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SHOULDER
JOINT
Dr Riafat mehmood
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Assistant professor
MSPT SPT
 shoulder joint

 Joint Motions

 Arthrokinematics of shoulder joint

 Bones and Landmarks shoulder joint

 Ligaments and Other Structures

 Muscles of the Shoulder Joint

 Anatomical Relationships

 Glenohumeral Movement

 Common Shoulder Pathologies

 Functional anatomy- static and dynamic

 Full upper limb elevation

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 SHOULDER JOINT
 The shoulder joint is a ball-and-socket joint with movement in all
three planes and around all three axes .
 Therefore, the joint has three degrees of freedom.
 The humeral head articulating with the glenoid fossa of the scapula
makes up the shoulder joint.
 It is one of the most movable joints in the body and, consequently,
one of the least stable.

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 JOINT MOTIONS
 There are four groups of motions possible at the shoulder joint
 (1) flexion, extension, and hyperextension
 (2) abduction and adduction
 (3) medial and lateral rotation
 (4) horizontal abduction and adduction.
 Circumduction is a term used to describe the arc or circle of
motion possible at the shoulder. Because it is really only a
combination of all the shoulder movements.

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 scaption. This motion is similar to
flexion or abduction but occurs in
the scapular plane as opposed to the
sagittal or frontal plane.
 The scapular plane is
approximately 30 degrees forward
of the frontal plane. It is not quite
midway between flexion and
abduction.
 With scaption of the shoulder, 180
degrees of up and down motion is
possible. Most common functional
activities occur in the scaption
plane.
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 Flexion, extension, and hyperextension occur in the sagittal plane
around the frontal axis. Flexion is from 0 to 180 degrees, and
extension is the return to anatomical position. Approximately 45 degrees
of hyperextension are possible from the anatomical position.
 Abduction and adduction occur in the frontal plane around the
sagittal axis with 180 degrees of motion possible.
 Medial and lateral rotation occur in the transverse plane around the
vertical axis. (internal and external). From a neutral position, it is
possible to move 90 degrees in each direction.
 Horizontal abduction and horizontal adduction also occur in the
transverse plane around the vertical axis.

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 ARTHROKINEMATICS OF
SHOULDER JOINT
 The convex humeral head moves within the concave glenoid fossa.
 As stated by the concave-convex rule, the convex joint surface (humeral
head) moves in a direction opposite to the movement of the body segment
(the arm).
 Therefore, when the shoulder joint flexes or abducts, the humeral head
glides inferiorly.
 In extension and adduction, the humeral head glides superiorly.
 With medial rotation, the head glides posteriorly,
 and with lateral rotation (extrnal), it glides anteriorly.

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BONES AND LANDMARKS
SHOULDER JOINT

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 Glenoid Fossa
A shallow, somewhat egg-shaped socket on the
superior end, lateral side; articulates with the
humerus.
 Glenoid Labrum
Fibrocartilaginous ring attached to the rim of
the glenoid fossa, which deepens the articular
cavity
 Subscapular Fossa
Includes most of the area on the anterior (costal)
surface, providing attachment for the
subscapularis muscle
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 Infraspinous Fossa
Below the spine, providing attachment for the
infraspinatus muscle
 Supraspinous Fossa
Above the spine, providing attachment for the
supraspinatus muscle
 Axillary Border
Providing attachment for the teres major and teres
minor muscles
Acromion Process
Broad, flat area on the superior lateral aspect,
providing attachment for the middle deltoid muscle
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 HUMERUS
 Head
Semirounded proximal end; articulates with the scapula
 Surgical Neck
Slightly constricted area just below tubercles where the head meets
the body
 Anatomical Neck
Circumferential groove separating the head from the tubercle.
 Shaft
Or “body”; the area between the surgical neck proximally and the
epicondyles distally
Greater Tubercle Large projection lateral to head and lesser tubercle;
provides attachment for the supraspinatus, infraspinatus, and teres
minor muscles
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 Lesser Tubercle
Smaller projection on the anterior surface, medial to the greater tubercle; provides
attachment for the subscapularis muscle.
 Deltoid Tuberosity
 On the lateral side near the midpoint; not usually a well-defined landmark.

