LECTURE 10: LUMBAR SPINE

The Motion Segment: The Functional Unit of the Spine (front and back)

Anterior Portion:
- 2 intervertebral bodies
- Disk
- Longitudinal Ligaments
Posterior Portion:
- Vertebral Arches
- Facet (Zygapophyseal Joints) - joints in your spine that make your back flexible and
enable you to bend and twist. Nerves exit your spinal cord through these joints on their
way to other parts of your body. Healthyfacet joints have cartilage, which allows your
vertebrae to move smoothly against each other without grinding.
- Transverse and Spinous Process
- Ligaments - very thin, not a lot of protection, we were made to be on all fours

The Anterior Portion:

- There's 5 lumbar vertebrae
1. Vertebral Body:
- Bears progressive, compressive loads
- Becomes larger caudally (closer to the end of the body)
2. Disc:
- Bears loads and restrains excessive movement
- Nucleus Pulposus (NP) is
hydrophilic (water binding)
and is more posterior in the
lumbar spine,surrounded by
fibrous cartilage, annulus
fibrosus.
- When the spine is loaded,
the NP acts hydrostatically,
allowing even distribution of
the load
- Ageing: the disc has less
water content and therefore
can not distribute or store
energy efficiently, so less
ability to respond to
stresses.
- The disc is more posteriorly
displaced so when we do flexion, the disc will go in opposite direction of trunk (if we go
forward it goes backwards, if we go to the left, it goes to the right)
 - Since it is already posterior and if we go more posterior when we flex forward, we only
have thin longitudinal ligament that really cant protect it
- If we combine flexion and rotation (Double whammy), you are putting a lot of torque
forces on the disk which can cause ripping of the Annulus fibrosus which causes NP to
leak through.
- Lose water to the disks as we get older, which makes it much worse later
The Posterior Portion:
1. Facet Joints:
- Oriented at right angles to the transverse plane and 45 degrees to the frontal plane
- Allows flexion, extension and sidebending, but hardly any rotation
- Facets have a load-bearing function, highest during extension (this is because they are
posterior and are being brought closer together, the lumbar lordosis is extended even
when standing so with a movement is worse)
- Forward bending and rotation:
highest loads within the disc
2. Vertebral Arch and Intervertebral
Joint
- Resists shear forces
3. Transverse Process and Spinal
Process:
- Sites for attachment of spinal
muscles

Facet Joint Orientation:

1. Cervical (C3-C7)
Transverse: 45 degrees
Frontal: 0 degrees
2. Thoracic
Transverse: 60 degrees
Frontal: 20 degrees
3. Lumbar
Transverse: 90 degrees
Frontal: 45 degrees

Ligaments of the Spine:

- Except Ligamentum Flavum, all
ligaments of spine have high collagen
content which limit extensibility of the
spine creating stability
- Ligaments are supposed to create
stability but allow for a little bit of
movement

Ligamentum Flavum:
 - Sometimes it gets hypertrophy from excessive movement and loads, which causes it to
get thicker which can cause it to encroach upon a peripheral nerve
- Large content of elastin
- Contracts during extension (along with the posterior longitudinal ligament)
- Elongates during flexion (along with the posterior longitudinal ligament)
- Under constant tension during neutral spine
- What is neutral spine? A good posture, lordotic spine, no sagging and not forcing to sit
up straight, pull in belly button into spine (dynamic lumbar stabilization) while still
breathing, hold in transverse abdominus
- Helps create pressure in the disc for support of the spine
- Degenerative changes of spine, loads the Ligamentum Flavum (LF), causing
hypertrophy, causes peripheral nerve compression when it thickens and also causes
bone spurs

Muscles of the Lumbar Spine:

- Flexors: abdominals and psoas
- Lateral: Quadratus Lumborum (used for side planks), Obliques
- Extensors: erector spinae, multifidus, intertransversarii
- Major Supporters:
1. Multifidus
2. Transversus Abdominus

How to exercise the Multifidus?

