Examination Methods in Rehabilitation (19.10.2020) Mgr. Veronika Mrkvicová (physiotherapist) Manual muscle test: Scapula, shoulder http://media-1.web.britannica.com/eb-media/36/113036-004-A3D5BB7D.jpg Scapula C:\Users\Verca\Desktop\scapula.jpg Scapular muscles (from behind) • Scapula (Shoulder Blade) Anatomy, Muscles, Location, Function | eHealthStar in 2020 | Shoulder muscles, Shoulder anatomy, Shoulder blade muscles Scapular muscles (from the front) • Shoulder blade (scapular) muscles: origin, insertion, function | Shoulder blade muscles, Muscle anatomy, Pectoral muscles Scapular movements C:\Users\Verca\Desktop\blog-examprep-091313.jpg Muscles of the shoulder girdle •Muscles distribution according their location: • •Muscles going downward to the scapula • (trapezius – upper part, levator scapulae, rhomboidei, serratus anterior – upper part) • •Horizontal shape • (trapezius – medial part, serratus anterior, pectoralis – partially) • •Muscles going upward to the scapula • (serratus anterior – lower part, trapezius – lower part, latissimus dorsi, pectoralis minor, pectoralis maior – lower part) • Muscles of the shoulder girdle •Muscles distribution according muscle function: • •Group of muscles connecting shoulder girdle with the trunk • (trapezius, rhomboidei, levator scapulae, serratus anterior, pectoralis minor) • •Group of muscles connecting shoulder girdle with the arm (supraspinatus, infraspinatus, teres maior et minor, subscapularis, deltoideus, coracobrachialis, pectoralis maior, lattisimus dorsi) • •Group of muscles connecting shoulder blade with forearm (biceps brachii et triceps brachii) • Scapular adduction (retraction) C:\Users\Verca\Desktop\740152-training-m_trapezius.jpg Trapezius muscle http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/rhomboid-majo r-and-minor/atlasImage_large Rhomboid maj. et min. C:\Users\Verca\Desktop\blog-examprep-091313.jpg Trapezius •Origin •Medial third of superior nuchal line; external occipital protruberance, nuchal ligament, and spinous processes of C7 - T12 vertebrae • •Insertion •Lateral third of clavicle, acromion, and spine of scapula • •Action •Elevates, retracts and rotates scapula •superior fibers elevate, middle fibers retract, and inferior fibers depress scapula •superior and inferior fibers act together in superior rotation of scapula • •Innervation •Spinal root of accessory nerve (CN XI) (motor) and cervical nerves (C3 and C4) (pain and proprioception) (XI, C3, C4) • Rhomboid Major and Minor •Origin •Minor: nuchal ligament and spinous processes of C7 and T1 vertebrae •Major: spinous processes of T2 - T5 vertebrae • •Insertion •Medial border of scapula from level of spine to inferior angle • •Action •Retract scapula and rotate it to depress glenoid cavity •fix scapula to thoracic wall • •Innervation •Dorsal scapular nerve ( C4 and C5) (C4, C5) Scapular adduction – grade 5,4 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_003.jpg Position: lying prone, head on the chin, upper limbs extended, relaxed, palms up Movement: adduction of scapula (draw up the shoulder blades) Resistance: PT puts the resistance against the movement of scapula using his/her palms on the patients vertebral edge of scapula Scapular adduction – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_004.jpg Position: lying prone, head on the chin, upper limbs extended, relaxed, palms up Movement: adduction of scapula (draw up the shoulder blades) Scapular adduction – grade 2 Position: siting on the chair, the tested upper limb lying on the table (horizontal plane), elbow extended, palm down Fixation: shoulder of the uninvolved side and the chest on the tested side Movement: adduction of scapula by pulling the whole arm on the table C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_005.jpg Scapular adduction – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_006.jpg Position: siting on the chair, the tested upper limb lying on the table (horizontal plane), elbow extended, palm down Fixation: shoulder of the uninvolved side Attempt to move: palpate the area between scapula and Th spine during patients attempt of scapula adduction Scapular adduction – notes: •Don´t allow the patient to do a rotation of trunk, elevation of the upper limb, elevation of scapula or shoulders •Put the same level of resistance against the movement of scapula •The position of the head is important • C:\Users\Verca\Desktop\1108586068_2694.jpg Adduction with depression C:\Users\Verca\Desktop\blog-examprep-091313.jpg Trapezius muscle (lower part) C:\Users\Verca\Desktop\740152-training-m_trapezius.jpg Adduction with depression – grade 5,4,3 Position: prone position, head on the forhead, uninvolved upper limb lying relaxed along the body, the tested upper limb elevated, elbow extended, ulnar part of the forearm on the table Fixation: supporting the patients arm Movement: adduction and depression of scapula Resistance: PT put resistance against the lower angle of scapula and its movement down and rotation inward. The grades 5,4,3 differentiate according the amount of resistance C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_007.jpg Adduction with depression – grade 2 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_008.jpg Position: prone position, head on the forhead, uninvolved upper limb lying relaxed along the body, the tested upper limb elevated, elbow extended, ulnar part of the forearm on the table Fixation: the trunk on the uninvolved side, support the patients arm Movement: adduction and depression of scapula Adduction with depression – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_009.jpg Position: prone position, head on the forhead, uninvolved upper limb lying relaxed along the body, the tested upper limb elevated, elbow extended, ulnar part of the forearm on the table Fixation: support the patients arm Attempt to move: PT palpate a trace of contraction of lower part of trapezius muscle, in the area between lower angle of scapula and the lower Th spine Adduction with depression – notes: •The correct position of the tested upper limb is important Scapular elevation C:\Users\Verca\Desktop\blog-examprep-091313.jpg C:\Users\Verca\Desktop\740152-training-m_trapezius.jpg http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/levator-scapu lae/atlasImage_large Trapezius muscle (upper part) Levator scapulae Levator scapulae •Origin •Posterior tubercles of transverse processes of C1 - C4 vertebrae • •Insertion •Superior part of medial border of scapula • •Action •Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula • •Innervation •Dorsal scapular (C5) and cervical (C3 and C4) nerves (C3, C5, C4) Scapular elevation – grade 5,4 Position: patient sits on the chair without backrest, upper limbs relaxed along body side Fixation: not necessary Movement: elevation of shoulders in full range of motion Resistance: PT put resistance against shoulder movement C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_010.jpg Scapular elevation – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_011.jpg Position: patient sits on the chair without backrest, upper limbs relaxed along body side Movement: elevation of shoulders in full range of motion Scapular elevation – grade 2 Position: prone position, head on the table, upper limbs relaxed, lying along body side Fixation: not necessary, PT supports patients´ arm Movement: elevation of shoulders in full range of motion C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_012.jpg Scapular elevation – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_013.jpg Position: prone position, head on the table, upper limbs relaxed, lying along body side Attempt to move: PT palpates the trace of levator scapulae and trapezius muscle contraction during patients´ attempt to elevate the shoulders Scapular elevation – notes: •The movement is tested on both sides together •The arms should be supported during testing grade 2 •The head should be in central position, no movement of the head should be allowed https://www.physioadvisor.com.au/assets/256/images/13124256(300x300).jpg Scapular abduction with rotation Serratus anterior C:\Users\Verca\Desktop\atlasImage_large.jpg C:\Users\Verca\Desktop\blog-examprep-091313.jpg Stand arms-length from the wall. Keeping your feet in place, slowly move your body forward until your chin touches the wall. Push your body back to the starting position and repeat this movement 12 to 15 times. You may increase the difficulty of this exercise by holding a stability ball against the wall at the height of your head as you perform wall, push-ups. In order to keep your arms straight as you press the ball against the wall, you will have to move your feet farther away from the wall. Serratus anterior •Origin •Superolateral surfaces of upper 8 or 9 ribs at the side of chest • •Insertion •Vertebral border of scapula • •Action •Draws scapula forward and upward •abducts scapula and rotates it •stabilizes vertebral border of scapula • •Innervation •Long thoracic nerve (C5, C6, C7) (C5, C6, C7) C:\Users\Verca\Desktop\Scapular-winging-trap-shrug1.jpg