SHOULDER

COMPLEX
ROEL B. DEL ROSARIO, PTRP
Instructor KINESIOLOGY

THE SHOULDER COMPLEX:

composed of;
1.Humerus
2.Scapula
3.Clavicle
with 3 joints linking the UE to the thorax
1.GH joint: ball and socket jt
2.Sternoclavicular joint: plane synovial jt
3.AC joint: plane jt

STERNOCLAVICULAR JOINT:
serves as the only structural attachment of
the clavicle, scapula, and upper extremity to
the axial skeleton/thorax.
enables the humerus to move through
a full 180 of abduction
type of jt: plane synovial jt.
medial end of the clavicle:
convex in a sup./inf. direction
and concave anterior and posterior (saddle)

articulates with the reciprocal shape of the

sternum in a fibrocartilaginous jt.
3 degrees freedom of motion
has a synovial capsule: thickens anteriorly than
posteriorly
deepens by the articular disk or meniscus
preventing medial displacement
3 major ligaments
1. ant. & post. SC ligament
2. interclavicular ligament
3. costoclavicular ligament

The sternal end of the clavicle and the

manubrium are incongruent;
there is little contact between their articular
surfaces.
The superior portion of the medial clavicle
does not contact the manubrium at all;
instead it serves as the attachment for the
SC joint disk and the interclavicular ligament.

motions allowed by SC jt:

1. elevation
2. depression
3. protraction
4. retraction
5. ant./post. rotation
ROTATION OF THE CLAVICLE:
occurs as an accessory motion when
the humerus is elevated above
horizontal
SCAPULA: upwardly rotates
it cannot occur as an isolated voluntarily

SC jt:
Resting position: arm rest by the side in the
normal standing position
Closed pack position: full or maximum
rotation of the clavicle
Capsular pattern: pain at the extreme ROM

THE STERNOCLAVICULAR DISK:

ARTICULAR DISK:
function: increases congruence between
joint
surfaces.; also a shock-absorber
The upper portion of the SC disk is attached
to the posterosuperior clavicle.
The lower portion is attached to the
manubrium and first costal cartilage, as well
as to the anterior and posterior aspects to the
fibrous capsule.

The disk diagonally transects the SC joint

space and divides the joint into two separate

Given its attachments, the disk acts like a

hinge or pivot point during clavicle motion.
In elevation and depression of the clavicle:
the medial end of the clavicle rolls and
slides on the relatively stationary disk, with
the upper attachment of the disk serving as a
pivot point.

In protraction/retraction of the clavicle:

the SC disk and medial clavicle roll and
slide together on the manubrial facet, with
the
lower attachment of the disk serving as a
pivot point.
The disk is considered part of the manubrium
in elevation/depression and part of the
clavicle in protraction/ retraction.

The SC disk serves an important stability

function by increasing joint congruence and
absorbing forces that may be transmitted
along the clavicle from its lateral end.
Large forces through the clavicle often cause
Fx of the bone before the SC jt dislocates.

it can be seen that the unique diagonal

attachment of the SC disk will check medial
movement of the clavicle that might
otherwise cause the large medial articular
surface of the clavicle to override the shallow
manubrial facet.

The disk also has substantial contact with

the medial clavicle, permitting the disk to
dissipate the medially directed forces that
would otherwise cause high pressure at the
small manubrial facet.

3 COMPARTMENT OF SC JT:
1. LATERAL COMPARTMENT:
a lateral compartment between the disk and
clavicle for elevation and depression
2. MEDIAL COMPARTMENT:
a medial compartment between the disk
and manubrium for protraction and retraction;

3. COSTOCLAVICULAR JT:
a costoclavicular joint for anterior and
posterior long axis rotation.
Anterior and posterior rotation are thought to
occur between a portion of the disk over the
first rib and a conus on the antero-inferior
edge of the articular surface of the medial
clavicle.

SC JT CAPSULE AND LIGAMENTS:

3 LIGAMENTS OF SC JT:
1. SC Ligament (ant and post.):
reinforce the capsule and function primarily to
check anterior and posterior translatory
movement of the medial end of the clavicle.

2. Costoclavicular ligament:
a very strong ligament found between the
clavicle and the first rib.
helps limit and stabilize the elevated position
of the clavicle
has two segments or laminae.
1. ANTERIOR LAMINA:
has fibers directed laterally from the first
rib to the clavicle,
2. POSTERIOR LAMINA:
the fibers are directed medially from
the rib to the clavicle.

Both ant & post lamina:

segments check elevation of the lateral
end of the clavicle
and when the limits of the ligament are
reached, may contribute to the inferior gliding
of the medial clavicle that occurs with
clavicular elevation.