- To isolate these muscles, you will do best to co-contract them with your pelvic floor
- Start by lying on the floor with your knees bent and gently pull up on your pelvic floor
- You will then tighten your multifidus by pulling your tailbone up towards your spine
- You should feel a tightening on your lower
back, but do not let your back arch up, it
should stay in its neutral position
- Some people are able to feel the muscles
tighten by putting their hand in the small of
their back about one half an inch off of your
spine; not everyone can feel these muscles
tighten so do not get frustrated if you cant feel
them.

Muscle Activity with Lumbar ROM

- When you bend to the right, most of the work is
being down by the left side muscles
- Mostly being pulled downward by gravity
- Similar to quad when leg is swinging through, it is
mostly being carried by momentum
- Side bending and lateral flexion are the same
Statics and Dynamics of the Spine

Statics:
- S-shape: cervical lordosis, thoracic kyphosis, lumbar lordosis, there should be curves in
the spine
- This S-shape allows for more shock absorption versus a straight spine.

Statics of the Spine:

- Standing: Postural muscles are active
- Center of gravity of trunk is ventral of L4, creating a forward bending moment, increasing
activity of posterior ligaments and muscle activity (always have tendency to go forward
so erector spinae muscles are always working to pull us back to create equilibrium)
- Overweight people are being pulled forward even more
- Postural Sway - standing in one spot and going to move, one of reasons for this is
pooling of blood so we dont faint
- Sacral tilt is normally 30 degrees
- Sacrum tilting forward
> increases angle and accentuates the lumbar spine lordosis: what does this do to the
iliopsoas?
> anterior pelvic tilt, increased lumbar lordosis
> hip is flexed so hip flexors are shortened
> facet joints are closer together
- Sacrum tilting backward
> decreases angle and decreases the lumbar spine lordosis: what does this do to the
Hamstrings?
> Less than 30 degrees, causes posterior tilt, muscles in thigh are shortened so
hamstrings are going to be tight

Comparative loads of lumbar spine with Standing, Sitting, and Reclining

- Reclined: low loads
- Standing: Medium loads, keep lordosis, keep curve in spine, loads are gonna be more
manageable
- Sitting: high loads: why? When we sit, we usually slouch forward, pelvis rotates
backward anyway, goes into a posterior pelvic tilt, so
loads automatically go up
Different Positions Affecting the Loads in the Lumbar Spine
- Sitting with lumbar support and reclined position of
about 110 degrees creates fewer loads on the disc
than unsupported sitting (least amount of pressure on
disks when you are sitting)
- Supine positions with legs extended have higher loads
than when the legs are bent .., why? When the leg is
extended, you pull on psoas, pull on spine more, psoas
is more relaxed when knee is bent.
Static Loads on the Lumbar Spine During Lifting:
- Highest loads on the spine occur with lifting
- Flexion and rotational movements create the greatest loads (are the worst)
- Age and degree of degeneration creates a situation where it takes less forces and less
range of motion (ROM) into flexion and rotation to cause an injury
- Several factors influence the loads on the spine:
1. The position of the object relative to the center of motion of the spine (keep it close to
body)
2. The size, shape, weight of the object
3. Degree of flexion and rotation of the spine
4. Rate of loading (repetition, repetitive use injury)

Dynamics:

Walking:
- Maximal loads of the spine during toe-off (because you are pushing off, more forces
involved)
- Trunk extensors are the most active because you are moving forward
- Limited arm swing increases compressive loads
- Faster walking speed can increase the loads of the spine

Exercises:
- Supermans: high activation of the erector spinae muscles, high stress of the spinous
processes, preferable to put a pillow under the abdomen
- Full sit up:produces higher loads on the lumbar spine, crunches are more preferred
because it limits lumbar loading
- Reverse curl: performed isometrically can be as effective with muscle activation than sit
up with less load on the lumbar spine.

