Bruce Reider - The Orthopaedic Physical Exam (, Saunders).pdf - Ebook download as PDF File .pdf), Text File .txt) or read book online. Examination 1st Edition. by Bruce Reider AB MD (Author) Netter's Orthopaedic Clinical Examination: An Evidence-Based Approach (Netter Clinical Science). Bruce Reider, AB, MD, Professor of Surgery, Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery, The University of Chicago;.
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Reider, Bruce. The orthopaedic physical exam/Bruce Reidernd edition. p. cm. ISBN 1. Physical orthopedic tests. 2. Physical diagnosis. I. Title. Clinical Examination: A Systematic Guide to Physical Diagnosis. 1, Pages· · The orthopaedic physical exam/Bruce Reidernd edition. p. cm. Reider 2nd Ed. - Ebook download as PDF File .pdf), Text File .txt) or read book online. Data Reider, Bruce The orthopaedic physical exam/Bruce Reider. The same can be said for the orthopaedic physical examination: Although the.
The second is to quantitate the amount of laxity present. Shrugging of the scapula to increase abduction right shoulder. The sternoclavicular joint is inflammatory arthritis. If the weakness is subtle. The rotator cuff muscles assist the deltoid in this function by stabilizing the humeral head in the gle- noid fossa. This is upper limb to describe the structure popularly known as so immediate and automatic that it is often done the arm. To look at the truly test a single muscle in isolation.
Some confusion can arise owing to conflicts between the anatomic and the common names for the limb segments. Range of Motion. This is so immediate and automatic that it is often done almost unconsciously.
Auscultation and percussion were eliminated as major components of the examination process for various reasons. To minimize redundancy. Sensation Testing. When percussion is used. When they are used to describe relative position. This division is somewhat arbitrary because anatomic structures and patients' symptoms often overlap adjacent body segments. Muscle Testing. The confusion is greater when the individual segments of the limbs are identified.
The exact order varies according to the requirements of the particular body part described. For example. Anatomists use the terms upper extremity and upper limb to describe the structure popularly known as the arm. This structure has been modified for this text. Although these same four terms can be applied to the wrist and hand.
In general medicine. Most chapters describe the appearance of the body part from each of the traditional anatomic perspectives: These terms are applied with the assumption that the patient is in the classic anatomic position see Fig.
Stability Testing. Terms and Techniques Bruce Reider T he body of this book is divided into chapters. The examiner observes the outward appearance of the body part. The Inspection section of each chapter presents an organized mental checklist. Reflex Testing. Auscultation is rarely used in the orthopaedic examination.
Surface Anatomy Each Surface Anatomy section takes the reader on a visual tour of the surface of the area to be examined.
Surface Anatomy. Because this usage conflicts with the popular meanings of these terms. A and B. C and D. The anatomic position. In a clinical situation. Axial alignment refers to the longitudinal relationships of the limb segments. The terms proximal and distal are also used to describe the relative position of structures. Rotational alignment refers to the twisting of the limb around its longitudinal axis.
Nomenclature for rotational alignment is less standardized. So much variation in appearance is possible among individuals that mild deformities can be overlooked. These terms are explained in Chapter 4. Hand and Wrist. In valgus alignment. In addition. In genu valgum. Some clinicians prefer to say cephalad or rostral when they mean toward the head and caudad when they mean toward the sacrum. CHAPTER 1 confusing owing to the forearm's ability to rotate and thus change the orientation of structures within the distal forearm.
In this case. When such deviations are toward or away from the midline. Possible variations or abnormalities. The reader must remember that few individuals possess ideal skeletal alignment. In the foot. The Surface Anatomy sections help orient the reader within the body part to be examined by pointing out anatomic landmarks that are visible in many or most patients.
The terms dorsal. In the limbs. In hallux valgus. Another way to define valgus is to say that the distal segment forming the angle points away from the midline. In the spine. In these photographs. As the reader is guided around the surface anatomy. In each case. At the same time. In the trunk or the limbs. Comparison with the patient's other contralateral side is the best way to evaluate a potential abnormality.
