We're going to talk about
the upper extremity
and the osteopathic considerations
when thinking about the arms.
We're going to talk about the shoulder first,
the elbow, the wrist, and the hands.
We're going to cover anatomy, pathologies,
diagnosis, and management.
I want to start with the shoulder
because it's a complicated joint.
There are a lot of problems that
happen with the shoulder girdle.
It's actually four joints. But let's talk about
the scapula (the wing bone),
the humerus (the arm), the clavicle,
and the sternoclavicular joint
that all come together to
form the shoulder girdle.
That joint has a lot of
problems, a lot of pain,
and is a complicated
one to assess.
So besides the four joints, the bones,
there are also four muscles.
We call them them the
rotator cuff muscles.
It's the supraspinatus, infraspinatus,
teres minor, and subscapularis.
Those are the four muscles
that make up the rotator cuff
and move the shoulder
in all the directions.
The supraspinatus will cause abduction,
moving it closer to the body.
The infraspinatus will
cause external rotation.
The teres minor also
helps in external rotation.
The subscapularis does
So those are the
four main muscles.
But you also have a contribution for
shoulder motion from the biceps
because the long head of the biceps is going
to go into the subglenoid region.
The short head is going to go into the
coracoid process and move the shoulder.
So, if you go back and look at
the shoulder one more time
and think of it as a strut, it's important
to realize that the coracoid process
that comes out under the clavicle
is part of the scapula.
The scapula is connected to both the
arm and to the acromion bone.
So it's going to have multiple connections
which makes it complicated
and difficult to manage because one problem
is going to cause other problems.
Having the four muscles and the four tendons
there can cause problems with motion.
The long head of the biceps is going to have
its origin in the subglenoid tubercle.
The short head of the biceps is going to
have its origin in the coracoid process
and insert in the radial tuberosity
in the bicipital aponeurosis.
So these are the basic
areas to think about.
The boundaries of the
shoulder are the clavicle,
the first rib which is deep to the clavicle,
the subclavian muscle,
and the anterior and posterior
scalene muscles that you can see,
the subclavian vein which is deep
and able to be cannulated,
the subclavian artery even deeper,
and the brachial plexus of nerves
which is coming
underneath the muscles.
Shoulder pathologies: We are going
to see shoulder dislocation
particularly with trauma.
We’ll see shoulder separation.
We'll see adhesive capsulitis.
Those are the three
main shoulder pathologies you'll
see in a general practice.
A shoulder joint location is
typically anterior and inferior.
It's from a smack, or a hit, or a fall,
kind of when playing contact sports.
It's when the humeral head,
the top of the arm,
gets pulled out of the glenoid
fossa and inhibits motion
because it's no longer
pulled efficiently by
the muscles involved.
If you want to test for it,
it's a tough test
because somebody who dislocates
their shoulder is in a lot of pain.
They're protecting their arm.
They don't want to move it.
What you want to do is to have them
go to 90 degrees and lift up.
But if you try and separate it and it's got
an anterior and inferior dislocation,
they're not going
to let you.
If you do get there and you see the grimace,
you understand there's a dislocation.
If you can't get it externally rotated, there's a good chance it's dislocated.
If you can't get it to 90 degrees, there's a good chance it's dislocated.
Some of the issues to worry about are joint
instability and assessing for the arm
being out of the shoulder joint
and unable to function.
So if a person cannot externally
rotate because the supraspinatus
is unable to abduct,
that's a good sign.
If they can't move their arm and
they're protecting their arm,
that's a sign you may have
a shoulder joint dislocation.
The management of a shoulder dislocation
is a reduction, put it back into joint.
The problem is when you
dislocate the shoulder,
you're going to have some hypertonicity.
You're going to have some contraction.
As the hours go on, the contraction of
the muscle is going to get tighter.
Pulling the arm to where it can go back
in the joint is going to get more difficult.
From an osteopathic perspective,
you can deal with the hypertonicity.
You can treat the hypertonicity as a prelude
to putting the arm back into place.
So while muscle strengthening
is a long-term treatment,
flexion and extension
muscle energy techniques
and fatiguing the muscle will
help with the hypertonicity
and help you put a dislocated
shoulder back into joint.
Shoulder separation is also trauma-related
when the AC joint is pulled.
It could be simple or complex.
It could be one ligament or two.
connect bone to bone,
they will connect the sternoclavicular joint
and the AC joint, acromioclavicular joint.
The management of an AC separation
is going to be medical:
rest, ice, analgesia, immobilization,
and if it is severe, surgery.
