Professional Documents
Culture Documents
2021
PTR2007 BIOMECHANICS AND
KINESIOLOGY
SHOULDER COMPLEX
PELİN PİŞİRİCİ, PT, M.Sc, PHD
Shoulder
complex
• The shoulder joint can
move and position the
entire upper extremity.
• Supports the weight of
the arm.
• Stabilizes the arm
during fine movements.
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The shoulder COMPLEX consists of sternum, clavicle, costas,
scapula, humerus and the joints formed between them.
OSTEOLOGY
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STERNUM
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CLAVICULA
• The shaft of the clavicle is convex at the medial and concave at the lateral.
• When viewed from the top, the long axis of the clavicle makes an angle of 20° with
the frontal plane.
• The clavicle is articulated with sternum and inferior 1 st costa. It is articulated with
acromion at the lateral level.
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M. Subclavius
• M. Subclavius is the most important muscle that supports the
sternoclavicular joint.
• Prevents dislocation.
SCAPULA
• The scapula is a triangular shaped bone.
• Since the scapula is in a postero‐lateral
position on the thorax, the glenoid fossa
makes an angle of about 35 ° with a frontal
plane.
• This position of the scapula is called a
scapular plane.
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Scapula
• While resting, the medial
margin is almost parallel to
the vertebral column.
• Scapula is on the back side
of the chest and placed
between 2‐7th the costas.
• The scapula makes an angle
of 30‐45° with the frontal
plane.
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Scapula
• The medial margin of 5
scapula is approximately cm!
5 cm further than the
spinous processes of the
thoracic vertebraes.
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• The glenoid fossa is in the
tilt position up to 5°.
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The large and rounded greater
tubercle has an upper, middle, and
lower facet, marking the distal
attachment of the supraspinatus,
infraspinatus, and teres minor,
respectively.
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Sharp crests extend distally
from the anterior side of the
greater and lesser tubercles.
These crests receive the distal
attachments of the pectoralis
major and teres major.
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Between these crests is the
intertubercular (bicipital) groove, which
houses the tendon of the long head of
the biceps brachii.
The latissimus dorsi muscle attaches to
the floor of the intertubercular groove,
medial to the biceps tendon.
Distal and lateral to the termination of
the intertubercular groove is the deltoid
tuberosity.
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The radial (spiral) groove runs
obliquely across the posterior
surface of the humerus.
The groove separates the proximal
attachments of the lateral and
medial head of the triceps.
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• For example, restoring the correct
prosthetic anatomy during
arthroplasty has significant clinical
implications for range of motion,
kinematics, and impingement.
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SPİNA
SKAPULA
FOSSA SUPRASPINATA FOSSA INFRASPINATA
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Coracoid
process
Crow's beak
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ARTHROLOGY
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JOINTS OF SHOULDER COMPLEX
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PP1
Sternoclavıcular
Joint
The clavicle, through its attachment to
the sternum, functions as a mechanical
strut, or prop, holding the scapula at a
relatively constant distance from the
trunk.
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Slayt 30
Sternoclavicular joint
• SC joint is between clavicula ve sternum.
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Sternoclavicular joint is supported by 3
ligaments.
• Kostaklavikular lig.
(restrict elevation)
• İnterklavikular lig.
(between claviculas)
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Kinematics
• The osteokinematics of the clavicle
involve a rotation in all three
degrees of freedom.
• Each degree of freedom is
associated with one of the three
cardinal planes of motion: sagittal,
frontal, and horizontal.
• The clavicle elevates and depresses,
protracts and retracts, and rotates
around the bone’s longitudinal axis.
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Kinematics
• The primary purpose of these movements is to place the scapula in
an optimal position to accept the head of the humerus.
• Essentially all functional movements of the glenohumeral joint
involve some movement of the clavicle around the SC joint.
• 35‐45° elevation
• 10 ° depression
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Elevation Depression
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Protraction + Retraction:
A maximum of 15 to 30° of motion have
been reported in each direction.
Posterior rotation:
20‐35°
rection
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Sternoclavicular joint subluxation
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Acromioclavikular Joint
Synovial- Plana type joint
• The acromioclavicular (AC) joint is the
articulation between the lateral end of the
clavicle and the acromion of the scapula.
• The clavicular facet on the acromion faces
medially and slightly superiorly, providing
a point of attachment with the
corresponding acromial facet on the
clavicle.
• An articular disc of varying form is present
in most AC joints.
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Acromioclavikular joint
Acromioclavikular lig. (İnf‐sup)
To prevent post.dislocation
To support the joint capsul
Coracoclavikular lig.
To prevent posterior scapular
movement
To prevent scapular rotation
Corakoacromial lig.
Supporting the coracoacromial arch
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If elevation occurs in the
acromioclavicular joint, depresson is
formed in the sternoclavicular joint.