Instead of forming a straight line. In the example just given. These two terms are commonly used but often confused. Varus alignment is the opposite of valgus. As in most aspects of human anatomy. Terms and Techniques 3 Alignment The Alignment section of each chapter describes the relationships of structures or body segments to one another.
Angulation does not have to occur at a joint for these terms to be used. The examiner should always be on the lookout for such visible abnormalities. In varus alignment. In the femur. Gross departures from the realm of the normal may be quite obvious. In the tibia. The terms pronation and supination are sometimes used analogously in the foot and toes.
These are defined in Chapter 8. In the hand and forearm. Lumbar Spine. Cervical and Thoracic Spine.
Figure Genu valgum. The spine. In the normal individual. Genu varum. Examination in the prone position with knees flexed demonstrates external tibial torsion. The colloquial equivalents of these two terms are pigeon-toed for in-toeing and slew-footed for out-toeing. When the kneecaps angle inward. A number of other terms are used to describe rotational alignment in different areas of the body.
Because evaluation of alignment is such an intimate part of spine inspection. When the angle between the femoral neck and the plane of the knees flexion axis is less than the average amount. When the first heel strikes the ground again. After toe-off. Much of this information is therefore obtained during the active range of motion ROM examination. A complete gait cycle is considered to be the series of events that occur between the time one foot contacts the ground and the time the same foot returns to the same position.
Each pair of terms describes movement that takes place in one of the body's cardinal planes when the body is in the anatomic position Fig. At times. Flexion and extension. The point at which the swinging limb passes the weight-bearing limb is the point of midstance for the weight-bearing limb. The examiner must make a conscious effort to include the examination of gait in the office evaluation of musculoskeletal problems. Most clinicians possess an intuitive understanding of normal gait patterns.
In the shoulder and hip. Although traditionally the examiner might have observed the patient's gait as the patient was walking into the examination room.
In order to observe and describe abnormalities of gait. To understand or detect these abnormalities. It is sometimes divided into heel-off.
CHAPTER 1 Terms and Techniques 5 Gait One of the most valuable components of the musculoskeletal examination is observation of the motion of the body segment in question while it is functioning dynamically. As the individual continues to move forward. The portion of the cycle during which both lower limbs are weight-bearing is called double leg stance. These movements could also be described as occurring around a transverse axis.
The point at which both the forefoot and the heel are in contact with the ground is called foot flat. During this time. The exact meaning of the terms flexion and extension varies depending on the nature of the joints in question. The portion of the gait cycle just described. The material presented in each Gait section is by no means a description of laboratory gait analysis.
As the opposite limb continues to move forward. In the upper extremity. Although ambulation is a continuous process. This description is sometimes only approximate. In the wrist. Range of Motion The Range of Motion section of each chapter teaches the reader how to observe and quantitate the amount of motion possible in each joint.
In the elbows. Because first contact normally is made with the heel. The process of push-off provides much of the propulsive energy used for ambulation. This means that the examiner often does not see the patient walk unless he or she makes a conscious effort to include this observation in the examination. Most abnormalities are evident during this gait phase because the involved limb is bearing weight and thus under stress. The most basic function of the lower extremities is ambulation.
This is an extremely helpful point in the gait cycle to look for abnormalities. Swing phase. Foot flat. The normal gait cycle right foot. Push off. Heel strike. Coronal plane. Cand D. Sagittal plane. Planes and axes of movement A and B. In any given joint. When greater accuracy is necessary. In the interests of time and patient comfort.
Most examiners can learn to estimate flexion angles fairly accurately by comparing the angle being measured with an imaginary right angle. Differences between active and passive ROM raise diagnostic questions that require further evaluation. E and F. The spine is a midline structure. Needless to say. This can be estimated or measured. External rotation describes movements in which the limb rotates away from the midline when viewed from an anterior perspective.
The ROM examination is not just a time to systematically record numbers. Abduction describes movements that take the limb away from the midline of the body. This may not be strictly accurate because factors other than ligaments may.
