KOTA DPAM - Anatomy Review You should have access to an anatomy reference. I suggest the THIEME anatomy book. This is available in any major bookstore and it is relatively new. A good reference book is good to have as a student and as a clinical therapist for patient education. Our focus will be on the hand but we need to cover the shoulder and elbow since they relate to function. During our class, we will cover topics such as stability, ROM and function and how modalities play a role in treatment. This is meant to be a very general anatomy review. We will become more specific as we discuss DPAM application and its role in pain control, mobility and restoring strength to a specific area. Shoulder Anatomy Introduction The shoulder has the greatest range of motion of any other joint in the body. Because of this and the fact that it’s attachment to the body relies on the strength of the muscles for stability, it is a joint that be a source of many problems. We need to understand how the different layers of the shoulder work together in order to understand how it functions, how it can be injured and how to structure a challenging rehabilitation program. The deepest layer of the shoulder includes the bones and the joints. The next layer is made up of the ligaments of the joint capsule. The tendons and the muscles come next.
Important Structures The important structures of the shoulder can be divided into several categories. These include • • • • • • bones and joints ligaments and tendons muscles nerves blood vessels bursae Bones and J oints The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed by a part of the scapula called the acromion. There are actually four joints that make up the shoulder. The main shoulder joint, called the glenohumeral joint, is formed where the ball of the humerus fits into a shallow socket on the scapula. This shallow socket is called the glenoid. The acromioclavicular (AC) joint is where the clavicle meets the acromion. The sternoclavicular (SC) joint supports the connection of the arms and shoulders to the main skeleton on the front of the chest. A false joint is formed where the shoulder blade glides against the thorax (the rib cage). This joint, called the scapulothoracic joint, is important because it requires that the muscles surrounding the shoulder blade work together to keep the socket lined up during shoulder movements. Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in most large, weight-bearing joints. It is a bit thinner in joints such as the shoulder, which don't normally support weight. Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. In the shoulder, articular cartilage covers the end of the humerus and socket area of the glenoid on the scapula.
Ligaments and Tendons There are several important ligaments in the shoulder. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments that connect the humerus to the glenoid. These ligaments are the main source of stability for the shoulder. They help hold the shoulder in place and keep it from dislocating. When this capsule is damaged, from a fall for instance, it can become a source of shoulder instability, especially if the mechanism of injury was a fall on an outstretched arm. Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony knob that sticks out of the scapula in the front of the shoulder. A special type of ligament forms a unique structure inside the shoulder called the labrum. The labrum is attached almost completely around the edge of the glenoid. When viewed in cross section, the labrum is wedge-shaped. The shape and the way the labrum is attached create a deeper cup for the glenoid socket. This is important because the glenoid socket is so flat and shallow that the ball of the humerus does not fit tightly. The labrum creates a deeper cup for the ball of the humerus to fit into. The labrum is also where the biceps tendon attaches to the glenoid. Tendons are much like ligaments, except that tendons attach muscles to bones. Muscles move the bones by pulling
on the tendons. The biceps tendon runs from the biceps muscle, across the front of the shoulder, to the glenoid. At the very top of the glenoid, the biceps tendon attaches to the bone and actually becomes part of the labrum. This connection can be a source of problems when the biceps tendon is damaged and pulls away from its attachment to the glenoid. The tendons of the rotator cuff are the next layer in the shoulder joint. Four rotator cuff tendons connect the deepest layer of muscles to the humerus. Muscles The rotator cuff tendons attach to the deep rotator cuff muscles. This group of four muscles lie just outside the shoulder joint, and help keep the shoulder joint stable, by keeping the humeral head in the glenoid socket. This stability component is important in that it allows for functional mobility of the upper extremity, as well as controlling impingement syndromes. Modalities such as functional electric stimulation can assist with strengthening of these muscles. The large deltoid muscle is the outer layer of shoulder muscle. The deltoid is the largest, strongest muscle of the shoulder. Once elevation of the upper extremity has been initiated and the rotator cuff muscles have stabilized the glenohumeral joint, the deltoid muscle takes over lifting the arm once the arm is away from the side. Nerves All of the nerves that travel down the arm originate from the cervical spine at around the C4-5 area and have contributions all the way down to C7-T1. They continue toward the clavicle and then pass through the axilla just under the shoulder joint. Three main nerves begin together at the shoulder: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry the signals from the brain to the muscles that move the arm. The nerves also carry sensory and motor such as touch, pain, and temperature. Blood Vessels The main artery that travels along with these nerves is the axillary artery and can be palpated at the axillary space under the arm pit. It travels medial to the humerus to the cubital fossa of the elbow where it bifrucates into the ulnar and radial artery. It supplies all of the muscles in the upper extremity. Bursae Sandwiched between the rotator cuff muscles and the deltoid muscles are structures known as bursa. Bursa are everywhere in the body. They are found wherever two body parts move against one another and there is no joint to reduce the friction. A single bursa is simply a sac between two moving surfaces that contains a small amount of lubricating fluid.
