Movement Impairment Syndrome of shoulder & scapular joint 세란척추운동센터김대훈 1 Normal alignment of scapula Vertebral borders about 2 to 3 inches frome the spine and parallel to the spine Scapula held flat against the thorax Scapular on thorax between T2 and T7 30deg. Anterior to frontal plane 2 Depressed scapular Scapula 의 superior border 는 thoracic V7 보다밑에위치하게된다. Long - Upper trapezius short -pectoralis major latissmus dorsi 견갑골하강은견관절굴곡시상완견관절과견쇄관절에스트레스제공 Elevated scapular Right slightly higher than left Inferior angle 이 thoracic V7 보다위에위치 Lateral clavicle higher than medial Short-Upper trapezius levator scapulae 만약 Rhomboid 까지단축되면내전되어보인다. 3 4 Adducted Scapula Scapula is less than 2 and ½ inches from the midline Short: Rhomboid upper trapezius Long: Serratus anterior Brace 8 figure ( 스튜디어스한쪽으로물건끌때 ) Abducted Scapula The vertebral border of the scapular is more than 3 inches from the midline It is also rotated more than 30deg. Anterior to the frontal plane Glenoid face anteriorly ( 앞쪽이파인다 ) Short : serratus anterior pectoralis major 5 6 1
Scapula downward rotation Tilted or tipped Upper : wide Lower : narrow Short muscle - Levator scapulae - Rhomboid muscle Long muscle - Trapezius upper - Serratus anterior ( 어깨통증있는사람들은흔하다 ) The inferior angle protrudes away the rib cage Short muscle : Pectoralis minor biceps short head Coracobrachial Anterior deltoid 7 8 Winging Scapula The vertebral border protrudes posteriorly from the thorax This alignment is often associated with weakness of serratus anterior muscle Rounder shoulder or scoliosiscontributing factor Shoulder 움직일때 scapulohumeral muscle 이짧아져서 medial rot 시 winging of the scapula 유도한다. 9 10 * Scapulohumeral rhythm = 1( 견갑골 ):2( 상완골 ) 완전히굴곡했을때상완관절움직임은 120 도이고견흉관절움직임은 60 도이다 * Check timing and range of scapular motion * Use thumb and compare both side * Coordinate system for the trunk, scapular and humerus Inferior angle laterally no more than 1/2inch beyond posterolateral border of thorax with humerus in full flexion or abduction * Inferior angle resches midaxillary line with full shoulder flex and abd * Minimal scapular abduction during shoulder flexion or abduction ( 과도하게움직이면 teres major short) 11 12 2
검사법 - Teres major short : elbow inter. rot Back wall 자세에서양팔을올릴때 inter rot 이생기면 shortening 또한양팔을올릴때벽에서허리나등이들리면광배근단축 ) 굴곡시저항을주면 ROM 이감소 13 * Scapulae do not wing during arm movements, during flexion or abduction and return from flexion and abduction( 근육이이완되는타이밍의문제이다 ) Ex) During return from shoulder flexion, wining of scapula occurs because serratus anterior is elongating faster than the scapulohumeral muscle (Sacpular 가갑자기과도하게움직이면전거근이 Ecc. Con 못하여팔을내릴때소리가난다 ) 14 * Spine Shoulder full flexion, abduction 하는동안 Minimal movement of the spine 가일어난다. 따라서비교적 thoracolumbar Junction 이유연해야한다 * Kyphosis 의경우견갑골은늑골볼록 (convexity) 에의해앞쪽으로기울어져견관절굴곡을제한 Shoulder girdle muscle * Alterations in the counterbalancing actions are a major factor in the development of movement impairment syndromes * Alteration in the actions of the a: Thoracoscapular muscle b: Scapulohumeral muscle c: Thoracohumeral muscle 15 16 Shoulder muscle Thoracoscapular muscle * Thoracoscapular muscle: responsible for the scapula movement * Scapula 는 glenohumeral joint 에비정상적인스트레스를최소화하기위해 humerus 와최적의상태를유지하려한다. * Muscle - Upper tra. Levator scapula, rhomboid, serratus ant, pectoralis minor 17 18 3
