Chiropractic+



Student Number 1055468Name of lecturer Jim OdellAssignment 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: BiomechanicsWord Count Word Count 1,649Introduction 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. 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) 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 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 2Rotator 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 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). 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 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 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. ReferencesFongemie, 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. Appendix: IShoulder Girdle ComplexSANDERSON, 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 MusclesSANDERSON, 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 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 GirdleSANDERSON, 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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