1, Shoulder Joint The shoulder girdle is composed of the clavicle and the scapula. The glenohumeral joint is made up of the scapula and the humerus. The shoulder joint is the most mobile joint in the body, but it is not very stable. It mainly depends on muscles and ligaments to maintain stability. 2, the position of the scapula The upper medial aspect of the bone is aligned with the first thoracic vertebrae; the lower angle of the scapula is aligned with the eighth thoracic vertebrae; the scapula is located between the second and seventh ribs; the medial edge of the scapula is diagonal to the thoracic vertebrae, so that the glenoid of the joint is outwardly directed and anteriorly and slightly upwardly oriented to help keep the humerus in the correct position in a solid manner. The clavicle is at a 60-degree angle to the scapula; the scapula is at a 30-degree angle to the anterior facet; the biceps tendon faces anteriorly; and the head of the humerus is beyond the outer edge of the acromion. (1) From the trunk skeleton to the shoulder girdle Anterior serratus, upper trapezius, middle trapezius, lower trapezius, rhomboids, pectoralis minor, and pectoralis major lift the scapular muscles. (2) From the trunk skeleton to the humerus Pectoralis major, broad back muscles. (3) From shoulder girdle to humerus Deltoid, rotator cuff, supraspinatus, infraspinatus, teres minor, subscapularis, teres major, rostro-humeral, biceps, triceps. (4) Scapulohumeral Rhythm In the first 0 to 60 degrees of shoulder flexion the scapula remains stable and immobile, and only the glenohumeral joint moves. The shoulder joint goes from 60 to 90 degrees. As flexion continues, the scapula begins to follow the glenohumeral joint, and the glenohumeral to scapular motion ratio is 2 to 1. i.e., for every two degrees of humeral motion, the scapula moves by one degree. The clavicle is elevated and rotated. (5) Scapulohumeral Head Rhythm Flexion of the shoulder joint from 90 to 120 degrees and external rotation of the humerus to a neutral position helps move the humeral head downward to keep the tubercle bicipital tubercles away from the rostral process of the coracoid process. upward rotation of the scapula moves the superior horn closer to the vertebrae, bringing the glenoid upward. The clavicle rotates posteriorly axially. The shoulder joint flexes from 120 to 180, and the arm is raised by extension of the thoracic corridor, extension of the lumbar spine, and upward translation of the scapula. 3, the correct placement of the upper limbs of hemiplegic patients hemiplegic patients in the acute stage if you can choose the correct posture placement of the upper limbs, to prevent attacks to reduce complications, reduce the degree of disability has a great role. In the shoulder of the affected limb. It is important to correct bad posture and keep the patient in the correct position when the elbow and palm are completely inactive. (1) supine position, keep the shoulder joint fully abducted, insert a small slanting pillow and cushion on the back of the shoulder of the affected limb, balance the shoulders; under the forearm, use one end of the square pillow to support, keep the elbow joint extended; slightly tilt the square pillow outward, so that the upper arm rotates outward; the wrist in the neutral position, the knuckle extension on the pillow or use the hand to support. (2) Lying on the affected side Weight-bearing on the affected side helps to improve the patient’s attention to the affected side; the scapula on the affected side is fully pronated, the upper arm is externally rotated to avoid compression and posterior rotation; the trunk is slightly posterior, with a pillow behind; the upper arm is abducted, the elbow is adducted, the wrist is in neutral position, and the palms of the hands are upward and spread out. (3) Lying position on the healthy side Put a pillow in front of the chest, so that the shoulder of the affected side is stretched forward, elbow joint is extended, wrist joint is in the neutral position, and knuckle joints are stretched and placed on the pillow or supported by a hand rest; the height of the support pillow is suitable, and the healthy side is placed in the natural position for comfort. (4) Semi-recumbent position The forearm is supported by a pillow; the wrist joint is in the neutral position, and the knuckles are extended on the pillow or supported by the hand. (5) Sitting position The lateral upper limb should be placed on the table or chair armrest in front of the patient; the forearm should be supported by a square pillow to avoid prolonged flexion of the elbow; the wrist and fingers should be placed flat on the table or supported by the hand fixed on the table. (6) Standing and transfer When standing or transferring, support the affected limb with a shoulder sling. (7) Transfer Appropriate support. The person holding the patient puts his/her hand on the shoulder blade of the hemiplegic side; the other hand is put on the hip joint of the healthy side; the knee of the hemiplegic side is immobilized; and the patient is guided to tilt his/her center of gravity forward and then stand up. Semi-dislocation of shoulder joint in hemiplegic patients Semi-dislocation of shoulder joint can be divided into three types. It is related to the condition of muscle tension state of hemiplegic patients, the style of muscle weakness or tension. Semi-dislocation of shoulder joint is categorized into: inferior subluxation of shoulder joint, inferior anterior subluxation of shoulder joint, and superior subluxation of shoulder joint. (1) Inferior subluxation of the shoulder The inferior subluxation occurs when the head of the humerus lies inferior to the labrum of the inferior glenoid; a notch one or two fingers’ breadth may be felt at the glenohumeral joint; the scapula is rotated inferiorly, descending on the thorax, and the inferior angle of the scapula may pteronavigate; it occurs universally in the flaccid stage, when the absence of control of the trunk or muscular weakness has caused the scapula to lose its stabilization in the thorax; and the head of the humerus slips down along the perpendicular glenoid. (2) Inferior anterior subluxation of the shoulder Combination of inferior subluxation of the shoulder and internal rotation