What is Torticollis – Congenital and Acquired

Common conditions, Health, Injury, Pain

MAIN WRY NECK

What is Torticollis?

Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”.  It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.

What happens in torticollis?

Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles. 

Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.

sternocleidomastoid FRONT VIEW

In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2. 

CT

Pathophysiology of torticollis

As shown in Fig 2, Torticollis can be of two types.

  • Congenital
  • Acquired

Congenital Torticollis

“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as, 

  • Intrauterine (inside uterus) malposition of the baby 
  • Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth. 
  • Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.

Acquired Torticollis

This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults. 

Reasons for Acquired Torticollis

  • Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion). 
  • Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
  • Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
  • Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
  • Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
  • Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
  • Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.  
  • Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region. 

Signs and Symptoms of Torticollis

  • Inability to move the neck with limited range of motion
  • Chin tilted to one side
  • Headaches
  • Head tremor
  • Neck muscle spasm and pain
  • One shoulder is higher than the other
  • Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
  • Stiffness of the neck muscles
  • Swelling of the neck muscles (possibly present at birth)
  • Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.

When to seek medical care?

Congenital torticollis can be easily identified after childbirth and determine  the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.  

How is torticollis diagnosed?

A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).  However, it’s unlikely that the exact cause of the muscle spasm can be isolated.

In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.

How can torticollis be treated?

Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent. 

Other problems with delayed treatment 

  • Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
  • Open mouth posture with the tongue pulled to one side or the other.
  • Suck/swallow may be affected leading to feeding issues.
  • A permanent trunk and facial asymmetry can occur.

 Chances of torticollis relapse

Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.

The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.

General goals for treatment,

  • Reducing pain, spasm and muscle strains of the neck.
  • Improving mobility and flexibility of the soft tissue structures affected.
  • Reducing stiffness in the neck and mobilizing the joints of the neck.
  • Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
  • Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
  • Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.

There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery. 

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Pregnancy – Things to note

Exercise, Health, Lifestyle, Pregnancy

preg main

Pregnancy is a time when the mother undergoes many physical and physiological changes. These changes happen so that the mother’s womb can nurture and host the growing baby. However, there are other possible effects of these changes on the musculoskeletal, cardiovascular and respiratory system of the expectant mother. Therefore, it is important to be aware of these effects in order to help the expectant mother to cope with the challenges of pregnancy.

What are the effects of the hormonal and Physiological changes during pregnancy?

Hormonal changes: Progesterone and Relaxin are two hormones whose levels are extraordinarily high during pregnancy. 

  • They cause changes in the collagen fibres of the connective tissues of the joints and soft tissue structures.
  • Loosening of ligaments decreases the stability of the joints.

Weight gain: Excessive weight and gravity can slow down the circulation of blood and body fluids mainly in the lower limbs. 

  • This can cause excessive workload on the body with physical activity
  • Excessive fluid retention
  • Swelling in the limbs and even face.

Postural change: 

PregnancyPosturePositions
Fig 1: Improper postures and good posture

Improper postures as shown in Fig 1, due to increased weight gain and forward shift of the centre of gravity. It can also affect balance and gait.

Improper postures:

  • increased lower back curvature – lumbar lordosis,
  • compensatory curving of the upper back – kyphosis or scoliosis,
  • rounding of shoulders 
  • forward chin position

Muscular changes:  As the baby grows the mother’s abdominal muscles and ligaments get stretched.

  • Weakness of the abdominal muscle 
  • Less support or bracing to the spine

Due to weight gain, improper posture and possibly lack of gait control, there will be an excessive strain to the muscles of the hips, knees and ankles.

Blood Pressure changes: Pregnancy hormones can suddenly affect the blood vessels by narrowing or expanding them, causing a drop or sudden increase in blood pressure. This if may affect the blood supply to the vital organs like the brain and in severe cases may also affect the growing baby. 

Low blood pressure may cause:

  • Dizziness 
  • Brief loss of consciousness (passing out)

High blood pressure in pregnancy is also known as pre-eclampsia which may worsen to a condition called eclampsia.

Symptoms of Eclampsia:

  • Severe headaches and convulsions.
  • Problems with your vision, such as blurred vision, flashing lights or spots in front of your eyes.
  • Tummy (abdominal) pain, vomiting later in your pregnancy (not the morning sickness of early pregnancy).
  • Sudden swelling or puffiness of your hands, face or feet.

Changes in the Respiratory system: As the uterus enlarges, the movement of the diaphragm (main breathing muscle) may be limited. The uterus moves upwards, it progressively obstructs the downward movement of the diaphragm as shown in fig 2.

diaphragm pushed up
Fig 2: Uterus and abdominal contents pushing the diaphragm

It can force the diaphragm upwards mostly towards the end stage of pregnancy causing:

  • Breathlessness: difficulting in breathing normally.
  • Painful ribs: Rising pressure pushes the rib cage out sideways and forwards, resulting in pain in the front of the lower ribs, also known as rib flare.

Increased Metabolic Rate: Basal or resting metabolic rate (RMR) is the amount of energy the body uses while at rest. Due to hormonal changes, this RMR increases significantly during pregnancy that may put the pregnant women at a higher risk of developing hypoglycemia or low blood sugar leading to light-headedness and fainting.

