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Present era of globalization results as making life more sedentary & stressful giving rise to big health issues. So now days due to changed fast, stressful, sedentary lifestyle there is luck of exercise causing increase in frequency of disorders related to joints &postural deformities, as affecting of disorders related to joints postural deformities, as affecting day to day activities. Ayurveda is the better science fir treating these disorders than other. Since ancient era Ayurveda has been emphasizing on a healthy life as the priority .The impact of dietary and behavioral habits has an importance in Ayurvedic literature. According to Ayurveda excess or inappropriate movements of body or actions will always lead to relevant pathologies.
Sandhi is where two or more particular surfaces of bones are articulated sass per modern definition .This has been quoted by Sushruta in the following quotations.
************** Sholk ************* su .sha. 5/25
Where the two or more than two articular surfaces of bones articulate with each other with the help of Sandhibhandhan (Ligaments) it is called Asthi-Sandhi (joints).
We come across, many people are suffering from joint related health problems like Vatarakta, Amavata, and Avabahuka etc. joints play an important role in daily activity. These joint related problems are being attributed mainly by inappropriate and sedentary life style, occupation, food habits, trauma etc. Occurrence of these problems is showing rinsing in today’s life style.
**************sholk************ cha /sha 6/19
The Vaidya who knows the entire Sharer (body) always from its all aspects knows the science of life in its entirety, which helps to promote the happiness of the world.
In the above reference Charakacharya has mentioned the importance of Sharir, so it its basic need of vaidya to understand Rachana Sharer well with respect to medical science.
Shoulder joint i8s one of the important joint. This joint has maximum Movements in all direction & most of the work household, l occupational work carried out with the help of shoulder joints. As the shoulder joint is one of the most mobile joints in the body allowing one great deal of freedom of movement; it works as complex involving many structural details, hence rightly called as shoulder complex.
In samhita, ansa sandhi is described as follows
**********sholk********** suchi ,3/31
“STUDY OF STRUCTURES OF ANSA SANDHI, INVOLVED IN AVABAHUK ‘’
Ansa sandhi is included in chal sandhi i.e. Ulukhal Sandhi and it is sandhi of bahu shir having maximum range of movement A Ulukhal.
It has been noted that the increased in disciplined vehicle driving and continuous work on computer, overuse causes harm to shoulder. So that, the cost of such versatility is an increased risk of injury leading to the pathological condition like Avabahuka. Pathological conditions of shoulder affect day to day activity vigorously.
Avabahuka is one of the vatavyadhi stated in Ayurveda samhita which affects the normal functioning of the upper limb.
***********sholk************ su.ni. 1/82
Due to vitiated vata dosha, shosha occurs in ansa bandhan.
Also it causes Sira Akunchana & thus leading to degradation or functional loss of Bahu alias Arm and hence called as ‘Avabahuka ‘.
Avabahuka comprises of two words ‘Ava ‘and ‘Bahuka”.
Ava – Viyoga, Vikratou, and Viyogou means dysfunction, separation.
Bahuka - ***********shlok**********
Means it starts from elbow joint to Shoulder region.
Incidence of Avabahuka is more among people who perform strenuous work related to their upper limbs. Thus, the term Avabahuka means “loss of function of Bahusandhi i.e. Praspeanditahara (stiffness or disability in the arm).
In clinical practice we come across the patients with the complains of pain / stiffness of shoulder joint / upper arm in different conditions. This requires a thorough differentiation of these conditions for successful treatment.
Essentiality of study:-
As above, shoulder joint is very important for daily work. And during review of samhita, it is found that many diseases related to shoulder / Ansa sandhis are described. Avabahuka is one of them .At the ancient time, it was not possible to see minute structures in the body with help of naked eye. So whatever description given is not sufficient to the need of era .In context to Avabahuka there are multiple opinions of Samhitakar And their respective Commentators. But not much work has been done through anatomical or sharer perspective prediction of exactly which structures get affected & development Avabahuka can be explained either helps of advanced technologies, which will help to diagnosis & proper treatment. So in order to know more about structures responsible for development of Avabahuka, and does any Structural changes found in ansa sandhi in Avabahuk, topic is selected for research.
This work is an effort to “STUDY OF STRUCTURES OF ANSA SANDHI INVOVLED IN AVABAHUK”
Aim and Objectives
Study of the structural changes of ansa sandhi , involved in Avabahuka.
To study the anatomical changes of ansa sandhi in Avabahuka vyadhi &to find out prone structure which is responsible for development of Avahuka vyadhi.
1. To study ansa sandhi sharer as per Ayurvedic & modern compendia.
2. To study of Avabahuka Vyadhi from Ayurvedic compendia .
3. To correlate findings of Avabahuka Vyadhi with modern joint disorders if any.
Previous Work Done
1. A comparative clinical study of Nasya (sapta prashtha brihat masha taillam) & Sweda (panda sweda) in the management of Avabahuka .2007-2008(MD KAYACHIKITSA),MUHS,Nashik (
2. “A Study of sandhi sharer with special reference to amsa sandhi vikruti in Avabahuka ‘.2009-2010-muhs,Nashik.
My subject is differ from the clinical as well as in diagnostic manner.
Chapter No. 4
Review of Literature
4.Review of Literature
Review of Ayurvedic literature
Review of modern literature
Although threr is no direct evidence of the disease named Avabahuka ,in the ancient literature we can observe it through various similar conditions………………..
**********sholk********** ch/chi 1/4/42
While going through ancient literature there is a disease named Bhaujastambha which occurred to lord indra and was treated dy Ashwini Kumar , who was the phisicianand Surgeon of gods.
Other than this,there are many references in ancient literature in context with Avabahika, for example-Bahu ,Skandha,Kaksha,Bhuja etc.These terms are used for the same meaning and hence their correlation becomes more evident.
4.2 Review of Ayurevedic Literature
CONCEPT OF SANDHI SHARIR:-
Nirikti of sandhi:
Dhatu –(dha)means-dharana ,poshna.
Prefix (Upasarga) ‘sam(**).
Forms the word sandhi.
Sandhi is award if masculine gender.
Definition of sandhi:
Where the two or more than two articular surfaces of bones articulet with each other with the help of Sandhibhandhan (Ligaments)its is called Asthi – Sandhi (joints).
In Sankya sharer while stating joint term used for joints of bones only . The joints of Muscles , ligaments and blood vessels not included as they are innumerable.
Type of Sandhi:
According to movement :-
Joints are of two types,movable and immovable
Related to movement
In relation To Structure:
Samudga (AvyaCheshta amsapeethe)
According to structure:-
CONCEPT OF ANSA:-
Nirukti of Ansa:
According to Amarkosha :-
Etymologically,the term Ansa is derived from the Sanskrita root – (Dhatu)
The word Ansa means –to settle .
That means bearing a durden on the shoulder or to afford stability.