 Bicipital Groove
Also called the “intertubercular groove”; the longitudinal groove between the
tubercles, containing the tendon of the long head of the bicep.
 Bicipital Ridges
Also called the lateral and medial lips of the bicipital groove, or the crests of the
greater and lesser tubercles, respectively. The lateral lip (crest of the greater tubercle)
provides attachment for the pectoralis major, and the medial lip (crest of the lesser
tubercle) provides attachment for the latissimus dorsi and teres major.

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 LIGAMENTS AND
OTHER STRUCTURES

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 The joint capsule is a thin-walled, spacious container that attaches
around the rim of the glenoid fossa of the scapula and the anatomical
neck of the humerus
 The joint capsule is formed by an outer fibrous membrane and an inner
synovial membrane. With the arm hanging at the side, the superior
portion of the capsule is taut, and the inferior part is slack.
 When the shoulder is abducted, the opposite occurs:
The inferior portion is taut, and the superior part is slack.
 The superior, middle, and inferior glenohumeral ligaments
reinforce the anterior portion of the capsule. These are not well-
defined ligaments but actually pleated folds of the capsule

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 coracohumeral ligament attaches from the lateral side of the coracoid
process and spans the joint anteriorly to the medial side of the greater
tubercle. It strengthens the upper part of the joint capsule.
 The glenoid labrum is a fibrous ring that surrounds the rim of the
glenoid fossa Its function is to deepen the articular cavity
 Bursae
 There are several bursae in the shoulder joint area.
 The subdeltoid bursa is large and located between the deltoid muscle
and the joint capsule.
 The subacromial bursa lies below the acromion and coracoacromial
ligament,

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 The rotator cuff is the tendinous band formed by the blending
together of the tendinous insertions of the subscapularis,
supraspinatus, infraspinatus, and teres minor muscles.
 These muscles help to keep the head of the humerus “rotating”
against the glenoid fossa during joint motion. This rotating
motion is what inspired the term rotator cuff, not the muscular
action of medial or lateral rotation.

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 As mentioned, the shoulder joint allows a great deal of motion,
making it rather unstable. Several features contribute to whatever
stability this joint does have.
 The fairly shallow glenoid fossa is made deeper by the glenoid
labrum.
 The fossa is positioned in an anterior, lateral, and upward
direction. This upward direction provides some stability to the
joint. The joint is held intact by the joint capsule and is
reinforced by the coracohumeral and glenohumeral ligaments.

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 Because the capsule completely surrounds the joint, it creates a
partial vacuum, which helps hold the head against the fossa.
 The rotator cuff muscles hold the joint surfaces together during
joint motion. It is mostly the shoulder muscles that keep the joint
from subluxing, or partially dislocating.
 An individual who has had a stroke and has lost function in the
involved extremity often develops a subluxed shoulder. The lack of
a deep socket for the humeral head to fit into, the loss of muscle
tone, the weight of the extremity, and gravity all contribute to joint
subluxation.

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MUSCLES OF THE
SHOULDER JOINT

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 The muscles that span the shoulder joint are as follows:
 Deltoid
 Pectoralis major
 Latissimus dorsi
 Teres major
 Supraspinatus
 Infraspinatus
 Teres minor
 Subscapularis
 Coracobrachialis
 Biceps brachii
 Triceps brachii, long head
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ANATOMICAL
RELATIONSHIPS

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 The relationship between the shoulder girdle and
shoulder joint muscles is logical.
 Shoulder girdle muscles attach to the scapula and trunk
to move or stabilize the scapula.
 Shoulder joint muscles attach mostly to the scapula and
humerus to move the arm.
 These muscles are superficial to muscles of the shoulder
girdle.
 This arrangement allows both sets of muscles to
function without getting in each other’s way.

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 The deltoid forms a superficial cap over
the anterior, lateral, and posterior sides of
the shoulder
 Anteriorly, the pectoralis major covers
most of the superficial chest wall, while the
biceps brachii and triceps brachii
encompass most of the anterior and
posterior arm, respectively.
 Several shoulder muscles can be seen
posteriorly if the trapezius muscle is
removed
 The supraspinatus lies deep to the trapezius
above the scapular spine.
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In descending order, the infraspinatus, teres minor, and
teres major lie below the scapular spine.
The latissimus dorsi covers the lumbar and lower
thoracic region of the back.
Viewed anteriorly, the coracobrachialis lies deep to the
pectoralis major and anterior deltoid and lies medial to
the short head of the biceps .
The subscapularis is truly a deep muscle. With the
pectoralis major and deltoid muscles removed and with
the arm slightly abducted, the subscapularis can be
seen as it passes between the rib cage and the scapula,
and it runs horizontally through the axilla to the
proximal end of the anterior humerus.