of the humerus due to spasm and shortening of the pectoral and biceps muscle groups; there is a notched area at the glenohumeral joint. The greater trochanter protrudes anteriorly in the joint; the scapula is rotated downward, and increased muscle tone causes the scapula to be elevated in the thoracic contour. Lower anterior subluxation of the shoulder joint; in prolonged cases the scapula loses its mobility in downward and upward rotation, and the elbow is flexed with the forearm inward across the abdomen; the humerus is hyperextended at its end, and the head of the humerus is fixed anteriorly and fails to glide back into the glenoid; this occurs in patients who have the worst spasm of the muscles; upper subluxation of the glenoid joint occurs when the humerus is moved upward above the glenoid and is fixed below the acromion, the glenohumeral The space of the glenohumeral joint is thus reduced. (3) Superior subluxation of the shoulder The scapula is elevated above the thorax in abduction and neutral rotation; the humerus is pulled tightly into an internally rotated and abducted position; and the humeral head protrudes anteriorly from the greater tuberosity of the humerus and squeezes the acromion tightly. (1) Reset of lower shoulder subluxation Correct the linear relationship of the torso to achieve a straight posture Key points: ① pelvis ② torso ③ feet ④ head Place the upper limb with the shoulder in posterior position on a tabletop or pillow for a weight-bearing position of the forearm to strengthen the effect of reset; control the lower angle of the scapula with the tiger’s mouth, rotate the scapula upward in the thorax to a neutral position; slide the humeral head upward to the glenoid. . (1) Repositioning of inferior anterior subluxation of the shoulder Maintain the scapula in the normal position and rotate the humeral head outward; then slide the humeral head upward to the articular glenoid; keep the affected shoulder in slight flexion to prevent the humeral head from protruding forward during repositioning. (2) Repositioning of upper subluxation of the shoulder Correct the linear relationship of the trunk to achieve an upright posture; attach the scapula downward with the fingers at the scapula-gang position, and at the same time rotate the clavicle backward at the outer edge to strengthen the effect of the scapula’s downward fall; hold the lower corner of the scapula with the tiger’s mouth, and rotate the scapula upward to the median position; press the stabilizing shoulder against the clavicle with the other hand; use the hand at the proximal end of the humerus medially as a pivot; and turn the humerus internally in the proximal end position; and then turn the head of the humerus inward to prevent it from protruding forward during the reset. end position retract the humerus internally to separate the head of the humerus from the top of the glenoid; flex the humerus anteriorly and then rotate it externally; place the hand in the proximal medial position of the humerus as a fulcrum and slide the head of the humerus downward back to the glenoid position. 6. Activities to promote the scapulohumeral rhythm (1) Scapular adduction Key point: squeeze the rhomboids to promote the patient’s scapular adduction movement. (2) Scapular retraction Key points: control the lower corner of the scapula with the tiger’s mouth, and work on the outer edge of the scapula to promote scapular retraction; use the palm of the hand to press on the head of the humerus for support; and the patient should turn the torso to the healthy side to strengthen the degree of extension. (3) Abduction of the shoulder joint Key point: Use the medial edge of the scapula as a support point with both hands to abduct the scapula. (4) Scapular abduction Key Points: Use the tiger’s mouth to control the lower corner of the scapula to exert force on the medial edge of the scapula to promote scapular abduction; place the hand on the outer edge of the shoulder girdle for holding; put the affected limb forward across the torso and push the shoulder out to strengthen scapular abduction. (5) Scapular uplift Key points: control the lower angle of the scapula with the tiger’s mouth to promote scapular uplift; lift the shoulder girdle upward with the proximal end of the palm of the hand pressing against the lower part of the outer edge of the clavicle. (6) Scapular uplift Key point: keep control of the scapula and clavicle elevation, so that the patient sits with the back hanging down and shoulders, in order to enhance the pull on the distal muscle fibers of the anterior serratus rhomboids rhomboids. (7) Lowering of the scapula Key Points: Make the patient sit with a straight torso; the therapist uses the fingers to jam on the upper edge of the scapular gonad to lower the scapula downward; at the same time, the therapist rotates backward with the proximal end of the palm of the hand pressing on the outer edge of the clavicle; and ask the patient to look downward in the direction of the healthy shoulder in order to increase the pull on the distal muscle fibers of the rhomboid muscle of the trapezius muscle. (8) Glenohumeral extension and scapular retraction Method 1: Key point: Use the thigh or square to support the patient’s palm to keep the glenohumeral joint extended; use the muzzle of the tiger on the outer edge of the scapula to grasp the scapula retracted; use the head of the humerus as a support; ask the patient to turn the torso to the healthy side to strengthen the degree of retraction; this can also be done with the healthy side when dressing. Method 2: Key points: support the patient’s hands on the armrests of the chair as if to stand up from the chair; support the patient’s humeral head and control the key point of the lower corner of the scapula with the tiger’s mouth to internalize the scapula. (9) Glenohumeral Flexion and Scapular Superior Rotation Method 1: Sitting position Key points: rotate the scapula superiorly with the inferior angle of the scapula, rotate the clavicle with the lateral clavicle, support the patient’s elbow to promote humeral flexion. Method 2: Lying position Key point: Lying position is more likely to inhibit compensatory activity of the trunk and other upper limbs. and other upper extremity involuntary activities.