Extension Adduction Internal Rotation o

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Anterior depression

Serratus anterior (lower), pectoralis minor, rhomboids

Shoulder

Extension, adduction, internal rotation

Pectoralis major, teres major, subscapularis

Elbow

Extended (position unchanged)

Triceps, anconeus

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar flexion

Flexor carpi ulnaris

Fingers

Flexion, ulnar deviation

Flexor digitorum (superficialis and profundus), lum-bricales, interossei

Thumb

Flexion, adduction, opposition

Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

Grip

Distal Hand

Your left hand contacts the palmar surface of the patient's hand. Your fingers are on the radial side (2nd metacarpal), your thumb gives counter-pressure on the ulnar border (5th metacarpal). There is no contact on the dorsal surface.

! Caution

Do not squeeze the patient's hand.

Proximal Hand

Your right hand comes from the radial side and holds the patient's forearm just proximal to the wrist. Your fingers contact the ulnar border. Your thumb is on the radial border.

Elongated Position

Place the wrist in radial extension and the forearm into supination. Maintain the wrist and hand in position while you move the shoulder into flexion and abduction. You may use gentle traction to help elongate the shoulder and scapula muscles. The palm faces about 45° to the lateral plane. The traction brings the scapula into posterior elevation. Continuation of the traction elongates the patient's trunk diagonally from left to right. Too much abduction prevents trunk elongation. Too much external rotation prevents the scapula from coming into full posterior elevation.

If the patient has just completed the antagonistic motion (flexion-abduction-external rotation), begin at the end of that pattern.

Body Mechanics

Stand in a stride position above the patient's shoulder with your left foot forward. Face the line of motion. Start with the weight on your back foot and let the patient's motion pull your weight to your front foot. Continue facing the line of motion.

Stretch

Apply the stretch to the shoulder and hand simultaneously. Your proximal hand does a rapid traction with rotation of the shoulder and scapula.

! Caution

Do not force the shoulder into more flexion.

Your distal hand gives traction to the wrist.

! Caution

Traction the wrist in line with the metacarpal bones. Do not force the wrist into more extension.

Command

"Squeeze my hand, pull down and across." "Squeeze and pull!"

Resisted Abduction Internal Rotation

Fig. 7.5a,b. Extension-adduction-internal rotation

Fig. 7.5a,b. Extension-adduction-internal rotation

Movement

The fingers and thumb flex as the wrist moves into ulnar flexion. The radial side of the hand leads as the shoulder moves into extension with adduction and internal rotation and the scapula into anterior depression. Continuation of this motion brings the patient into trunk flexion with neck flexion to the right.

Resistance

Your distal hand combines traction through the flexed wrist with rotary resistance to ulnar deviation. The rotary resistance at the wrist provides resistance to the forearm pronation and shoulder adduction and internal rotation. The traction at the wrist resists the wrist flexion and the shoulder extension.

Your proximal hand combines a traction force with rotary resistance. The line of resistance is back toward the starting position. Maintaining the traction force will guide your resistance in the proper arc.

Your hands change from traction to approximation as the shoulder and scapula near the end of their range. The approximation resists the scapula depression and stabilizes the shoulder.

End Position

The scapula is in anterior depression. The shoulder is in extension, adduction, and internal rotation with the humerus crossing the midline to the right. The forearm is pronated, the wrist and fingers flexed with the palm facing toward the right ilium.

Timing for Emphasis

You may prevent motion in the beginning range of shoulder extension or allow the shoulder to reach the mid-position and exercise the wrist, hand, and fingers. To exercise the fingers and thumb, move your proximal hand to give resistance just distal to the wrist. Your distal hand can now exercise the fingers, together or individually.

Points to Remember

— The stretch at the wrist and shoulder is done with traction, not more flexion

— Approximate at the end range to resist the scapula and stabilize the shoulder

— The humerus crosses mid-line b a

7.3.1 Extension - Adduction - Internal Rotation with Elbow Extension (o Fig. 7.6)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Anterior depression

Serratus anterior (lower), pectoralis minor, rhomboids

Shoulder

Extension, Adduction, Internal Rotation

Pectoralis major, teres major, subscapularis

Elbow

Extension

Triceps, anconeus

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar flexion

Flexor carpi ulnaris

Fingers

Flexion, ulnar deviation

Flexor digitorum (superficialis and profundus), lumbricales, interossei

Thumb

Flexion, adduction, opposition

Flexor pollicis (longus and brevis), adductor polli-cis, opponens pollicis

Grip

Your distal grip is the same as for the straight arm pattern. Wrap your proximal hand around the humerus from underneath so that your fingers can give pressure opposite the direction of rotation. During the starting position the therapist can give resistance with the forearm against the forearm of the patient on the palmar side (O Fig. 7.6 a).

Elongated Position

The humerus is in full flexion with the scapula in posterior elevation. The elbow is flexed, and the patient's forearm is touching the head. The wrist is in full radial extension with the fingers extended.