Mechanical Stability of the Lumbar Spine:

Intra-Abdominal Pressure:
- Unloads and creates stability of the spine
- The pressure by the coordinated efforts of the diaphragm, abdominal and pelvic floor
muscles
- This contraction creates an extensor moment decreasing compressive forces on the
spine
- Contributes to stability because of co-contraction of the extensors and flexors
- Transverse abdominis, diaphragm and multifidus creates stability of the spine

Herniated Discs:
- As we bend forward, the NP migrates posteriorly
- As we extend backward, the NP migrates anteriorly
 - Posterior Longitudinal Ligament: is the thinnest in the lumbar spine, combine with
repetitive loads from bending and twisting can cause disc bulging or herniation
- HNP can occur antero-centrally, postero-centrally, postero-laterally
- Repetitive movements (McKenzie Treatment) how can this reduce a disc? Uses idea of
bending forward, NP goes back, go through 4 movements: weighted flexion and
extension then unweighted flexion and extension on back, look for repetitive movements
if they put this material back into its central location, if symptoms go down to calf, its
peripheral, if it goes to buttocks its centralizing. WAnt you to centralize your symptoms,
pain should go to center, promote movements that centralize symptoms. Sometimes
centralizing symptoms makes pain worse, which is what we want because it gets bad
but then it can heal, give patient education
- Large HNP? Smaller HNP?

Use of Lumbar Bracing

- No significant studies support efficacy of the use of brace
- Not preventative, may give false sense of security
- No change of decreasing muscle activity
- Best treatment and advice: Proper posture,body mechanics, and ergonomics

Other Pathologies:
- Spinal Stenosis: caused by osteo or disc? Different types of treatment? Stenosis is a
narrowing of a passageway. Caused by bone spurs, NP herniating, hypertrophy with LF.
Treatment is repetitive movements backwards, normally NP goes in opposite direction,
so we have movement of choice. Sometimes herniated disk is so massive, it leaks so
much so do extension and cause more of a problem so need surgery. If NP is still
contained then extension might be ok.
- Spondylolisthesis: contra-indications? It is when one vertebrae is more forward than the
other. Promotes flexion, avoid extension (grade 3 or 4, need surgery to fuse spine)
- Osteoporosis: precaution? It is having weak bones. The precaution is to be careful of
flexing forward since the vertebrae are getting closer together. When you extend, facet
joints get closer together. Have to be careful with extreme movements.
- Osteophyte:

Effect of Foot Posture on the Lumbar Spine:

- If one foot is overpronated, it can create a snowball effect, travels up body causing
problems further up
- Even for a headache, check foot to see if rest of the side is okay

Dermatomes
- Nerve roots that line up with sensory patterns with your leg, a map of the body
- Numbness or tingling, should see how it lines up in a pattern in connected nerve roots in
area in body
Myotomes: muscular aspect of nerve roots
- L2 - Hip Flexion
 - L3 - Knee Extension
- L4 - Ankle Dorsiflexion
- L5 - Hallux Extension
- S1 - Knee Flexion or Ankle Plantarflexion

LECTURE 11: the Cervical

The Cervical
- 7 Cervical vertebrae: C1-C7
- Atypical joints: OA (occiput and atlas or atlanto-occipital joint) and the AA or atlanto-axial
joint.
- C3-C7 are more similar in structure
- Lordosis is assisted by wedge shaped discs, like lumbar discs, which are larger
anteriorly
- O-A-A joints make up 40% of cervical flexion and 60% cervical rotation (upper cervical
spine)
- Atlas has concave masses that joint with convex occipital condyles: Flexion and
Extension, sagittal plane

OA Movement:
- Tilting, nodding, flexion, and rotation (upper cervical spine movements)
- Tilt head to Right:
> Right occipital condyle moves anteriorly (forward)
> Left occipital condyle moves posteriorly (backwards)
> when we flex, both condyles go backwards
> when we extend, both condyles go forward

Component Anatomy and Biomechanics

- C3-C7 - angle of facet joints transitions to thoracic vertebrae
- Spinous process and transverse process is much bigger in C7
1. Spinous Process
2. Transverse Process
3. Lamina
4. Facet Joints
5. Uncinate Process: arise from the lateral margins of the superior end plates of the
vertebral body

Discs:
- Contribute to height of spine
- Viscoelastic material allowing it to sustain great loads when they are rapidly applied
- NP has Type II collagen resisting higher loads than type I
- Helps create stability of NP to keep it encapsulated
- NP is 90% water and AF is 78% water
- AF collagen fibers run 120 degrees to each other allowing for stability and flexibility
 - AF has 60% Type II and 40% Type I collagen

Mechanical Properties

Ligaments:
- High collagen content
- Ligamentum Flavum highly elastic
Vertebrae:
- Compression strength increases from the Cervical to the Lumbar direction
- Bending moments occur in the vertebral bodies during movements
- Flexion causes tensile forces posteriorly and compressive forces anteriorly
Disc:
- Viscoelastic properties such as creep and relaxation
- Hysteresis: viscoelastic phenomenon that refers to deformation of a tissue because of
short duration loading. Helps to protect the spine and nervous system during rapid
loadings.

