Conclusion

The shoulder joint is the most complex joint in the body. Due in part to its

many articulations with other joints in the body, it is susceptible to dysfunction

and injury. Two pertinent conditions that affect lateral flexion of the shoulder

are impingement syndrome and supraspinatus tears. These both create pain

and limitations in movement, notably lateral flexion. Chiropractic may assist in

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a range of shoulder cases using adjustive techniques, specific shoulder

mobilizations, cryotherapy as well as targeted rehabilitation programmes that

look to address strength and flexibility deficits.

References

Fongemie, A., Buss, D., Rolnick, S.,1998. Management of shoulder impingement syndrome and rotator cuff tears. American Family Physician, 57 (4): 667–74, 680–2.

Hall, S. 2012. Basic Biomechanics (6th ed). McGraw-Hill.

Keener, J., Wei, A., Kim, M., May, K., Yamaguchi, K.,2009. Proximal Humeral Migration in Shoulders with Symptomatic and Asymptomatic Rotator Cuff Tears. Journal of Bone and Joint Surgery, 91 (6): 1405-1413.

Maitland, G.,1984. Vertebral Manipulation (4th ed). Butterworth & Co.

McHardy, A., Hoskins, W., Pollard, H., Onley, R., Windsham, R., 2008. Chiropractic Treatment of Upper Extremity Conditions: A Systematic Review. Journal of Manipulative and Physiological Therapeutics, 31: 146-159.

Morrison, D., Frogameni, A., Woodworth, P.1997. Non – operative treatment of subacromial impingement syndrome. Journal of Bone and Joint Surgery, 79 (5): 732-7.

Sanderson, M., Odell, J.,2012. The Soft Tissue Release Handbook; Reducing Pain and Improving Performance. Lotus Publishing.

Souza, T.,2001. Differential Diagnosis and Management for the Chiropractor, protocols and algorithms. Aspen Publishers.

Ticker, J., Warner, J.,1997. Single Tendon Tears of The Rotator Cuff. Orthopaedic Clinics of North America, vol 28 (1): 99-116.

Warner, J., Michelli, L., Arslanian, L., Kennedy, J., Kennedy, R. (1992). Scapulothoracic Motion in Normal Shoulders and Shoulders with Glenohumeral instability and Impingement Syndrome: A study using moire topographic analysis. Clinical Orthopaedics and Related Research, vol 285.

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Appendix: IShoulder Girdle Complex

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SANDERSON, M. AND ODELL, J.Shoulder girdle complex. Illustration.In-text: (Sanderson and Odell)Bibliography: Sanderson, Mary, and Jim Odell. Shoulder girdle complex. 2012. Print

Appendix: IIShoulder Girdle Muscles

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SANDERSON, M. AND ODELL, J.Shoulder girdle muscles. Illustration.In-text: (Sanderson and Odell)Bibliography: Sanderson, Mary, and Jim Odell. Shoulder girdle muscles. 2012. Print

Appendix: IIIGross Observational Movements

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SANDERSON, M. AND ODELL, J.Gross Observational Movements. Illustration.In-text: (Sanderson and Odell)Bibliography: Sanderson, Mary, and Jim Odell. Gross observational movements. 2012. Print

Appendix: IVMuscle Movement at the Shoulder Girdle

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SANDERSON, M. AND ODELL, J.Muscle movement at the shoulder girdle. Table.In-text: (Sanderson and Odell)Bibliography: Sanderson, Mary, and Jim Odell. Muscle movement at the shoulder girdle. 2012. Print

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