The costoclavicular ligament is also

positioned to counter the superiorly directed
forces applied to the clavicle by the
sternocleidomastoid and sternohyoid
muscles.
The medially directed fibers of the posterior
lamina will resist medial movement of the
clavicle, absorbing some of the force that
would otherwise be imposed on the SC disk.

3. Interclavicular ligament:
resists excessive depression of the distal
clavicle and superior glide of the medial end
of the clavicle.
The limitation to clavicular depression is
critical to protecting structures such as the
brachial plexus and subclavian artery that
pass under the clavicle and over the first
rib.

In fact, when the clavicle is depressed and

the interclavicular ligament and superior
capsule are taut, the tension in the
interclavicular ligament can support the
weight of the upper extremity.

SC MOTIONS:
has 3 degrees freedom of motion
1.Elevation/depression
2.Protraction/retraction
3.Ant and posterior clavicular rotation

STERNOCLAVICULAR MOTIONS:

ELEVATION/DEPRESSION OF THE
CLAVICLE:
occurs on an antero-posterior axis
between a convex clavicular surface and a
concave surface formed by the manubrium
and the first costal cartilage.
With elevation, the lateral clavicle rotates
upward, and with depression, the lateral
clavicle rotates downward.

The cephalocaudal shape of the articular

surfaces and the location of the axis indicate
that the convex surface of the clavicle must
slide inferiorly on the concave manubrium
and first costal cartilage, in a direction
opposite to movement of the lateral end of
the clavicle.
normal clavicular elevation: 0-48 degrees
normal passive depression: <15 degrees

CLAVICULAR PROTRACTION AND

RETRACTION:
occurs in a superioinferior axis/vertical axis
With PROTRACTION: the lateral clavicle
rotates anteriorly
RETRACTION: the lateral clavicle rotates
posteriorly
the medial end of the clavicle is concave, and
the manubrial side of the joint is convex.

During protraction, the medial clavicle is

expected to slide anteriorly on the manubrium
and first costal cartilage
normal protraction: 15-20 degrees
normal retraction: 20-30 degrees

ANTERIOR/POSTERIOR CLAVICULAR
ROTATION:
or long axis rotation
occurs as a spin between the saddle-shaped
surfaces of the medial clavicle and
manubriocostal facet.
the clavicle rotates primarily in only one
direction from its resting position.
The clavicle rotates posteriorly from neutral,
bringing the inferior surface of the clavicle to
face anteriorly.

This has also been referred to as backward

or
upward rotation rather than posterior
rotation.
From its fully rotated position, the clavicle can
rotate anteriorly again to return to neutral.
Available anterior rotation past neutral is very
limited, generally described as less than 10
degrees.
normal clavicular rotation: as much as 50

The axis of rotation runs longitudinally

through the clavicle, intersecting the SC and
AC joints.

STERNOCLAVICULAR STRESS
TOLERANCE:
serves its purposes of joining the upper limb
to the axial skeleton, contributing to upper
limb mobility, and withstanding imposed
stresses.
the SC joint is considered incongruent, the
joint does not undergo the degree of
degenerative change common to the other
joints of the shoulder complex.

Strong force-dissipating structures

such as the SC disk and the costoclavicular
ligament minimize articular stresses and also
prevent excessive intra-articular motion that
might lead to subluxation or dislocation.
Dislocations of the SC joint represent
only 1% of joint dislocations in the body.

2. ACROMIOCLAVICULAR JOINT (AC joint):

A. Characteristic:
Attaches the scapula to the clavicle
Type of joint: plane joint /gliding
3 degrees of freedom of motion
Resting position: arm rest by the side
in the normal standing position
Closed pack position: arm is abducted 90 deg
Capsular pattern: pain at the extreme ROM
AC jt. may or may not have articular disk
reinforced by sup. and inf. AC lig. and
coracoclavicular ligament (CC lig.)

lat. end of the clavicle: convex

acromion: concave
D. Function of AC jt:
to allow the scapula additional range
of rotation on the thorax and allow for
adjustments of the scapula (tipping and
internal/external rotation) outside the
initial plane of the scapula in order to
follow the changing shape of the thorax
as arm movement occurs.

 In addition, the joint allows transmission

of forces from the upper extremity to
the clavicle.
C. Arthrokinematics:
the acromial process slides in the
SAME DIRECTION in which the
scapula moves
D. Stability:
AC ligament & CC ligament
no ms cross this joint for support

AC jt ARTICULATING SURFACE:
between the lateral end of the clavicle and a
small facet on the acromion of the scapula

AC jt DISK:
variable in size between individuals, at
various ages within an individual, and
between sides of the same individual.
Through 2 years of age, the joint is actually a
fibrocartilaginous union.
With use of the upper extremity, a joint space
develops at each articulating surface that
may leave a meniscoid fibrocartilage
remnant within the joint.