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GLENOHUMERAL
MOVEMENT

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 The movement of the humeral head on the glenoid
fossa must be given some additional attention.
 Notice that the articular surface of the humeral
head is greater than that of the glenoid fossa . If
the humeral head simply rotated in the glenoid
fossa, it would run out of articular surface before
much abduction occurred.
 Also, the vertical pull of the deltoid muscle would
pull the head up against the acromion process. It is
the arthrokinematic motions of glide, spin, and roll
that keep the head of the humerus articulating with
the glenoid fossa.

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 As abduction occurs, the humeral head rolls across the glenoid
fossa. At the same time, the head glides inferiorly, keeping the head
of the humerus articulating with the glenoid fossa. This is
accomplished by the rotator cuff muscles .
 In addition to abducting the shoulder joint, the supraspinatus
muscle pulls the humeral head into the glenoid fossa. The other
rotator cuff muscles (subscapularis, infraspinatus, and teres minor)
pull the head in and downward against the glenoid fossa. The
glenoid labrum serves to slightly deepen the glenoid fossa, making
the joint surfaces more congruent.

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 Another feature of shoulder abduction is that complete
range of motion can be accomplished only if the shoulder
joint is also laterally rotated.
 Try this on yourself. Start with your arm at your side
(shoulder adduction) and in medial rotation; abduct your
shoulder, keeping your thumb pointed down. This is referred
to as the “empty can” position.
 Notice how much motion you can comfortably achieve.
 Next, repeat the motion with your shoulder in a neutral
position between medial and lateral rotation (fundamental
position) and with your thumb pointed forward.
 Notice how much motion you can comfortably accomplish.

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 Finally, repeat the motion with your shoulder in a laterally rotated
position, keeping your thumb pointed up in the hitchhiking
position. This is referred to as the “full can” position. It is this
laterally rotated position that should allow the most comfortable
shoulder motion, because the greater tubercle is being rotated from
under the acromion process, allowing full abduction. The greater
tubercle in the medially rotated or neutral position runs into the
acromion process overhead.

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COMMON SHOULDER
PATHOLOGIES

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 ACROMIOCLAVICULAR SEPARATION

the various amounts of ligament injury at the acromioclavicular joint.

In a first-degree sprain, the acromioclavicular ligament is stretched.
In a second-degree sprain, the acromioclavicular ligament is ruptured and the coracoclavicular
ligament is stretched.
In a third-degree sprain, both the acromioclavicular and coracoclavicular ligaments are ruptured.
CLAVICULAR FRACTURES
account for the most frequently broken bone in children. They usually result from a fall on the
lateral aspect of the shoulder or on the outstretched hand.
The clavicle usually breaks in its midportion.
HUMERAL NECK FRACTURE
is an caused by a fall on the outstretched hand. It is common in the elderly and is usually an
impacted fracture

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 MIDHUMERAL FRACTURES
 are often caused by a direct blow or a twisting force. Spiral fractures in this region
increase the risk of a radial nerve injury, as the nerve passes next to the bone.
Pathological fractures of the humerus may be caused by benign tumors or metastatic
carcinoma from primary sites such as the lung, breast, kidney, and prostate.

 One of the most common joint dislocations involves the shoulder, and most of those are
anterior shoulder dislocations.
 A forced shoulder abduction and lateral rotation tends to be the dislocating motion
causing the humeral head to slide anteriorly out of the glenoid fossa.
 Glenohumeral subluxation is commonly seen in individuals who have hemiplegia, usually
from a cerebrovascular accident (stroke). Paralysi muscles leaves them no longer able to
hold the head of the humerus in the glenoid fossa. This paralysis combined with the pull
of gravity and the weight of the arm over time causes this partial dislocation.