Risk of health conditions during Pregnancy 

  • Ligament and joint sprain: As the ligaments are lax due to hormonal changes, there is more risk of ligament and joint sprains especially in the ankle joint during pregnancy. Ligaments of the feet become lax and with the additional weight of pregnancy, results in flat feet and development of painful conditions like plantar fasciitis, Achilles tendonitis etc.
  • Supine hypotensive syndrome (Restriction of blood flow): The enlarging fetus compressing the aorta and inferior vena cava against the lumbar spine, restricting blood flow.
  • Painful joints: Incorrect posture causes abnormal curves like kyphoscoliosis and scoliosis which may cause issues for anesthesia during pregnancy and delivery. They also exert excessive strain and fatigue on the body, particularly in the spine, pelvis and other weight-bearing joints (i.e. knees). This results in aches and pains, such as lower back, with the pain spreading to the buttocks, thighs and down the legs.
  • Low back Pain: The extra weight of the baby coupled with the shift in weight distribution may strain the back muscles and can cause muscular spasms. Excessive pressure placed on the back may also cause low back disc herniation that may affect the spinal nerves.
  • Posterior pelvic pain (PPP): Lax ligaments of the body allows the pelvis to enlarge, in preparation for childbirth. Also, due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened. This affects the stability of the sacroiliac (SI) joints – the joints between the tail bone and the pelvic bones on either side at the lower back region as shown in Fig 2.
SI Joint
Fig 2: Sacroiliac joint
  • Diastasis recti: “Diastasis” means separation. “Recti” refers to your abdominal muscle called the “rectus abdominis.” The rectus abdominis muscle runs in the front of the stomach and is excessively stretched during pregnancy. Sometimes the pressure increase due to baby growth may be too much causing the muscle to separate as shown in Fig 3. 
Diastasis recti
Fig 3: Separation of Rectus abdominis muscle.

This separation in the abdominal muscles may lead to:

  • Low back pain: due to lack of bracing to the spine.
  • Hernia: a condition when the abdominal contents can protrude out due to increasing pressure from growing baby and lack of support by the abdominal muscles. Umbilical hernia as shown in Fig 3.
umblical hernia

Fig 3: Umbilical hernia

  • Pubic symphysis pain: The weight-bearing joints, such as the pelvis, is increasingly stressed and loaded during pregnancy. Coupled with the instability that relaxin causes, the pelvis is susceptible to pain and injury. Sometimes due to stress, the pubic symphysis may be separated causing a condition known as symphysis pubis diastasis as shown in Fig 4. This commonly occurs during delivery.
Pubic symphysis
Fig 4: Symphysis Pubis Diastasis
  • Transient osteoporosis: This is a bone condition that happens during pregnancy and symptoms disappear within weeks of labour. It has no known cause, although hormones, nutrient deficiency, and other causes have been proposed. There is a sudden drastic loss of bone mass and swelling in the affected portion during pregnancy. This causes weakness of the bones which may lead to fractures during delivery and other complications for the mother.
  • Gestational Diabetes: Due to hormonal changes in your body, your cells can become less responsive to insulin. When the body needs additional insulin, the pancreas dutifully secretes more of it. However as the cells are unable to respond to it, your blood glucose levels rises too high resulting in gestational diabetes. This may lead to excessive weight gain and development of diabetes post pregnancy.
  • Carpal tunnel syndrome: “Water retention” or swelling in ankles, feet and hands in late pregnancy may lead to joint stiffness and nerve compression syndromes, such as carpal tunnel syndrome.
  • Varicose veins: Varicose veins of the legs may occur during pregnancy or worsen during this period. This is due to a reduction in the vascular tone and changes in the collagen structure in the body (due to progesterone and relaxin) that affect the veins. 

How to prevent health conditions during pregnancy?

Always monitor your health status and evaluate the presence of any specific health condition at an initial stage.

It is important to understand your body in order to avoid conditions and the potential complications it may cause. Proper treatment planning is undertaken at an early stage to ensure the safety and health of both the expectant mother and the baby. 

 As most of these conditions can be prevented with lifestyle and dietary changes, it is best to consult with the experts to know more in details about how to manage and prevent them. 

What is Blood Pressure?

Exercise, Health, Lifestyle

Blood pressure main

What is blood pressure (BP)?

Blood pressure is the pressure exerted by the circulating blood on the walls of the blood vessels.

What system is it part of and why?

BP is a part of the blood circulatory system, which is also known as the cardiovascular system(Refer Fig 1)

  • The heart
  • The blood vessels – arteries and veins
CirculatorySystem

Fig 1: The Circulatory System

The heart acts as a pump that is responsible for,

  • pumping oxygenated blood carried by the arteries to our organs
  • pumping deoxygenated blood that it receives through the veins from our organs. 

One of the functions of the circulatory system is to regulate the blood pressure for maintaining good blood flow throughout the body. This is required in order to transport nutrients and oxygen for every body part, for regulating body temperature, pH balance and for normal functioning of the body.

For example, when the heart pumps out oxygenated blood through the arteries, the blood flow exerts a force on the walls of the arteries. This force is measured as arterial blood pressure as shown in Fig 2. Any problems with this arterial BP may lead to a problem with the normal functioning of the body.

blood pressure

Fig 2: Arterial Blood pressure 

How is Arterial BP measured? 

The instrument that can measure the blood pressure is called Sphygmomanometer (Refer Fig 

Sphygmomanometer

Fig 3: Sphygmomanometer

It consists of:

  • a cuff,
  • a pump, and
  • a calibrated mercury scale

Typically two numbers that are being recorded on the scale which is written as a ratio. For example, BP of 120/70 mmHg, where 120 is the top number and 70 is the bottom number.

BP Measurement

Fig 3: Measuring BP

As shown in Fig 3, the BP is measured in four steps,

Step 1: Locate the pulse on an artery of the arm

Step 2: The health professional wraps the cuff around your arm and inflates it to squeeze your arm. This is done to temporarily press on the artery and close the blood flow in your arm. 

Step 3:  After the cuff is inflated, the health professional will slowly let air out. While doing this, he or she will listen to your pulse with a stethoscope and watch the mercury level on the calibrated scale to accurately note the measurements. The first pulse sound is heard and simultaneously measured on the scale.

Step 4: As the successive pulse sounds continue the professional hears it until the last pulse sound is heard which is again measured. 