Muscle:
- Cervical spine requires good strength and control for head and neck balance
- Direct relationship between muscle strength and decreased stresses on the bone
- Higher tensile loads in low cervical spine during flexion moments

Neural Elements:
- Low tolerance for axial translation
- Compressive tolerance between 2.75 to 3.44 kN
- Extreme or sudden flexion-extension movements can cause injury if combined with
spinal stenosis. (if you already have spinal stenosis, a whiplash injury can cause
neurological issues if there is swelling because nerve has nowhere to go)

Kinematics:
- 3 degrees of freedom
- Rotation and sidebending occur during the same amount of flexion/extension
- Rotation and sidebending occur in the SAME direction

Range of Motion:
- C3-C7 Rotation: 90 degrees total between C3-C7, 45 degrees from neutral each way
- Side-bending: about 98 degrees, 49 degrees each way (almost same as above)
- Flexion/Extension: 40 degrees of flexion, 24 of extension
- During normal activities:
Tying shoes
Backing up a car - blind spot, neck problem person has issue with driving
Washing hair in shower
Crossing street
Surface Joint Motion:
- Instant Center Point of flexion/extension is located in the anterior part of the lower
vertebrae
- When you are moving neck (flexion/extension) there is a gliding motion and instant
center goes anterior to posterior if it is degenerated
- Analysis that takes place with instant center point analysis is that gliding takes place (11-
18)
- A
cciden
t
occur
s with
whipla
sh
injury,
what
happe
ns to
the
instan
t
center
point?

(11-19)
- Increase size of foramina with flexion and
decrease in size with extension.

Coupled Motion of the Cervical Spine

Atlanto-axial Segment:
- Rotation of C1-C2 is coupled with vertical
translation and a degree of antero-posterior
displacement (there is some movement up and
forward and back)
- C1C2 is most stable in neutral position

Coupled Motion of the Cervical Spine

- All movements determined by direction of vertebral
body
- Subaxial Spine
Side-bending one way causes SP to move in the
opposite direction (11-21)
 Axial level C2, there are 2 degrees of coupled axial rotation for every 3 degrees of side-
bending
At C7, there is 1 degree of axial rotation for every 7.5 degrees of lateral bending or side-
bending
Facet joints and uncovertebral joints (joints of Luschka) (climb up to vertebrae above it
and cause fusion) contribute the most with coupled movements of the low cervical spine
Uncinate Process reduce motion coupling and primary movement

Uncovertebral Joints:
- Uncovertebral joint arthrosis involves what is known as the joints of Luschka, extending
from C3 to C7
- Lateral aspect of vertebral body has superior projection (uncinate process)
- As the disks become degenerative, these projections approximate with the body of the
next highest vertebra
- Result is degenerative joint changes called the joint of Luschka

Conceptual Types of Instability

- Combined Component and Kinematic
- Component Instability:
Trauma, Tumor, Surgery
Degenerative and Developed changes
- Kinematic Instability:
Motion increased
Axis of rotation altered
Coupling characteristics changed
Paradoxical motion present

Spinal Stability

Subaxial Cervical Spine:

- Muscles and discs provide the most stability
- Supraspinous and interspinous and nuchal ligaments
OAA Complex:
- Transverse Ligament disruption from the following:
RA:
Downs syndrome

Decompression:
- Cervical laminectomy: , remove lamina
- Removal of lamina to decompress nerve. Problem with this is it is the attachment point
for muscles and ligaments, have nothing to pull upon to keep head straight
- Symptoms can come back from scar tissue
- Multiple site lami is a problem, why?
- Foramenectomy: remove bone spurs, less invasive, less loss of blood
 - Facetectomy:same potential problems, remove parts of facet
1. Loss of coupled motions with lateral bending
2. Reduced motions since joints are not there anymore