ACROMIOCLAVICULAR CAPSULE:
weak and cannot maintain integrity of the
joint
without reinforcement of the superior and
inferior acromioclavicular and the
coracoclavicular ligaments.

ACROMIOCLAVICULAR LIGAMENTS:
1. Sup AC lig.:
assists the capsule in apposing articular
surfaces and in controlling A-P joint stability.
The fibers of the superior AC ligament are
reinforced by aponeurotic fibers of the
trapezius and deltoid muscles, which makes
the superior joint support stronger than the
inferior.

2. CORACOCLAVICULAR LIGAMENT:
divided into;
2.1 TRAPEZOID LIGAMENT:
lat. portion of the CC lig.
quadrilateral in shape & is
nearly horizontal in orientation.
2.2 CONOID LIGAMENT:
medial portion of the CC lig.
is more triangular and
vertically oriented

CONOID LIGAMENT:
provides the primary restraint for the AC joint
in the superior and inferior directions.
TRAPEZOID LIGAMENT:
provides the majority of resistance to
posterior translatory forces applied to the
distal clavicle.
BOTH PORTIONS OF CC LIG.:
limit upward rotation of the scapula at the AC
joint.

When medially directed forces on the

humerus (such as those produced with
leaning on the arm) are transferred to the
glenoid fossa of the scapula, medial
displacement of the scapulas acromion on
the clavicle is prevented by tension in and
the
strength of the coracoclavicular ligament
(especially the horizontal trapezoid portion)
that transfer the force to the clavicle, and
then on to the very strong SC joint

ACROMIOCLAVICULAR MOTIONS:
1. Internal/External Rotation
occurs on a vertical axis
2. Anterior/Posterior Tipping or Tilting
occurs on oblique coronal axis
3. Upward and Downward Rotation
occurs in an oblique A-P axis

1. INTERNAL/EXTERNAL ROTATION AC JT:

occur to maintain contact of the scapula with
the horizontal curvature of the thorax as the
clavicle protracts and retracts, sliding the
scapula around the thorax in scapular
protraction and retraction, and to aim the
glenoid fossa toward the plane of humeral
elevation

The orientation of the glenoid fossa is

important to maintain congruency with the
humeral head; maximize the function of GH
muscles, capsule, and ligaments; maximize
stability of the GH joint; and maximize
available motion of the arm.
The available range of motion (ROM) at the
AC joint is difficult to measure.
normal AC jt int/ext. rot. value: 30degrees

2. ANTERIOR & POST. TIPPING of the AC JT:

occurs in an oblique coronal axis
ANTERIOR TIPPING:
will result in the acromion tipping forward and
the inferior angle tipping backward

POSTERIOR TIPPING:
will rotate the acromion backward and the
inferior angle forward.

SCAPULAR TIPPING:
occurs to maintain the contact of the scapula
with the contour of the rib cage & orient the
glenoid fossa.
As the scapula moves upward or downward
on the rib cage in elevation or depression,
the scapula must adjust its position to
maintain full contact with the vertical
curvature of the ribs.

Elevation of the scapula:

occurs with shoulder shrug, can result in
anterior tipping.
During normal flexion or abduction of the
arm,
the scapula posteriorly tips on the thorax as
the scapula is upwardly rotating.
normal ant./post. tipping at the SC jt in a
cadaver is 60 degrees

3. UPWARD/DOWNWARD ROTATION:
occurs in an oblique A-P axis
perpendicular to the scapular plane

upward rotation tilts the glenoid fossa upward

downward rotation (vice versa)
The amount of available passive motion into
upward/downward rotation specifically at
the AC joint is limited by the attachment of
the coracoclavicular ligament.
In order for upward rotation to occur at the
AC joint, the coracoid process and superior
border of the scapula need to move inferiorly

normal value for upward/downward rot is 30

degrees passively
normal value for upward rotation is 30
degrees actively (CONWAY)
normal value for downward rotation is 17
degrees actively (CONWAY)

AC JT. STRESS TOLERANCE:

susceptible to trauma and degenerative
changes
due to its small and incongruent surfaces
that result in large forces per unit area.
Degenerative change is common from the
second decade on, with the joint space itself
commonly narrowed by the sixth decade.

