The Shoulder The shoulder is the upper part of the upper extremity, where our arms connect with our central axis — the spine and ribcage. The shoulder girdle is composed of the scapula and clavicle. The shoulder joint is the gleno-humeral joint. The humerus is loosely attached to the scapula by the shallow gleno-humeral joint. It is supported and moved by a series of short powerful muscles which have their origin on the scapula. Two larger muscles, Pectoralis major and Latissimus dorsi, run from the spine and ribcage, bypassing the scapula to attach to the humerus. The scapula in turn can move freely over the posterior aspect of the ribcage. It is moved and stabilised by powerful muscles that have their origin on the spine (Trapezius, Rhomboids, Levator scapulae) and ribcage (Pectoralis minor and Serratus anterior). The clavicle performs the major bracing task, helping keep the shoulder at a useful distance from the midline. It is attached to the scapula at the acromio- clavicular joint and to the sternum at the sterno-clavicular joint. This combination of a mobile shoulder joint and a scapula that can move into the optimum position gives the humerus enormous flexibility relative to the spine. This helps us get our hands where we want them so we can feel, manipulate and otherwise interact with the world. Chinese Medicine Perspective All the arm meridians cross the shoulder. However, most of the important structures of the shoulder are in the lateral and posterior aspects and are thereby governed by the arm yang meridians - Large Intestine, Sanjiao and Small Intestine. Of the yin meridians, only the most superficial (or least yin), the tai yin meridian of the Lung, plays any significant roll in the shoulder. Palpate your own armpit where the Heart and Pericardium meridians pass and feel how little substance there is there. Notice also that the distance between the Lu and Ht meridians is small relative to that between the LI and SI meridians. Thus the LI, SJ and SI (and to a lesser extent the Lu) are those most involved in shoulder problems. The author’s perspective on the sinew channels (jinjing) as they cross the shoulder is: Jingjin Pathway - elbow to neck/chest Large Intestine Up lateral intermuscular septum to Deltoid insertion, Deltoid, binds at acromion, Trapezius Sanjiao Up lateral intermuscular septum (with LI) to lateral tubercle, Supraspinatus, Levator scapula Small Intestine Triceps, Infraspinatus, Teres major and minor, Rhomboids, Serratus posterior superior, contra-lateral Splenius cervicis and capitis Lung Brachialis and Biceps, Coracobrachialis, binds at coracoid process, Pectoralis minor, subclavius Pericardium Up medial intermuscular septum to axilla, divides, Subscapularis, Serratus anterior, and Latissimus dorsi, Teres major Heart Up medial intermuscular septum, Pectoralis major The arm yang meridians do not seem to have any direct relationship with the organs whose names they bear. They have no points that directly affect those organs, the points that do directly affect them being on other meridians, notably the Bl and St meridians. It is more useful to think of the arm yang meridians as reflecting the yang aspects of the related zang. Therefore, LI meridian relates to yang aspects of Lu SJ “ “ “ “ “ PC SI “ “ “ “ “ Ht 2 of 25 Points that affect the shoulder The many local points of the shoulder have precise local effects that often depend on precise needling. Choices about direction and depth are particularly important. The anatomy of the target tissue is the main guide. In addition to the meridian points there are several extra points. Even with this many points there are many situations requiring the use of ah shi points. Local points LI15 (Jianyu) Gleno-humeral joint and supraspinatus tendon LI16 (Jugu) Acromio-clavicular joint and supraspinatus SJ 14 (Jianliao) Supraspinatus and infraspinatus tendons SI 9 (Jianzhen) Teres major, Latissimus dorsi SI10 (Naoshu) Infraspinatus SI 11 (Tianzong) Infraspinatus SI 12 (Bingfeng) Supraspinatus muscle SI 14 (Jianweishu) Levator scapulae SI 15 (Jianzhongshu) Splenius cervicis SJ 15 (Tianliao) Trapezius Bl 41 (Pohu) Serratus posterior superior Bl 43 (Gohuangshu) Serratus posterior superior Lu 1 (Zhongfu) Pectoralis major and minor There is little agreement in available texts about the names and locations of extra points around the shoulder. Extra (Jianqian, Taijian, N-UE-11) 1.0 - 1.5 cun anterior to LI 15 below clavicle Gleno-humeral joint Extra (Taijian, Jianshu, N-UE-42) In the hollow below AC jt, lateral to the tip of the coracoid process. Gleno humeral joint Extra (Jianneiling, Jianqian, M-UE-48) With the arm hanging at the side, midway between the end of the anterior axillary crease and LI15 (Jianyu) Anterior deltoid, short head of