Arthrodesis:
Cervical Fusion:
- Indication:
1. Spinal Instability
2. Neoplasm
3. Degenerative changes in the spine
- Internal fixation assists with proper alignment
- Anterior approach more common now, will see incision lateral of trachea
- Take out disc and replace it with a graft
- What happens to the unfused levels? C4-C7, C3 is not fused and C7-T1 is not fused,
those levels have more stresses, have to work harder at areas that are not fused

Cervical Spine Fixation:

- Excised disc or bone must be replaced to maintain column height, either autographic or
allographic
- Iliac crests are more preferable because it tends to incorporate itself more so within the
fusion
- The new fusion can withstand normal axial loads of the spine
- Posterior Arthrodesis can be for OAA and subaxial fusions where anterior Arthrodesis
can only be for subaxial fusions
- Allographic options:
1. Calcium phosphate ceramics
2. Hydroxylapatite Blocks for interbody cervical Arthrodesis
- Autograph interbody:

Biomechanics of Cervical Trauma:

Airbag Injuries:
- Children who sat in front passenger had more traumatic cranial-brain injuries from airbag
deployment
- Rear-facing car seat, more cervical injuries, causing some OA dislocation; fragile
pediatric cervical spines cant withstand substantial loads
- Infants must always ride in the back seat facing the rear of the car

Whiplash Syndrome:
- Hit from behind, seat moves forward and unrestrained head whips into hyperextension, if
then hits a car in front, hyperflexion can occur
- Head goes in opposite direction to the hit
- Common Injuries from Whiplash:
1. Ligament tears
 2. Spinous Process Fractures
3. Ligamentum Flavum ruptures
4. Stretching of Anterior muscles
5. Facet Joint Disruption
- Extension with Headrest is 10-47 degrees, without headrest can reach max of 80
degrees
- Proper positioning of the headrest behind the skull is more important than behind the
neck
- Common areas of tenderness: SternoCleidoMastoid (movements limited: diffuclty with
left rotation, right sidebending, and head flexion), UT, Erector Spinae, scalenes

Cervical Disc Herniation:

- most frequent at C 6-7 level (because that is where most of the movement for flexion
comes from) but also occur at C 5-6 & to a lesser extent at C4-5 & other levels;
- Types of herniation:
1. Intraforaminal herniation:
* most common type:
* cause predominately sensory changes;
2. Posterolateral type:
* occurs near near entrance zone of foramen;
* causes predominately motor changes;
3. Central type:
* if disc herniation occurs more to the midline (ie posterior herniation), then
* it compresses spinal cord in addition to, or instead of the nerve root;
* results in cervical myelopathy:-
* Symptoms:
1. neck pain from nerve root compression;
2. pain radiating into ipsilateral upper extremity w/ paresthesias, numbness, or weakness;
3. pain & paresthesias may be intensified by neck movement, especially by extension or by
lateral flexion to side of herniation, & by coughing or straining;
Exam:
- Limitation of neck extension
- Downward head compression increases PTs radicular pain and paresthesias, especially
if neck is flexed to side of involvement
- Shoulder abduction relief test: if symptoms go away, it takes tension off from nerve
when lifting shoulders
- Significant relief of arm pain with shoulder abduction
- This sign is more likely to be present with soft disc herniation, whereas, the test is likely
to be negative with radiculopathy caused by spondylosis(osteophyte compression)
- Spurlings Sign:
> mechanical stress, such as excessive vertebral motion, may exacerbate symptoms
> the provocation of the patients arm pain with induced narrowing of the neuroforamen
- gentle neck hyperextension with the head tilted toward the affected side will narrow the
size of the neuroforamen and may exacerbate the symptoms or produce radiculopathy;
 - ipsilateral rotation of the neck will also increase radiculopathy;
- downward head compression increases the patient's radicular pain and paresthesias,
especially if the neck is flexed to the side of involvement;
- provocation of pt's arm pain w/ induced narrowing of neuroforamen
- oblique cervical extension augments root compression & increases symptoms;
- lower motor neuron dysf(x) (muscle weakness & hypotonia, reduction of deep tendon
reflexes) at level of cord compression;
- upper motor neuron dysfunction (spasticity, clonus, increased deep tendon reflexes,
Babinski's sign, reduction of sensation) below level;
loss of erection, bladder, & bowel f(x) may occur