SCAPULOTHORACIC JOINT:
a.k.a. scapulocostal joint
formed by the articulation of the
scapula with the thorax.
NOT a true joint
because it has none of the usual joint
characteristics (union by fibrous,
cartilaginous, or synovial tissues).
functions as an integral part of the
shoulder
NO capsular pattern or closed pack
position

The SC and AC jts are interdependent

with the ST joint
Any movement of the scapula on the
thorax must result in movement at either
the AC joint, the SC joint, or both
that is, the functional ST joint is part of
a
true closed chain with the AC and
SC joints and the thorax.

Observation and measurement of

individual SC and AC joint motions are
more difficult than observing or
measuring motions of the scapula on
the thorax.

RESTING POSITION OF THE SCAPULA:

rest on the post thorax; 2 from the
midline; between 2nd -7th ribs
The scapula also is;
internally rotated 30 to 45 from the
coronal plane; is tipped anteriorly
approximately 10 to 20 from vertical
and is upwardly rotated 10 to 20 from
vertical.

The magnitude of upward rotation has

as its reference a longitudinal axis
perpendicular to the axis running from
the root of the scapular spine to the AC
joint

MOTIONS OF THE SCAPULA AT THE SC JT:

1. upward/downward rotation
are called primary scapular motions
2. int./ext. rot.
secondary scapular motions
3. ant. tipping/post. tipping
secondary scapular motions
Of these three AC joint rotations, only
upward/downward rotation is readily
observable at the ST jt

MOTIONS OF THE SCAPULA:

1. UPWARD/DOWNWARD ROTATION:
is the principal motion of the scapula
observed during active elevation of the arm
and plays a significant role in increasing the
range of elevation of the arm overhead.
Most often, scapular upward/downward
rotation results from a combination of these
SC and AC motions.

2. ELEVATION & DEPRESSION OF THE

SCAPULA:
can be isolated (relatively speaking) by
shrugging the shoulder up and depressing
the shoulder downward.
described as translatory motions in which the
scapula moves upward (cephalad) or
downward (caudally) along the rib cage from
its resting position.

 Scapular elevation, however, occurs through

elevation of the clavicle at the SC joint and
requires subtle adjustments in
anterior/posterior tipping and
internal/external rotation at the AC joint to
maintain the scapula in contact with the
thorax.

3. PROTRACTION & RETRACTION:

described as translatory motions of the
scapula away from or toward the vertebral
column.
if protraction of the ST joint occurred as a
pure translatory movement, the scapula
would move directly away from the vertebral
column, and the glenoid fossa would face
laterally.
Only the vertebral border of the scapula
would remain in contact with the rib cage.

 In reality, full scapular protraction results in

the glenoid fossa facing anteriorly with the
full scapula in contact with the rib cage. The
scapula follows the contour of the ribs by
rotating internally and externally at the AC
joint in combination with clavicular
protraction and retraction at the SC joint

4. INTERNAL/EXTERNAL ROTATION:
should normally accompany protraction/
retraction of the clavicle at the SC joint.
Internal rotation of the scapula on the thorax
that is isolated to (or occurs excessively at)
the AC joint results in prominence of the
vertebral border of the scapula as a result
of loss of contact with the thorax.
often referred to clinically as scapular
winging

 Excessive internal rotation may be indicative

of pathology or poor neuromuscular control
of the ST muscles.

5. ANTERIOR/POSTERIOR TIPPING:
is critical to maintaining contact of the
scapula against the curvature of the rib
cage.
occurs at the AC joint and normally will
accompany anterior/posterior rotation of the
clavicle at the SC joint.
Anterior tipping that is isolated to or occurs
excessively at the AC joint will result in
prominence of the inferior angle of the
scapula

may occur in pathologic situations

(poor neuromuscular control) or in abnormal
posture.

SCAPULOTHORACIC STABILITY:
is provided by the structures that maintain
integrity of the linked AC and SC joints.
The muscles that attach to both the thorax
and scapula maintain contact between these
surfaces while producing the movements of
the scapula.
stabilization is provided through the ST
musculature by pulling or compressing the
scapula to the thorax.

THE GLENOHUMERAL JT:

ball and socket joint
3 degrees freedom of motion
a capsule and several associated ligaments
and bursae.
Resting position: GH is 55 shoulder
abduction & 30 horizontal adduction
Closed pack position: full abd and ext. rot.
Glenoid labrum: deepens the fossa for
greater congruency
small portions of the humeral head comes in
contact with the fossa (half of a sphere)

GLENOHUMERAL ARTICULATING SURFACE:

Glenoid fossa: faces anteriorly; laterally &
upward
the HUMERAL head faces medially,
superiorly, and posteriorly with regard to the
shaft of the humerus and the humeral
condyles.