Think of a bursa like this: If you press your hands together and slide them against one another, you produce some friction. In fact, when your hands are cold you may rub them together briskly to create heat from the friction. Now imagine that you hold in your hands a small plastic sack that contains a few drops of salad oil. This sack would let your hands glide freely against each other without a lot of friction. Summary The complex shoulder provides a maximum amount of mobility and range of motion when it functions properly. Function, relies on the strength and stability of the shoulder to get the hand in the right position to perform a task. We will learn how to use DPAM to focus on specific levels of musculature to reduce pain and restore function.
Elbow Anatomy Introduction At first, the elbow seems like a simple hinge but when the complexity of the interaction of the elbow with the forearm and wrist is understood, it is easy to see why the elbow can cause problems when it does not function correctly. The range of motion is what makes the elbow an important link in being able to position our hand in space. Effective positioning of our hands requires stable, painless elbow joints. Important Structures The important structures of the elbow can be divided into several categories. These include • • • • • bones and joints ligaments and tendons muscles nerves blood vessels
Bones and J oints The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb). The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the proximal radial head) meets the humerus. This joint is complicated because the radius has to rotate to allow for pronation and supination. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna. Ligaments and Tendons There are several important ligaments in the elbow. In the elbow, two of the most important ligaments are the medial collateral and the lateral collateral ligament. The medial collateral is on the medial side of the elbow, and the lateral collateral is on the lateral side. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury or dislocation to the elbow. If they do not heal correctly the elbow can be too loose, or unstable. There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring shaped, and the annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated. There are several important tendons around the elbow. The biceps tendon attaches the large biceps muscle on the proximal radius and performs flexion and assists with supination of the forearm. It allows the elbow to bend with force. You can feel this tendon crossing the front crease of the elbow when you tighten the biceps muscle.
The triceps tendon connects the large triceps muscle on the back of the arm with the ulna. It allows the elbow to straighten with force, such as when you perform a push-up. The muscles of the forearm cross the elbow and attach to the humerus. The outside, or lateral, bump just above the elbow is called the lateral epicondyle. Most of the muscles that straighten the fingers and wrist all come together in one tendon to attach in this area. The inside, or medial, bump just above the elbow is called the medial epicondyle. Most of the muscles that bend the fingers and wrist all come together in one tendon to attach in this area. These two tendons are important to understand because they are a common location of tendonitis. Muscles The main muscles that are important at the elbow have been mentioned above in the discussion about tendons. They are the biceps, the triceps, the wrist extensors (attaching to the lateral epicondyle) and the wrist flexors (attaching to the medial epicondyle).
Nerves All of the nerves that travel down the arm pass across the elbow. Three main nerves begin together at the cervical spine: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry signals from the brain to the muscles that move the arm. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.
