Anterior Thoracic Nerves

Nerves from each segment of the spinal cord connect to specific regions of the body. The cervical region or neck are referred to as C1 through C8; they control signals to the neck, arms, and hands. The segments in thoracic or upper back region T1 through T12 relay signals to the torso and some parts of the arms. The segments in the upper lumbar or mid-back region just below the ribs, L1 through L5, control signals to the hips and legs. Last, the sacral segments S1 through S5 lie just below the lumbar segments in the mid-back and control signals to the groin, toes, and some parts of the legs. The effects of spinal cord injury at different segments reflect this organization.(SC-Basic Anatomy of Spine-http://www.goes.com/billr/html/_anatomy_of_a_spinal_cord.html)

Inspection of the right shoulder joint reveals atrophy. Movements are restricted with flexion to 90 degrees limited by pain and abduction to 75 degrees limited by pain. Hawkin’s test, Neer’s test, Shoulder crossover test, Empty Cans test, Lift-off test, and Apprehension test is positive. On palpation, tenderness is noted in the acromioclavicular joint and subdeltoid

The rotator cuff is a group of 4 muscles, the supraspinatus, infraspinatus, subscapularis, and the teres minor. These muscles helps to lift your shoulder up over your head and also rotate it toward and away from your body. Unfortunately, it is also a group of muscles that is frequently injured by tears, tendonitis, impingement, bursitis, and strains. The major muscle that is usually involved is the supraspinatus muscle. Rotator Cuff Injuries are usually broken up into the following categories.

The Rhomboid Orgin is located near the spinous process of C7 and T1-T5 and the insertion is located near the medial boarder of scapula below the spine. This action intended for this muscle is to draw the scapula toward spinal column creating a downward rotation and a elevation of the mthe anterior deltoiuts that target this muscle Rhomboid row and the isometric contraction. The third muscle is called the pectoralis minor. The orgin of this muscle is located near the Anterior surfaces 3rd to 5th ribs. The Insertion is located near the Coracoid process of the scapula. The action of this muscle is to draw the scapula forwad in a downward rotation and depress the muscle. Workouts that target the pectorials minor are the dumbbell

On examination of the right shoulder, there is pain on range of motion. Abduction was 160 degrees. Forward flexion was 165 degrees.

The patient was an active participant in both contact as well as non-contact athletic activities. The patient reported occurrence of different symptoms that included; pain, weakness, instability, paresthesia, crepitus, as well as instability of the shoulder during sleep. Sulculus sign was conducted to assess the rotator interval and load and shift test for determination of the patient’s posterior stability. The doctor diagnosed positive for multidirectional instability. The patient’s multidirectional instability was not caused by a traumatic event. The patient had not exercised the joint over a long period of time, hence he had a weak shoulder joint, particularly the rotator cuff. The doctor recommended that the patient should be treated for the pain and inflammation of the shoulder caused by the multidirectional instability and then placed on physical therapy aimed for one year aimed at helping in the strengthening of the muscles of the patient that support the scapula (shoulder blade) and the rotator cuff (shoulder joint) so as to help the patient in returning to normal physical activity and also prevent an injury at the same place

The axillary nerve connects the main shoulder muscle (deltoid) to an arm bone (humerus) and three arm muscles (teres minor, teres major, triceps). The humerus and these four muscles muscles form a space in the back of the shoulder. This space is where the axillary nerve is located.

The insertion point is at the flat tendon 2 or 3 inches wide to the outer lip of the intertuberculer. The clavicular action of the pectoralis major is internal rotation, horizontal adduction, flexion abduction and adduction. The sternal pectoralis major has an origin on the anterior surfaces of costal cartilage of the first 6 ribs and adjacent portion of the sternum. The sternal insertion is the groove of the humerus. The intended action of the sternal pectoralis major is internal rotation, horizontal adduction, extension, and adduction of the glenohumeral joint. An example from the radioulnar joint is the brachialis. Its origin is the distal half of the anterior portion of the humerus, and the insertion point is the coronoid process of the ulna. The brachialis intended action is flexion of the elbow. The hip joint and pelvic girdle work with multiple muscles including gluteus maximus and semitendinosus muscle. The origin of the gluteus maximus is the posterior ¼ of the crest of the ilium, the posterior surface of the sacrum and coccyx near the illium, and fascia of the lumbar area. The point of insertion is the oblique ridge on the lateral surface of the greater trochanter and iliotibial band of fasciae. The intended action of