HUMERAL ANGLE OF INCLINATION:

An axis through the humeral head and neck
in relation to a longitudinal axis through the
shaft of the humerus.
NORMAL: angle of 130 to 150 in the frontal
plane

ANGLE OF TORSION:
In the transverse plane, the axis through the
humeral head and neck in relation to the axis
through the humeral condyles forms an
angle.
approximately 30 posteriorly

RETROVERSION/RETROTERSION:
The normal posterior position of the humeral
head with regard to the humeral condyles

Because of the internally rotated resting

position of the scapula on the thorax,
retroversion of the humeral head increases
congruence of the GH joint by turning
the humeral head back toward the glenoid
fossa of the scapula

HUMERAL ANTEVERSION:
results in a more anterior position of the
humeral head on the glenoid surface when
the arm is in an anatomically neutral position

Humeral Anteversion:
can result in an increased range of medial
rotation of the humerus and a reduced range
of external rotation that places the humeral
head at risk for anterior subluxation at the
end range.

HUMERAL RETROVERSION:
Increased retroversion results in a more
posterior position of the humeral head on the
glenoid surface when the arm is in an
anatomically neutral position
can result in increased range of external
rotation of the humerus and a reduced range
of medial rotation that puts the humeral head
at risk for posterior subluxation at end range.

Increased GH external rotation and

decreased GH medial rotation have been
demonstrated in the dominant arm of throwing
athletes, and evidence suggests that an
increase in humeral retroversion may be one
contributing mechanism for this ROM
adaptation.

GLENOID LABRUM:
is attached to the periphery of the glenoid
fossa , enhancing the depth or curvature
of the fossa by approximately 50%.

sup labrum is loosely attached and the inf

labrum is firmly attached and relatively
immobile.
The glenoid labrum also serves as the
attachment site for the glenohumeral
ligaments and the tendon of the long head of
the biceps brachii.

GLENOHUMERAL CAPSULE
is taut superiorly and slack anteriorly and
inferiorly in the resting position (arm
dependent at the side)
More than 2.5 cm of distraction of the head
from the glenoid fossa is allowed in the
loose-packed position.
The relative laxity of the GH capsule is
necessary for the large excursion of joint
surfaces but provides little stability without
the reinforcement of ligaments and muscles.

When the humerus is abducted and laterally

rotated on the glenoid fossa, the capsule
twists on itself and tightens, making
abduction and lateral rotation the closepacked position for the GH joint.
The capsule is reinforced by the;
1. superior GH lig.
2. middle GH lig.
3. inf. GH lig.
4. coracohumeral ligament

FORAMEN OF WEITBRECHT:
a thin area of capsule between the superior
and the middle GH ligaments is a particular
point of weakness in the capsule.
the capsule is reinforced anteriorly by the
subscapularis tendon
the foramen of Weitbrecht is a common site
of extrusion of the humeral head with anterior
dislocation of the joint.

GLENOHUMERAL LIGAMENT:
vary considerably in size and extent and may
change with age.
shows the three ligaments as they appear on
the interior surface of the joint capsule.

A. SUPERIOR GH ligament:
passes from the superior glenoid labrum to
the upper neck of the humerus deep to the
coracohumeral ligament.
the superior capsule, and the coracohumeral
ligament as interconnected structures that
bridge the space between the supraspinatus
and subscapularis muscle tendons, forming
as the rotator interval capsule

A. SUPERIOR GH ligament:
contribute most to anterior and inferior
stability by limiting anterior and inferior
translations of the humeral head when the
arm is at the side (0 abduction).

B. MIDDLE GH LIGAMENT:
runs obliquely from the superior anterior
labrum to the anterior aspect of the
proximal humerus below the superior GH
ligament attachment
found to be absent in up to 30% of subjects in
several anatomic studies.

B. MIDDLE GH LIGAMENT:
contributes primarily to anterior stability by
limiting anterior humeral translation with the
arm at the side and up to 45 of abduction

C. INF GH LIGAMENT COMPLEX/IGHLC:

With abduction beyond 45 or with combined
abduction and rotation, it plays a major role
of stabilization.
has 3 bands
1. Anterior band:
2. Posterior band
3. Axillary pouch

AXILLARY POUCH (IGHLC):

With abduction, the axillary redundancy or
slack is taken up, and the IGHLC resists
inferior humeral head translations.
ANTERIOR BAND (IGHLC):
fans out to provide anterior stability and
resistance to anterior humeral translation.

