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 back to top 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 g e l n o h u m e r a l j o i n t s t e r n o c l a v i

c u l a r j o i n t a c r o m i o c l a v i c u l a r j o i n t 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

back to top 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 back to top 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 shoulder flexion prime movers deltoid, anterior fibers coracobrachialis biceps brachii, long head pectoralis major, clavicular head latissimus dorsi teres major triceps brachii, long head deltoid, posterior fibers deltoid supraspinatus biceps brachii, long head pectoralis major latissmus dorsi teres major triceps brachii, long head deltoid, posterior fibers

shoulder extension

shoulder abduction

shoulder adduction

shoulder external rotation

shoulder internal rotation

infraspinatus teres minor deltoid, posterior fibers subscapularis teres major pectoralis major latissimus dorsi deltoid, anterior fibers

  Muscles for scapulothoracic (shoulder girdle) motions motion scapular elevation prime movers upper trapezius levator scapulae rhomboid major rhomboid minor serratus anterior pectoralis major pectoralis minor trapezius serratus anterior motion scapular depression prime movers pectoralis minor lower trapezius latissmus dorsi subclavius trapezius rhomboid major rhomboid minor levator scapula rhomboid major rhomboid minor

scapular protraction

scapular retraction

scapular upward rotation

scapular downward rotation

  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 back to top 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 back to top 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