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WATCH ME!
• https://www.youtube.com/watch?v=l7h2FJnSXyw
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• The acromioclavicular (AC) joint is
inherently susceptible to dislocation
(separation) because of the sloped nature
of the articulation and the high probability
of receiving large shearing forces.
AC Joint • Consider a person falling and striking the
Separation tip of the shoulder abruptly against the
ground.
• Such horizontal shear is resisted primarily
by the joint’s superior and inferior capsular
ligaments.
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• The coracoclavicular ligament, however,
offers a secondary resistance to horizontal
shear, especially if severe.
• On occasion, the force applied to the
scapula exceeds the tensile strength of all
AC Joint the ligaments, resulting in their rupture and
Separation complete dislocation of the AC joint.
• Trauma to the AC joint and associated
ligaments can lead to instability and pain
and possibly posttraumatic osteoarthritis.
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WATCH ME!
• https://www.youtube.com/watch?v=ZOAbcQWp8tA
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AC Joint Separation
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Scapulo‐Thorasic joint
It is a physiological joint.
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Scapulothoracic Joint
(ST)
• The scapulothoracic joint is not a true joint per se
but rather a point of contact between the anterior
surface of the scapula and the posterior‐lateral wall
of the thorax.
• ST motion = AC motion + SC motion
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Scapula stabilization
• The primary factor holding the scapula on the chest wall is
atmospheric pressure.
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Watch me!
• https://www.youtube.com/watch?v=JEHBKxO56aU
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The Functional Importance of
Full Upward Rotation of the
Scapulothoracic Joint
• The ability to raise the arm fully overhead is a
prerequisite for many functional activities.
• A fully upward rotated scapula is an important
component of this movement, accounting for
approximately one third of the near 180° of
shoulder abduction or flexion.
• As with all scapulothoracic motions, upward
rotation is mechanically linked to the motions of
the sternoclavicular and acromioclavicular joints.
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The Functional Importance of Full Upward
Rotation of the Scapulothoracic Joint
• The upward rotation of the scapula that occurs during full shoulder
abduction in the plane of the scapula (about 35° anterior to the
frontal plane) serves at least three important functions.
• First, the upwardly rotated scapula projects the glenoid fossa upward
and anterior‐laterally, providing a structural base to maximize the
upward and lateral reach of the upper limb.
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The Functional Importance of Full Upward
Rotation of the Scapulothoracic Joint
• Second, the upwardly rotated scapula
preserves the optimal length‐tension
relationship of the abductor muscles of
the glenohumeral joint, such as the
middle deltoid and supraspinatus.
• Third, the upwardly rotated scapula
helps maintain the volume within the
subacromial space: the area between
the undersurface of the acromion and
the humeral head
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The Functional Importance of Full Upward
Rotation of the Scapulothoracic Joint
• A reduced subacromial space during
abduction may lead to a painful and
damaging impingement of the residing
tissues, such as the supraspinatus tendon.
• Kinematics associated with upward rotation
of the scapula are essential to optimal
function of the shoulder, especially for full
and pain‐free range of abduction.
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Coraco‐Acromial Arch
• Acromion
• Acromioklavicular joint
• Corokoid process
• Corakoacromial ligament
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Coracoacromial Arch & Bursa
• 1 cm of space between
acromion process and
humeral head
• Arch contains supraspinatus,
subacromial bursa, long
head of the biceps, superior
joint capsule
• Site of Impingement
Syndrome
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Impingement Syndrome
Activities that require
forceful overhead actions often
result impingement.
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WATCH ME!
• https://www.youtube.com/watch?v=D3GVKjeY1FM
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Glenohumeral
joint
• The glenohumeral (GH)
joint is the articulation
formed between the large
convex head of the
humerus and the shallow
concavity of the glenoid
fossa.
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GLENOHUMERAL • It is a spheroid type joint.
JOINT • Capsule, bursa and ligaments maintain joint integrity.
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• This joint operates in conjunction with
the moving scapula to produce an
extensive range of motion of the
shoulder.
Glenohumeral
• In the anatomic position, the articular
joint surface of the glenoid fossa is directed
anterior‐laterally in the scapular plane.
• In most people the glenoid fossa is
upwardly rotated slightly.
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• In the anatomic position, the humeral
head is directed medially and
Glenohumeral superiorly, as well as posteriorly
because of its natural retroversion.
joint • This orientation places the head of the
humerus directly into the scapular
plane and therefore directly against the
face of the glenoid fossa.
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GH joint capsule • The GH joint is
surrounded by a
fibrous capsule that
isolates the joint
cavity from most
surrounding tissues.
• The capsule attaches
along the rim of the
glenoid fossa and
extends to the
anatomic neck of the
humerus.
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• A synovial membrane
GH joint capsule lines the inner wall of
the joint capsule.