For many routine purposes. Transverse plane. ROM may be measured both actively and passively. External rotation and internal rotation describe movements that take place within the transverse plane.
Abduction and adduction refer to motion within the coronal plane of the body. This has given rise to other descriptive terms particular to specific parts of the anatomy. Excessive joint motion has traditionally been described as a sign of ligamentous laxity.
Active range of motion refers to the range through which the patient's own muscles can move the joint. In general. In the hip and shoulder. In each chapter. Several joints are capable of movements that resist being forced into this system of classification. Additional tests allow the examiner to determine the specific cause in each patient. In the Range of Motion section of each chapter. The reader must remember that normal ROM varies considerably.
For most movements. External rotation. Internal rotation. C Abduction. Paired motions in the shoulder. The structures described in each Palpation section should serve as a basic framework for the clinician.
In this manner. A person who can perform three or four of these tests is usually considered ligamentously lax. In this way. By determining the location of specific easily recognizable structures. In truth. Percussion of the peripheral nerves can yield similar information and is also described in the Palpation sections. The third purpose of palpation is to verify the continuity of anatomic structures. Palpation can pinpoint the specific structure involved in an injury.
Four specific tests are widely used to evaluate generalized ligamentous laxity Fig. Changes in temperature can often be quite subtle. Tenderness must therefore always be interpreted with the knowledge that conscious deception or unconscious overreaction may be playing a role in the patient's response.
For reasons of visual Figure Screening for generalized ligamentous laxity may be an important adjunct to a specific joint examination. In multidirectional instability of the shoulder.
As a clinician's knowledge of anatomy grows. The amount of pressure can then be progressively increased when the examiner is certain that light pressure does not cause excessive discomfort. It requires the patient to inform the examiner verbally or physically that palpation of a given structure is painful. These factors include morphology of the bones involved and tightness of the muscle-tendon units that cross the joint. Palpation has special uses in the examination of neurovascular structures.
In the same way. Pressure on peripheral nerves can elicit or amplify pain or paresthesias. Careful palpation of an injured Achilles tendon. Palpation has many purposes. Any anatomic structure that is identifiable by touch or that may become tender may be palpated. Point tenderness can confirm or strongly corroborate such diagnoses as stress fracture. The contents of the Palpation section of each chapter are not exhaustive. Tenderness is a semi-objective finding. The question is often asked.
Use of the goniometer to measure elbow motion. During palpation. By palpating pulses. Careful palpation can help the examiner identify the location of specific anatomic structures. Grade 2 is assigned to a muscle that can move the appropriate joint if the limb is oriented so that the force of gravity is eliminated.
For this reason. Tests of ligamentous laxity. This section describes ways to evaluate the strength of the major muscles or muscle groups used to move the joint or joints. In some of these photographs. The passive ROM examination can certainly be considered to involve manipulation.
Grade 0 indicates that no contraction of the muscle is detectable. Thumb to forearm. Knee hyperextension. Index finger metacarpophalangeal joint hyperextension.
Elbow hypcrextension. Elbow and Forearm. Grade 4 is assigned to a muscle that is capable of moving Muscle Testing Bach chapter that deals with the examination of the limbs contains the section Muscle Testing. This method is thought to provide the most logical grouping of tests. Any examination technique that did not seem to fit readily under the rubrics of inspection or palpation is included here.
Grade 3 is assigned to a muscle that is strong enough to move a joint against the force of gravity but is unable to resist any additional applied force. Grade 1 is assigned to a muscle in which a contraction can be seen or palpated but strength is insufficient to move the appropriate joint at all.
When possible. Additional photographs that show the palpation of specific individual landmarks are included. Resistive testing can also yield additional diagnostic information. Sensation Testing The chapters that deal with the extremities contain sections entitled Sensation Testing. If the patient is unable to execute this maneuver. Resisted contraction of a muscle that crosses a painful joint can often elicit or exacerbate the associated joint pain. To further grade the muscle. If the patient is still unable to extend the knee.
In this fashion. Arrow shows direction of motion. Grade 5 means that the muscle strength is considered normal. Testing strength of the right quadriceps with gravity eliminated. If the muscle being tested is not capable of moving the appropriate joint against the force of gravity.
