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The Shoulder Complex

Functions of the Shoulder Complex


Structure of the Shoulder Complex
Kinematics of the Shoulder Complex
Muscles at the Shoulder
Shoulder Stability
Mechanism of Injury at the Shoulder

Objectives: After studying this topic, the students will be able to

1. to identify the structure of the shoulder and the shoulder girdle, including joint type, articular shape, and
the surrounding tissues
2. to describe joint motions occurring at the shoulder complex, including osteokinematic and
arthrokinematic movements, muscle actions, and factors checking shoulder motions
3. to understand the stability mechanism of the shoulder complex and the possible mechanisms of injury
4. to distinguish the three-degree-of-freedom joint from the one- or two-degree-of-freedom joint
5. to understand the effect of muscle synergies and the influence of weakness or paralysis of one single
muscle in coupled-muscle motions

1. Neumann DA (2002). Shoulder complex. In Neumann DA: Kinesiology of the Musculoskeletal


System: Foundations for Physical Rehabilitation. Philadelphia: Mosby. Chapter 5, pp. 91-132
2. Smith LK, Weiss EL, Don Lehmkuhl L (eds, 1996). Brunnstrom's Clinical Kinesiology, 5th ed.
Philadelphia, F.A. Davis. Chapter 5, pp. 223-225
3. Craig J et al. (2001). Biomechanics of the shoulder. In Nordin M & Frankel VH: Basic Biomechanics
of the Musculoskeletal System. Philadelphia: Lippincott Williams & Wilkins. Chapter 12, pp.318-339

Functions of the Shoulder Complex

To link the upper extremity to the trunk


dependent arm position
control of rotator cuff muscles
To provide extensive mobility of the arm in space
To provide stability for elbow and hand skillful or forceful movements

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Joint Structure of the Shoulder Complex

Joints at the shoulder complex


glenohumeral
joint (shoulder
joint)

sternoclavicula
r joint

acromioclavic
ular joint

scapulothoraci
c articulation:
msucle-bone
articulation
NOTE:
classified by
Smith et al.,
1996

bony
articulati
ons

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functional joints
scapulothoracic articulation
suprahumeral articulation (subacromial articulation): the articulation between the
coracoacromial ligament and the humerus
bicipital groove: the groove between the greater and lesser tuberosities of the humerus

Glenohumeral joint (GH joint)

proximal component: scapula


concave glenoid cavity covered with glenoid labrum
that is a fibrocartilage to deepen the glenoid cavity
distal component: humerus
convex humeral head
retroversion of the humeral head about 30º posterior to
the frontal axis of the elbow joint
joint type: ball-and-socket joint
motion: convex on concave
shoulder flexion/ extension with posterior/ anterior glide of the humeral head on the
glenooid cavity
shoulder abduction/ adduction with inferior/ superior glide of the humeral head on the
glenooid cavity
shoulder internal/ external rotation with posterior/ anterior glide of the humeral head on the
glenooid cavity
shoulder horizontal abduction/ horizontal adduction with anterior/ posterior glide of the
humeral head on the glenooid cavity
DOF = 3
neutral position: anatomic position
resting position: 70° of shoulder abduction and 30° of flexion (horizontal adduction)
closed packed position: 90° of shoulder abduction and full external rotation

Joints at shoulder complex

Sternoclavicular joint (SC joint)

proximal component: sternum


saddle-shaped sternal manubrium
distal component: clavicle
saddle-shaped medial end of the clavicle
disc between 2 articular surfaces
joint type: saddle joint
motion: shoulder girdle motion
clavicle elevation/ depression
clavicle protraction/ depression
clavicle posterior rotation
DOF = 3

NOTE: clavicle
convex forward medially and concave forward laterally
quadripedal animals do not have clavicles
isokinetic strength of shoulder flexor and abductor decreases 50% if the clavicle is removed