• An extension of this
synovial membrane
lines the intracapsular
portion of the tendon
of the long head of the
biceps brachii.
• This synovial
membrane continues
to surround the biceps
tendon as it exits the
joint capsule and
descends into the
intertubercular (i.e.,
bicipital) groove.
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GH joint capsule
• The fibrous capsule of the GH joint is relatively thin and is reinforced
by thicker external ligaments.
• By crossing superiorly over the humeral head, the long head of the
biceps also contributes to GH stability.
• The primary functional stability of the GH joint is based not only on
passive tension within embedded ligaments, but on the active forces
produced by local muscles, such as those of the rotator cuff
(subscapularis, supraspinatus, infraspinatus, and teres minor).
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GH joint capsule
• Unlike the capsular ligaments, which produce their greatest stabilizing
tension only when stretched at relatively extreme motions, muscles
generate large, active stabilizing tensions at virtually any joint
position.
• The rotator cuff muscles are considered the “dynamic” stabilizers of
the GH joint because of their predominant role in maintaining
articular stability during active motions.
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Glenohumeral capsular
ligaments
• By reinforcing the walls of
the capsule, the capsular
ligaments also assist with
maintaining a negative
intra‐articular pressure
within the GH joint.
• This suction force offers an
additional source of
stability.
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Süperior glenohumeral
ligament
• The ligament becomes
particularly taut in full
adduction.
• Once taut in adduction, the
superior capsular ligament
provides a restraint to inferior
and anterior‐posterior
translations of the humeral
head.
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Süperior glenohumeral
ligament
• The superior glenohumeral
ligament has its proximal
attachment near the
supraglenoid tubercle, just
anterior to the long head of
the biceps. The ligament, with
adjacent capsule, attaches
near the anatomic neck of the
humerus above the lesser
tubercle.
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Middle glenohumeral
ligament
• The middle glenohumeral
ligament has a wide proximal
attachment to the superior and
middle aspects of the anterior
rim of the glenoid fossa.
• The ligament blends with the
anterior capsule and broad
tendon of the thick subscapularis
muscle, then attaches along the
anterior aspect of the anatomic
neck.
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Middle glenohumeral
ligament
• This ligament provides a
substantial anterior restraint to
the GH joint, especially in a
position of 45 to 60 ° of
abduction.
• Based on its location, the middle
glenohumeral ligament is very
effective at limiting the extremes
of external rotation.
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• The extensive inferior glenohumeral
ligament attaches proximally along the
anterior‐inferior rim of the glenoid fossa,
including the glenoid labrum.
• The hammock‐like inferior capsular
ligament has three separate
components: an anterior band, a
posterior band, and a sheet of tissue
connecting these bands known as an
axillary pouch.
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• The axillary pouch and the surrounding
inferior capsular ligaments become most
taut in about 90° of abduction.
• Acting as a sling, the taut axillary pouch
supports the suspended humeral head
and provides a cradling effect that resists
inferior and anterior‐posterior
translations.
• From this abducted position, the
anterior and posterior bands become
further taut at the extremes of external
and internal rotation, respectively.
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• Over many repetitions, this
action can overstretch or tear
the anterior band, thereby
compromising one of the
prime restraints to anterior
translation of the humeral
head.
• Injury and increased laxity of
this portion of the anterior
and inferior capsule are
indeed associated with
recurrent anterior
dislocations of the GH joint.
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Coracohumeral
ligament
• This ligament extends from
the lateral border of the
coracoid process to the
anterior side of the greater
tubercle of the humerus.
• The coracohumeral ligament
also blends with the
superior capsule and
supraspinatus tendon.
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Coracohumeral ligament
• Similar to the superior capsular ligament, the position of adduction pulls
the coracohumeral ligament taut.
• From this position, the coracohumeral ligament provides significant
restraint to inferior translation and external rotation of the humeral head.
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• The subscapularis, the thickest of
the four muscles, lies just
anterior to the capsule.
• The supraspinatus, infraspinatus,
and teres minor lie superior and
posterior to the capsule.
• These four muscles form a cuff
that protects and actively
stabilizes the GH joint, especially
during dynamic activities.
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• In addition to the belly of the rotator cuff muscles being located very
close to the joint, the tendons of these muscles actually blend into
the capsule.
• This unique anatomic arrangement helps explain why the mechanical
stability of the GH joint is so dependent on the innervation, strength,
and control of the rotator cuff muscles.
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• It is clinically important to note that,
the rotator cuff fails to cover two
regions of the capsule: inferiorly, and a
region between the supraspinatus and
subscapularis known as the rotator
interval.
• The inherently weakened region of the
rotator interval is, however, reinforced
by the tendon of the long head of the
biceps and the coracohumeral
ligament.