Although this is a valuable rule of thumb. To distinguish between these two possibilities. If a contraction of the muscle is felt or seen. If the patient can extend the knee in this position. Testing quadriceps strength against gravity and resistance. In particular. The relative strength and size of the patient and the examiner also influence the ability of the examiner to resist a given muscle group.
The examiner should keep in mind that manual testing measures the effective strength of the muscle group and can thus be diminished by factors. Most muscles that the clinician encounters have at least grade 3 strength. These sections describe the testing for sensory deficits associated with peripheral Figure The patient is then instructed to attempt to extend the knee with the lower leg and thigh supported by the examination table Fig.
Normal muscle strength varies tremendously among individuals depending on body habitus. The reader should remember that peripheral sensory nerve anatomy is highly variable and that the exact boundaries of altered sensation vary considerably from one individual to another. Terms and Techniques 13 Because the distribution of peripheral nerves may overlap.
The area supplied by an injured peripheral nerve may be only hypoesthetic or even hyperesthetic. The border between altered or absent and normal sensation can be marked with a pen Fig. The patient is instructed to close his or her eyes and to notify the examiner when a touch is felt.
Testing for two-point discrimination. Although specialized calipers. To test light touch. The examiner then touches the fingertip with the device a number of times. The patient is instructed to close his or her eyes and notify the examiner whether the finger in question is being touched by one or two points. The tactile ability of the fingertips is so refined that a specialized method of testing. Delineating an area of altered sensation. Because an average individual should be able to distinguish between two points separated by 5 mm.
If this is the case. More quantitative testing may be done using Semmes-Weiss filaments. The examiner again starts touching in the abnormal area and proceeds outward in different directions. The examiner can then begin touching the patient in the area of suspected hypoesthesia or anesthesia and move outward until the patient feels the touch normally.
Because of the intimate relationship between the spine. In areas of peripheral nerve injury.
If two-point discrimination is impaired. Only the most commonly affected peripheral nerves are described in each chapter. In a grade 1 ligament injury. Sometimes this modification is done consciously to improve the usefulness of the test and sometimes it happens inadvertently. The terms positive and negative are traditionally used to report the results of tests. A text dedicated to the orthopaedic physical examination can never be truly complete.
The patient should be encouraged to relax so that the limb being tested feels completely limp in the hands of the examiner. Over time. The goal was to include the tests that the authors themselves have found valuable in their own clinical practices. The authors deal with this dilemma through a compromise.
For each dermatome. Stability testing of such ligaments reveals increased laxity compared with the other side. Some classic tests that have been surpassed by more recent ones or whose reliability remains unproved are included for their historical interest. These data are often used to establish the anatomic severity of a ligament injury. In certain cases. Stress testing of grade 3 ligament injuries can actually be less painful than stress testing of grade 2 injuries because the continuity of the injured structure is completely disrupted.
In the presence of a grade 3 injury of one ligament. When the test is being performed. In this text. In these cases. Although these two terms are often used interchangeably in the literature.
There can sometimes be confusion as to whether a positive result means that a test is normal or abnormal. Chapter 8. Such ligaments are elongated but not completely disrupted. In the Sensory Testing sections. In a grade 3 ligament injury. The number of special tests that have been described over the years is enormous.
If the ligament is superficial enough to be palpated. In a grade 2 ligament injury. Miscellaneous Special Tests In each chapter. Although some of these newer tests may not prove to have staying power.
Some of the techniques originated with the contributors or were absorbed from colleagues through clinical interactions. Reflexes that are obscure or difficult to elicit are generally omitted. It is important that any examination for abnormal joint laxity be conducted as gently and painlessly as possible. Because the exact distribution of a given dermatome varies from one individual to another.
When this state is obtained. Stressing such a ligament should induce pain but not reveal any abnormal play in the joint. A description of sensory testing that is particularly relevant to the evaluation of spinal injuries.