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 IMPINGEMENT SYNDROME is an overuse condition that involves
compression between the acromial arch, humeral head, and soft tissue
structures such as the coracoacromial ligament, rotator cuff muscles,
long head of the biceps, and subacromial bursa. A type of impingement
known as swimmer’s shoulder is common with swimmers specializing
in freestyle, butterfly, and backstroke.
 ADHESIVE CAPSULITIS refers to the inflammation and fibrosis of
the shoulder joint capsule, which leads to pain and loss of shoulder
range of motion. It is also known as frozen shoulder.
 A TORN ROTATOR CUFF
 involves the distal tendinous insertion of the supraspinatus,
infraspinatus, teres minor, and subscapularis on the greater/lesser
tubercle area of the humerus.

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 CALCIFIC TENDONITIS
 Tears can be the result of acute trauma or gradual degeneration. Chronic
inflammation of the supraspinatus tendon can lead to an accumulation of
mineral deposits and can result in calcific tendonitis, which may be
asymptomatic or quite painful. Bicipital tendonitis usually involves the
long head of the biceps proximally as it crosses the humeral head,
changes direction, and descends into the bicipital groove. The biceps long
head tendon commonly ruptures during repetitive or forceful overhead
positions. Irritation as it slides in the groove can lead to subluxing of the
biceps tendon (long head). Overloading the muscle in an abducted and
laterally rotated position tends to be the force subluxing the tendon out of
the bicipital groove.

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FUNCTIONAL ANATOMY-
STATIC AND DYNAMIC

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FUNCTIONAL ANATOMY-
STATIC AND DYNAMIC
 The Glenohumeral Joint is Synovial ball and socket articulation Between the head of the
humerus and the glenoid cavity of the scapula.
 It is the major joint connecting the upper limb to the trunk
 SHOULDER JOINT is component of SHOULDER GIRDLE which comprises of five linkages.

1. Glenohumeral
2. Suprahumeral articulation: Coracoacromial arch above with head of humerus below with
subdeltoid bursa in between.
3. Acromioclavicular
4. Sternoclavicular
5. Scapulothoracic (muscular)

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STATIC STABILIZERS
 Static stabilizers are the non-contractile tissue of the glenohumeral
joint. They are very important in shoulder stability at end-range
ROM and/or when there is a dysfunction of the
dynamic stabilizers.
 These static stabilizers set the base of support for the shoulder
joint.
 The main static stabilizers of the shoulder in the functional position
(abducted) are the anterior and posterior bands of the inferior
glenohumeral ligament
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 The anterior band of the inferior glenohumeralligament prevents
anterior translation, and the posterior band prevents posterior
translation of the humeral head.
 The superior margin of the anterior band of this ligament attaches
to the glenoid fossa anteriorly at the two o'clock position
 When the arm is placed into abduction and external rotation. this
broad ligamentous band rotates anteriorly to prevent subluxation of
the joint.

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GLENOID LABRUM
 A ring of fibrous tissue attached to the rim of the glenoid, which
expands the size and depth of the glenoid cavity.
 Enhances shoulder stability
 It increases the superior- inferior diameter of the glenoid by 75%
and the anterior- posterior diameter by 50%.

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DYNAMIC STABILIZERS
 Dynamic stabilizers include the rotator and
scapular stabilizers (ie, teres major, rhomboids, serratus anterior,
trapezius, levator scapula).
 The rotator cuff is composed of 4 muscles: the supraspinatus,
infraspinatus, subscapularis, and teres minor.

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FULL UPPER LIMB ELEVATION
 It requires upward rotation of the scapula, which ensures that the
coraco-acromial arch is removed from the path of the greater
tuberosity of the elevating humerus, thus avoiding potential
impingement.
 Scapular control also enhances joint stability at greater than 90" of
abduction by placing the glenoid fossa under the humeral head,
where stability is assisted by the action of the deltoid muscle.

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THREE-DIMENSIONAL
SCAPULAR MOVEMENT
 The main upward rotation force couple involves
the upper trapezius coordinating with the lower
trapezius/serratus anterior.
 Anterior/ posterior tilt and rotation involve the
upper trapezius/pectoralis minor force coupled
with the serratus anterior/lower trapezius.
 A stable scapula provides a base for the muscles
arising from the scapula and acting on the
humerus, allowing them to maintain their
optimal length-tension relationship.
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SHOULDER PAIN
DIFFERENTIAL

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 CLINICAL
PERSPECTIVE OF
SHOULDER PAIN
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 Rotator cuff
 Instability
 Labral injury
 Stiffness
 Acromioclavicular (AC) joint pathology
 Referred pain.