Transient Brachial Plexopathy and Cervical Cord Neuropraxia in Athletes: Burners/Stingers

- Named or temporary sensation that radiates from shoulder to hand
- One of the most common injuries in Sports Medicine
- 65% of collegiate football players during 4-year career get this
- Most episodes last seconds to minutes
- 5-10% of cases, neurologic deficit may last hours, days, or weeks
- Most often involves C5 and C6 nerve roots, which make up the upper trunk of the
brachial plexus
- Upper trunk brachial plexus injuries are common football tackling injuries, which may be
referred to as stingers
- Brachial plexus stretch/traction
- Direct blow causing contralateral lateral neck flexion and ipsilateral shoulder depression
or traction as nerve is fixed proximally
- More frequent in younger athletes without cervical stenosis or degenerative changes
- Similar to Erbs palsy seen in birth injury
- Clinical Findings:
Burning pain radiating from the affected shoulder circumferentially down the arm
They have been noted to occur in more than 50% of players
Its important to note that no complaints of neck pain occur with stingers
Players should not return to competition if the he has neck pain or has motor weakness
Weakness of shoulder abductors and external rotators as well as biceps weakness

Myotomes
- C4-upper traps
- C5- shoulder abduction
- C6-wrist extension, elbow flexion
- C7-wrist flexion,elbow extension
- C8-finger flexion
- T1 - finger abduction and adduction

LECTURE 12: Biomechanics of the Shoulder

The Shoulder:
 - Range of Motion: 3 degrees of freedom: Abduction/adduction, internal/external rotation,
flexion/extension
- Plane of the scapula or scapular plane: more functional because the muscles are in
better alignment and the capsule is not twisted

3 True Joints of the Shoulder Complex and 1 False

Joint
1. Glenohumeral
2. Acromioclavicular
3. Sternoclavicular
4. Scapulothoracic: false

SC Joint:
- Links the Upper extremities with thorax
- Small articulation with 1st rib
- Synovial joint with fibrocartilaginous disc that
divides the joint into 2 compartments
- Disc prevents medial and inferior
displacement
- 50 degrees of axial rotation, 35 degrees of
superior-inferior and anterior-posterior
translation

AC Joint
- Transmits loads from the chest to the upper extremeties
- Synovial joint
- Fibrocartilagernous disc
- AC ligament supports the joint superiorly restraining axial rotation and posterior
translation
- Vertical stability provided by the coracoclavicular ligaments, the coroid and trapezoid
- Coroid ligaments limit superior and inferior translation
- Trapezoid ligaments resist horizontal or axial compression
- Limited motion at the AC joint with shoulder elevation because of synchronous scapular
and clavicular motion

Clavicle:
- Connects the arm to the thorax, S-shaped joint
- Protects the brachial plexus and vasculature
- Ratio of 4 degrees of clavicular elevation with every 10 degrees of arm elevation with
majority of elevation at SC joint

Glenohumeral Joint and Related Structures:

- Humerus has anterior and lateral orientation
- Main joint of all four joint articulations
 - Joint between humeral head and glenoid fossa is superior to the plane of the scapula
adding stability
- Glenoid fossa is shallow articulating with of the diameter of the humeral head
- Motion of the humeral head on the glenoid is rotational
- Stability from the capsule, ligaments and muscles

Glenoid Labrum:
- Fibrocaritlage ring that deepens the socket by 50%
- Superior portion is consistent with long head of biceps at supraglenoid tubercle
- With intact labrum, shoulder can resist tangential forces of 60% of the compressive load;
resection of labrum can only resist 20% of the compressive load
- SLAP lesion can occur from traction or compression; causes include overhead activities,
sudden pull on the arm or FOOSH, causing severe pain and instability
- Treatment of SLAP lesion

Joint Capsule:
- Attaches onto and around the labrum
- Reaches the anatomical neck of the humerus
- Attaches to the base of the coracoid enveloping the long head of the biceps

Stabilizing Role of the Capsule:

- Adduction: superior capsule tightens
- Abduction: inferior capsule tightens
- IR: tightening posteriorly
- ER: tightening anteriorly
- Posterior capsule:
Restrains anterior translation
Primary posterior stabilizer

Glenohumeral and Coracohumeral Ligaments:

- Superior, inferior, middle ligaments are extensions of the anterior glenohumeral joint
capsule
- Critical stabilizers

Superior GHL:
- Originates from the anterior superior labrum and inserts to the lesser tuberosity
- Main restraint is inferior translation with arm in resting or adducted position

Coracohumeral Ligament:
- Originates from lateral side of base of coracoid to insert on anatomical neck of the
humerus
- Reinforces superior aspect of the joint capsule

Middle GHL:
 - Originates inferior to the Superior GHL and inserts on lesser tuberosity
- Secondary restraint to inferior translations of the GH joint with arm in the abducted and
ER position
- Restraint to anterior translation maximally at 45 degrees of abduction

Inferior GHL:
- Originates from inferior aspect of the labrum and inserts on anatomical neck of humerus
- Has 3 components: anterior band, posterior component, axillary pouch
- Primary anterior stabilizer of shoulder with arm in 90 degrees of abduction (ER
(externally rotate) the anterior band restrains, IR (internally rotate) the posterior band
restrains)
- Resists inferior translation with arm abducted

Additional Constraints to GH Stability:

- Synovial fluids acts via cohesion and adhesion
- Intra-articular cartilage is negative polarity pulling things inward

Scapulothoracic Articulation:
- Scapula is angled 30 degrees anterior to coronal plane of the thorax
- Rotated toward midline at its superior end and tilted anteriorly with respect to sagittal
plane
- Coracoclavicular ligament and muscular attachments help with scapular attachments
- Serratus anterior and subscapularis prevent scapular winging, wall test
- Average ratio between GH and ST is 2:1 degrees

Spinal Contribution to Shoulder Motion:

- Lateral bending away from the reaching upper
extremities enhances movement
- Rounded thoracic spine vs. shoulder elevation
- Slouched sitting posture vs. shoulder elevation

Muscle Anatomy:
- Deltoid
Anterior: flexor and IR
Middle: abductor
Posterior: extensor and ER
- Pec Major:
ADD and IR
Clavicular Head: FF
Sternocostal head: extension
- Pec Minor:
Scapular stabilizer
Respiratory
Rotator Cuff:
- Supraspinatus: forms force couple with deltoid for abduction
- Infraspinatus and teres minor: ER of humerus
- Subscapularis: IR, anterior stabilizer of humerus with arm abducted at 45 degrees
- Total shoulder patient
Teres Major: ADD and IR
Biceps: short and long head
- Long head is humeral head depressor and stabilizer
- Short head attaches to coracoid process of scapula
Trapezius:
- Elevate, retract, rotate scapula
- Middle trapezius scapular stabilizer
Lats:
- Extend, ADD, IR
Rhomboids:
- Scapular stabilizer
- Retraction
- How to differentiate between middle trap and rhomboids
Levator scapulae
- Elevate and inferiorly rotate the shoulder blade
Serratus Anterior:
- Scapular stabilizer
- How does one isolate serratus

Integrated muscular activity of the shoulder complex

- Force couple
- Scapular Plane Elevation
- Coronal plane: between deltoid and inferior portion of rotator cuff
- Transverse plane: between subscapularis anteriorly and posterior rotator cuff
musculature, the infraspinatus and teres minor
Deltoid and Supraspinatus work together while the remainder of the rotator cuff
depresses the humerus to counter humeral subluxation
Supraspinatus initiates abduction while the deltoids lever arm improves further into
abduction
Supraspinatus compresses the humeral head at about 75 degrees for GH stability
The remaining RC muscles pull at 45 degrees to compress and depress the humeral
head to maintain stability

External Rotation:
- Primary ER is infraspinatus
- During abduction, subscapularis prevents anterior translation of humeral head during ER
- Further abduction, the posterior deltoid increases activity as secondary ER

Internal Rotation:
 - Subscapularis, lats, teres major, sternal head of pec major
- Subscapularis is active during all ranges of IR
- Sternal head of pec major and lats decreases with abduction
- Posterior and middle heads of deltoid increase their eccentric activity during IR while
arm is abducted