Scapular abduction with rotation – grade 5,4 Position: supine position, lower limbs flexed, tested upper limb fully flexed in elbow, 90° flexion in the shoulder, scapula on the table Fixation: PT fix patients trunk below the lower angle of scapula Movement: patient moves the arm up (thus the scapula abduct and rotate) Resistance: PT put the resistance on patients´ flexed elbow, against the movement upwards C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_014.jpg Scapular abduction with rotation – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_015.jpg Position: supine position, lower limbs flexed, tested upper limb fully flexed in elbow, 90° flexion in the shoulder, scapula on the table Fixation: PT fix patients trunk below the lower angle of scapula Movement: patient moves the arm up (thus the scapula abduct and rotate) Scapular abduction with rotation – grade 2 Position: patient sits in front of the table, tested upper limb lying on the table (90° flexion in the shoulder, elbow extended, forearm on the ulnar side) Fixation: lateral part of the trunk on the tested side, below the lower scapula angle, shoulder on the untested side Movement: patient move the arm lying on the ulnar side forward (thus the scapula abduct and rotate) C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_016.jpg Scapular abduction with rotation – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_017.jpg Position: patient sits in front of the table, tested upper limb lying on the table (90° flexion in the shoulder, elbow extended, forearm on the ulnar side) Fixation: if it´s need, lateral part of the trunk on the tested side, below the lower scapula angle Attempt to move: during patients´ attempt to move the arm forward, PT palpate the serratus anterior on the vertebral edge of scapula Scapular abduction with rotation – notes: •Fixation of the trunk is necessary, any attempt of rotation of the trunk should be allowed, no elevation of the shoulders •Be precise during palpation of the serratus anterior contraction, the trace can be often overlook • •Weakness of serratus anterior • leads to scapula alata • C:\Users\Verca\Desktop\scapula alata.jpg Shoulder C:\Users\Verca\Desktop\shoulder.jpg C:\Users\Verca\Desktop\back.jpg Superficial shoulder muscles C:\Users\Verca\Desktop\blog-examprep-092513-2.png Movement of the shoulder C:\Users\Verca\Desktop\blog-examprep-092513-1.png Shoulder flexion Deltoid muscle Coracobrachialis muscle C:\Users\Verca\Desktop\deltoid.jpg C:\Users\Verca\Desktop\coracobrachialis.jpg C:\Users\Verca\Desktop\blog-examprep-092513-1.png Deltoid muscle •Origin •Lateral third of clavicle, acromion, and spine of scapula • •Insertion •Deltoid tuberosity of humerus • •Action •Anterior part: flexes and medially rotates arm •Middle part: abducts arm •Posterior part: extends and laterally rotates arm • •Innervation •Axillary nerve (C5 and C6) (C5, C6) Coracobrachialis muscle •Origin •Tip of coracoid process of scapula • •Insertion •Middle third of medial surface of humerus • •Action •Helps to flex and adduct arm • •Innervation •Musculocutaneous nerve (C5, C6 and C7) (C5, C6, C7) Shoulder flexion – grade 5,4 Position: patient sits, tested upper limb along body side, 90° flexion of the elbow, forearm in prone position Fixation: upper part of the scapula Movement: 90° flexion in the shoulder Resistance: PT put resistance on the lower part of the arm against the movement (arched) C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_018.jpg Shoulder flexion – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_019.jpg Position: patient sits, tested upper limb along body side, 90° flexion of the elbow, forearm in prone position Fixation: upper part of the scapula Movement: 90° flexion in the shoulder Shoulder flexion – grade 2 Position: lying on the untested side, lower limbs flexed, tested upper limb lying extended inner rotated on the desk Fixation: upper part of the scapula Movement: 90° flexion in the shoulder (pushing the arm along the desk) C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_020.jpg Shoulder flexion – grade 1,0 Position: supine position, tested upper limb extended, in inner rotation, lying along body side Attempt to move: PT palpates a trace of deltoid muscle contraction on the anterior part of shoulder during patients´ attempt to move the arm forward C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_021.jpg Shoulder flexion – note: •The movement has to be done with arm inner rotated. Dont´ allow the patient to do outer rotation (substitution of biceps muscle can then occur) •Dont´ allow to move the scapula (elevation or protraction) or move the trunk (usually extension) •Do the movement just in sagital plane (any abduction or rotation of the shoulder) Shoulder extension C:\Users\Verca\Desktop\blog-examprep-092513-1.png C:\Users\Verca\Desktop\latissimus.jpg Latissimus dorsi Teres maior Deltoid C:\Users\Verca\Desktop\Teres.jpg C:\Users\Verca\Desktop\deltoid.jpg Latissimus dorsi •Origin •Spinous processes of inferior 6 thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior 3 or 4 ribs • •Insertion •Floor of intertubercular groove of humerus • •Action •Extends, adducts, and medially rotates humerus •raises body toward arms during climbing • •Innervation •Thoracodorsal nerve (C6, C7, and C8) (C6, C7, C8) Teres maior •Origin •Dorsal surface of inferior angle of scapula • •Insertion •Medial lip of intertubercular groove of humerus • •Action •Adducts and medially rotates arm • •Innervation •Lower subscapular nerve (C6 and C7) (C6, C7) Shoulder extension – grade 5,4 Position: lying prone, head on the table, upper limbs internal rotated, lying relaxed along body side Fixation: upper part of scapula Movement: shoulder extension (30-40°) Resistance: PT puts resistance on the lower part of the arm against the patients´ elevation of the arm C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_022.jpg Shoulder extension – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_023.jpg Position: lying prone, head on the table, upper limbs internal rotated, lying relaxed along body side Fixation: upper part of scapula Movement: shoulder extension (30-40°) Shoulder extension – grade 2 Position: lying on the untested side, lower limbs flexed, uninvolved arm flexed, below the head, tested upper limb lying extended inner rotated on the desk Fixation: upper part of scapula Movement: shoulder extension (30-40°) pushing the arm along the desk C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_025.jpg Shoulder extension – grade 1,0 Position: lying prone, head on the table, upper limbs internal rotated, lying relaxed along body side Attempt to move: PT palpates the trace of contraction of latissimus dorsi and teres maior, during patients´ attempt to elevate the arm C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_026.jpg Shoulder extension – notes: •The arm should be inner rotated during the whole movement •The trunk and scapula shouldn´t move during testing •Don´t allow the patient to adduct the scapulas or protract the shoulders Shoulder abduction C:\Users\Verca\Desktop\blog-examprep-092513-1.png C:\Users\Verca\Desktop\deltoid.jpg Deltoid Supraspinatus C:\Users\Verca\Desktop\supraspinatus.jpg Shoulder abduction – grade 5,4 Position: sitting, elbow 90° flexed Fixation: upper part of scapula Movement: 90° shoulder abduction Resistance: PT put resistance at the lower part of the arm, against the movemet (arched) C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_027.jpg Shoulder abduction – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_028.jpg Position: sitting, elbow 90° flexed Fixation: upper part of scapula Movement: 90° shoulder abduction Shoulder abduction – grade 2 Position: lying supine, tested upper limb extended lying on the ulnar part of the forearm Fixation: upper part of scapula Movement: 90° shoulder abduction (pushing the arm along the table/desk) C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_029.jpg Shoulder abduction – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_030.jpg Position: lying supine, tested upper limb extended lying on the ulnar part of the forearm Attempt to move: PT palpates the trace of contraction of deltoid and supraspinatus Shoulder abduction – notes: •Don´t allow the patient to: elevate the shoulder, do the external rotation of the arm (substitution of biceps brachii or front part of deltoid can occur), move the trunk Extension in abduction (horizontal abduction) C:\Users\Verca\Desktop\blog-examprep-092513-1.png C:\Users\Verca\Desktop\deltoid.jpg Deltoid muscle (scapular part) Extension in abduction – grade 5,4 Position: lying prone, head on the table, tested upper limb 90° abducted and inner rotated in shoulder, 90° flexion in elbow Fixation: fix scapula over the spina scapulae Movement: extension from the above mentioned position Resistance: PT put resistance on the lower part of the arm against the movement C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_031.jpg Extension