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Rotator interval
• The rotator interval is one
common site for anterior
dislocation of the GH joint.
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• In addition, the position of the tendon across the dome of the
humeral head also suggests a role in resisting superior migration of
the humeral head—an important force needed to control the natural
arthrokinematics of abduction.
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Glenoid labrum
• The rim of the glenoid fossa is encircled by a fibrocartilage ring, or lip, known as
the glenoid labrum.
• The labrum is a fibrocartilagenous tissue, which functions to enlarge and deepen
the glenoid fossa while increasing the the conformity of the articulating surfaces.
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CORACOACROMIAL ARCH
• The coracoacromial arch is formed by the coracoacromial ligament
and the acromion process of the scapula.
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CORACOACROMIAL ARCH
• The coracoacromial arch forms the functional “roof” of the GH joint.
The space between the coracoacromial arch and the underlying
humeral head was referred as the subacromial space.
• In the healthy adult, the subacromial space measures only about 1 cm
in height.
• The very clinically relevant subacromial space contains the
supraspinatus muscle and tendon, the subacromial bursa, the long
head of the biceps, and part of the superior capsule.
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CORACOACROMIAL ARCH and RELATED BURSA
• Multiple separate bursa sacs exist around the shoulder.
• Some of the sacs are direct extensions of the synovial membrane of
the GH joint, such as the subscapular bursa, whereas others are
separate structures.
• All are situated in regions where significant frictional forces develop,
such as between tendons, capsule and bone, muscle and ligament, or
two adjacent muscles.
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CORACOACROMIAL ARCH and RELATED BURSA
• Two important bursa sacs are
located superior to the humeral
head.
• The subacromial bursa lies within Subacromial bursa
the subacromial space above the
supraspinatus muscle and below
the acromion process. This bursa
protects the relatively soft and
vulnerable supraspinatus muscle
and tendon from the rigid
undersurface of the acromion.
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CORACOACROMIAL ARCH and RELATED BURSA
• The subdeltoid bursa is a lateral
extension of the subacromial
bursa, limiting frictional forces
between the deltoid and the
underlying supraspinatus tendon
and humeral head.
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Kinematics
• The GH joint is considered a universal joint
because movement occurs in all three degrees of
freedom.
• The primary motions at the GH joint are flexion
and extension, abduction and adduction, and
internal and external rotation.
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Kinematics
• Often, a fourth motion is defined at
the GH joint: horizontal flexion and
extension (also called horizontal
adduction and abduction).
• The motion occurs from a starting
position of 90° of abduction. The
humerus moves anteriorly during
horizontal flexion and posteriorly
during horizontal extension.
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Shoulder abduction‐adduction
• Normally, the healthy person has about
120° of abduction at the GH joint,
although a range of values has been
reported.
• External rotation of the GH joint naturally
accompanies abduction.
• This accompanying external rotation
allows the greater tubercle of the
humerus to pass posterior to the
acromion process and therefore avoid
jamming against the contents within the
subacromial space, most notably the
supraspinatus tendon.
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Shoulder abduction‐
adduction • Full abduction of
the shoulder
complex requires
a simultaneous
approximate 60°
of upward
rotation of the
scapula.
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Shoulder abduction‐
The arthrokinematics
adduction of abduction involve
the convex head of the
humerus rolling
superiorly while
simultaneously sliding
inferiorly.
With regard to
arthrokinematics,
adduction is similar to
abduction but occurs in
a reverse direction.
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120
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Importance of Roll‐and‐Slide
Arthrokinematics
at the Glenohumeral Joint
• In some pathological conditions,
ideal roll and glide arthrokinematics
do not occur.
• For example, consider excessive
thickening of the inferior capsular
ligament of the GH joint associated
with adhesive capsulitis.
• This may limit the inferior gliding of
the humeral head during abduction.
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Importance of Roll‐and‐Slide Arthrokinematics
at the Glenohumeral Joint
• Without a sufficient concurrent inferior slide during abduction, the
superior roll of the humeral head would ultimately lead to a jamming
of the head against the unyielding coracoacromial arch.
• An adult‐sized humeral head that is rolling up a glenoid fossa without
a concurrent inferior glide would translate through the 10‐mm
subacromial space after only 22° of GH joint abduction.
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Importance of Roll‐and‐Slide Arthrokinematics
at the Glenohumeral Joint
• This situation would create
an impingement of the
supraspinatus tendon and
subacromial bursa between
the head of the humerus and
the coracoacromial arch.
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Rotations
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Dynamic
Stability of
Shoulder
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Overall Kinematics of
Shoulder Abduction:
Establishing the Six Kinematic Principles of
the Shoulder Complex
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SCAPULOHUMERAL
RHYTHM
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WATCH ME!
• https://www.youtube.com/watch?v=3VygGuBObVc
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Brachial
plexsus
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