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1)Rotator cuff muscles and tendons
 May be acute, chronic, or acute on chronic. Acute injuries include
muscle strains, and partial or complete tendon tears. Overuse injuries
include tendinopathy. Sports people with rotator cuff tendon injuries
present with shoulder pain and difficulty with overhead activities.

2)Shoulder instability
May arise from the anterior, posterior, or superior shoulder capsule and
labrum, and from the periscapular muscles. Instability may result from
changes to passive structures such as ligament, capsule or labrum (Le.
hypermobility), or it can be caused by poor motor control (i.e. dyuamic
instability).
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3)Labral injury
Glenoid lahrallesions may occur either as an acute injury or from
overuse. Instability may be obvious clinically in patients with
recurrent episodes of dislocation or subluxation. In many cases,
however, instability may initially cause relatively minor symptoms,
such as impingement or joint pain.

4)Shoulder stiffness
Hypomobility may be secondary to trauma, including surgery, or from
injury to the cervical nerve roots or brachial plexus. It may occur
spontaneously in middle age-a condition termed "idiopathic adhesive
capsulitis" or "frozen shoulder."
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5)Acromioclavicular joint pathology
Pain is usually localized over the acromioclavicular joint.

6)Referred pain
Pain can refer to the shoulder from the cervical spine, the upper
thoracic spine, and associated soft tissues .Similarly, shoulder
dysfunction can lead to trapezial fatigue or may radiate into the neck.
behind the scapula, the upper ann, forearm, or, less commonly. the
wrist and hand. Diagnosis of shoulder pain in the sportsperson
requires taking a thorough history, performing a thorough
examination, and organizing appropriate investigations

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TAKING HISTORY

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 acromioclavicular joint pain and bicipital pain are well localized, the pain of most other
shoulder pathologies is more diffuse. The onset of shoulder pain may be either acute (e.g. a
dislocation, subluxation, or rotator cuff tear), or insidious (e.g. rotator cufftendinopathy).
 Identify the position of the shoulder at the time of injury. If the arm was twisted backward
while in a vulnerable position, it suggests anterior dislocation or subluxation.
 A fall onto the point of the shoulder can cause acromioclavicular joint injury. In chronic
shoulder pain, the activity or position that precipitates the patients pain should be noted (such
as the cocking phase of throwing or the pull·through phase of swimming).
 Night pain is very common in rotator cuff dysfunction and adhesive capsulitis.
 Sensory symptoms such as numbness or pins and needles should be noted, as should any
episodes of "dead arm" (in a baseball pitcher this suggests labral injury). Assess upper limb
strength. He or she may report catching and locking, or inability to develop normal speed in
the action

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THE PHYSICAL EXAM

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 While discussing the onset of the injury, it is important to also focus on the initial symptoms in
regard to type, severity, and irritability.
 The subsequent behavior of the symptoms can then be traced to the current stage through
appropriate questioning. The following can be utilized for the assessment of the initial or
current symptoms and is divided into three areas:
 1) Type: esthesia (hyper-, hypo-,), mobility (hyper- or hypo-), thermal sensation, coloration,
crepitis, and strength (fatigue and/or weakness); this in turn should be evaluated as to whether
the symptoms are constant or variable.
 2) Severity: percentage of initial (if sudden onset) and percentage of maximal possible pain
that could be tolerated.
 3) Irritability (response to the following): activity (walking and specific use of the affected
extremity), inactivity (standing, ipsilateral side lying, and gravity eliminated positioning),
treatment modalities (heat, cold, compression, elevation, massage, traction, splinting or sling,
and medication), circadian behavior, and any other additional means of increasing or
decreasing the symptoms.
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 A COMPLETE EXAMINATION INVOLVES:
1. Observation 3. Passive movements
(a) to (e) as for active movements (above)
(a) from the front
(b) from behind. 4. Resisted movements
2. Active movements external rotation
subscapularis lift-off test-Gerber's test
(a) arm elevation-watch scapular
motion and position deltoid
supraspinatus
(b) external rotation with elbows at side Uppercut
(c) external rotation at 90° of abduction 5. Palpation
(d) internal rotation
(a) acromioclavicular joint
(b) rotator cuff tendon
(e) horizontal flexion (c) bicipital groove