Biceps, Coracobrachialis Extra (Jubei) 3 cun above anterior axillary fold. Gleno-humeral joint 3 of 25 Distal points LI 11 (Quchi) The best general point for mechanical shoulder problems Lu 7 (Lieque) Anterior shoulder. Combines well with Lu 2 Lu 5 (Chize) Anterior shoulder pain and qi stagnation Lu 9 (Taiyuan) Bilateral shoulder pain Extra point The most tender point between St 36 and St 38 about two fingers width from the edge of the tibia. Needled and manipulated while patient moves their shoulder around. To increase range of movement of stiff shoulder Examination of the shoulder A thorough examination of the shoulder is almost always productive Patient sitting Look: from the front for asymmetry, swelling etc. Move: Test passive and active resisted movements Passive movements: These test the quality and range of joint movement. You are looking for: • differences between the ranges of movement of the two shoulders. Restricted shoulder movement can be caused by tight muscles, contracted ligaments or joint capsules, or bony deformity. • an altered quality of the end feel and pain at the end of the (passive) range. In general tight muscles produce little pain at the end of the passive movement and the endfeel is springy. Contracted joint capsules and ligaments, on the other hand are often painful at the end of range and have a more sudden endfeel. A single reduced range of movement is usually a sign of a trigger point in a muscle that performs the opposite action to the restricted movement. For instance, restricted internal rotation can indicate a trigger point in infraspinatus, a major external rotator. Several restricted ranges of movement, on the other hand, usually indicate a disorder of the gleno-humeral joint. Active resisted movements - test a muscle’s integrity and strength. 4 of 25 Pain indicates some sort of inflammation or damage to the musculo tendinous structures responsible for the movement being tested. For instance, painful shoulder abduction can indicate disorder of Supraspinatus, a major abductor. Weakness is more difficult to interpret as it can be caused by neurological phenomena or atrophy from lack of use. Stand behind patient with one hand on the shoulder and the other holding the arm to move or resist. Test flexion & extension abduction & adduction internal & external rotation Feel: Diagnosis of shoulder dysfunction is greatly aided by the accessibility of all the major structures. By palpating these, suspicions derived from the movement tests can be confirmed and areas of dysfunction that produced no positive movement signs can be uncovered. During the palpation the operator tests each structure with appropriate pressure and the patient reports any tenderness elicited. The operator tries to feel the dysfunction Stand behind patient and examine both sides at once. • sterno - clavicular joint • the clavicle (signs of previous fracture) • coracoid process (mainly as a landmark) • coraco-clavicular ligaments (conoid and trapezoid) • head of the humerus (tenderness - capsule tightness/ inflammation) • pectoralis minor (muscle belly for trigger points) • pectoralis major (muscle belly for trigger points) • coracobrachialis (muscle belly for trigger points) • anterior deltoid (muscle belly for trigger points) • acromion process, acromio-clavicular joint • bicipital groove (for bicipital tendinopathy and as a landmark) • supraspinatus tendon (for tendinopathy) • infraspinatus / teres minor tendons (for tendinopathy) • infraspinatus / teres minor muscle bellies (muscle belly for trigger points) • medial to medial scapula border (upper ribs, serratus post. sup.) 5 of 25 • levator scapula and upper trapezius (muscle belly for trigger points) • subscapularis (muscle belly for trigger points) Note: If you cannot elicit or aggravate pain in the shoulder region by testing the active and passive movements of the shoulder then the most likely cause of the pain is referred pain from the neck &/or the upper back. Check this by testing neck movements. On the following page I have reproduced a list of the muscles responsible for the various shoulder movements. Keep a copy in your clinic to assist your examination. 6 of 25 Muscles of the Shoulder Movement Primary movers Secondary movers Flexion Anterior Deltoid Pectoralis major Coracobrachialis Biceps brachialis Extension Latissimus dorsi Teres minor Teres major Triceps (long head) Posterior deltoid Abduction Deltoid - middle Deltoid - rest Supraspinatus Serratus anterior Adduction Pectoralis major Teres major Latissimus dorsi External Rotation Infraspinatus Posterior deltoid Teres minor Internal Rotation Subscapularis Anterior deltoid Pectoralis major Latissimus dorsi Teres major Scapular Elevation Trapezius Rhomboids Levator scapulae Scapular Depression Latissimus Dorsi