According to Shabdakalpadrum:-
The place which bears a load or burden means shoulder.
According to Sanskrit – Hindi kosha :-
The word Ansa (**) is formed from – when the Dhatu Amsa/Ansa(**) get mixed with Pratyaya ‘ach’(**)
According to Ayurvediya shabakosha :- the word Ansa means Shoulder/ Skandha (***)
************sholk********** cha,vi 8/119
************sholk********** su.ni 1/82
************sholk********** su sha 5/11
SAnskrita –English dictionary :-
Means to divide,distribute ,share among
** - belonging to the shoulder
The shoulder ,shoulder blade
A bull hump ,the protuberance between the shoulders.
Concept of Ansa : Sandhi
Ansa SAndhi :-
*************sholk******** su.chi, 3/31
Ansa means shoulder/Skandha(**).
***********sholk********** su.sha 6/26
***********sholk********** a.s.sa 7/8
Sandhi :- Ulukhal – this means an action simiar to the action of piston and Morter.
RELATIONOF ANSA SANDHI :-
Sandhi –Snaya Reltion
***********sholk**********- su.sha 5
***********sholk********** -Su.sha 5/3.
***********sholk********** a.san.sha 5/105.
As aboat which is consisting of wooden logs tied by the strong rope –like structures I . e tendrils of plant becomes capable of carrying weight of passengers while folting in a river by proper tying ,likewise all the joints in the body are tied with many ligaments;a person is capable of bering weight due to these parts.
Sandhi – Dosha Reletion :-
***********sholk********** a.hu.su 12/18
***********sholk********** a.san,sha 5/20
At the site of SAndhi ( joints) kapha is always present called Shaleshak Kapha;therefore the joints become movable.
When quantity of Shleshak kapha is reduced ,than Cracking of joints and crepitus is noted.
3) Sandhi – Srotas Relationship:
***************sholk************ - cha.vi.2/8.
Bones and joints are the sites of orgin of Majjavasha Srotas.
4) Sandhi –kala Relationship:-
**************sholk************ su.sha 4/15
The fourth Kala is Shleshmadharakala (KApha supporting ) which is situated in all joints of living beings .
As a wheel moves on a well by lubricating the axis , joints also function properly if supported with kapha.
5) Sandhi – Marma :
Sushruta – 20
**************sholk**************************sholk************ - su sha 6/7
**************sholk************ su sha.6/32
ANSA SANDHI VIKRUTI:-
According to ashatang Hridaya,injury causes-
i.e loss of function of the arms :- Stabhabahuta.
Stabdhabahuka :- **************sholk************ -ch .si 1/32
**************sholk************ -cha,su 5/90
**************sholk************ - su,sha 6/26
Stabdhabahuka :- loss of function or restriction of movements of arm.
**************sholk************ - a.san,sha,7/19
Sandhi marma viddha lakshanani :
**************sholk************-a.ha ,sha 4/51
**************sholk************a,ha,sha, 4/51 (indu**)
All above references state that,in case of injury to Sandhi Marma , the site of injury feels as though full of thorns , even after healing (of wound) there is crooked or bend or curved,lameness, decrease of strength & movement & emaciation and swelling of the joints.
**************sholk************ - a,hu,sha 4/8
**************sholk************-a.hu,sha,4/8.9(**indu tika )
All these reference state that trauma at the site of Sandhi Marma leads to Kuni (ie.crooked or curved or bend at the shoulder joint,a major deformity).
D) Avabahuka :
**************sholk*********** - su,ni,1/82
Due to vitiated Vata Dosha,Shosha occurs in Amsa Pradesha.
Also it causes Sira Akunchana & thus leading to degradation or functional loss of arm called as ‘ Avabahuka’.
In Charaka Samhita,there is reference regarding the disease Bhujastambha of lord indra and also reference has been quoted regarding the disease Bahushosha in sutra Sthana in the context of Nanatmaja Vata Vikaras.
In Sushruta Samhita Samprapti, Lakshana and chikitsa of Avabahuka has been discussed in detail in the context of Vata Vyadhi.
In Ashtanga Sangraha also describe disease.
Commentators like Aarunadatta , dalhana , hemadri have tried to analyza Avabahuka . Madava Nidana , yogaratnakara,Vangasena Samhita explained Avabahuka in vata vyadhi chapter.
Madavakara was the first to differentiate Avabahuka from Anasashosha . Other aauthors like Bhavamishra , Sarangadara have discussed Avabahuka, the recent text like Gadanigraha, Brihatnigantu Ratnakara have explained Avabahuka.
Avabahuka comprises of two words ‘Ava’ and ‘Bahuka’.
‘Ava’- deterioration or dysfunction.
‘Bahuka ‘- Muscular gender.
Thus Avabahuka can be defined as ,Bahustambho Avabahuka / bad arm,stiffness in the arm joint.
IN case of Avabahuka Hetu may be classified into two groups;
Bahya Hetu- causing injury to the sandhi .
Abhyantara Hetu- indulging in vata prakopaka Nidana leading to vitiation of vata in that region .This may be again of Bahya Abhigataja (External Trauma) which manifest vyadhi or disease frist . the othe is dosha prakopanjanya (Samshraya) which in turn leads to Karmahani of bahu.
Guna –laghu,Ruksha, sheeta,
Atiplavana ,Atiprapatana ,ativichestitam, Ativyayama, Kriyatioga
Mithyayoga- Asama chalana,malavat vigraha,bhara harana,dukhasana ,vegadharana,
Agantuja – abhighataja,Marmaghata.
Symptoms of Avabahuka:
In case of Avabahuka ,sthanika lakshanas acquire important place,as compared to Sarvadaihika lakshanas . the cardinal features of Avabahuka are as follows.
************** sholk*********** va.ni 15/41
Bahucheshta Kriyalpta (Bahu Praspanditahara)-
This has therr terms –
Bahu-means upper limb
Prasapandana-means movement or chalana , this is considered under normal function of vata in Sushruta SAnhita.
************** sholk*********** su,ni,1/18
Dalhana commenting on this says that praspandana means chesta or movement and chesta to ankunchana – prasaranadi karma,this karma is maintained by Vyanavata in the limds.
HARA – means loss of /impaired /difficult.Thus ,in the present context this may be taken up as (i.e praspanditahara) difficulty in the movement or impaired or loss of movement of the upper limb.
Although any of the texts did not mention about the shula as one of the lakshanas of Avabahuka,it is still a feature practically seen in Avabahuka patients recent Ayurvedic texts like Chikitsa sara –sangraha and Nidana sara,clearly mention about Savedana as a predominant lakshanas of Avabahuka, along with other lakshanas.
4.3 REVIEV OF MODERN LITERATURE
A JOINT IS PRESENT WHERE TWO BONES COME TOGETHER, WHETHER THERE IS MOVEMENT BETWEEN THEM OR NOT.Joints without movement are those where the adjacent bones have either fused or are united by a thin layar of dense fibrous tissue or cartilage.