POSTERIOR BAND (IGHLC):

With humeral abduction and medial rotation,
the posterior band of the IGHLC fans out and
provides posterior stability and resistance to
posterior humeral translation

Note:
In all positions of humeral abduction, the
capsule and GH ligaments tighten with
rotation of the humerus, producing tension
and consequently increasing GH stabilization

3. CORACOHUMERAL LIGAMENT:
reported as resisting humeral external
rotation with the arm adducted
HAS 2 BANDS:
3.1 FIRST BAND:
inserts into the edge of the supraspinatus
and onto the greater tubercle,

3.2 SECOND BAND:

inserts into the subscapularis and lesser
tubercle.
The two bands form a tunnel through which
the tendon of the long head of the biceps
brachii passes.
The location and interconnections of the
ligament imply a fairly complex function.
As part of the rotator interval capsule, it
appears to be most important in limiting
inferior translation of the humeral head in the
dependent arm.

CORACOACROMIAL ARCH OR
SUPRAHUMERAL ARCH:
formed by the coracoid process, the
acromion, and the coracoacromial ligament
& the inferior surface of the AC joint
It forms an osteoligamentous vault that
covers the humeral head and forms a space
within which the subacromial bursa, the
rotator cuff tendons, and a portion of the
tendon of the long head of the biceps brachii
lie.

FUNCTIONS: arch protects the structures

beneath it from direct trauma from above.
trauma is common and can occur through
such simple daily tasks as carrying a heavy
bag over the shoulder.
also prevents the head of the humerus from
dislocating superiorly, because an unopposed
upward translatory force on the humerus
would cause the head of the humerus to hit
the coracoacromial arch.

the contact of the humeral head with the

undersurface of the arch (while beneficially
preventing dislocation) can simultaneously
cause painful impingement or mechanical
abrasion of the structures lying in the
subacromial space.
The supraspinatus is particularly vulnerable
because of its passage beneath all of the
potentially impinging superior structures
except the coracoid

SUPRAHUMERAL SPACE/SUPRASPINATUS
OUTLET:
The subacromial space, or area between the
humeral head and coracoacromial arch.
Radiographically, this space has been
quantified by measuring a superior-to-inferior
acromiohumeral interval.
This interval averages 10 mm in healthy
subjects with the arm adducted at the side.
During elevation of the arm, this space

When the subacromial space is narrowed,

the likelihood of impingement of the rotator
cuff tendons and subacromial bursa during
elevation of the arm increases.
Narrowing of the space can be caused by
anatomic factors such as changes in the
shape of the acromion inferiorly, changes in
the slope of the acromion, acromial bone
spurs, AC joint osteophytes, a large
coracoacromial ligament, or a size mismatch
between the humeral head and area beneath
the coracoacromial arch

Abnormal scapular or humeral motions can

also functionally reduce the size of the
suprahumeral space.
Inadequate posterior tipping or upward
rotation of the scapula during arm elevation
or abnormal superior or anterior translation of
the humeral head on the glenoid fossa brings
the humeral head and rotator cuff tendons in
closer proximity to the humerus and
increases the risk of impingement.

Inflammation, fibrosis and thickening of the

soft tissues can occur with repetitive
impingement, further reducing the available
subacromial space for clearance of the soft
tissues during arm elevation.

SUBACROMIAL & SUBDELTOID BURSAE:

These bursae separate the supraspinatus
tendon and head of the humerus from the
acromion, coracoid process, coracoacromial
ligament, and deltoid muscle.
The bursae may be separate but are
commonly continuous with each other.
Collectively, the two are known as the
subacromial bursa.

SUBACROMIAL BURSAE:
permits smooth gliding between the humerus
and supraspinatus tendon and surrounding
structures.
Interruption or failure of this gliding
mechanism is a common cause of pain and
limitation of GH motion, although it rarely
occurs as a primary problem.

The inferior wall of the subacromial bursa is

also the superior portion of the supraspinatus
tendon sheath.
Subacromial bursitis is most commonly
secondary to inflammation or degeneration
of the supraspinatus tendon.
It is important to identify that, in the absence
of inflammation, the bursa are merely layers
of synovial tissue in contact with each
other with a very thin layer of fluid between.

When inflamed, the space occupied by the

bursa increases.
With an intact rotator cuff, the subacromial
bursa does not communicate with the GH
joint
space.

GLENOHUMERAL MOTIONS:
3 degrees freedom of motion
1. Flexion/extension:
sagittal plane
occurs on a medial/lat axis or coronal axis
2. Abduction/adduction
frontal plane
occurs on a antero-posterior axis
3. Internal/external rotation
transverse plane
vertical axis/longitudinal axis

SCAPULOHUMERAL RHYTHM:
is the 2:1 ratio of movement of the GH jt with
the scapulothoracic jt.
during 180 abduction, there is 2:1 ratio
between the GH jt and the scapulothoracic jt;
with 120 degrees in the GH jt and 60 degrees
in the ST jt.