The scale used is in “millimeters of mercury” (mmHg) to measure the pressure in your blood artery.

Blood pressure numbers- what does it indicate? 

systole and diastole

Fig 4: Systole and Diastole of the heart

The top number- Systolic pressure

The top number, which is also the higher of the two numbers, is the measure of the pressure in the arteries when the heart beats or contracts to pump the oxygenated blood. This is also known as the systole of the heart as shown in fig 4. 

The bottom number- Diastolic pressure

The bottom number is also the lower of the two numbers. It indicates the pressure in the arteries when the heart muscles are relaxing between two heart beats and refilling with blood. This is also known as the diastole of the heart as shown in fig 4.

BP Categories

Fig : BP Categories

Fig 5: BP Categories

Typically more attention is given to the top number (the systolic blood pressure), however, both the systolic and the diastolic pressures are important for indicating if a person is at risk of any heart disease.

What are the risk factors that will lead to high or low BP?

Risk factors

High BP

Low BP

  • Family history of High BP
  • Advanced age
  • Men get High BP more than women
  • Sedentary lifestyle
  • Poor diet, excessive salt intake
  • Drinking too much alcohol
  • Obesity
  • Smoking
  • Stress
  • Sleep apnea- a sleep disorder in which tissues in the throat collapse and block the airway.
  • Prolonged bed rest
  • Pregnancy
  • Trauma- loss of blood from major trauma, dehydration or severe internal bleeding
  • Certain medications
  • Abnormally low heart rate 
  • Endocrine problems- thyroid problems, Diabetes
  • Severe infection
  • Severe allergic reaction
  • Anemia
  • Nutritional deficiency- low blood volume due to Vit B12 and folic acid deficiency
  • Extreme heat- hot sauna and hot bath

When to seek Medical help?

There’s a common misconception that people will experience symptoms such as nervousness, sweating, difficulty sleeping or facial flushing. But the truth is that changes in blood pressure can be a symptomless condition. If you ignore your blood pressure because you think symptoms will alert you to the problem, you are actually taking a risk. It is important to know your blood pressure numbers as everyone should prevent blood pressure problems.

However, there are few signs and symptoms that may possibly occur with low and high BP. 

Signs and symptoms 
High BP Low BP
  • Severe headaches
  • Severe anxiety
  • Shortness of breath
  • Nosebleeds
  • Blood spots in the eyes
  • Facial flushing

 

  • Dizziness or lightheadedness
  • Fainting
  • Dehydration and unusual thirst
  • Lack of concentration
  • Blurred vision
  • Nausea
  • Cold, clammy, pale skin
  • Rapid, shallow breathing
  • Fatigue
  • Depression

 

How to manage BP problems?

Routine Check-up: Most people are unaware of their BP problems and going for a check-up will detect any blood pressure problems. This will prevent any potential health conditions. 

Understand your normal level of BP: There is no healthy level of high blood pressure or low blood pressure.  Your healthcare professional will determine your treatment goals based on your overall lifestyle and your body.

Lifestyle modifications

  • A nutritional diet, which may include reducing salt depending on High or low BP, Vitamin and mineral rich diet.  
  • Physical activity – exercise
  • Maintaining a healthy weight
  • Stress management
  • Smoking cessation support
  • Alcohol limitations
  • Prescribed medication in specific cases

Take precautions while exposed to heat 

When your body gets heated up during hot weather or during a hot tub or sauna bath, your blood pressure could drop and your heart rate may increase to counteract a drop in blood pressure. Normally, these events don’t cause problems. However, if you have an existing low BP you may be at risk of fainting, falls and heart problems.

Some of the precautions can be,

  • Limit your exposure to heat. Most experts say no more than five to 10 minutes is safe.
  • Stay hydrated.
  • Regulate water temperature during hot tub or sauna baths.

Conclusion

Managing blood pressure requires an individual’s adherence to the lifestyle changes and habits. It is advisable to get early assessment and treatment of your blood pressure problems in order to have a healthy circulatory system and to prevent the risk of many health conditions.    

Ankle 101

anatomy, Ankle, Foot

ankle joint only

The ankle plays an important role in the pattern of lower limb movements both in weight-bearing and non-weight-bearing positions.

Ankle movements: (Refer Fig 1)

  • Plantarflexion (down)
  • Dorsiflexion(up)
  • Inversion (inwards)
  • Eversion (outwards)
dorsi and plantar flexion

Fig 1: Dorsiflexion, Plantarflexion, Eversion and Inversion

Plantar flexion is the movement that describes the pointing of the toes toward the ground, as in standing on one’s toes.

Dorsiflexion is the opposite of plantarflexion and involves pulling the toes up as in walking on one’s heels.

Inversion is inward rolling of the foot towards the body’s midline and eversion is the exact opposite which involves outward rolling of the foot away from the midline of the body.

Joints in relation to movement

The ankle is made up of three distinct joints namely, 

  • Talo-crural joint (Ankle joint)
  • Subtalar joint 
  • Distal Tibiofibular joint (High ankle)
joints of the ankle

Fig 2: 3 types of ankle joints

Talo-crural joint (Ankle joint): It a hinge type of joint that allows movements of dorsiflexion and plantar flexion along one plane.The articulation of the lower ends of the leg bones and one of the tarsal bones (talus) forms the ankle joint.  

Subtalar joint: The movements of Inversion and eversion take place at this joint. It lies beneath the ankle joint and is formed by the articulation between the talus and the calcaneal bone of the foot. 

Distal tibiofibular joint (High ankle): This is a syndesmosis joint between the lower ends of the bones of the leg(tibia and fibula).  A syndesmosis joint is a joint where the bones are connected by ligaments and have minimal movements.