Type of joints According to Modern Science
Fibrous joints – a) Sutures
Cartilaginous joints –
Synchondroses - primary cartiiaginous joints
Symphyses- Secondarycartilagious joints.
Ball and socket – Shoulder joint.
Saddle joints- frist carpo-metacarpal joint.
Condylar joints – Knee joint.
Ellipsoid joints- Wrist joint meta –carpo-phalangeal joints.
Hinge joints- Elbow joint.
Pivot joints- Superior and inferior radio-ulnar.
Plane joints – Intercarpal joint.
Functional classification –( according to mobility)
Classification According to axial movement
1.Hinge joint-Flexion and extension
2.Piolet joint-Rotation only
c) Biaxial joints :
1. Condylar joints- Flexion,extension and limited rotation.
2. Ellipsoid joint- Flexion,extension,abdution,adduction and Circumductio.
d ) Multiaxial joints:
1.Sanddle joint- flexion ,extension, abduction, adduction and conjunct rotation.
2. Ball and socket – flexion ,extension ,abduction ,adduction and circumdution and rotation.
SYNOVIAL JOINTS- Synovial joints are the most common and important type functionally.they normally provide free movement between the bones they join , and they are typical of nearly all the joints of the limb (e.g shoulder and hip joints). They are called synovial joints because the fibrous capaule convering the joints internally lining by synovial membrane which secrets lubricating substance called as synovial fluid and are lined with synovial membrane or capsule.Injury to synovial joints (e,g – toen ligaments and cartilages)is common at all ages and both genders.
Components of synovial joints:-
Particular cartilage : - The ends of bone forming it i.e particular surface covered by thin layar of articula cartilages which reduces friction between the bones in the joint.Thesecartilages are usally of hyaline type . These cartilages have no nerve & blood suppy.It get nourished by synovial fluid convering its free surfaces.
Articular capsule: It envelopes the joint.It consists of two parts – fibrous capsule and synovial membrane.
Fibrous capsule is thickened or strengthened by accessory ligament which ether is part of fibrous capsule i.e intrinsic or separated from them i.e extrinsic .the fibrous capsule is sensitive to strtches to protect the joint from any sprain .this is called as the “Watch-Dog” action of the capsule.
Synovial membrane : - It is a vascular connective tissue membrane that lines whole of the interior of the joints ,except for the articular surfaces covered by hyaline cartilage . The membrane secretes a slimy viscous fluid called as the “synovial” or “Synovial Fluid” , which lubricates the joint and nourishes the articular cartilage.The viscosity of fluid is due to hyaluronic acid secreted by cells of the synovial membrane.
Joint cavity : - Between the articular surfaces there is a joint cavity filled with synovial fluid. The cavity may be sub- divided by an articular disc or meniscus.
Movements of joints: Verying degrees of movements are always permitted by the synovial joints
Anguar Movement :- Movement leading diminution or increase in angle between two adjoining bones.
Flexion and extension – bending and straightening respectively.
Abduction and adduction movments awaqy and towards the median respectively
Circumduction:-When a long bone circumscribes a conical space.
Rotation :- bone moves around a longitudinal axis.
Adjunct rotation –independent rotation
Conjunct rotation- rotations which accompany other movements.
Close pack Positions-when the joint surfaces become completely congruent, their area of contact is maximal and they are tightly compressed .In this position fibrous capsules and ligaments are maximal in spiralized and tense ;no further movement is possible ;surfaces cannot be separated by disruptive forces; articular surfaces are liable to trauma.
C ) loose packed position –all other positions are in congruency e.g.least packed.
Limitation of Movement:
Reflex contraction of antagonistic muscle;
Stimulation of mechano-receptors in articular ;
Approximation of soft parts.
Stability of Synovial joints
Various factors maintainingstability at a joint are described below inorder of their importance.
Muscels – The tone of different groups of muscles acting on the joint is the most important and the indispensably factor in maintaining the stability . Without muscles, the elbow the knee and shoulder would be unstable.
Ligaments- Are important in preventing any over movement.and in guarding against sudden accidental stresses.However,they do not help against of continuous strain,because once stretched,they tend to get elongated.
Bones – help inmaitaining stability only in firm type of joints, like the hip ,ankle, and elbow joints. Otherwise in most of the joints(shoulder, knee,sacroiliac,etc.)their role is negligible.
Applied Anatomy of synovial joint:-
Dislocation of joint-
This is a condition in which the articular surfaces of the joint are abnormally displaced;so that one surface loses its cotact completely from the other.If a partial contact is still retained,it is better called as sub-luxation.Dislocation is commonly caused by trauma ,and is characterized by pain deformity,and loss of function.x-ray is confirmatory.
Sprain-is ligament tear injury,but without any associated dislocation or fracture.The tear leads to effusion into the ligament and joint causing great pain.
Arthritis – is an inflammation of joint . It can be caused by a variety of diseases. but the common types of arthritis are rheumatic , rheumatoid, osteo – arthritis and tuberculosis. The involved joint is commonly swollen and its movements are restricted and painful.Osteoarthritis represents the ageing process. In old age ,the articular cartilage shows degenerative change in the center (fibrillation of cartilage), and proliferative change around in the edges (osteophytes), lipping of the joints means formation of the lips at edges.
Stiffness- Stiffness of joints related to weather the viscosity of synovial fluid increases with fall in temperature . this accounts for stiffness of the joints in cold weather.Mobility of joints in itself is an important factor in promoting lubrication.thus the stiffness of joints experienced in the morning gradually passes off as the movements are resumed.
Neuropathic joints – As joints are completely innervated diseases of nerves causes neuropathy resulting in painless swelling , excessive mobility and bony destruction. It is commonly caused by leprosy ,tabes dorsalis and syringomyelia .
ANATOMY OF SHOULDER COMPLEX
The shoulder complex is composed of the scapula , clavicle , humerus ,and the joints that link these bones into a functional entity . These components constitude one half of the weight of the entire upper limb.the shoulder complex is connected to the axial skeleton by a single anatomic joints the sternoclavicular joint and is suspended by muscles that serve as the primary mechanism for securing the shoulder gridle to the rest of the body .Shoulder complex includes –
Glenohumeral joints .
Type – synovial joint of the ball and socketvariety.
Articular surface :- Glenoid cavity of Scapula and the head of the humerus.
Thereforevit is also known as the glenohumeral articulation. Stability is also provided by the muscles attaching the humerus to the pectoral girdle, the long head of the muscles attaching the humerus to the pectoral girdle , the long head of the biceps, the long head of the triceps,and atmospheric pressure .
Ligaments of shoulder joint :-
Glenohumeral ligaments -
Three in numbers.
Superior glenohumeral ligament – to gether with the coracohumearal ligament,it is an important stabilizer in the inferior direction.