Joints at shoulder complex

Acromioclavicular joint (AC joint)


proximal component: convex lateral
end of the clavicle
distal component: concave
acromion process of the scapula
joint type: nearly plane joint
motion: shoulder girdle motion
scapular winging: medial
border of the scapula moves
backwards
scapular tipping: inferior
angle of the scapula moves
backwards
scapular upward/downward
rotation: inferior angle of the
scapula rotates
upwards/downwards
DOF = 3

Joints at shoulder complex

Scapulothoracic articulation (ST articulation)

proximal component: convex rib cage


distal component: concave anterior surface of the scapula
NOTE: an articulation between bone and muscle; not a synovial joint
motion: shoulder girdle motion; convex on concave
scapular elevation/ depression: whole scapula moves upwards/ downwards
scapular abduction/ adduction: medial border of the scapula moves away from/ toward the
spine
scapular upward/downward rotation: inferior angle of the scapula rotates
upwards/downwards
DOF = 3
functions of the scapulothoracic articulation
to provide movement base for the humerus
to maintain length-tension relationship for the deltoid muscle to function above 90º of arm
elevation
to provide stability of the GH joint working overhead
to absorb the shock for forces applied to the outstretched arm
to permit push-up during crutch walking

Joints at shoulder complex

Suprahumeral articulation
synonym: subacromial joint
coracoacromial arch: composed of the coracoacromial
ligament
spraspinatus tendon passing underneath this arch
not for joint stability
shoulder impingement occurs if the subacromial space is
insufficient
insufficient inferior glide of the humeral head
during arm elevation
insufficient external rotation of the humerus during
arm elevation
inflammation of the tendon of the supraspinatus
hypertrophy of the tendon of the supraspinatus
subacromial (subdeltoid) bursa

Joints at shoulder complex

Bicipital groove

groove between greater and lesser tuberosities of the humerus covered with the transverse humeral
ligament
passing tendon of long head of biceps brachii
intra-articular but extra-synovial

Joints at shoulder complex

Plane of scapula

the plane at the angle of 30º anterior


to the frontal plane
not parallel to the frontal
plane
capsules in the loose-packed position
no impingement in the
suprahumeral joint if shoulder motions
occurs in the plane of scapula

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Kinematics of the Shoulder Complex

Shoulder flexion and extension

joint involved
glenohumeral joint (principal joint)
sternoclavicular joint
acromioclavicular joint
scapulothoracic articulation
plane of motion: sagittal plane
axis of rotation: transverse axis through the center of the humeral head
osteokinematic movements
range of motion (ROM)
glenohumeral joint: 0-90º for shoulder flexion and 0-45º or 60º for shoulder
extension
closed kinematic chain motions
pull-up (引體向上)
push-up (伏地挺身)
rowing
upper extremity cycling on an ergometer
arthrokinematic movements
posterolateral glide of the humeral head on the glenoid cavity with shoulder flexion
anteromedial glide of the humeral head on the glenoid cavity with shoulder extension
factors limiting shoulder flexion
inferior glenohumeral ligament (most important)
tightness of the posterior joint capsule
factors limiting shoulder extension
superior and middle glenohumeral ligament (most important)

Shoulder abduction and adduction

arm elevation = shoulder abduction or flexion


joint involved
glenohumeral joint (principal joint)
sternoclavicular joint
acromioclavicular joint
scapulothoracic articulation
plane of motion: frontal plane
axis of rotation
GH joint: sagittal axis through the center of the humeral head
SC joint: sagittal axis through the center of the medial end of the clavicle
osteokinematic movements
range of motion (ROM)
total range:0-165 or 175º
glenohumeral joint:0-120º of shoulder abduction
0-60º with full internal rotation of humerus
0-90º with full external rotation of humerus
sternoclavicular joint:0-30 or 45º
most occurring in 1st 90º of arm elevation
scapulohumeral rhythm
Inman et al. (1944)
GH: ST = 2:1 after 30º of abduction
measured frontal plane motion
Bagg and Forrest (1988)
GH: at the beginning and the end
ST: 80-140 º of abduction
averaged ratio: 1.25:1
measured plane of scapula motion
Codman's paradox: conjunct rotation occurs during sequential motion
standing with dependent arm position with the palm of the hand facing medially and
the thumb facing anteriorly → shoulder flexion of 180º → shoulder adduciton of 180º →
the thumb faces posteriorly
arthrokinematic movements
shoulder abduction
inferior glide of the humeral head on the glenoid cavity
inferior glide of the clavicle on the sternum in most people
factors limiting shoulder abduction
inferior glenohumeral ligament (most important)
tightness of the inferior joint capsule of the glenoumeral joint
tightness of the costoclavicular and interclavicular ligaments and the subclavicius muscles
at the SC joint
factors limiting shoulder adduction
trunk