Muscles that cause ankle movements

The muscles from the leg end as tendons that attach to the foot bones. They contract and transfer forces to cause a movement across the ankle joint.

  • Outer muscles of the leg: The peroneal (Peroneus long and peroneus brevis) muscles are present on the outside aspect of the leg as shown in Fig 3. The contraction of the peroneal muscles help bend the ankle down moving the foot downwards (Plantar flexion) as in fig 3.
Peroneal muscles

Fig 3: Peroneal Muscles and Plantar flexion

The peroneals also help to stabilize the big toe as it attaches behind it. It helps to lift the arch and plantar fascia to produce spring-like effect during running and jumping activities.

  • Back muscles of the leg: The calf muscles (gastrocnemius and soleus) and the tibialis posterior muscles are present at the back of the leg as shown in Fig 4.
back of the leg

Fig 4: Calf and Tibialis posterior muscle.

The calf connects to the heel bone by the Achilles’ tendon. When the calf muscles contract they moving the foot downwards (Plantar Flexion). The posterior tibialis help to turn the foot inwards (Inversion). They help to propel the body forwards as the foot pushes on the ground while walking.

  • Front muscles of the leg: The tibialis anterior present in the front of the leg  and attached in the front of the foot as shown in Fig 5.
tibialis anterior muscle

Fig 5: Tibialis anterior muscle and dorsiflexion

The Tibialis anterior muscle pulls the ankle upwards (Dorsiflexion). It plays a role in striking the heel when you take a step forwards in walking.

Ligaments that support the ankle

Apart from muscles, the ankle is stabilized by many ligaments that surround the ankle. 

  • Lateral ligaments (outer ankle ligaments)
  • Medial ligaments (inner ankle ligaments)
  • High ankle ligaments

Lateral ligaments

Lateral ligaments are present on the outer aspect of the ankle that are attached at the anterior (front), lateral (outer side) and posterior (back) parts of the ankle as shown in Fig 6. 

Outer ligaments of the ankle

Fig 6: Lateral Ligaments

  • The Lateral ligaments play an important role to prevent excessive plantar flexion and inversion movements of the foot. 
  • Along with the medial ligaments, they also provide stability to the ankle during weight bearing movements.

Medial ligaments (Inner Ankle Ligaments) 

The medial ligament otherwise known as deltoid ligament is present on the inner aspect of the ankle, as shown in Fig 7. 

Ligaments of the ankle

Fig 7: Medial ligaments (Deltiod ligament)

  • The medial ligaments function as the main stabilizer of the inner aspect of the ankle against shear and rotational forces.
  • They also act to support the inner arch of the foot.

Distal tibiofibular ligaments

The distal tibiofibular ligaments are located above the ankle and connect the high ankle syndesmosis joint as shown in Fig. 8. 

Syndesmotic ligament complex

Fig 8. High ankle ligaments

  • The high ankle ligaments ensure stability between the lower end of the tibia and the fibula.
  • They resist any force that attempt to separate the tibia and fibula.

Risk of injury to the ankle 

Any inflexibility in the ankle may cause inability to perform a movement properly. For example, poor ankle mobility due to tight soft tissue structures can reduce the range of movement at the ankle causing the knees, hips and trunk to over compensate. This may impair the ability of the trunk to load the joints properly hence increasing the risk an injury.

Temporomandibular (TMJ) Joint and its Disorder

anatomy, Common conditions, Injury, Pain

TMJ

What is the TMJ?

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

TMJ disc

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

  • Joint Capsule
  • Ligaments
  • Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

  • The Lateral Ligament (temporomandibular ligament)
  • Sphenomandibular Ligament
  • Stylomandibular Ligament
  • Stylohyoid Ligament
CAPSULE

Fig 2: Showing the attachment of joint capsule, lateral ligament and stylomandibular ligament.

Muscles around the TMJ

The are four main muscles (Refer Fig 3) of the TMJ are,

  • Temporalis
  • Masseter
  • Medial Pterygoid
  • Lateral Pterygoid
muscles of tmj

Fig 3: Prime muscles for TMJ movement

Movements at the TMJ

There is a combination of hinge and sliding motions that can occur in the TMJ due to the movements of the mandible.

  • Protraction (forward) and Retraction (backwards)
  • Elevation (upward) and Depression (downward)
  • Lateral deviation (Side to side movements of the jaw)
MOVEMENT PROTRACTION RETRACTION

Fig 4: The forward and backward movements of the jaw

ELEVATION DEPRESSION

Fig 5: Upward and downward movements of the jaw

lateral deviation

Fig 6: side movement of the jaw

Temporomandibular Joint Disorder 

  • Muscular problem: Pain and discomfort in the muscles of the face during jaw movements.
  • Disc problem: Usually comprises of displaced disc, dislocated jaw, or injury to the mandibular condyle.
  • Joint problem: Degenerative inflammatory joint condition like Arthritis at the temporomandibular joint.

Reasons for TMJ Disorder

  • Genetics

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

  • Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

  • Inflammatory diseases 

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

  • Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.
  •  Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.
  • Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.
  • Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.
  • Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

Anatomy of the Hip

anatomy, Hip, Lifestyle

hip joint

The anatomy of the hip includes the ball-and-socket joint that involve two separate bones namely, the thigh bone and the pelvis.The unique anatomy of the hip enables it to be extremely strong and agile controlling every position of the lower limb in both weight-bearing and non-weight-bearing movements.

Bones of the Hip 

The Bones of the Hip include,

  • Pelvic bones (Ilium, Ischium, Pubis)
  • Femur (Thigh bone)

Fig 1: Shows the two Hip bones, sacrum, the acetabular socket of the hip joint, the entire Hip.