Middle glenohumeral ligament provides anterior stability at 45º & 60º abduction.
Inferior glenohumeral ligament- The anteriorband of the inferior glenohumeral ligament is the primary anterior stabilizer of the glenohumeral joint.
Fibrous capsule :- A fibrous capsule envelops the joint.
It is very loose and permits free movements.
It is least supported inferiorly where dislocations are common .
The fibrous capsule is supported by the tendons of supraspinatus (above) intraspinatus and teres minor (behind) ,Subscapularis (infront) and the long head of triceps (below). The capsule is least supported anateriorly.
Coracohumeral ligament : - It given strength to the capsule.
Transverse humeral ligament :- It bridges the upper part of the bicipital groove of the humerus . The tendon of the long head of the biceps brachii passes deep to the ligament.
Glenoid labrum :- the glenoid labrum is a fibrocatilagenous rim around the glenoid fossa.
The labrum deepens the cavity , may protect the bone and probably assist lubrication .
Its attachment is sometimes partly deficient anterosuperiorly in which case synovial membrane may protrude through the gap .
Subjected to strain in full abdution when it is stretched tightly across the humeral head.
Synovial membrane : - It lines the capsule from inside.
Bursae related to the shoulder joint :-
The subacromical bursa.
The subscapularis bursa.
The infraspinatus bursa.
Several other bursae related to the coracobrachialis , teres major,long head of the triceps , latissimus dorsi.
Structurally shoulder joint is a weak joint because the glenoid cavity is too small and shallow to hold the head of the humerus in place .however ,this arrangement permits great mobility. Stability of the joint is maintained by –
The glenoid labrum helps in deepening the glenoid fossa.
The Coracoacromial arch or secondary socket for the head of the humerus .
The musculo tendinous cuff of shoulder.
Muscles of the rotator cuff :- The four major muscles of the rotator cuff rotate the humerus and properly orient the humoral head in the glenoid fossa (socket).the tendons of these four muscles merge forming a cuff around the glenohumeral joint.
Supraspinatus: abducts the humeral head and acts as a its depressor.
Infraspinatus: externally rotates and horizontally axtends humerus.
Subscapularis :internally rotates the humerus .
Teres minor : externally rotates and axtends the humerus .
Relations of Glenohumeral joint :-
Superiorly –Coracoacromial arch, subacromial bursa, supraspinatus and deltoid.
Inferiorly – long head of triceps brachii.
Anteriroly – Subscapularis , coracobrachialis , short head of biceps and deltoid.
Posterioly – infraspinatus , teres minor and deltoid .
Within the joint – Tendon of the long head of the biceps brachii.
Blood supply :-
Anterior and posterior circumflex humerus vessels .
Suprascapular vessels .
Nerve supply :-
1] Axillary nerve.
2] Musculocutaneous nerve and suprascapular nerve.
Type - plane synovial joint.
Joint between the acrominal end of the clavicle and the medial acromiail margin.
It is appromately plane, but either surface may be slightly convex , the other reciprocally concave.
The clavicular surface is a narrow, oval area which faces inferolaterally and overlaps a corresponding facet on the medical acromial border.
Fibrous capsule:- the capsule completely surrounds the articular margin and is strengthened above by the acromioclavicular ligament. The capsule is lined by synovial membrane.
Acromioclavicular ligament :- The quadrilateralar ligament extends between the upper aspects of the lateral end of the clavicle and the adjoining acromion and Its parallel fibres interlace with the aponeurosis of trapezius and deltoid.
Articular disc :- The articular disc often occurs in the upper part of the joint, partially separating the articular surfaces.occansionally it completely divides the joint.
Coraco – Clavicular ligament :-
Connects the clavicle and the coracoids process of the scapula.
Though separate from the caromioclavicural joint, it is a most efficient accessory ligament ,and maintains the apposition of the clavicle to the acromion.
Parts :- 1] trapezoid part 2] conoid part
The trapezoid part is anterolateral and is broad , thin and quadrilateral , ascending slightly from the upper coracoids surface to the trapezoid on the inferior clavicular surface.
It is almost horizontal ,its anterior border is free , and its posterior border is joined to the conoid part , forming an angle which projects backwards.
The conoid part is posteromedial and is a dence , almost vertical triangular band.
Its base is attached to the conoid tubercle of the clavicle and attached posteromedialiiy to the root of the coracoids process in front of the scapular notch
Blood supply :- suprascapular and thoracoacromial arteries .
Nerve supply :- lateral supraclavicular nerve.
Movements of the pectrol (shoulder) girdle.
Clavicular movements at the sternoclavicular and acromioclavicular joints are inevitably associated with movements of the scapula and these are usually accompanied by movements of the humerus. The acromioclavicular joints allows anteroposterior gliding and rotation of the acromion ,and hence the scapula on the clavicle ; scapular range increased by movements at the sternoclavicular joint.
MOVEMENT OF SCAPULA :-
N. to L Scapulae
Pectoralis major – Sternal head
Trapezius – upper and lower part
Pectoralis major – sternal head
N. to ,L scapulae
Movements of shoulder joint
1] flexion 2] Extension 3] Abduction
4] Adduction 5] Medial and lateral rotation 6] Circumduction
Flexion and Extension :-
Flexion :- The arm moves forwards and medially.
Extension :- The arm moves backwards and laterally.
Thus flexion and extension take place in a plane parallel to the surface of the glenoid cavity.
In flexion , the humerus swings at right angles to the scapular plane and scapular rotation cannot increase the elevation (120) obtainable in full flexion. If the fully flexed humerus is also abducted then 180 degree of elevation becomes possible.
Abduction and Adduction :-
Take place at right angles to the plane of flexion and extension that is approximately midway between sagital and coronal plane .
Abduction raise the arm anterolaterally in the plane of the scapula.
Medial and lateral rotation :-
Medial and lateral rotation is best demonstrated with the modflex elbow. In this position the hand is moved medially in medial rotation and laterally in lateral rotation of the shoulder joint.
Continuation of flexion – extension adduction in succession to produce a movement called circumduction; as a result of which the hand moves along circle.
MOVEMENTS OF GLENOHUMERAL JOINT
Deltoid – anterior fibers
Pectoralis major – clavicular head
Deltoid – posterior fibers
Deltoid – anterior
Pectoralis major – sterna head
Deltoid - anterior
Deltoid – posterior
Injuries of the Acromiocalavicular Joint
Although , very little motion occurs at this joint the acromioclavicular joint helps to anchor the entire arm to the body. Therefore , tremendous loads are applied across this joint predisposing it to injury as well as arthritis .
Traumatic injuris to the acromioclavicular joint are commonly referred to as a ‘shoulder separation.” This typically occurs when an athlete falls directly onto the top of the shoulder and disrupts the ligaments which stabilize the acrornio clavicular joint.
Clinical features :-
There will usually be a history of relevant trauma and severe pain over the lateral shoulder.