Some tests have an identifiable original description. Although most tests have a standard descriptive name or eponym. The authors tried to avoid using the term instability to describe abnormal joint laxity. In cases of suspected joint instability.
Quantitate measurable parameters such as range of motion. Evaluate the overall alignment of the limb or spine before focusing on the specific area of complaint. D e g e n e r a t i v e Arthritis Point tenderness on the joint common Effusion variable Palpable crepitus variable Palpable or visible osteophytes more advanced cases Angular joint deformity more advanced cases Loss of motion variable Inflammatory Arthritis Effusion frequent Warmth frequent Erythema variable Diffuse tenderness Angular deformity variable.
During inspection. In the case of lower extremity problems. Use the patient's history to focus your examination. Always be gentle and reassuring in your manner and respect the personal sensitivities of each patient.
Compare each patient w i t h your "memory bank" of the normal range of variation of each physical finding. A-C, Anterior shoulder and upper arm. A, clavicle; H, sternoclavicular joint; C, sternocleidomastoid muscle; D, acromioclavicular joint; E, acromion; F, coracoid process; G, pectoralis major; H, deltoid; I, deltoid tubercle; J, biceps brachii; K, supraclavicular fossa. Fractured left clavicle. Acute fractures or chronic nonunions can be distinguished from healed fractures by the accompanying tenderness.
In the case of an acute injury, ecchymosis is usually present. At the medial end of the clavicle lies the sternoclavicular joint, a synovial articulation between the clavicle and the sternum. The sternocleidomastoid muscle connects the proximal clavicle and adjacent sternum with the corresponding mastoid processes of the skull. The two sternocleidomastoid muscles combine to produce the characteristic V shape seen in the anterior neck, with the superior sternal notch constituting the angle of the V Fig.
Sternoclavicular Joint. The sternoclavicular joint is bound together by strong ligaments. Considerable motion occurs here, particularly during active abduction of the shoulder. The joint is very superficial and easily seen in most patients.
Swelling and deformity overlying this joint may signify a fracture of the medial clavicle near the joint, a dislocation of the joint itself, or an arthritis of various etiologies Fig. In an anterior sternoclavicFigure Swollen sternoclavicular joint due to a fracture of the medial end of the left clavicle. This is usually obvious during visual inspection, although massive swelling may obscure the nature of the injury if the patient is examined on a subacute basis.
In a posterior sternoclavicular dislocation, the medial clavicle is displaced posteriorly with respect to the sternum and becomes less prominent Fig. Such a dislocation may compress the patient's airway and produce respiratory distress. Degenerative arthritis of the sternoclavicular joint may produce visible enlargement owing to synovitis or osteophyte formation.
Swelling accompanied by erythema suggests the possibility of infection or inflammatory arthritis. Acromioclavicular Joint. At the distal end of the clavicle lies the acromioclavicular joint, its articulation with the acromion process of the scapula.
This joint has strong ligaments that prevent anterior and posterior displacement of the distal clavicle, inferior displacement of the acromion from the clavicle is resisted by the coracoclavicular ligaments. The visibility of the acromioclavicular joint varies tremendously among individuals.
In some patients, it appears as a marked bony prominence,. Posterior dislocation of the right sternoclavicular joint. From Rockwood CA r. Green DP [eds]: Fractures, 2nd ed. Philadelphia, JB Lippincott, In the normal individual, however, both acromioclavicular joints should look the same. An asymmetric enlargement of the acromioclavicular joint may be due to acute or chronic inflammation, bony hypertrophy caused by degenerative arthritis, or acute ligamentous injury.
Ligamentous injuries, or sprains, of the acromioclavicular joint were divided by Rockwood into six types, which can often be distinguished by their clinical appearance.
In a Type I injury, the acromioclavicular ligaments are damaged but not fully ruptured. There is, therefore, no relative displacement of the bones constituting the joint, but the prominence of the joint may be slightly increased due to intraarticular hemorrhage and edema.
In a Type II injury, more severe damage to the acromioclavicular and coracoclavicular ligaments allows the joint to subluxate, subtly increasing the prominence of the distal clavicle Fig. The deformity is much more marked in the Type III injury, in which a complete rupture of the acromioclavicular and coracoclavicular ligaments allows the joint to dislocate completely Fig.