Pelvis

As shown in Fig.1, the pelvis is made up of two halves or two hip bones. Each hip bone is formed from the fusion of three bones: ilium, ischium and pubis. Fusion of these three bones, form one solid pelvic bone. The Pelvic bone contributes to the hip socket or acetabulum. Each pubic bone connect in front at the symphysis pubis.

Between the two hip bones, lies the foundation for the pelvis, the sacrum. The sacrum is a triangular-shaped bone that comprise of five fused bones at the lower end of the spine.

Fig 2. The Femur (thigh bone)

Femur

As shown in fig 2, the femur is more commonly known as the thigh bone which consists of the round head, the neck, the shaft and two condyles (lateral and medial) at the base of the femur.

The HIP joint

Like the shoulder, the hip joint is also a ball-and-socket joint, where the ball is the head of the femur, and the socket is the acetabulum.

Fig 3: Ball and socket hip joint

HIP JOINT 1

Articular Cartilage and labrum

The articular cartilage is a protective material that covers the articular surfaces of the hip joint (refer Fig.4).  It is about one-quarter of an inch in thickness with a rubbery consistency.The function of the cartilage is related to its structure and thus acts as a shock absorber by allowing better transmission of forces. It also helps prevent friction between the bones and is slippery enough to allow the joint surfaces to slide against one another without causing any damage.

The Labrum is a fibrous rim of cartilage around the acetabular socket that holds the femoral head in the joint providing stability.

Fig 4: Shows articular cartilage and labrum

cartilage and labrum

Joint capsule and ligaments of the Hip joint

The joint capsule is a watertight sac that surrounds the hip joint. The capsule is reinforced by three major ligaments, which are denser bands of connective tissue.

Fig 5: Shows Capsule and reinforced ligaments of the hip joint

capsule and lig

The attachments of each of these ligaments can be identified by its name- the iliofemoral ligament extends from the ilium on the pelvis to the femur, the pubofemoral ligament connects the pubic bone to the femur, and the ischiofemoral ligament extends from the ischium to the femur.

A small ligament called ligamentum teres connects the very tip of the femoral head to the acetabular socket. It accommodates a small artery within itself that brings an important blood supply to part of the femoral head.

Muscles around the hip joint:

Back muscles of the hip 

These Muscles are responsible for hip joint extension (backward movement)

They include,

  • Gluteus maximus
  • Hamstrings (long head of biceps femoris, semitendinosus, semimembranosus)

Fig 6: Extensor muscles

gluteal and hamstring muscles

These muscles cause the hip to move backwards in extension (Fig 7), it also causes knee flexion (bending the knee by bringing the heel towards the buttock). Hip extension is important during gait especially to propel your body forwards.

Fig 7: Hip extension movement of the hip joint

hip extention

Gluteus maximus contraction is a powerful action that opposes the force of gravity. The action of gluteus maximus is to move the hip bone(thigh) backward from a position of full flexion(bent), as in climbing stairs, or rising from a squatting or sitting position.

Fig 8: Action of Gluteus Maximus muscle

Gluteus max sit to stand

Front muscles of the pelvis

These muscles are responsible for hip joint flexion (forward movement).They include,

  • Iliopsoas (iliacus and psoas)
  • Rectus femoris
  • Tensor fasciae latae
  • Sartorius

Fig 9: Hip Flexor muscles

fllexor muscles

The hip flexors help you to draw your leg towards your chest and also helps to you move your legs from side to side and backwards. It serves to stabilize your hips, keeping the joints of your pelvis and lower back strong.

Fig 10: Hip flexion movement

hip flexion

Hip flexion movement is also important during the gait cycle in order to bring you leg forwards for heel strike.

Inner thigh muscles

These muscles are responsible for hip joint adduction (inward movement).They include,

  • Pectineus
  • Adductor brevis
  • Adductor longus
  • Gracilis
  • Adductor magnus.

Fig11: Aductor muscles of the hip joint

hip adductors

When the foot is not planted on the ground, the adductors will bring the leg toward the midline of the body. Also known as an open kinetic chain movement (open kinetic chain is defined as a combination of successively arranged joints in which the terminal body segment can move freely).

Fig 12: Adduction movement

adductors

Apart from the adduction movement in open kinetic chain, adductors also contributes during closed kinetic chain movements (In a closed kinetic chain movement, the distal end of the extremity is fixed, emphasizing joint compression and, in turn, stabilizing the joints).

A simple example would be during bilateral stance (standing on both legs) movement like squatting, adductors of both the hip joints help contribute to the stability in the pelvis. These adductors work with abductor muscles synergistically to provide side-to-side stabilization of the pelvis.

During walking, adductors also contribute throughout the gait cycle. For example, when you foot is move forwards before striking on the ground, the adductors will bring the leg towards the midline. Similarily, adductors with help in flexing the hip when the thigh is in an extended position as in the swing phase of the gait (walking) cycle.

Fig 13: Action of adductors during gait

Gait cycle

They are not the prime movers but function in reflex response to gait activities.

The only two-joint muscle of the adductor group, the gracilis, functions as an inner knee stabilizer and helps stabilize both the hip and knee during weight-bearing.

Outer muscles of the thigh

These muscles are responsible for hip joint abduction (outward movement). They include,

  • Gluteus medius
  • Gluteus minimus
  • Tensor fascia latae

Fig 14: Abductor muscles of the hip

abductors

In open kinetic chain movement when standing on one leg, the abductors move the leg away from the midline of the body.

Fig 15: Abduction in single leg stance

hip abduction

The gluteus medius however, is more of a lower extremity dynamic stabilizer than it is a pure hip abductor.  If the gluteus medius and minimus are weak or atrophied, the pelvis will drop to the opposite side when you bear full weight on the same side during walking. This dysfunctional postural pattern is referred to as the Trendelenburg sign.