The patient complaints of
Difficulty in raising the arm up.
The patient supports the affected shoulder by holding the elbow with unaffected hand .
On examination :-
Marked tenderness at the acromioclavicular joint.
Lateral end of clavicle is prominently felt.
A visible / palpable ‘step’ if there is clavicular separation. This is best viewed the arm adducted across the body.
Brachial and radial pulses should be checked along with sensory and motor function in the affected arm due to the possibility of injury to brachial plexus and axillary / subclavian vessels.
DISLOCATION OF SHOULDER
Symptoms :- Dislocated shoulder sings and symptoms may include:
A visibly deformed or out of place shoulder
Swelling or discoloration (bruising ).
Intense pain .
Inability to move the joint.
Shoulder dislocation may also cause numbness, weakness or tingling near the injury , such as in neck or down arm. The muscles in shoulder may spasm from the disruption , often increasing the intensity of pain.
Causes:- The shoulder joint is the most frequently dislocated joint of the body. Because it can move in many directions ,shoulder can dislocate forward , backward or downward completely or partially. in addition, fibrous tissue that joins the bones of shoulder (ligaments) can be streched or torn , often complicating the dislocation . When shoulder dislocates , a strong force such as a sudden blow to shoulder , pulls the bones in shoulder out of place (dislocation) . Extreme rotation of shoulder joint can pop the ball of humerus out of shoulder socket (glenoid), which is the part of shoulder blade (scapula ) . Partial dislocation (subluxation) in which upper arm bone is partially in and partially out of shoulder socket also may occur .
A dislocated shoulder may be caused by :
Sports injuries : shoulder dislocation is a commen injury in contact sports such as football and hockey and in sports that may involve falls , such as downhill skiing , gymnastics and volleyball.
Trauma not related to sports . A hard blow to your shoulder during a motor vehicle accident is a common source of dislocation .
Falls . You may dislocate your shoulder during a fall , such as from a ladder or from tripping on a loose rug .
Shoulder joint is vulnerable for dislocation more often than any other joint in the body .95% - anterior dislocation. 5% - posterior dislocation .
Recurrent anterior dislocation of the shoulder (rds):-
Very common complication of anterior dislocation of shoulder – 80%
Recurrence rate – 55%- 12to22 years.
Clinical Features :
History of previous dislocation .
There could be wasting of deltoid ,supraspinatus and infraspinatus muscles.
Complications : Complications of a dislocated shoulder may include :
Tearing of muscles ,ligaments and tendons that reinforce shoulder joint .
Nerve or blood vessel damage in or around shoulder joint .
Susceptibility to re injury (shoulder instability) if have severe dislocation or repeated dislocations. If ligaments or tendons in shoulder have been stretched or torn, or if nerves or blood vessels surrounding shoulder joint have been damaged , it may need surgery to repair these tissues .
SOFT TISSUE INJURIES :
The term soft tissues implies skin, subcutaneous tissue, fascia, muscles, ligaments, tendons, synovial capsules, nerves etc.
Sports persons are more prone to suffer from soft tissue injuries than the normal population
CLASSIFICATION OF SOFT TISSUE INJURIES –
Strain :- injury to the muscle & tendons is called strain
Severity of strain :-
First degree strain ( mild contusion)
Localized pain & tenderness
Pain & spasm prevents muscle stretching.
Function is not impaired to a greater extent.
Tenderness over the extent muscles.
Second degree strain
Pain is more severe.
Severe muscle spasm.
Tenderness is severe.
The patient is unable to move the limb.
Third degree strain
All the above symptoms are of greater intensity.
Larger are & greater number of muscle fibers are involved.
More than one muscle group may be involved. The fascia is partially torn.
Bleeding is widespread & more.
There could be both intramuscular & intermuscular bleeding. The patient experiences severe pain & loss of function.
Grade four strain
A snapping sound may be Heard by the patient
Severe loss of function
Palpable gap between the muscle felt
Joint function is not lost
Active muscle contraction is absent
Severe muscle spasm
Active movement produced by the agonist is absent
Injuries to the joint-
During an injury to a joint, three things could happen.
Injury to the ligaments only
Injury to the synovium
Sprain:- A ligament injury is called “sprain”.
Depending on the severity, it could be:-
Mild [Grade I]
Moderate [Grade II]
Severe [Grade III]
Types of Sprain:-
Grade I (minor):-
Slight pain & tenderness at the site of injury.
Slight swelling & loss of function.
Grade II (severe):-
More force results in this injury.
Swelling is more severe.
Pain & tenderness are also more acute.
Movement is grossly restricted.
Weight bearing is difficult.
Function is severely affected.
The ligament may be partially torn or detached from the attachment.
Grade III (complete rupture):-
Pain & tenderness is quite severe.
Joint is unstable
The patient is unable to bear weight.
Severe loss of function.
Inflammation of synovium is called synovitis.
Acute :- due to trauma
Chronic: - due to disease like TB, rheumatoid arthritis, trauma.
Swelling of the joint (develops slowly say within 2 to 24 hours).
Joint is hot & red
Pain is present over the injured structure.
Feeling of tension or pressure due to swelling.
Injury to the Bursa
Pain, more so if it ruptures.
Swelling is tender & hot.
Movements of the joints may be painful.
COMMON PATHOLOGY AROUND THE SHOULDER
ROTATARY CUFF INJURY
Rotator cuff injury symptoms may include:-
Pain & tenderness in shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side.
Loss of shoulder range of motion.
Inclination to keep your shoulder inactive.
Causes: - A rotator cuff injury which is fairly common, involves any type of irritation or damage to rotator cuff muscles or tendons, including:
Tendinitis. Tendon in rotator cuff can become inflamed due to overuse or overload, especially in athlete who performs a lot of overhead activities, such as in tennis.
Bursitis. The fluid-filled sac (bursa) between your shoulder joint & rotator cuff tendons can become irritated & inflamed.
Strain or tear. Left untreated, tendinitis can weaken a tendon & lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.
Common cause of rotator cuff injuries include:-
Normal wear & tear. Increasingly after age 40, normal wear & tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff tendon & muscles. This makes them more prone to degeneration & injury. With age, also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.
Pure posture. When slouch neck & shoulder forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under shoulder bones (including collarbone), especially during overhead activities, such as throwing.
Falling. Using arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
Lifting or pulling. Lifting an object that’s too heavy or doing so improperly especially overhead can strain or tear tendons or muscles. Likewise, pulling something such as high poundage archery bow it may cause an injury.
Repetitive stress. Repetitive overhead movement of your arms can stress rotator cuff muscles and tendon, causing inflammation and eventually tearing. This occurs often in athletes, especially base ball pitcher, swimmers and tennis players. It’s also common among people in the building trades, such as painters and carpenters.
Age. Older than 40.
Being an athlete. Athletes who regularly use repetitive motions, such as base ball pitchers, archers and tennis players.