Supraspinatus tendonitis typically occurs when there is an impingement of the supraspinatus muscle of the shoulder joint between the acromion as it passes by the acromion and humerus head. In response, the supraspinatus tendon and the contiguous peritendinous soft tissues become inflamed. The supraspinatus is a muscle located in the supraspinatus fossa of the scapula located in the shoulder and is largely affected by supraspinatus tendonitis. The supraspinatus allows for the abduction of the shoulder and its insertion is the greater tuberosity of the humerus. Tendonitis is the inflammation of a tendon and commonly occurs in the elbows, knees, and shoulders. Therefore, supraspinatus tendonitis is the inflammation of the supraspinatus. This condition is a very common inflammatory problem because it can be caused by the abduction of the arm, which is involved in many sports and activities.

^8,5 ASI occurs when the arm is in adduction with the shoulder internally rotated. The biceps complex pulley, also known as a capsuloligamentous complex, adjoins the anterior glenoid causing injury when in extreme motions. With the PSI, the pulley is put into risk with abduction and external rotation on the posterosuperior glenoid. ^8 PSI is also associated with partial-thickness tears on the deep side of the articular surface of the rotator cuff. ^5 This can be a common cause for a peel-back mechanism associated with a SLAP lesion. ^8 Peel-back mechanisms can be produced many different ways, but are mostly seen with a SLAP lesion or internal impingement. These can occur when the shoulder is placed into abduction and extreme external rotation with a torsional force added to the labro-bicipital complex that is at the base of the biceps on the posterior superior labrum. ^1,5 This causes fatigue and failure of the humeral head that rotates medially over the upper rim of the glenoid fossa creating a shearing force. ^1,5 Increased superior labral strain in overhead athletes occurs during the late-cocking phase of throwing when arm is externally rotated. ^1

Even with active assistance, the patient can only achieve approximately 140 degrees of forward elevation, 60 degrees of external rotation, and internal rotation barely to his upper sacrurn. He has 4/5 supraspinatus weakness and pain. Internal and external rotation strength seems to be normal. He has a nonspecifically painful Neer’s, Hawkins, and O’Brien’s test. His proximal biceps and acromioclavicular (AC) joint are both very tender to palpation.

Examination of the bilateral shoulder reveals tenderness to palpation about the anterior shoulders bilaterally. There is also restricted range of motion secondary to pain and her supraspinatus weakness and Hawkins’ impingement tests are both positive. In addition, Neer’s impingement and drop-arm tests are also positive.

*insert article *attachedBesides being able to see the inside of a shoulder, doctors use different physical tests to evaluate the shoulder in order to determine what type of injury and how severe an injury may be. One such test was recently developed by Dr. Carl J. Basamania at the Womack Army Medical center in Fort Bragg, N.C. The test was developed to evaluate shoulder instability in a patient. During the test the Dr. or examiner stands next to the patient who is to lay flat on his/her back. The hand of the examined should is held firmly by the examiner. The examiner then pushes against the clavicle to stabilize th scapula, while they also gently hold the pectoral muscle with their thumb in order to be able to assess relaxation. The examiner then rotates the arm form neutral to full external rotation. If the patient has AIGHL incompetence there is a lack of tightening as the arm reaches full external rotation. The test has appeared to be highly accurate and may be of value to Dr.'s and surgeons alike. After doctors have determined what type and what degree of injury a patient has sustained using various tests it is on to the next step, rehabilitation.

Barta reports his pain level was a 8 with any movement. Since the last appointment with Wesley Fischer PA the pain level has decreased to a /34 with movements. He was instructed on a home exercise program to avoid the shoulder becoming frozen. Mr. Barta’s examination showed an improvement with range of motion, and strength. Work restrictions were discussed. Per Mr. Barta he was told that he needs to be full duty to come back to work. I advised that the restrictions need to reflect what he can and cannot do with the right arm since that is the injured part. If the employer has the ability to bring him back to work then they must follow the restrictions. I asked that the restrictions reflect

The shape or thickness of the acromion sometime plays into effects of the rotator cuff. In some people the space between the undersurface of the acromion and the humeral head is very narrow, which can lead to being more likely to pinch the supraspinatus tendon. In some cases, there are people who have bone spurs on the front of the acromion, which increases the risk of impingement syndrome. Muscle imbalance is another situation