The acromion and attached limb are pulled downward by gravity, giving the impression that the distal clavicle is displaced upward. The next step in this progression of injury is the Type V, in which tearing of the deltoid and trapezius attachments to the distal clavicle allow the distal clavicle to become so prominent that it appears to be in danger of poking through the skin Fig. This type is sometimes humorously described as an ear tickler. Types IV and VI are rare injuries in which the increased superior prominence of the distal clavicle seen in the other types is absent.
In the Type IV injury, the distal clavicle is displaced posteriorly and lodged in the trapezius; in Type VI, it is displaced inferiorly and lodged beneath the coracoid process. The deformities in both these types may be more easily appreciated by palpation than by inspection.
The acromion is a long flat process of the scapula that articulates with the distal clavicle. It serves as an origin for the middle portion of the deltoid muscle and overlies the rotator cuff tendon. Its flat superior surface is easily seen in many patients. The straight lateral edge of the acromion is usually palpable but rarely visible. This is because the round humeral head normally extends lateral to the acromion underneath the deltoid muscle to give the lateral border of the shoulder its rounded appearance.
In anterior dislocation of the shoulder, the humeral head usually moves medially, increasing the visibility of the lateral edge of the acromion and converting the rounded contour to a straight one Fig. Axillary nerve injury, which is sometimes seen as a complication of acute shoulder dislocation, can lead to deltoid atrophy and also give the shoulder a straight-edged appearance. Coracoid Process.
The coracoid process is a deep scapular apophysis that is palpable but not normally visible. It serves as the origin for the short head of the biceps and coracobrachialis and the insertion for the pectoralis minor. This landmark may occasionally be seen in very thin patients, or in patients with significant deltoid atrophy.
It can also be visible in patients with a posteriorly dislocated shoulder. In this case, the anterior and lateral deltoid heads are flattened against the front of the glenoid rim, making the coracoid prominent. The coracoid can usually be palpated at a point about 2 cm inferior to the junction of the middle and lateral thirds of the clavicle. Pectoralis Major. The muscles that are most prominent when the shoulder is viewed anteriorly are the pectoralis major, deltoid, and biceps brachii.
The pectoralis major is a triangular muscle that originates broadly on the sternum, clavicle, and ribs and tapers to a flat tendon about 2.
The pectoralis major is a powerful adductor, flexor, and internal rotator of the arm. It constitutes the primary contour of the chest, particularly in the male, and forms the anterior border of the axilla. Ruptures of the pectoralis major are not common, but they seem to be occurring with greater frequency as weight training increases in popularity. They usually occur at or. Type V acromioclavicular joint injury left shoulder. A, Anterior. B, Lateral.
When a rupture occurs, it produces a characteristic clinical appearance of an abnormal anterior axillary crease Fig. Unilateral absence of all or part of the pectoralis major is a relatively common congenital abnormality. The deltoid is a superficial muscle that gives the shoulder its normal rounded contour.
As its name implies, it is triangular. Its broad origin begins anteriorly along the lateral third of the clavicle and continues across the acromioclavicular joint, along the lateral border of the acromion, and finally posteriorly along the scapular spine.
These three segments, or heads, taper to a common tendon of insertion on the lateral aspect of the humerus. Lateral edge of the acromion is more visible when an anterior dislocation of the shoulder is present.
Shoulder and Upper Arm innervated by the musculocutaneous nerve, a nerve that is occasionally injured after shoulder dislocation or surgery. The biceps is well known to the lay public because its muscle belly is quite prominent and contributes greatly to the appearance of muscularity.
Rupture of the short head tendon of the biceps almost never occurs, but rupture of the long head tendon is common and often associated with rotator cuff injury.
This injury is usually accompanied by pain and ecchymosis, which often accumulates distal to the site of injury. Rupture of the long head of the biceps causes a characteristic deformity, as the muscle belly bunches up distally when elbow flexion is attempted Fig. This is sometimes called a Popeye deformity, after the appearance of the biceps of the famous cartoon character. From this perspective, the biceps is seen in profile, along with the triceps brachii, the primary extensor of the elbow, which constitutes the bulk of the posterior arm.