Working in the construction trades. Carpenters and painters who also use repetitive motions.
Having poor postures.
Having weak shoulder muscles.
Test and diagnosis
An Ultrasound scan
Rotator cuff tendonitis:-
Many athletes put significant strain on the rotator cuff including overhead throwing athletes, swimmers, tennis players and volleyball players. Tremendous rotational torque is applied to the shoulder with the throwing motion the rotator cuff is main stabilizer of this rotational torque and is often injured by repetitive strain to the tendon. Initially the tendon becomes inflamed and thickened as a response to the injury, resulting in a rotator cuff tendonitis. With further repetitive microtrauma to the rotator cuff, tendon can become physically damaged leading to a rotator cuff tear.
Pain during activity and as the symptoms progress, pain can be felt even at rest. In fact most patients complaint of significant pain at night and difficulty sleeping due to the shoulder.
The patient has difficulty in initiating abduction of arm.
In other cases the torn shoulder cuff impinges on the acromion during abduction, giving rise to a painful are of movement.
When there is inflammation of the rotator cuff, raising the arm horizontally above shoulder level usually causes pain as the thickened tendon gets pinched between two bones. This position is often referred to as the position of “Impingement” As the impingement becomes worse, the tendon becomes more inflamed which sets up a cycle of progressive tendonitis.
Frozen shoulder or adhesive capsulitis is a condition that causes restriction of motion in the shoulder joint. No one really understands why some people develop a frozen shoulder. For some reason the shoulder joint becomes stiff and scarred. The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (glenoid). Surrounding this ball and socket joint is a capsule of tissue that envelops the joint. Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes contracted. The patients form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder become stiff and cause movement to become painful. A frozen shoulder causes a typical set of symptoms. The most important finding is restricted movement. Other shoulder condition can cause difficulty with movement of the shoulder, such as a rotator cuff tear, therefore it is important to have an examiner familiar with this condition for a proper diagnosis.
Most often frozen shoulder occurs with no associated injury or discernible cause. There are patients who develop a frozen shoulder after a traumatic injury to the shoulder, but this is not the usual cause. Some risk factors for developing a frozen shoulder includes.
Age and gender
Between the ages of 40 to 60 years old, and it is twice as common in women than in men.
Patient with diabetes are at particular risk for developing a frozen shoulder. Other endocrine abnormalities such as thyroid problems can also lead to this condition.
Shoulder trauma or surgery
Patient who sustain a shoulder injury or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilization, the risk of developing a frozen shoulder is highest.
Broken upper arm
The immobilization required to heal a fracture in the upper arm bone can sometimes result in painfully limited range of motion of the shoulder in all directions
Other systemic conditions
Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk of developing frozen shoulder. There may be autoimmune basis for disease.
Typical symptoms of frozen shoulder
Shoulder pain: usually dull, aching pain
Limited movement of the shoulder
Difficulty with activities such as brushing hair, putting shirt/ bras
Stages of a frozen shoulder
Frozen shoulder typically develops slowly and in three stages each of these stage last a number of months.
This is a most painful stage of a frozen shoulder. Motion is restricted but shoulder is not as stiff as the frozen stage. This painful stage typically lasts 6 to 12 weeks. During this stage pain occurs with any movement of shoulder and shoulders range of motion start to become limited.
During the frozen stage the pain usually eases up but the stiffness worsens and range of motion decreases. The frozen stage can last 4 to 6 months.
The thawing stage is gradual and range of motion steadily improves over a lengthy period of time. The thawing stage can last more than a year.
Stage to diagnose a frozen shoulder
Most often a frozen shoulder can be diagnosed on examination, and no special tests are needed. An X-ray is usually obtained to ensure the shoulder joint appears normal and there is no evidence of traumatic injury or arthritic changes to the joint. An MRI is sometimes performed if the diagnosis is in question but this test is better at looking for other problems rather than looking for frozen shoulder. If an MRI is done it is best performed with an injection of contrast fluid into the shoulder joint prior to the MRI. This will help show if the capsule of the shoulder is scarred down, as would be expected in patients with a frozen shoulder.
The small fluid-filled pads called bursae that act as cushions among bones and the tendons and muscles near joints. Bursitis occurs when a bursa becomes inflamed.
The most common locations for bursitis are in the shoulders, elbows or hips. But can also have bursitis by knee, heel and the base of big toe. Bursitis often occurs in joints that perform frequent repetitive motion. In most cases, bursitis pain goes away within a few weeks with proper treatment, but recurrent flare-ups of bursitis are common.
Symptoms- Affected joint:-
Feel achy or stiff.
Hurt more when move it or press on it.
Look swollen and red
The most common causes of bursitis are repetitive motions or positions that irritate the bursae round a joint. Examples include:
Throwing a baseball or lifting something over your head repeatedly
Leaning on elbows for long periods of time
Extensive kneeling, for tasks such as laying carpet or scrubbing floors
Prolonged sitting, particularly on hard surfaces
Some bursae at the knee and elbow lie just below the skin, so they are at higher risk of puncture injuries that can become infected and cause septic bursitis.
Age: - more common during middle age
Occupations or hobbies if someone work in a profession or have a hobby that requires repetitive motion or pressure on particular bursae, they are at an increased risk of developing bursitis.
Examples include:- Carpet laying, Tile setting, Gardening, Bicycling, Baseball, Ice skating
Other medical conditions
Certain diseases and conditions increase risk of developing bursitis, such as: Rheumatoid arthritis, Osteoarthritis, Gout, Thyroid disease, Diabetes.
Tests and diagnosis
X-ray images can’t positively establish the diagnosis, but they can help to exclude other causes of discomfort.
MRI is useful.
This may include blood tests or an analysis of fluid from the inflamed bursa.
4.4 CADAVERIC DISSECTION
Fascia from the surface of deltoid muscle removed. It has V shaped origin from the outer border of the subcutaneous bony arch formed by lateral third of the clavicle the acromion and the crest of the spine of the scapula it is inserted into deltoid tuberosity of the humerus long anterior and the posterior run parallel to each other. On the corresponding surfaces of the shoulder joint, the lateral fibers are short and multipinnate to increase the power of this part after separating the muscle from the spine of scapula reflected downwards
After removing the dense fascia from the surface of the infraspinatus muscle get exposed. Its attachment to infraspinatus fossa and greater tubercle of the humerus defined. The inferior border of nfraspinatus checked and separated from two teres muscles which arise from the lateral margins of the scapula the detached part of deltoid turned forward axillary and the posterior humeral circumflex vessels identified.
Long head of triceps exposed medially to the quadrangular space and traced as it descens from the infrglenoid tubercle beside the inferior part of the capsule of the shoulder joint passes between the teres minor and teres major muscles. Branch of the axilary to the teres minor identified.