Scapulothoracic motion:
- As humerus elevates, scapula rotates increasing stability and decreasing tendency of
impingement of subacromial soft tissue
- Rotational force couple between the following allow for scapular rotation that is
necessary for full forward elevation:
> upper traps, levator scapulae, upper serratus anterior with concomitant contraction of
low traps and lower serratus anterior

Loads of GH Joint:
- Major load bearing joint
- Forces equal to body weight greatest at 90 degrees of elevation, scapular plane

Posture and Shoulder Impingement

- Subacromial space
- Scapula positioning
- Cervical and Thoracic spine
- Forward head and rounded shoulders
- Effect of this posture on subacromial space and impingement
- Treatment

Pathology:
- Rotator Cuff Tear
- Impingement Syndrome
- Acromion Types I, II, III
- Shoulder bursitis
- SLAP Lesion
- AC joint separation
- Bankart Lesion is an avulsion of the anteroinferior glenoid labrum at its attachment to
IGHL complex; lesion is felt to result from anterior shoulder dislocation and is felt to be
primary lesion in recurrent anterior instability
- Total Shoulder Replacement
- Dislocation
- Frozen Shoulder
- Fractures
- Little League Shoulder

LECTURE 13: Elbow

Allows for two types of motion
- Flexion and extension
- Pronation and supination of the forearm to assist in moving the hand in space
Two articulations:
- Humero-ulnar: flexion and extension
- Humero-radial: flexion/extension & pronation and supination

Elbow Anatomy:
- Ulnas articulating surface is 30 degrees rotated posteriorly matching up with 30 degree
anteriorly directed distal humerus: important because it allows for stability of the elbow at
full extension
- Radial neck is angulated 15 degrees from the long axis of the radius
- 80% of radial head is covered by hyaline cartilage, the other 20% lacks the cartilage and
strong subchondral bone important because this is where most fractures occur
- Distal humerus divided into medial and lateral columns
- Medial column ends as the medial epicondyle
- Lateral column ends as the lateral epicondyle or capitellum
- Trochlea is between the two columns, forming an arc of 330 degrees covered by hyaline
cartilage
- Capitellum covered by hyaline cartilage as well and forms an arc of 180 degrees

Kinematics:
- Functional range of motion for flexion and extension: 30-130 degrees
- Functional range of motion for pronation and supination: 50 degrees to 50 degrees
- Flexion contractures greater than 30 degrees is related to loss of function
- Axis of rotation of flex/ext has a changing axis and is more complex than uniaxial hinge;
however articulation between proximal ulna and distal humerus is generally uniaxial
except at extremes of flexion/extension
- Pronation and supination takes place at the following two articulations:
1. Radial-humeral
2. Proximal radial-ulnar
- Radial head rotates within the annular ligament during pronation and supination with
distal radius moving around the ulna in an arc shaped like a cone
- Axis of rotation of pronation and supination is through the center of capitellum and radial
head and distal ulnar articular
surface in oblique angle
- When elbow is flexed the radial
head approximates the
capitellum, when the elbow
extends the radial head
distracts from the capitellum
 - Concave and convex rule?

Carrying Angle:
- Valgus position of the elbow in
full extension
- Orientation of the ulna with
respect to the humerus
- Less in children but greater in
adult females than adult males,
about 10-13 degrees

Elbow Stability:
- Valgus forces limited by MCL
(consists of anterior and posterior bundle
and transverse ligament):
Anterior bundle tightens with extension and
posterior bundle tightens with flexion
Radial head is secondary stabilizer for
valgus stresses with intact MCL
- With extension, the elbow articulation is
stable from varus stresses, followed by the
anterior capsule and the LCL
- Extension is also limited by anterior
capsule and anterior bundle of MCL

Elbow Stability:
- LCL consists of the radial collateral
ligament, lateral ulnar ligament, and
accessory LCL complex
- LCL: resists varus and external rotation
forces

Elbow Instability:
 Posterolateral rotatory instability
- Ulna supinates on the humerus
- Radial head dislocates in a posterior-lateral direction
- Lateral ulnar collateral ligament is primary restraint followed by the radial collateral
ligament and capsule