Fig 16: Pelvic stabilization (strong Gluteus medius) and pelvic drop (weak Gluteus medius)

Gluteus medius

As you can see in fig 16, weakness of the right gluteus medius will cause the left hip to drop when standing on the right leg. Thus, during walking the primary function of the gluteus medius is to stabilize the pelvis when weight is shifted from one side to the other.

External rotators of the hip joint

Muscles of the thigh responsible for hip joint external rotation (twisting hip outwards) include,

Primary External Rotators:

  • Obturatorius internus and externus
  • Gemellus superior and inferior
  • Quadratus femoris
  • Piriformis

Secondary External Rotators:

  • Gluteus Maximus (lower fibres)
  • Gluteus Medius and minimus muscles when the hip is extended
  • Psoas Major Muscle
  • Psoas Minor Muscle
  • Sartorius

In the open kinetic chain the primary and secondary external rotators turn the lower limb outwards in relation to a fixed pelvis. This action is seen with the movement of the hip with knee flexion as seen in Fig 17.

Fig 17: External rotation

hip-external-rotation

However, in the closed kinetic chain scenario, with the foot fixed on the ground, the activation of these same muscles will cause the same movement at the hip-pelvis interface will cause the pelvis/torso to rotate.  For example, refer Fig 18. a closed chain right lower limb, upon activation of the external hip rotators the person’s pelvis and trunk will rotate to the left simultaneously (counterclockwise rotation) along the vertical body axis about the fixed right limb.

Fig.18 external rotation of right hip

Standing twist

This rotation can occur from activation of not only the hip rotators but also from the muscles of the abdomen, thoracic spine and rib cage.

Role in Hip stabilization

The deep external rotators (quadratus femoris, obturator internus and externus and the gemelli) are also active stabilisers of the hip and, along with the internally rotator gluteus minimis, they are also described as the “rotator cuff muscles” of the hip. The quadratus femoris,

During weight bearing, the deep rotators having a short moment arm and smaller in area there is minimal capacity of rotational force and more of  a horizontal line of force, which is more important in the compression of the joint surfaces.Thus creating more stability in the hip joint during movements.

Hip Internal Rotators

The muscles that are responsible for twisting the leg inwards (Internal Rotators) are,

  •  Anterior portion of the gluteus medius
  • Tensor fasciae latae

The head of thigh bone (femur) rotates inwards within the hip joint. It also occurs in standing when the lower limb is fixed and the trunk/pelvis rotates as already seen in hip external rotation. Internal rotation is the exact opposite.

In the open kinetic chain, the internal rotators turn the lower limb inwards in relation to a fixed pelvis. This action is seen with the movement of the hip with knee flexion as seen in Fig 19.

Fig 19: Open chain internal rotation of hip joint

Hip Internal roation

Similarily, Fig 20 shows a closed chain right lower limb, upon activation of the internal hip rotators driven by the person’s pelvis and rotation to the Right side simultaneously (clockwise rotation) along the vertical body axis about the fixed right limb.

Fig 20: Right hip internal rotation and right side pelvic rotaion

Twist IR

Role of internal rotators

During walking, in order to sufficiently extend the hip toward the end of the gait cycle, there has to be enough hip internal rotation (Fig 21). Without sufficient internal rotation, the pelvis will move as far forward over the stance leg, and we instinctively shorten our stride.

Fig 21: Hip extension and internal rotation of left hip joint in the final phase of the gait cycle.

gait IR

In conclusion, a thorough understanding of pelvic and hip anatomy is important for undermining any cause of dysfunction or injury. Even a lack of range of motion due to tightness in the soft tissue structures can put you at risk of involving compensatory movements that can lead to postural problems. Always seek medical advice when in doubt.

Rotator Cuff Injury

Common conditions, Injury, Pain

shoulder

Our shoulders are the most movable joints in our body. Most activities whether simple or strenuous engage both our shoulders. That is the reason why with a little bit of pain in our shoulders, we find it very difficult to do even the simplest of tasks like putting on a coat or carrying groceries. Sometimes there is a crunchy sensation or you may hear clicking and popping sounds while you move your shoulder or do weights. This pain can worsen making you feel frustrated, leaving your shoulders feeling weaker than normal and stiff to move. There could be many reasons for the cause of your shoulder pain but the most common injury that could possibly show these type of symptoms would be a rotator cuff injury.

What is the rotator cuff and how does it get injured?

Rotator cuff injury

The Rotator cuff is a group of muscles coming from the shoulder blade and ending in tendons that attach to the arm bone. These muscles cup the shoulder and are responsible for its stability during movement. The muscles of the rotator cuff muscles include:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

“Centralisation”- Your rotator cuff is important

The function of the rotator cuff, in addition to generating torque, is to dynamically stabilize the shoulder joint. It keeps the ball of the shoulder centred over the small glenoid socket. Thus, stronger rotator cuff muscles result in the better glenohumeral joint stabilization and hold the humeral head into the glenoid by depressing it. This prevents impingement and decreased chances of shoulder dislocation when the deltoid abducts(arm sideways up) the shoulder. Without an intact rotator cuff, particularly during the first 60 degrees the ball of the shoulder would migrate up the glenoid cavity causing the rotator cuff attachments to get compressed by the acromion leading to impingement of the rotator cuff. In patients with large rotator cuff tears, the humeral head is poorly depressed and can migrate cephalad during active elevation of the arm.

Rotator cuff injuries

Sometimes sudden fall or high impact sports could be the cause of injury but in most cases, it is due to the repetitive injury over the tendons as they being pulled beyond their capacity to stretch. This gradually worsens causing partial or full tear of the tendons. Due to the way these tendons cup the shoulder by being closely spaced, they are more at risk of friction. Especially when you turn your shoulder or lift any weight at the end range of shoulder movement, the tendons in this tight space become taut and rub against the bony knob (acromion process of the scapula) above them or against a ligament at the front of the shoulder. This causes friction, pain and as a normal response, inflammation sets leading to pain, swelling and movement restriction.