Some of the more common problems around the elbow are problems of the nerves. Each nerve travels through its own tunnel as it crosses the elbow. Because the elbow must bend a great deal, the nerves must bend as well. Constant bending and straightening can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the arm and hand. Blood Vessels Traveling along with the nerves are the large vessels that supply the arm with blood. The largest artery is the brachial artery that travels across the front crease of the elbow. If you place your hand in the bend of your elbow, you may be able to feel the pulsing of this large artery. The brachial artery splits into two branches just below the elbow: the ulnar artery and the radial artery that continue into the hand. Damage to the brachial artery can be very serious because it is the only blood supply to the hand. Summary As you can see, the elbow is designed to provide maximum stability as we position our forearm to use our hand. The wrist and hand function is directly related, in many ways, to the proper kinematics of the elbow.
Introduction Few structures of the human anatomy are as unique as the hand. The hand needs to be mobile in order to position the fingers and thumb. Adequate strength forms the basis for normal hand function. The hand also must be coordinated to perform fine motor tasks with precision. The structures that form and move the hand require proper alignment and control in order for normal hand function to occur. Important Structures The important structures of the hand can be divided into several categories. These include • • • • • bones and joints ligaments and tendons muscles nerves blood vessels
Bones and J oints There are 27 bones within the wrist and hand. The wrist itself contains eight small bones, called carpals. The carpals join with the two forearm bones, the radius and ulna, forming the wrist joint. Further into the palm, the carpals connect to the metacarpals. There are five metacarpals forming the palm of the hand. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb. The main knuckle joints are formed by the connections of the phalanges to the metacarpals. These joints are called the metacarpophalangeal joints (MCP joints). The MCP joints work like a hinge when you bend and straighten your fingers and thumb. The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb phalanges. The IP joints of the digits also work like hinges when you bend and straighten your fingers and thumb.
Ligaments and Tendons Two important structures, called collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.
In the PIP joint (the middle joint between the main knuckle and the DIP joint), the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury. The tendons that allow each finger joint to straighten are called the extensor tendons. The extensor tendons of the fingers begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger. The place where the extensor tendon attaches to the middle phalanx is called the central slip. When the extensor muscles contract, they tug on the extensor tendon and straighten the finger. Problems occur when the central slip is damaged, as can happen with a tear. Muscles Many of the muscles that control the hand start at the elbow or forearm. They run down the forearm and cross the wrist and hand. Some control only the bending or straightening of the wrist. Others influence motion of the fingers or thumb. Many of these muscles help position and hold the wrist and hand while the thumb and fingers grip or perform fine motor actions. Most of the small muscles that work the thumb and pinky finger start on the carpal bones. These muscles connect in ways that allow the hand to grip and hold. Two muscles allow the thumb to move across the palm of the hand, an important function called thumb opposition. The smallest muscles that originate in the wrist and hand are called the intrinsic muscles. The intrinsic muscles guide the fine motions of the fingers by getting the fingers positioned and holding them steady during hand activities. Nerves All of the nerves that travel to the hand and fingers begin together at the shoulder: the radial nerve, the median nerve, and the ulnar nerve. These nerves carry signals from the brain to the muscles that move the arm, hand, fingers, and thumb. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.