Upper Trapezius * Short - elevated scapula - shoulder flexion시반대로 neck rot * Long - depressed scapula - Scapula fail to elevate during shoulder flex.abd (neck pain) but Both shoulder flexion - no pain due to stabilization * 승모근강화운동 ( 양손들고 10간유지 ) Levator scapula Function- add and downward rot scapular elevation adduction 시 trapezius 와 Synergist 역할, Rotation 시는 antagonist Short: elevation of the superior angle of the scapular with depression of the acromion Quadruped 자세에서강화운동 ( 목회전후 10 초간유지하기 ) 19 20 Rhomboid muscle Function- add,downward rot 승모근보다우세하면 scapula 의 upward rotation 을제한한다 Shrugging exercise - reinforcement rhomboid and levator scapula Shrugging with arm overhead exercise- facliltate upper trapezius muscle Rhomboid dominance 검사 1. Elbow flexed and external rotation - normal: No adduction of scapula first 35deg - abnomal: Adduction occur 2. Rhomboid dominance and poor control of glenohumeral lateral rotation ( 외회전근육의약화 -Infraspinatus and teres minor 3. Shorting 시승모근이견갑골상방회전시키기위해시도함으로써 AC joint 에스트레스부과 21 22 Serratus anterior Function: abd, upward rot, hold the scapular flat against the rib cage 대게 serratus anterior m 에의해서 scapular 의조절에손상 * Trapezius& serratus anterior Both ; upward rotator 로써 shoulder flex and abd 시 Scapula 의 medio-lateral position 을조절하는데중요하다 * 전거근강화운동 ( 짐볼 ) Pectoralis minor * Function: Tilt the scapula anteriorly,downward rot. Short: 견갑골 anterior tilt 로 upward rot 을방해한다 - more sever-short and stiff abdonimal muscle - 단축시견갑골외연이바닥에 1 인치이상뜬다 ( 대원근신장 ) * Wall ex(shoulder-90deg abd. elbow-flex) 23 24 4
Pectoralis major Thorcohumeral muscle Function - 상부섬유 : 견관절굴곡 - 하부섬유 : 견갑대하강 임상적양상 : sternal portion 은단축되고 clavicle portion 는길어진다. ( 흉골부단축은견관절 155 외전제한 ) 이완법 (rib 거상막고 sternal 위, clavicle- 옆 ) Latissimus dorsi Function - 견관절내회전내전신전 - 견갑대하강 - 양측성시척추신전, plevic ant-tilt 단축시 견관절굴곡제한 (full flexion 시단축검사 ) *Teres major( 단축검사 ) 25 26 Scapulohumeral muscle * Most common impairment 1. lateral rotator shortness or stiffness 2. lateral rotator 의활동이약하면 acromion 이 greater tuberosity 의충동을예방하기위해 lateral rotator 의부적당한움직임이발생한다. 3. Subscapularis 의활동이약하면 Causing anterior and superior glide 4. Deltoid 가우세하면 전방, 상방골두유발 Causing humerus head to glide superiorly 5. Shortness of capsule( 특히후방하부관절낭 ) 27 Functions of the Rotator Cuff muscles Supraspinatus : compresses the humeral head directly into the glenoid fossa subscapularis, infraspinatus, teres minor : produces in inferior-directied translation force on the humerus head infraspinatus, teres minor : rotates the humeral head externally 28 Impingement Primary impingement in the shoulder * Shoulder instability 정의어깨의생리학적움직임에있어 functional 및 structural 결함 * 1 차적충돌 : 불안정성이없는완전한충돌 * 2 차적충돌 : 불안정성을가지고있는충돌 극상근 is impinged under acromion and coracoacromial lig. 상완골내회전상태에서견관절 90 이상외전시충돌위험증가 마찰의증가 - 염증반응 건염으로진행 ( 치유가어렵다 ) 충돌로인한마찰반복시미세열상과회전근비대 - 견쇄관절의 2 차적골의변화진행 ( 상완이두건과견쇄관절의충돌도비슷하다 ) 29 30 5
Force couples * Coronal plane FC * Transverse FC DRST (dynamic rotary stability test) CFC 는역동적으로움직일떄 glenoid fossa 안에상완골두를유지하는역할 ( 앞 : subscpularis, 뒤 : infraspinatus) ( 앞 : Deltoid 의 superiorly, 뒤 : rotator cuff 의 lower 요소 ) 31 Rotation 시 glenoid fossa 안에상완골두를유지하는 rotator cuff 의능력을평가한다. ( 검사시 end rang 에서는 HH 가튀어나오지만 Mid rang 에서부터나오면음성 ) 32 supraspinatus * Function:abd,lat rot, 상완골두을견갑관절와안에 stabilize 시키고하강시킨다. Acromion 밑으로통과하여어깨가하강하였을때손상받기쉽다. (ex: 오훼견봉인대는 abd 90 도나내회전을증가할때대전자결절이 impingment 위험이증가한다 ) 33 Infraspinatus and teres minor * Function: lat rotator, depressor * Short and stiff : 상완골두를 posterior glide 시킨다. ( 짧아지면팔이뒤로간다 ) * External rotation test ( 검사 : prone 상태에서 External rotation 실시 ) -- infraspinatus 보다 post deltoid 많이사용 34 Subscapularis * Function:med rot, anterior glide 없이 depressor pectorlis major 와 latissmus dorsi 도같은내회전근육으로크고강력하기때문에 Subscapularis 는약화되기쉽다 Subscapularis 가약하면과도한전방미끄러짐으로 anterior capsule 이얇아진다 ( 충돌증후근 ) 검사법 : supine 에서 int rot 시킨다상완골두가들리면단축, pectorlis major 와 latissmus dorsi 는 end-range 에서수축해야한다 등척성운동시킬것 35 * Function: med rot, add, * Short : limt shoulder ext rot * 검사법 : back wall 에서주관절과견관절을 flex 시키고 Teres major 36 6