Physiology of rotator cuff damage

1. Tendonitis (acute Inflammation)

Tendonitis can occur in a particular rotator cuff tendon causing pain, inflammation and irritation. If this condition becomes more chronic, more tendons can become involved or it may progress to a tendinosis (degeneration).

2. Impingement Syndrome (compression of the tendon)

The most common site of impingements is within the “supraspinatus outlet”. This outlet is a space formed by the acromion process of the scapula, the coracoacromial ligament and the upper rim of the humeral head. Subacromial outlet

Impingement within the outlet can be caused by:

  • Thickened Coracoacromial ligament: This can cause impingement by becoming thickened due to excess calcium deposits that will compress the supraspinatus tendon.
  • Hooked acromium: In repetitive overhead activities, the tendons rubs against the acromion process of the Scapula and gets damaged. When the inflammation spreads into the pocket of fluids (subacromial bursa) that lubricates the rotator cuff tendons under the acromion bone. This causes subacromion bursistis and the pain gets even worse on movements.
  • Abnormal Scapular Movement: With normal shoulder movement, the scapula moves outward and upwards helping the shoulder to move up

scaphumerorhythm movement

  • In the case of an unhealthy shoulder, the scapula does not move in the same fashion as the healthy shoulder and gets “stuck” in a lower position. This could lead to abnormal movement of the scapula during shoulder movement. Poor scapular movement will cause compression of the tendons in the supraspinatus outlet increasing the chances of impingement of the rotator cuff tendon that goes under it.
  • The picture below shows an unhealthy right shoulder at a risk of impingement, showing improper movement in the scapula.

chances of impingement

3. Rotator cuff tears

A tear is a result of the worsening of the tendon damage. Although an acute fall can tear the rotator cuff tendon, chronic inflammation and degeneration due to impingement is the major cause of tears. This tear can start small and get larger over time due to repetitive use or a re-injury. When a tear occurs, there will be severe weakness and atrophy(loss of muscle mass) of the muscles around the arm and loss of movements of the shoulder. impingement

How is Rotator Cuff Injury Diagnosed?

Pain in the shoulder could be caused by various other reasons like joint injury, capsule injury, nerve problems and many more. A thorough examination of the shoulder should be done to distinguish the injury type. If a tear is suspected in the rotator cuff an MRI or an arthrogram (X-ray of the shoulder joint after injecting a contrast dye) can be taken.

normal

Prevention and Management

A proper diagnosis and plan of management is necessary for the treatment and prevention of rotator cuff damage. Initial treatment would be pain relief, rest and avoiding any activity that aggravates pain in order to enhance the healing process. Further treatments will be decided upon the individual’s condition. Thorough assessment and planning by the experts with an application of knowledge of the condition and correct methods of treatment will promote recovery and prevent injury reoccurrence.

Shoulder 101

anatomy, Exercise

shoulder

The main joint of our upper limb is the shoulder joint which can be moved in various positions when looked at in a three-dimensional perspective. In order to be able to have these movements, many other components help in order to maintain a stable shoulder. In short, there is a complex interplay between the shoulder joint, other joints, muscles and ligaments that make the shoulder a complex and unique part of our body.

Anatomy of the Shoulder Complex

The Shoulder complex consists:

  • The true joint called the Shoulder joint (Glenohumeral joint – GH)
  • The Clavicular joint with the scapula (Acromioclavicular joint – AC)
  • The Scapular joint with the body wall (Scapulothoracic joint – ST)
  • The Clavicular joint with the breastbone sternum (Sternoclavicular joint – SC).

The shoulder joint (GH) is made of two main bones that articulate with each other forming the ball and socket joint. The ball of the arm bone(humerus) and the glenoid cavity of the shoulder blade(scapula) is articulated at the shoulder joint (GH joint). Similarly, on the inner chest, the clavicle articulates with sternum to form the SC joint while on the outer end towards the shoulder the clavicle articulates with the acromion process of the scapula bone to form the AC joint. Both GH, SC and AC are true joints with union by fibrous, cartilaginous or synovial tissues. Lastly the ST joint, while this is not a true bony joint, its muscular attachments create a shoulder joint complex.SHOULDER

The humeral head (ball) is about three times larger than the glenoid fossa. Actually, only 25 percent of the humeral head articulates with the glenoid fossa. Glenoid cavity (fossa) forms a very shallow socket as compared to the hip socket of the hip joint. Therefore, the humeral head articulates with a smaller open and shallow saucer- type of articulation, lacking stability in its own. However, it is with all the soft tissue structures both inside and outside the joint that are responsible for the overall stability of the arm during movements.

Soft tissue structures that support the Shoulder Joint

The important soft tissue structures are:

  • Articular Cartilage
  • Labrum
  • Joint Capsule
  • Ligaments
  • Muscles

Articular Cartilage

A smooth, white tissue that covers the humeral head (ball) and the glenoid fossa to make it easier for the two bones to move at the joint. It allows the bones to glide over each other with very little friction.

Articular cartilage

Labrum 

Since the head(ball) of the upper arm bone is larger than the glenoid fossa, the articular cartilage forms a soft fibrous tissue rim called the labrum which surrounds the socket to help fit the head into it thus stabilizing the joint.

labrum

The socket can be divided into four regions namely anterior (front), posterior ( back), superior (the upper end near your head), and inferior (the lower end which is towards the elbow). Based on these regions the labrum is also called as superior, inferior, anterior and posterior labrum.

labrum 2

Joint Capsule

The shoulder joint capsule is a membranous sac that encloses the entire joint. The joint capsule of the shoulder is attached along the outside rim of the glenoid labrum of the glenoid cavity and attaches to the neck of the arm bone. The capsule by itself is quite loose and it is the surrounding reinforcement by the muscles, tendons, and ligaments that are largely responsible for keeping the shoulder joint stable.

capsule of the shoulder

Ligaments

In the shoulder, there is a group of ligaments that is responsible for the stability of the shoulder.

ligaments

Glenohumeral Ligaments (GHL)

This ligament attaches from along the outer glenoid socket covering the joint to the upper part of the arm bone.