in abduction – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_032.jpg Position: lying prone, head on the table, tested upper limb 90° abducted and inner rotated in shoulder, 90° flexion in elbow Fixation: fix scapula over the spina scapulae, lower trunk if needed Movement: extension from the above mentioned position Extension in abduction – grade 2 Position: sitting next to the table, tested upper limb lying on the table – shoulder 90° abducted and inner rotated, elbow in 90° flexion Fixation: fix scapula over the spina scapulae, lateral side of the trunk Movement: extension from the above mentioned position C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_034.jpg Extension in abduction – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_033.jpg Position: sitting next to the table, tested upper limb lying on the table – shoulder 90° abducted and inner rotated, elbow in 90° flexion Attempt to move: PT palpates the trace of contraction of deltoid muscle during patients´ attempt of extension Extension in abduction – notes: •The movement should occur just in shoulder joint – no adduction of scapula or rotation of the trunk, no elevation of the shoulder Flexion in abduction (horizontal adduction) C:\Users\Verca\Desktop\blog-examprep-092513-1.png C:\Users\Verca\Desktop\pectoralis.jpg Pectoralis maior Pectoralis maior •Origin •Clavicular head: anterior surface of medial half of clavicle •Sternocostal head: anterior surface of sternum, superior six costal cartilages, and aponeurosis of external oblique muscle • •Insertion •Lateral lip of intertubercular groove of humerus • •Action •Adducts and medially rotates humerus •draws scapula anteriorly and inferiorly •Acting alone: clavicular head flexes humerus and sternocostal head extends it • •Innervation •Lateral and medial pectoral nerves; clavicular head (C5 and C6, sternocostal head (C7, C8, and T1) (C5, C6, C7, C8, T1) Flexion in abduction – grade 5,4 Position: lying supine, lower limbs flexed, tested upper limb 90° abduct in the shoulder, 90° flexed in the elbow Fixation: fix the shoulder from above Movement: 90° flexion in the shoulder from the position mentioned above Resistance: PT put resistance at the lower part of the arm (arched) against the movement C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_035.jpg Flexion in abduction – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_036.jpg Position: lying supine, lower limbs flexed, tested upper limb 90° abduct in the shoulder, 90° flexed in the elbow Fixation: fix the shoulder from above Movement: 90° flexion in the shoulder from the position mentioned above Flexion in abduction – grade 2 Position: sitting in front of the table, tested upper limb lying on the table, 90° abduction and inner rotation in the shoulder, 90° flexion in the elbow Fixation: fix the shoulder from above, lateral side of the trunk on the tested side Movement: horizontal flexion in the shoulder, pushing the arm on the table, in full range of movement C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_037.jpg Flexion in abduction – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_038.jpg Position: sitting in front of the table, tested upper limb lying on the table, 90° abduction and inner rotation in the shoulder, 90° flexion in the elbow Attempt to move: PT palpates trace of contraction of pectoralis muscle during patients´ attempt to move the arm forward Flexion in abduction – notes •Don´t allow the patient to do elevation or protraction of the shoulder •Flexion of the elbow should be 90° during whole tested movement • External rotation C:\Users\Verca\Desktop\blog-examprep-092513-1.png Infraspinatus Teres minor C:\Users\Verca\Desktop\infraspinatus.jpg C:\Users\Verca\Desktop\teres minor.jpg Infraspinatus •Origin •Infraspinous fossa of scapula • •Insertion •Middle facet on greater tuberosity of humerus • •Action •Laterally rotate arm •helps to hold humeral head in glenoid cavity of scapula • •Innervation •Suprascapular nerve (C5 and C6) (C5, C6) Teres minor •Origin •Superior part of lateral border of scapula • •Insertion •Inferior facet on greater tuberosity of humerus • •Action •Laterally rotate arm •helps to hold humeral head in glenoid cavity of scapula • •Innervation •Axillary nerve (C5 and C6) (C5, C6) External rotation – grade 5,4 Position: lying prone, head rotated to the tested side, tested upper limb lying on the table – shoulder 90° abducted, elbow 90° flexed (arm supported with the pillow, forearm relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: external rotation in full range of motion from the position mentioned above Resistance: PT put resistance on the distal part of the forearm C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_039.jpg External rotation – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_041.jpg Position: lying prone, head rotated to the tested side, tested upper limb lying on the table – shoulder 90° abducted, elbow 90° flexed (arm supported with the pillow, forearm relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: external rotation in full range of motion from the position mentioned above External rotation – grade 2 Position: lying prone, head rotated to the tested side, tested upper limb in 90° flexion and inner rotation in the shoulder (hanging from the table, relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: external rotation in full range of motion from the position mentioned above C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_043.jpg External rotation – grade 1,0 Position: lying prone, head rotated to the tested side, tested upper limb in 90° flexion and inner rotation in the shoulder (hanging from the table, relaxed) Attempt to move: PT palpates contraction at the dorsal part of the shoulder during patients´ attempt to external rotate the arm C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_044.jpg External rotation – notes: •The muscles of the forearm and the hand should be relaxed during testing •No extension of the elbow or wrist is allowed •When testing grade 2, no rotation of the forearm Stand with your feet shoulder-width apart and raise your upper arms so that they are parallel to the floor with your elbows bent at right angles. Gently rotate your arms downward as far as you can without experiencing pain. Repeat for 15-20 repetitions. Internal rotation C:\Users\Verca\Desktop\blog-examprep-092513-1.png Subscapularis Pectoralis maior Latissimus dorsi Teres maior C:\Users\Verca\Desktop\subscapularis.jpg C:\Users\Verca\Desktop\pectoralis.jpg C:\Users\Verca\Desktop\latissimus.jpg C:\Users\Verca\Desktop\Teres.jpg Subscapularis •Origin •Subscapular fossa of scapula • •Insertion •Lesser tuberosity of humerus • •Action •Medially rotates arm and adducts it •helps to hold humeral head in glenoid cavity of scapula • •Innervation •Upper and lower subscapular nerves (C5, C6 and C7) (C5, C6, C7) Internal rotation – grade 5,4 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_045.jpg Position: lying prone, head rotated to the tested side, tested upper limb lying on the table – shoulder 90° abducted, elbow 90° flexed (arm supported with the pillow, forearm relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: internal rotation in full range of motion from the position mentioned above Resistance: PT put resistance on the distal part of the forearm Internal rotation – grade 3 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_046.jpg Position: lying prone, head rotated to the tested side, tested upper limb lying on the table – shoulder 90° abducted, elbow 90° flexed (arm supported with the pillow, forearm relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: internal rotation in full range of motion from the position mentioned above Internal rotation – grade 2 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_047.jpg Position: lying prone, head rotated to the tested side, tested upper limb in 90° flexion and external rotation in the shoulder (hanging from the table, relaxed) Fixation: fix the lower part of the arm (lightly), scapula over the spina scapulae if needed Movement: internal rotation in full range of motion from the position mentioned above Internal rotation – grade 1,0 C:\Users\Verca\Desktop\MMT (4) Shoulder, scapula, elbow, fotky\WP_20151001_048.jpg Position: lying prone, head rotated to the tested side, tested upper limb in 90° flexion and inner rotation in the shoulder (hanging from the table, relaxed) Attempt to move: PT palpates contraction at the dorsal part of the shoulder during patients´ attempt to internal rotate the arm (deep palpation) Internal rotation – notes: •The muscles of the forearm should be relaxed during whole tested movement •Flexion of the elbow should be 90° during whole tested movement Literature, e-sources •http://www.webmd.com/pain-management/picture-of-the-shoulder •https://www.acefitness.org/blog/3535/muscles-that-move-the-arm •http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body • Thank you for your attention J C:\Users\Verca\Desktop\bad_shoulder_2.png