A. Setting phase:
1st phase of 30 of movement
the outer end of the clavicle elevates
12 to 15; while the scapula is said to
be setting.
setting phase: means that the scapula
may rotate in, rotate out, or not move
at all

B. 2nd phase: (during the next 60 of elevation)

the clavicle will elevate 30 to 36 &
there will be a 2:1 ratio of
scapulohumeral movement
no rotation of the clavicle at this stage
C. 3RD phase: (final 90 of motion)
continuation of 2:1 ratio
angle between the scapular spine and
the clavicle increases an additional 10
the clavicle will elevate 30 to 60
clavicle will rotate posteriorly 50 on a
long axis

the humerus laterally rotates 90 so

that the greater tuberosity of the
humerus avoids the acromion process

REQUIREMENTS OF FULL ELEVATION:

1.Scapular stabilization
2.Inferior glide of humerus
3.External rotation of humerus
4.Clavicular rotation at the SC jt
5.Scapular abduction and lateral rotation of AC
jt
6.Straightening of thoracic kyphosis

REVERSE SCAPULOHUMERAL RHYTHM:

means that the scapula moves more
than the humerus
seen in frozen shoulder
A. UPWARD ROTATION of the scapula:
done by upper and lower trapezius &
serratus anterior

CLAVICULAR ELEVATION & ROTATION

WITH HUMERAL ROTATION:
upward rotation of the scapula, 30 of
elevation of the clavicle
occurs at the SC jt.
as the coracoclavicular ligament
becomes taut, the clavicle rotates 38 to
50 about its longitudinal axis, which
elevates its acromial end
scapula then rotates an additional 30
at the SC jt.

EXTERNAL ROTATION OF THE HUMERUS

WITH FULL ELEVATION THROUGH
ABDUCTION:
weak or inadequate external rotation
will result in impingement of the soft
tissue in the suprahumeral space,
causing pain, inflammation & loss of
function.

INTERNAL ROTATION OF THE HUMERUS

WITH FULL ELEVATION THROUGH
FLEXION:
most of the shoulder flexor ms are also
medial rotators of the humerus
infraspinatus & teres minor stabilize
the humeral head against the inward
rotating forces
weakness in these ms may contribute
to excessive anterior translation &
instability

ELEVATION OF THE HUMERUS

THROUGH THE PLANE OF THE
SCAPULA:
30 anterior to the frontal plane
called SCAPTION
NEITHER int. or ext. rot. of the
humerus is necessary to prevent
greater tubercle impingement in
elevation through scaption.

DELTOID-SHORT ROTATOR CUFF &

SUPRASPINATUS MECHANISM:
force of the deltoid causes upward
translation of the humerus
if unopposed = (+)impingement of soft
tissues
combined effect of the short rotator cuff
ms (infra, teres minor & subscapularis)
causes a stabilizing compression &
downward translation of the humerus
deltoid & short rotators: = > abduction

supraspinatus leads to abduction of the

arm
(+) interruption of function => fatigue or
poor coordination leads to microtrauma
=> shoulder dysfunction

SC & AC JT CONTRIBUTIONS:
Elevation of the arm in any plane involves
motion of the SC and AC joints to produce
ST joint motion.
The initial ST upward rotation as the arm is
flexed or abducted appears to be caused by
clavicular elevation at the SC joint.
As elevation of the arm progresses, the ST
axis of rotation gradually shifts laterally,
reaching the AC joint in the final range of
scapular upward rotation.

This major shift in the axis of rotation

happens because the ST joint motion can
occur only through a combination of motions
at the SC and AC joints.
When the axis of scapular upward rotation
is near the root of the scapular spine, ST
motion is primarily a function of SC joint
motion;
when the axis of scapular upward rotation is
at the AC joint, AC joint motions
predominate;

when the axis of scapular upward rotation is

in an intermediate position, both the SC and
AC joints are contributing to ST motion.

UPWARD ROTATORS OF THE SCAPULA:

produced by a balance of the forces between
the trapezius and serratus anterior muscles
through their attachments on the clavicle and
the scapula

SCAPULAR WINGING:
paralysis of the serratus anterior muscle
The scapular winging is internal rotation of
the scapula, produced by the remaining
muscles without the stabilizing external
rotation influence of the serratus.
The serratus anterior muscle also has a large
MA to produce posterior tipping of the
scapula.

The trapezius may have some ability to

contribute to tipping or internal/external
rotation torques in some positions of the arm.

DELTOID MS FUNCTION:
Anterior fiber:
is the prime mover for flexion
can assist with abduction after 15 of GH
motion.
During abduction in the plane of the scapula,
the anterior and middle deltoid segments are
optimally aligned to produce elevation of the
humerus.