  • Superior (upper) GHL
  • Middle GHL
  • Inferior (lower) GHL

Coraco-acromial Ligament (CAL)
This ligament attaches from the coracoid process to the acromion process of the shoulder blade (Scapula).

Coraco-clavicular Ligaments (CCL)
These two ligaments (trapezoid and conoid ligaments) attaches from the clavicle to the coracoid process of the scapula. This ligament can carry the load and is extremely strong. These tiny ligaments (with the AC joint) keep the stability between the scapula and the clavicle and thus keeping your shoulder ‘square’.

Transverse Humeral Ligament (THL)

This ligament protects the long head of biceps tendon muscle in the groove of the arm bone.

Muscles for the stability of the Shoulder Joint

Muscles of the shoulder connect the shoulder girdle, the clavicle and arm bone.

  • Muscles that origin from the spine and attaches to scapula and/or clavicle
  • Muscles that origin from the clavicle or scapula and/or body wall(ribs) to the top end of the humerus.

Trapezius, Levator scapulae, Rhomboids and Serratus Anterior

Originate from the base of the skull and/or spine and connect the scapula and clavicle to the trunk of the body.

traps, levator...

  • Trapezius forms cross-shaped web along the neck and run from the spinal column out to the shoulder blade and clavicle bone. It helps to shrug the shoulders.
  • Rhomboids and levator scapulae are important muscles that join the shoulder blade to the spinal column helping the scapular movements.
  • Serratus anterior muscle helps to stabilize the shoulder blade on the chest wall. When this muscle is weak, winging of the scapula occurs which is when the shoulder blade protrudes from the back.
winged scapula

Winged Scapula

Deltoid, Pectoralis major, Pectoralis minor, Latissimus dorsi, Teres major, Serratus Anterior

These arise from the clavicle and/or scapula and/or body wall and connect to the upper end of the arm (humerus) and anchor the shoulder joint to our body.

MUSCLES PECS

  • Deltoid muscle is a muscle that is responsible for overhead activities. It helps to move the arm sideways up.
  • Pectoralis major muscle like the deltoid is another powerful muscle which is the main muscle when doing push-ups. It originates from the front of the chest and collar bone and inserts on the upper part of the arm bone (humerus).
  • Latissimus dorsi is another powerful muscle that together with the teres major muscle pulls the arm down to the side. We use this muscle when doing chin-ups.

What are the Shoulder blade movements?

The muscles of the shoulder complex work together to perform a particular action. The Scapula and arm bone move together in a pattern to perform a movement.

The movements of the Scauplo-thoracic joint includes,

  • Depression – Downward arm and shoulder girdle movement
  • Elevation – Upward arm and shoulder girdle movement
  • Retraction – backward shoulder girdle movement
  • Protraction – forward shoulder girdle movement

movements in shoulder

Rotator cuff muscles- small in size, big in importance

The four rotator cuff muscles are important for the stability and movements of the shoulder joint. They are,

  • Subscapularis
  • Supraspinatus
  • Infraspinatus
  • Teres minor

Rotator cuff

These muscles connect the shoulder blade (Scapula) to the arm bone (Humerus) supporting the entire shoulder joint during movements.

The major function of the four rotator cuff muscles is to work simultaneously with each other to allow the arm to move freely in numerous positions. They do all this while pulling the humeral head downward and inward within the glenoid fossa.

Movements at the shoulder joint

The main movemnts at the GH joint are:

  • Flexion-Extension
  • Abduction-Adduction
  • Internal and External rotation

MOVEMENTS AT THE SHOULDER

  • Supraspinatus assists with lifting the arm with the deltoid above the head (abduction). This is the most common muscle / tendon to tear in the shoulder.
  • Subscapularis twists the arm behind (Internal rotation) the back.
  • Infraspinatus and the teres minor twists the arm outwards(External rotation) and sideways from the body.
  • Subscapularis assists with Deltoid, Biceps, coracobrachialis, Tere major to bring about shoulder forward flexion movement.
  • Triceps, latissimus dorsi, pectoralis major, teres major brings the arm backwards (Extension).

Why is the Rotator cuff is so important?

In order to prevent upward dislocation of the arm or tear within the inner soft tissue structures like labrum and capsule of the shoulder, balanced rotator cuff strength and function are necessary.  All the rotator cuff muscles work together stabilizing the humeral head within the glenoid while the larger muscles like the ltissimus dorsi, pectoralis major and deltoid produce the forces necessary for movements.

Common Injuries to the shoulder

  • Broken collar bone (Clavicle)
  • Dislocations of the shoulder
  • Frozen shoulder (Adhesive capsulitis)
  • Rotator cuff injury or strain (tendonitis or tendinopathy)
  • Acromioclavicular joint sprain
  • SLAP Tear (Superior Labrum Anterior Posterior tear)
  • Bankart’s lesion (Anterior inferior Labral tear, sometimes a part of the genoid cavity bone is also broken)

Most injuries to the shoulder are due to sudden trauma or repetitive trauma to the soft tissues and bones. Some of the injuries occur because of improper exercise selection, faulty technique, lack of warm-up, lack of dynamic stretches, dehydration and many more. However, knowing the anatomy and functions of the joints and soft tissue structures of the shoulder complex not only gives you a better understanding of it but will possibly give you a prospective as to how important is their role in maintaing the stability of the shoulder.