But most of the time we're
letting it heal on its own,
giving it time to see
what's going to happen.
In the osteopathic treatment realm,
you have indirect techniques
and passive techniques to
deal with the discomfort
and to help the body heal
itself as much as possible.
Adhesive capsulitis is a loss of motion,
a restriction in the shoulder
Autoimmune disease, diabetes,
hypothyroidism can all cause
an adhesive capsulitis more
common later on in age.
An adhesive capsulitis
is a loss of motion
from an autoimmune
disease or other etiology.
The test is called the Apley's
Scratch test to see
if you have a loss of motion
in the shoulder joint.
The Apley’s Scratch test is when
you touch your scapula,
touch your scapula,
and touch your scapula
and see how far a person can
go to touch their scapula.
If you get to about the same area,
you're in good shape.
If you can't get close, you're starting
to have some trouble.
We'll do a separate short video
on the Apley’s Scratch test
just so you're aware of how
to do it and when to do it.
Management of adhesive capsulitis
is local with heat, ice, analgesics.
Occasionally, you can get a corticosteroid
injection or anti-inflammatory.
Surgery is an
option as well.
From the osteopathic medical world,
we will do some muscle energy.
We will work on the external rotation
in order to help enhance motion.
There's something called
the 7 Steps of Spencer.
The Spencer techniques will help
enhance motion, maintain motion,
and is a treatment for
Other shoulder issues we worry about are rotator cuff tears,
and biceps tendonitis,
and biceps issues.
Starting with the rotator cuff tear,
a rotator cuff tear
is a tear of one of the four
muscles of the rotator cuff:
the supraspinatus, infraspinatus,
teres minor, or subscapularis.
You will know if you tear
a portion of the rotator cuff
by having a loss of use
or a loss of motion.
The test for the rotator cuff
muscles are simple tests.
It's drop arm. Can you lift your arms
all the way up and do they fall?
Can you lift them
above 90 degrees?
The empty can test is basically holding
a can and spilling it over.
If you can do that, your rotator
cuff is intact, all three things.
Generally, you will know when
you have a rotator cuff tear.
It is painful. People will
hear a snap or a pop.
Again, they've lost the ability to do
something they were doing before.
They may not always try
and empty a can
but they know if they
Management of rotator cuff
tears is very difficult.
We treat it locally at
with rest, ice, analgesics,
We do offer myofascial release and
facilitated positional release
to help enhance motion. But if you
have a loss of anatomic motion,
you're also going to have a
loss of physiologic motion.
So, you're going to get some
benefit but not total benefit.
this is an inflammation
of the tendons of
the rotator cuff.
Usually, the supraspinatus is the most
common impingement syndrome
but it can occur with any of
the rotator cuff muscles.
We'll talk about
the tests later.
The Neer’s sign and the
are different ways of looking
for impingement syndromes.
Again, there'll be short videos on Neer’s
sign and Hawkins-Kennedy test.
Management of an impingement
syndrome is medical at first
with rest, ice, analgesia, a corticosteroid
injection or analgesics.
We will do strain counterstrain
for impingement syndromes.
We'll do myofascial release as
well and muscle energy.
The counterstrain point is around
the area of shoulder flexion
of the forearm.
So, you're going to find
the counterstrain point
and then find the
position of ease.
Muscle energy can also be done to
help with impingement syndrome.
When you have inflammation,
or degenerative changes,
surrounding the long
head of the biceps.
We'll talk about the different
tests for bicep tendonitis.
There's the Yergason's test
and Speed’s test,
both of which we'll have
short videos showing you
how to do these
tests as well.
Treatment of impingement
syndrome is local at first
with rest, ice, analgesia,
and question of steroids.
We will do counterstrain
and myofascial release.
This is to both the long
head of the biceps
and the short head
of the biceps.
When the shoulder neurovasculature
is interrupted or hurt,
it may be a medical
and it needs to be taken
care of right away.
When someone has severe pain,
or numbness and tingling
in the vascular or
it could be due
to a compression
of the neurovascular structures
of the shoulders.
This needs to be
paid attention to.
The test for neurovascular compromise
is called Adson's test.
You can evaluate this and
we'll go through that test
in a separate
video as well.
But if you have a loss of pulse
when you're doing the test,
to worry about.
When you talk about osteopathic
management of thoracic outlet,
we will treat
the first rib.
We will treat the
as well as the
You can use muscle energy or
balanced ligamentous tension
to treat these