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OBSERVATION
• Inspection –
from the front and back!
• Asymmetry
• Bony deformity or abnormal
contour
• Muscle atrophy or bulge
• Scapular winging
• Posture

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RANGE OF MOTION
 Active
 Passive
 Apley’s “scratch” test
 Scapular movement
 Strength Testing/Resisted Movements

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Observation from behind. Look for Active movements-elevation. Watch for
wasting or asymmetry of shoulder prominence of the medial scapular
height, scapular position, and muscle border. This indicates Joss of scapular
bulk control, which is called "scapular
dyskinesis" 66
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PALPATION
• AC, SC, and GH joints
• Biceps tendon
• Coracoid process
• Acromion
• Scapula
• Musculature

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SHOULDER INVESTIGATIONS

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 X-ray Plain
 Routine views (AP with internal and external rotation, and axillary lateral)
 AP view is useful for assessing joint space narrowing (i.e. arthritis).
 In cases of Tauma, an adequate axillary view may not be possible and it is
mandatory to obtain a true lateral film to exclude dislocation.
 The conditions that can be identified on plain films are:
 calcific tendinopathy glenohumeral
 joint arthritis
 impingement (sclerosis of anterior and/or lateral acromion, sclerosis of greater
tuberosity)
 proximal humeral head migration (severe rotator cuff dysfunction)
 fractures.

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 Typical shoulder X-ray views include:
 Antero-posterior (AP) view
 Lateral/scapula Y view (named due to the “Y” shape of the
scapula in this view)
 An axial view can also be used as an alternative to the scapula Y
view if the patient is unable to tolerate the positioning required to
obtain this view.

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FRACTURE

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 ULTRASOUND
 Evaluate rotator cuff and adjacent
muscles, bursa, long head of biceps,
fluid collections
 Diagnose tendinopathy, tears, bursal
thickening, impingement
 However, not great at quantifying
large tears
 Less expensive, non-invasive
 Static and dynamic evaluation

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MRI
 Multiplanar, non-invasive
 Can better characterize large RC tears, can diagnose occult
fractures, morei nformation on ligaments and nerves
 More expensive, static
 Do not need immediately if full ROM and only complains of pain
and weakness
 Add arthrogram (contrast) for labral pathology

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 Degenerative joint disorders like arthritis
 Shoulder impingement, or pressure on tendons or nerves in the shoulder
 Rotator cuff injury
 Torn ligaments
 Sports injuries
 Repetitive strain that causes injury and pain
 Bone infections
 Shoulder pain that doesn’t get better with treatment
 Trouble moving your shoulder
 Shoulder healing after surgery
 Tumors

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SPECIAL TESTS

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Rotator Cuff
• “Drop-arm”
• “Empty can,” lift-off,
and resistance testing

Impingement
• Neer’s
• Hawkins/Kennedy

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Biceps
 Speed’s
 Yergason’s

AC Joint
 Cross-arm/scarf test

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Shoulder Instability
 Sulcus sign
 Apprehension,
relocation,release

Load and shift

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 Labrum
 O’Brien’s
 Crank test
 SLAP prehension

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 1. Lie prone on a table with your arm over the
edge and with your shoulder flexed 90 degrees,
elbow extended, and a weight in your hand Lift
the weight away from the table in a sideward
motion.

 a. What is the shoulder joint motion?

 b. What type of contraction (isometric, concentric,
 eccentric) is occurring?
 c. What muscles are prime movers in this shoulder joint
motion?

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 2. Stand with your arm adducted at the side of your body,
elbow flexed to 90 degrees, and hold a loop of elastic tubing
whose other end is anchored in front of you at the same level as
your hand. In a sawing motion (back and forth motion like you
are sawing wood), pull back on the tubing.

 a. What is the shoulder joint motion?

 b. What type of contraction (isometric, concentric,eccentric) is occurring?
 c. What muscles are prime movers in this shoulder joint motion?

97
 The ability of this gymnast to perform
this iron cross maneuver may be limited
by the strength of which group of
shoulder joint muscles?

98
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