Posterior deltoid:
it serves primarily as a joint compressor and
in functions such as horizontal abduction.
DELTOID:
deltoid has a peak ms activity at 90 degrees
shoulder abduction
has a peak activity in flexion at end range
with complete derangement of the rotator
cuff, a contraction of the deltoid results in a
shrug of the shoulder

If the scapular upward rotators

(trapezius and serratus anterior muscles) are
absent, the middle and posterior fibers of the
activate deltoid (originating on the acromion
and spine of the scapula) will act not on the
heavier arm but on the lighter scapula;
that is, without the stabilizing tension in the
upward rotators, the middle and posterior
deltoid will downwardly rotate the scapula

SUPRASPINATUS MS FUNCTION:
an abductor of the humerus in all
planes of humeral elevation
secondary functions of the supraspinatus
are to compress the GH joint, to act as a
steerer for the humeral head, and to assist
in maintaining the stability of the dependent
arm.

With isolated and complete paralysis of the

supraspinatus muscle, or an isolated
supraspinatus tear, some loss of abduction
force is evident, but most of its functions can
be performed by remaining musculature.

UPPER, LOWER TRAPEZIUS AND

SERRATUS ANTERIOR FUNCTION:
together elevates scapula
support the shoulder girdle against the
downward pull of gravity.
When the trapezius is intact and the serratus
anterior muscle is paralyzed, active
abduction of the arm can occur through its
full range, although it is weakened.

When the trapezius is paralyzed (even

though
the serratus anterior muscle may be intact),
active abduction of the arm is both weakened
and limited in range to 75, with remaining
range occurring exclusively at the GH jt
This active range of abduction is only slightly
better than the range that can be obtained by
the deltoid when neither of the upward
rotators of the scapula are present (60 to
75 degrees)

Without the trapezius (with or without the

serratus anterior muscle), the scapula rests
in a downwardly rotated position as a result
of the unopposed effect of gravity on the
scapula.

If the serratus anterior muscle is intact,

trapezius muscle paralysis results in loss of
force of shoulder flexion, but there is no
range deficit.
If the serratus anterior muscle is paralyzed
(even in the presence of a functioning
trapezius), flexion will be both diminished in
strength and limited in range to 130 or 140 of
flexion.

The role of the serratus anterior muscle in

normal shoulder function being the only
muscle capable of producing simultaneous
scapular upward rotation, posterior tipping,
and external rotation, the three component
motions of the scapula that have been
identified as occurring during elevation of the
arm.

The serratus anterior and trapezius muscles

are prime movers for upward rotation of the
scapula.
These two muscles are also synergists for
the
deltoid during abduction at the GH joint.
The trapezius and serratus anterior muscles,
as upward scapular rotators, prevent the
undesired downward rotatory movement of
the scapula by the middle and posterior

RHOMBOIDS FUNCTION:
are active in elevation of the arm, especially
in abduction.
These muscles serve a critical function as
stabilizing synergists to the muscles that
upwardly rotate the scapula.
If the rhomboids, downward rotators of the
scapula, are active during upward rotation of
the scapula, these muscles must be working
eccentrically to control the change in position
of the scapula produced by the trapezius and
the serratus anterior muscles.

Paralysis of these muscles causes disruption

of the normal scapulohumeral rhythm and
may result in diminished ROM.
Like the lower trapezius, the rhomboid
muscles act primarily to offset the lateral
translation component of the serratus
anterior
muscle.

MUSCLES OF DEPRESSION:
involves the forceful downward movement of
the arm in relation to the trunk.
If the arm is fixed by weight-bearing or by
holding on to an object (e.g., a chinning bar),
shoulder depression will move the trunk
upward in relation to the arm.
In depression activities, the scapula tends to
rotate downward and adduct during the
humeral motion.

LATISSIMUS DORSI & PECTORAL

MINOR/MAJOR FUNCTION:
latissimus dorsi muscle may produce
adduction, extension, or medial rotation of
the humerus.
Through its attachment to both the scapula
and humerus, the latissimus dorsi can also
adduct and depress the scapula and
shoulder complex.

When the hand and/or forearm is fixed in

weight-bearing, the latissimus dorsi muscle
will pull its caudal attachment on the pelvis
toward its cephalad attachment on the
scapula and humerus.
This results in lifting the body up as in a
seated pushup.

When the hands are bearing weight on the

handles of a pair of crutches, a contraction of
the latissimus dorsi will unweight the feet as
the trunk rises beneath the fixed scapula,
allowing the legs to swing forward through
the crutches.

Happiness lies in the

joy of achievement and
the thrill of creative
effort
--- Franklin D. Roosevelt
Thank you
Sir Roel