Remaining part of deltoid divided to the origin and turned downwards as it lies on the proximal end and the surgical neck of humerus. To the anterior side subscapularis muscle followed from subscapular fossa to lesser tubercle and separated inferiorly from teres major. Then teres major muscle traced to its insertion on crest of the lesser tubercle of humerus. Insertion lie laterally to the coracobrachialis and short head of bicep along with lattissimus dorsi insertion. Then axillary nerve traced from the posterior cord of brachial pluxes. It lies between subscapularis, teres major. Radial nerve identified from the posterior cord as continuation and traced anterior to lattissimus dorsi and teres major and posterolaterally between tricep muscle after giving branches to lateral and medial head of the muscle. Then fascia covering coracobrachialis and short head of bicep from coracoid process to insertion on medial aspect of shaft of humerus. Then musculocutaneous nerve from the lateral cord of brachial plexus identified with its branches. Long head of the bicep identified after pulling the coracobrachialis and short head of bicep medially. It lies in the itertubercular sulcus and disappears into capsule of the joint.
Subacromial bursa exposed after removing the fascia covering superior surface of greater tubercle. Bursa opened and explored its limits with blunt seeker. It is seen that bursa separate the superior of the humerus and capsule of the joint from the acromion and coracoacromial ligament.
coracoacromial ligament is strong triangular band as its base is attached to lateral border of the coracoids process and its apex to the tip of the acromion. It lies between the subacromial bursa and deltoid muscle supraspinatus exposed after removing subacromial arch and bursa to the superior part of greater tubercle the tendon of supraspinatus is firmly fused to this part of capsule of joint. Infraspinatus and teres minor muscles cut across the level of neck and scapula and turned medially and laterally suprascapular an dcircumflex scapular arteries, scapular nerve identified deep to muscles. Tendons of the teres minor and infraspinatus fuse with the capsule as they pass to the greater tubercle.
Tendon of long head of tricep followed to its attachment to infraglenoid tubercle and looked after the dependent part of capsule at this point axillary nerve indentified as it passes posteriorlly on surgical neck.
Subscapularies cut across at neck of the scapula and reflected its part, though fused with capsule of shoulder joint laterally; it is separated from medially and from neck of scapula and root of the coracoids process by subscapular bursa. Which fascilates its movement over these structures. This bursa is continuous with cavity of shoulder joint through aperture in its capsule.
Coracoclavicular ligament exposed in the space between coracoids process and the clavicle.
Make a vertical incision through the posterior part of articular capsule of shoulder joint. Arm rotated medially and head of humerus dislocated through cut in the capsule, then tendon of passing long head of bicep over superior surface of the head of humerus reaching to supraglenoid tubercle identified. It was seen that it becomes continuous with fibrocartilaginous ring, the labrum glenoidale, which is attached to margin of the glenoid cavity and the internal surface of articular capsule. By surrounding the glenoid cavity the labrum slightly depens it and continuous inferiorly with fibers of the tendon of long head of tricep through capsule. Glenohumeral ligaments deeper to surface of the anterior part of capsule exposed and aperture of the scapular bursa between them noted and tendon of long head of bicep cut and movements of humerus and shoulder joint observed.
MATERIAL AND METHODS
Hypothetically it is a expected that in avabahuk vyadhi- joint capsule synovial membrane tendons of rotator cuff muscles, ligament of ansa sandhi are commonly affected structures.
CRITERIA FOR INCLUSION
Age- between 20 to 70 years
Prediagnosed patient having symptoms of avabahuk
CRITERIA FOR EXCLUSION
Age- below 20 and above 70 years
Avabahuk associated with major illness.
Patient having any metallic implant.
Open randomized clinical observational study.
A special Performa of the case paper prepared for study with references to avabahuk on basis of granthokta laxanas and clinical stage included as per requirement.
Total 50 diagnosed patient was taken for the study irrespective of sex and religion and occupation.
Written consent was taken from patient after explaining risk for a clinical as well as investigational study.
Clinical study of shoulder joint movements and function of muscles related to shoulder joint and required test carried out in patient.
Anatomical changes in ansa sandhi in avabahuk had been noted and prone structured predicted.
CLINICAL EXAMINATION OF SHOULDER
Examination of shoulder include inspection, palpitation, evaluation of range of motion.
A complete history started with the patients age, dominant hand and sport or work activity.
It is important to assess whether the injury prevent or hampers normal work activities, hobbies and sports.
The patient ask about shoulder pain, instability, stiffness, locking, catching and swelling.
Stiffness or loss of motion may be the major symptoms in patient with adhesive capsulitis (frozen shoulder), dislocation or glenohumeral joint arthritis.
Pain with throwing suggest anterior glenohumeral instability.
Distinguishing between an acute and a chronic problem is diagnostically helpful. For example a history of acute trauma to the shoulder subuxation or dislocation and possible glenoid labral injury. In contrast, chronic pain and loss of passive range of motion suggest frozen shoulder or tears of the rotator cuff.
Neck pain and pain that radiates below the elbow or often subtle sign of cervical spine disorder that is mistaken for a shoulder problem.
A patient asked about paresthesias and muscle weakness. Pneumonia cardiac ischemia and peptic ulcer disease can present with shoulder pain.
Assessment of range of motion and strength
The properly asked to permit complete inspection of both shoulder.
Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distension if any noted.
Deformity such as squaring of the shoulder that occurs with anterior dislocation, can immediately suggest a diagnosis.
Scapular “winging” which can be associated with shoulder instability and serratus anterior or tripezius disfunction noted.
Atrophy of the supraspinatus or infraspinatus noted as prompt a further work up for such condition as rotator cuff tear, suprascapular nerve entrapment or neuropathy.
Inspection: from the front-
Prominent sternoclavicular joint (subluxation)
Deformity of clavicle (old fracture)
Prominent acromiclavicular joint (subluxation or osteoarthritis)
Deltoid wasting (disuse or axillary palsy)
Inspection: from the side-
Any swelling of the joint, suggesting infection or inflammatory reaction from, for e.g calcifying supraspinatus tendonitis, pyogenic infection of the glenohumeral joint or trauma.
Inspection: from behind: -
Looked for the scapulae normal shape and situation of the scapula or small and high and look for winging of scapula.
Inspection: from above: -
Swelling of shoulder deformity of the clavicle asymmetry of the supraclavicular fossa.
In palpation, examination of the acromioclavicular and sternoclavicular joint, the survicle spine and the biceps tendon were included.
The anterior glenohumeral joint, coracoid process, acromion and scapula
Should also be palpated for any tenderness and deformity.
palpate the anterior and lateral aspect of glenohumeral joint. Diffused tenderness a suggestive of infection or calcifying Supraspinatus tendonitis.
Palpate the upper humeral aspect of shaft and head via the axila
Tenderness over the acromioclavicular joint is found after recent dislocation and in osteoarthritis of the joint lipping is usually palpable and crepitus may be detectable when the arm is abducted.