The triceps is innervated by the radial nerve, which it covers. As its name reflects, the triceps has three heads of origin. The medial and lateral heads arise from the humerus itself, whereas the long head arises from the inferior aspect of the posterior glenoid and is sometimes the site of painful tendinitis in throwing athletes.
Inspection of the posterior aspect of the shoulder provides a valuable perspective on shoulder anatomy and function Fig. From this viewpoint, the scapula can be seen as the foundation of the shoulder. The scapula is a flat triangular bone that is enveloped almost entirely by muscle.
One side of this triangle, the medial border, is oriented parallel to the thoracic spine in a roughly vertical manner. The glenoid fossa is perched. This point of insertion, the deltoid tubercle, is usually visible as a small depression in the lateral arm. The deltoid is a major motor of the arm, producing abduction, flexion, and extension. Deltoid atrophy may occur as the nonspecific result of disuse of the shoulder or as the specific result of injury to the axillary nerve.
As noted, deltoid atrophy increases visibility of underlying bony prominences such as the acromion, the scapular spine, the coracoid process, and humeral tuberosities. Rotator cuff pain is frequently referred to the deltoid insertion. Deltoid tendinitis, on the other hand, is extremely rare. Pain at the deltoid insertion is, therefore, almost always the result of rotator cuff pathology, although patients may be extremely skeptical of this assertion.
Subacromial Bursa. The subacromial bursa subdeltoid bursa lies deep to the acromion and deltoid and is therefore not normally visible. Because the subacromial bursa has a synovial lining, it may become inflamed in rheumatoid arthritis and cause swelling in the anterior superior shoulder Fig.
Swelling related to subacromial bursitis or synovitis in the glenohumeral joint is more likely to be visible in the presence of disorders such as rheumatoid arthritis, owing to the deltoid atrophy that often accompanies these diseases.
Biceps Brachii. The biceps brachii is the most prominent muscle of the anterior arm. It is primarily a flexor of the elbow and supinator of the forearm, although its attachments to the glenoid and coracoid give it some limited function in shoulder flexion.
True to its name, it has two heads and two proximal tendons. The first, or long head tendon, originates at the superior glenoid labrum, passes distally through the shoulder joint, then continues through the groove between the greater and the lesser tuberosities of the humerus.
The second, or short head tendon, originates from the coracoid process in a common tendon with the coracobrachialis muscle. The biceps is. Lateral aspect of the shoulder and upper arm. Posterior aspect of the shoulder and upper arm. This spine is a ridge of bone oriented at right angles to the main plane of the scapula. As noted. Medial border of the scapula becomes more prominent when the shoulder is internally rotated.
The belly of the supraspinatus muscle fills the superior. Injury to this nerve. It can be seen only when the trapezius is severely atrophied. The levator scapula raises the superior angle of the scapula. The supraspinatus arises from the supraspinatus fossa of the scapula.
Prominence of this part of the scapula may be the result of latissimus dorsi atrophy. Winging is most commonly the result of weakness of the serratus anterior.
They are innervated by the dorsal scapular nerve and function by elevating and adducting the scapula. The posterior aspect of the shoulder displays the contours of a number of visible muscles. It is usually slightly prominent. Of the three borders of the scapula.
It is innervated by the posterior roots of C2 to C4. It begins at the medial border of the scapula and proceeds toward the supraiateral corner of the scapula. The trapezius helps to stabilize. Cervical spine pain is often referred to the upper trapezius and is perceived by the patient as upper shoulder pain. This muscle is not normally visible but may be seen in a patient with a spinal accessory nerve palsy. The spine serves as the insertion site of the trapezius and the origin of the posterior third of the deltoid.
Levator Scapula. It thus forms the superior border of the shoulder. It inserts on the superior angle of the scapula.