The radial nerve originates in the cervical spine at C5-T1. It runs down the posterior aspect of the arm in the radial groove of the humerus which is a common site of injury. It passes anterior to the lateral epicondyle, between the brachailis and the brachioradialis muscles where it divides into deep and superficial branches. The Deep branch gives sensation to the back of the hand from the thumb to the third finger and supplies the muscles of the back of the forearm. The superficial branch runs under the brachioradiais to the dorsum of the hand to supply the radial side of the hand and the radial two and a half digits over the proximal phalanx. Superficial radial nerve syndrome is a pure sensory neuropathy due to compression of the superficial sensory branch of the radial nerve as it pierces the deep fascia between the dorsal border of the brachioradialis and extensor carpi radialis longus muscles. It is most common in sports requiring repetitive wrist extension, ulnar deviation, and pronation/supination. Wearing constrictive wristbands, tape, archery guards, gloves, or racquet straps may contribute to the compression. Sensory symptoms include burning, numbness, and tingling over the dorsal radial aspect of the wrist, thumb, and web space. Activity modification and removal of compressive devices usually results in improvement in symptoms; cortisone injection may be helpful for recalcitrant cases. The median nerve (C5-T1) enters the forearm between the humeral and ulnar heads of the pronator muscle and then passes between the flexor digitorum superficialis and flexor
digitorum profundus muscles. At the cubital fossa, it gives off a nerve called the anterior interosseous nerve which suplies the flexor pollicis longus, pronator quadratus and the flexor digitorum profundus. The main nerve then travels through a tunnel within the wrist called the carpal tunnel. This nerve gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and allow opposition. Carpal tunnel syndrome, due to compression of the median nerve deep to the transverse retinacular ligament in the volar aspect of the wrist, is likely the most common nerve entrapment in athletes. It is reported in badminton, baseball, cycling, gymnastics, field hockey, racquetball, rowing, skiing, squash, tennis, and rock climbing. It is most common in sports that require gripping, throwing, or repetitive wrist flexion and extension. It has also been reported in body builders abusing growth hormone. Symptoms include forearm, wrist, and hand pain, paresthesias that are worse at night, and thumb weakness that may be increased with exercise activity. Examination may reveal hypothenar atrophy and weakness with gripping and pinching. Phalen's sign, reproduction of pain and paresthesias with bilateral wrist flexion (which compresses the median nerve) is the most reliable clinical test; a positive Tinel's sign at the wrist is a less reliable indicator. Conservative treatment includes activity modification, neutral splinting, rehabilitation exercises to maintain independent tendon gliding through the carpal tunnel, and corticosteroid injection, which may be both diagnostic and therapeutic; surgical decompression is necessary if the athletes do not improve with these measures. The ulnar nerve (C7-T1) runs down the medial aspect of the arm and behind the medial epicondyle in a groove. In the hand, it travels through a separate tunnel, called Guyon's canal. This tunnel is formed by two carpal bones, the pisiform and hamate, and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm. Ulnar tunnel syndrome results from compression of the ulnar nerve in Guyon's canal at the wrist. This entrapment is most common cyclists, hence the name handlebar or cyclist's palsy; it has been reported in racquetball players and wheelchair athletes. The canal, through which the ulnar artery passes, is bordered volarly by the volar carpal ligament, dorsally by the transverse retinacular ligament, medially by the pisiform, and laterally by the hook of the hamate. In addition to direct pressure from contact of the volar ulnar aspect of the wrist with a hard surface, entrapment may result from hook of the hamate and pisiform fractures, ganglion cysts, ulnar carpal instability, hypothenar hammer syndrome, and ulnar artery aneurysm. Symptoms may be pure motor, pure sensory, or both motor and sensory depending on the location of the compression. Pain and paresthesias in the fourth and fifth digits, intrinsic hand incoordination and weakness, and a positive Tinel's sign at the wrist are common findings. Proper bicycle fitting, adjustment of handlebar type and position, frequent change in hand position, handle bar and glove padding, splinting, and use of unloading wrist splints to avoid nerve compression should be encouraged. Surgical decompression should be reserved for those who fail conservative measures, have evidence of denervation, or have nonunions or space-occupying lesions.
Blood Vessels Traveling along with the nerves are the large vessels that supply the hand with blood. The largest artery is the radial artery that travels across the front of the wrist, over the head of the radius. The radial artery is where the pulse is taken in the wrist. The ulnar artery runs next to the ulnar nerve through Guyon's canal (mentioned earlier). The ulnar and radial arteries arch together within the palm of the hand, supplying the front of the hand, fingers, and thumb. Other arteries travel across the back of the wrist to supply the back of the hand, fingers, and thumb. Summary The hand is formed of numerous structures that have an important role in normal hand function. Conditions that change the way these structures work can greatly impact whether the hand functions normally. When our hands are free of problems, it's easy to take the complex anatomy of the hand for granted. Thank you for reviewing upper extremity anatomy as part of the KOTA DPAM modality course. I hope this will be helpful when we consider restoration of functional movement and the muscles that accomplish the movement, as well as to help with placement of our modalities to accomplish our goals.