Press below the acromion and abduct the arm sudden tenderness occurring during the portion of the arc of movement is found in tears and inflammatory lesion involving shoulder cuff and subdeltoid bursa.
Palpate the length of clavicle tenderness is found in sternoclavicular dislocation and infection (TB) Tumours and radionecrosis.
Range of motion (ROM) tests:-
The following RMO tests conducted both actively (patient’s own strength) and passively (performed by examiner), and the results considered separately. The reason for this is that if the patient is experiencing pain, he/she may restrict movement.
Definition of Goniometry:-
The term goniometry is from Greek words Gonio means angle and Metron means measures (Norkin and white,1994). The amount of motion that is available at a joint is called as range of motion (ROM). Therefore goniometry refers to the measurement of angles, in particulars the measurements of angles created at human joints by the bones of the body.
Universal: it is the most commonly used instruments to measure joint position and motion. The name universal implies the wide use of this instrument for almost all the joints.
It is made up of metal steel and plastic
This are of different size and shapes. The basic design is common.
The basic design of universal goniometry includes:
Body central part which looks like protractor and to arm stationary arm and movable arm(the body of instrument is placed on it)
Start with joint at zero position- this is the reference point for the measurement. If zero position can’t be achieved, this must be documented.
Permit complete range of motion.
Poor stabilization is the most frequent cause of invalid measurements. (e.g. observe a normal ROM of elbow extension when movement of shoulder and arm masks a limitation actually measuring shoulder and arm movement)
Usually stabilize proximal joint components.
Promote patient relaxation so voluntary muscle contraction doesn’t interfere
The body of goniometry is placed at the joint (bone prominence) which acts like a fulcrum, one arm usually the stationary arm is placed along the proximal bone to the joint and the movable arm along the distal bone of joint being measured.
As mentioned in the definition, goniometry is used to measured the joint angle i.e. range of motion in the particular joint. Normal ROM varies from joint to joint. Age and gender also have an influence on ROM. Dominant side and non dominant side also has their effect on ROM. An examiner should have an understanding of the following points before taking the measurement.
Surface anatomy to palpate the exact landmark.
Normal range of motion of each joint
Position of patient.
Starting position of joint
Position of therapist.
Alignment of the goniometry
Knowledge of normal and abnormal end feel.
The quality of resistance at the end of range
Each joint has a normal end feel at normal point in the range of motion.
Incorrect end feel or correct end feel at incorrect ROM indicate pathology.
Range of motion testing:-
The affected extremity compared with the unaffected side to determine the patient’s normal range.
Shoulder abduction involves the glenohumeral joint and the scapulothoracic articulation. Glenohumeral motion can be isolated by holding the patients scapula with one hand while the patients abducts the arm. The first 20 to 30 degree of abduction should not required scapulothoracic motion. With the arm internally rotated (palm down ), abduction continues to 120 degree. Beyond 120 degree full abduction is possible only when the humerus is externally rotated.
Flatten lumbar spine (flex knees)
Shoulder no abduction, adduction or rotation
(note: to measure gleno-humeral motion, stabilize scapula)
Shoulder flexion (0~180°)
Axis – center of humeral head near acromion process
Stationary arm – parallel mid-axillary line
Moving arm – aligned with midline of humerus (lateral epicondyle)
Shoulder 0° flexion and extension
Shoulder laterally (externally) rotated
Stabilize thorax (note: to measure gleno-humeral motion, stabilize scapula)
Stationary arm – parallel to sternum
Moving arm – aligned with midline of humerus
Shoulder external rotation (0~90°)
Shoulder 90° abduction
Elbow flexed 90°
Axis – olecranon process of ulna
Stationary arm – aligned vertically
Moving arm – aligned with ulna (styloid process)
Shoulder internal rotation (0~70°)
Moving arm – aligned with ulna (styloid process)
Abduction (1): pain during abduction (which may have to be assisted.)
During the arc 70 to 120 degree suggestive of shoulder cuff impingement in the region of acromion.
During the later phase of abduction, suggestive of shoulder cuff impingement in the region of acromioclavicular joint or coracoacromial ligament or from osteoarthritis of the acromioclavicular joint.
Abduction (2): if the patient can not abduct the arm actively,attempt to do this passively and rotate the arm externally. Afull range indicates an intact glenohumeral joint.
Abduction (3):- in the normal shoulder the arm can touch the ear with only slight tilting of the head.
Measure the range of abduction.
Normal range: 0 to 180degree
Adduction in extension:-
Place hand on the shoulder and swing the arm, flexed at the elbow, across the chest.
Normal range: 0 to 50 degree.
Ask the patient to swing the arm forward and lift it above his head. View the patient from the side.
Normal range up to 180 degree.
Ask the patient to swing the arm directly backwards, again viewing and measuring from the side.
Normal range 0 to 60 degree.
Horizontal flexion and adduction:-
View the patient from above the arm is moved forward from a position of 90 degree. abduction. (it need not to be routine)
Normal range 0 to 140 degree
The pain during this movement is common in osteoarthritis or trauma to acromioclavicular joint.
External rotation in extension:-
Place the elbows in to the sides and flex then 90 degree with the hand facing forwards. Move the hands laterally, comparing one side with the other.
Normal range 70 degree.
An increase in external rotation in extension is feature of tears of the subscapularis muscles.
Internal rotation in extension:-
Move the hand to the chest from the facing forward position.
Normal range 80 degree.
Shoulder elevation and depression:
But hallacelia and Gunal advocate the use of goniometer, centered on the jugular notch, with one arm vertical and other on the acromion.
Normal range: elevation and depression in the order of 37 degree and 8 degree.
Elevation (shrugging) gives a measure of trapezius function and may also be used to assess hand recovery after stroke. These movements are also impaired in any condition involving scapulothoracic movements.
Biceps tendon instability test:
The shoulder abducted to 90 degree. And the elbow flex to the right angle. The tendon is then located as it lies in the bicepitalgroove and keeping the examining fingers in position. The patient shoulder is internally rotated. If the tendon is unstable it may be felt to move out of position. This may be accompanied by an audible click.
Ask the patient to keep the arm elevated in abduction while you press down on his elbow, look and feel for deltoid contraction. Traction injuries of the axillary nerve resulting in deltoid involvement are seen most frequently after dislocations of the shoulder. If the auxillary nerve palsy is suspected, test for sensory loss on the lateral aspect of the arm.
With assessment of normal range of motion of joint following symptoms, where also checked.
Sandhi shool i.e. pain.
For SANDHI SHOOL-
Sevearity of pain
Unable to do normal movement and Unable to sleep due to pain
Unable to do normal movement
Pain with restriction of movement
Duration of morning stiffness
Above 60 min.
For LOCAL TEMPERATURE-
Local temperature for increase and decrease also
0s – olecranon process of ulna
Abduction (2): if the patient can not abduct the arm actively,attempt to do this passively