Shoulder internal/ external rotation

joint involved
glenohumeral joint (principal joint)
sternoclavicular joint
acromioclavicular joint
scapulothoracic articulation
plane of motion: transverse plane
axis of rotation: vertical axis through the center of the humeral head
osteokinematic movements
range of motion (ROM)
shoulder internal rotation: 0-70º as the arm at 90º of shoulder abduction and 90º
elbow flexion
shoulder external rotation: 0-90º as the arm at 90º of shoulder abduction and 90º
elbow flexion
Note: If the elbow is extended, shoulder rotation occurs simultaneously with
forearm rotation.
arthrokinematic movements
posterolateral glide of the humeral head on the glenoid cavity with shoulder internal
rotation
anteromedial glide of the humeral head on the glenoid cavity with shoulder external
rotation

factors limiting shoulder internal rotation


posterior capsule
factors limiting shoulder external rotation
coracohumeral ligament
3 glenohumeral ligaments
 

Shoulder horizontal abduction/ horizontal adduction

synonym: horizontal extension/ flexion


shoulder flexion/ extension at 90º of shoulder abduction
horizontal abduction: arm moves backward as the arm is at 90º of shoulder abduction
horizontal adduction: arm moves forward as the arm is at 90º of shoulder abduction
joint involved
glenohumeral joint (principal joint)
sternoclavicular joint
acromioclavicular joint
scapulothoracic articulation
plane of motion: transverse plane
axis of rotation: vertical axis through the center of the humeral head
arthrokinematic movements
anteromedial glide of the humeral head on the glenoid cavity with shoulder horizontal
abduction
posterolateral glide of the humeral head on the glenoid cavity with shoulder horizontal
adduction

Frontal plane motions at shoulder girdle

shoulder girdle elevation


definition: ST joint elevation associated with SC
elevation and AC tipping
joint involved
scapulothoracic articulation
sternoclavicular joint
acromioclavicular joint

arthrokinematic movement
elevation of the scapula on the rib cage
inferior glide of the clavicle on the sternum in most people
limited by the costoclavicular and interclavicular ligaments and the subclavicius muscle
shoulder girdle depression
important for crutch walking
definition: ST joint depression associated with SC depression
joint involved
scapulothoracic articulation
sternoclavicular joint
acromioclavicular joint
range: 10-15 cm from maximum scapular elevated position
arthrokinematic movements
depression of the capula on the rib cage
superior glide of the clavicle in most people
limited by first rib

Transverse plane motions at shoulder girdle


protraction
definition: ST joint abduction
associated with SC protraction
joint involved
scapulothoracic articulation
sternoclavicular joint
axis of rotation: vertical axis passing
through the center of the medial head of the
clavicle
range
0-15º
abduction of scapula:13-15 cm
arthrokinematic movements
abduction of the scapula
protraction of the clavicle
limited by posterior sternoclavicular and costoclavicular ligaments
retraction
definition: ST joint adduction
associated with SC retraction
joint involved
scapulothoracic articulation
sternoclavicular joint
axis of rotation: vertical axis passing
through the center of the medial head of the
clavicle
range:0-15º
arthrokinematic movements
adduction of scapula
retraction of clavicle
limited by anterior sternoclavicular
ligament
total range: 25º totally