The lateral border of the scapula is covered by the latissimus dorsi. Despite these muscular attachments. Even in the absence of winging. These include stabilizers of the scapula. The levator scapula is a small muscle that originates on the spinous processes of C1 through C4.
The trapezius originates from the occiput. Even then. Hyperinternal rotation of the shoulder normally causes the medial border to stand out from the chest wall Fig. Because it is covered completely by the trapezius. The most visible bony feature of the posterior shoulder is the spine of the scapula. If this protrusion of the Shoulder and Upper Arm 25 medial scapula occurs in situations in which the scapula should be stabilized against the chest wall.
The superior border of the scapula is covered by the trapezius and supraspinatus muscles and is not normally visible. Atrophy of the supraspinatus. In a muscular individual with a well-developed trapezius and deltoid.
The rhomboids are not normally distinctly seen but may be visible in a patient with spinal accessory nerve palsy. The rhomboid muscles arise from the nuchal ligament and spinous processes of C7 through T5 and insert on the posterior medial border of the scapular spine. It is innervated by the XI-th cranial nerve. The spine divides the posterior scapula into two unequal portions.
Weakness or denervation of the serratus due to long thoracic nerve injury results in the classic. Its serrated origins can be seen in the axilla of lean muscular individuals Fig. Serratus Anterior. The serratus anterior arises from the outer surface of the upper eight or nine ribs and inserts on the deep surface of the medial scapula. In the case of posterior dislocation of the shoul- Figure It can be atrophied in both rotator cuff tears and suprascapular nerve entrapment see Fig.
The posterior third of the deltoid. Left supraspinatus and infraspinatus atrophy due to a suprascapular nerve palsy. Winged right scapula. Atrophy of the supraspinatus muscle is most commonly the result of a rotator cuff tear but may occasionally reflect a suprascapular nerve palsy due to impingement of the suprascapular nerve at the suprascapular notch.
If the suprascapular nerve is compressed before it enters the supraspinatus. Dynamic tests to bring out this winging are described later in this chapter. Although the serratus itself is not usually visible. If it is entrapped at the spinoglenoid notch distal to the innervation of the supraspinatus. The infraspinatus arises from the superior portion of the infraspinatus fossa and also passes beneath the acromion to insert on the greater tuberosity of the humerus posterior to the supraspinatus insertion.
Although it is covered by the posterior third of the deltoid. The usual resting position can vary widely among individuals. Overhead view of the normal right shoulder. Imaginary lines drawn between paired landmarks such as the sternoclavicular joints or acromioclavicular joints should be horizontal.
Although the orientation of the scapula on the thorax changes as the shoulder is abducted. When a shoulder is painful. Some people tend to carry their shoulders with their scapulae retracted toward the "attention" position. Differences between the two shoulders can exist.
The inclination of the clavicles and scapular spines should be symmetric in both shoulders. Prominent serratus anterior arrows in a muscular wrestler. Anterior to this groove. In manual laborers and individuals who participate frequently in sports such as baseball or tennis. Whether the patient is viewed. The groove itself marks the location of the axillary sheath. The patient may carry the dominant shoulder slightly lower than the nondominant one.
In Sprengel's deformity. Posterior to this groove lies the muscle belly of the triceps brachii. In most individuals. This abnormality can be detected by measuring the distance from the inferior tip of the scapula to the midline Fig. In throwing athletes. This has been called the lateral scapular slide. The normal range of some motions such as abduction and forward flexion is fairly consistent among normal individuals.
The Shoulder. Popular Features. New in The Orthopaedic Physical Examination. Description Here is the most comprehensive and up-to-date look at the orthopaedic physical examination available today. Reider, a highly experienced educator and practitioner, covers all the current examination techniques - including the jobe test, the periformis test, the Lachman test, the carpal tunnel compression test, the quadriceps active drawer test, and much more. Product details Format Paperback pages Dimensions Table of contents Terms and Techniques.
The Shoulder and Upper Arm. The Elbow and Forearm. The Hand and Wrist. The Pelvis, Hip, and Thigh. The Knee. The Lower Leg, Foot, and Ankle. The Cervical and Thoracic Spine.