Body Mechanics

Your body mechanics are the same as for the straight arm pattern.

Stretch

Apply the stretch to the shoulder and hand simultaneously. Your proximal hand does a rapid traction with rotation of the shoulder and scapula. Your distal hand gives traction to the wrist. Usually the patient's forearm is touching the head, preventing increased elbow flexion.

Command

"Squeeze my hand, push down and across, straighten your elbow." "Squeeze and push!" "Reach for your right hip."

Movement

The fingers and thumb flex and the wrist moves into ulnar flexion. The shoulder begins its motion into extension-adduction, and then the elbow begins to extend. The hand moves down toward the opposite hip. The elbow reaches full extension as the shoulder and scapula complete their motion.

Resistance

Your distal hand resists the wrist and forearm, as in the straight arm pattern. Give resistance to the elbow extension by rotating the forearm and hand back toward the starting position of elbow flexion. Give approximation to facilitate the elbow extension.

Your proximal hand gives traction through the humerus combined with rotary resistance back toward the starting position. Change from traction to approximation as the shoulder and scapula pass about halfway through their range.

Each of your hands uses the proper force to make the resistance appropriate for the strength of the elbow and the strength of the shoulder.

Fig. 7.6a-c. Extension-adduction-internal rotation with elbow extension

Fig. 7.6a-c. Extension-adduction-internal rotation with elbow extension

End Position

The end position is the same as the straight arm pattern.

Timing for Emphasis

Prevent elbow extension at the beginning of the range and exercise the shoulder. Lock in shoulder extension in mid-range and exercise the elbow extension with pronation.

Points to Remember

The humerus crosses mid-line Normal timing: the elbow and shoulder motion occur together b a c

7.3.2 Extension - Adduction - Internal Rotation with Elbow Flexion (o Fig. 7.7)

Joint

Movement

Muscles: principal components (Kendall and Mc-Creary 1993)

Scapula

Anterior depression

Serratus anterior (lower), pectoralis minor, rhomboids

Shoulder

Extension, Adduction, Internal Rotation

Pectoralis major, teres major, subscapularis

Elbow

Flexion

Biceps, brachialis

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar flexion

Flexor carpi ulnaris

Fingers

Flexion, ulnar deviation

Flexor digitorum (superficialis and profundus), lum-bricales, interossei

Thumb

Flexion, adduction, opposition

Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

Grip

Your distal and proximal grips are the same as those used for extension-adduction-internal rotation with elbow extension.

Alternative Grip

After the motion begins, the proximal hand may move to the scapula to emphasize that motion.

Elongated Position

The position is the same as the straight arm pattern.

Stretch

The stretch is the same as for the straight arm pattern.

Command

"Squeeze my hand, pull down and across and bend your elbow." "Squeeze and pull."

Movement

The fingers and thumb flex and the wrist moves into ulnar flexion. The shoulder starts into extension-adduction and the elbow begins to flex. The elbow reaches full flexion as the shoulder and scapula complete their motion.

Resistance

Your distal hand resists the wrist and forearm, as in the straight arm pattern. Give resistance to the elbow flexion by rotating the forearm toward supination and back toward the starting position of elbow extension.

Your proximal hand gives traction through the humerus combined with rotary resistance back toward the starting position. Change from traction to approximation as the shoulder and scapula pass about halfway through their range.

Each of your hands uses the proper force to make the resistance appropriate for the strength of the elbow and the strength of the shoulder.

End Position

The humerus is in extension with adduction, the scapula in anterior depression. The elbow is fully flexed. The wrist is in ulnar flexion and the hand closed. The rotation in the shoulder and forearm is the same as in the straight arm pattern. If you extend the patient's elbow, the position is the same as the straight arm pattern.

Timing for Emphasis

With the three moving segments, shoulder, elbow and wrist, you may again lock in any two and exercise the third.

Adduction Internal Rotation Shoulder
Fig. 7.7. Extension-adduction-internal rotation with elbow flexion. a-c Standard grips; d,e grip variations

With the elbow bent it is easy to exercise the internal rotation separately from the other motions. Exercise this motion where the strength of shoulder extension is greatest. You may work through the full range of shoulder internal rotation during these exercises and return to the groove before finishing the pattern.

When exercising the patient's wrist or hand, move your proximal hand to the forearm and give resistance to the shoulder and elbow by pulling back toward the starting position. Your distal hand is now free to give appropriate resistance to the wrist and hand. To exercise the fingers and thumb, move your proximal stabilizing hand just distal to the wrist.

You may prevent motion in the beginning range of shoulder extension and exercise the elbow, wrist, hand, or fingers. In addition, you may lock in the shoulder and elbow motion in mid-range to exercise the wrist and hand. This places the hand where the patient can see it as it moves.

Points to Remember

With the proper rotation the humerus will cross mid-line

Resist the elbow flexion with traction back toward the starting position Normal timing: the elbow and shoulder motion occur together

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Responses

  • philipp
    What are extension adductions and internal rotation?
    5 months ago

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