Circumduction motions at the SC joint

A combination of elevation, protraction, depression, and retraction or in the reversed sequence


SC joint as the pivot
tip of shoulder (acromion process of the scapula) moves in a circle path

Scapulothoracic Rotation
upward rotation
definition: glenoid fossa facing upwards with
inferior angle of scapula sliding laterally and anteriorly
osteokinematic movements
fisrt 30º: elevation of the clavicle through
the axis at the base of the spine of scapula
last 30º: posterior rotation of the clavicle
and scapular rotation around AC joint

downward rotation
definition: glenoid fossa facing downwards with inferior angle of scapula sliding medially
and posteriorly
total range: 60º

Transverse rotation of clavicle

axis of rotation: longitudinal axis of the clavicle


total range: 40º
occurring after 90º of arm elevation due to tightening of the coracoclavicular ligament
arm elevation limited to 110º if this posterior rotation is not taken place

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Muscles at the Shoulder Complex

The muscle at the shoulder complex act together as a team to produce highly coordinated motions.

Muscles for glenohumeral (shoulder) motions

motion prime movers


deltoid, anterior fibers
coracobrachialis
shoulder flexion
biceps brachii, long head
pectoralis major, clavicular head
latissimus dorsi
teres major
shoulder extension
triceps brachii, long head
deltoid, posterior fibers
deltoid
shoulder abduction supraspinatus
biceps brachii, long head
pectoralis major
latissmus dorsi
shoulder adduction teres major
triceps brachii, long head
deltoid, posterior fibers
infraspinatus
shoulder external rotation teres minor
deltoid, posterior fibers
subscapularis
teres major
shoulder internal rotation pectoralis major
latissimus dorsi
deltoid, anterior fibers

Muscles for scapulothoracic (shoulder girdle) motions

motion prime movers motion prime movers


upper trapezius pectoralis minor
levator scapulae lower trapezius
scapular elevation scapular depression
rhomboid major latissmus dorsi
rhomboid minor subclavius
serratus anterior trapezius
scapular protraction pectoralis major scapular retraction rhomboid major
pectoralis minor rhomboid minor
levator scapula
trapezius
scapular upward rotation scapular downward rotation rhomboid major
serratus anterior
rhomboid minor

Serratus anterior

saw muscle
origin: rib 1-9
insertion: medial border of the
scapula
motion: protraction + upward
rotation
winging scapula if paralyzed
displacement of medial
border of the scapula

Rotator cuff muscle


supraspinatus
infraspinatus
teres minor
subscpularis

Pectoralis minor

origin: rib 2-5


insertion: coracoid process of the scapula
depression + downward rotation
agonists
depressors
downward rotators
 
antagonists:
elevation + upward rotation
stablizers
neutralizers
for pure depression motion:
for pure downward rotation motion:

Important coupled muscles

levator scapula
latissimus dorsi
pectoralis major
trapezius: upper, middle, and lower
rhomboid major and minor

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Shoulder Complex Stability

Factors affecting stability of the glenohumeral joint: primarily dependent on muscles and ligaments

bony configuration
5º of superior inclination (upward tilt) of the glenoid cavity
shape of cartilage
deepened glenoid labrum
tension of ligaments
superior glenohumeral ligament
middle glenohumeral ligament
inferior glenohumeral ligament
coracohumeral ligament
muscular arrangement: rotator cuff
supraspinatus
infraspinatus
teres minor
subscapularis
capsule

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Mechanism of Injury at the Shoulder

Direct stress

direct stress  acromioclavicular (AC) joint separation


anterior stress  anteroinferior dislocation of the humeral head

Repeated stresses

repeated shoulder rotation motions as the shoulder is placed at 90º of abduction  repeated tensile
stress on rotator cuff  rotator cuff tendinitis

Muscle paralysis

repeated shoulder rotation motions as the shoulder is placed at 90º of abduction  repeated tensile
stress on rotator cuff  rotator cuff tendinitis