Shoulder Joint

Type
• synovial joint
• ball and socket variety.
• Multiaxial joint
• With 3 degree of freedom of
mobility
Articular Surface
The joint is formed by articulation of
• the glenoid cavity of scapula and
• the head of the humerus.
• known as the glenohumeral articulation.
• Structurally - weak joint
• because the glenoid cavity is too small and
shallow
• to hold the head of the humerus in place
(the head is four times the size of the
glenoid cavity).
• this arrangement permits great mobility.
• Stability of the joint is maintained by
1. The coracoacromial arch or secondary socket for
the head of the humerus
2. The musculotendinous cuff of the shoulder
3. The glenoidal labrum helps in deepening the
glenoid fossa.

Stability is also provided by

• the muscles attaching the humerus to the pectoral
girdle,
• the long head of the biceps brachii,
• the long head of the triceps brachii.
• Atmospheric pressure also stabilises the joint.
Coraco- arcomial arch
• Is formed by
1. Coracoid process
2. Acromial process
3. Connected by coraco -acromial ligament
• Extends from tip of acromion to lateral border
coracoid process
• This arch is separated from supraspinatus
muscle by an extensive sub acromial bursa
• This bursa Acts as a secondary socket for
head of humerus
• Allows lateral rotation of humerus in raising
the arm above the head, when the greater
tubercle impinges on the lateral border of the
arch
Ligaments:

1. The capsular ligament:

• very loose
• permits free movements.
• least supported inferiorly where dislocations are
common.

• Such a dislocation may damage the closely related

axillary nerve

• Medially, is attached to the scapula beyond the

supraglenoid tubercle and the margins of the labrum.

• Laterally, it is attached to the anatomical neck of the

humerus with the following exceptions:

• Inferiorly, the attachment extends down to the

surgical neck.

• Superiorly, it is de cient for passage of the tendon

of the long head of the biceps brachii.
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Ligaments:
• Anteriorly, the capsule is reinforced by
supplemental bands called

- superior,

- middle and

- inferior glenohumeral ligaments.

The area between the superior and

middle glenohumeral ligament is a point
of weakness in the capsule (Foramen of
Weitbrecht) which is a common site of
anterior dislocation of humeral head.
• The capsule is lined with synovial
membrane.

• An extension of this membrane

forms a tubular sheath for the tendon
of the long head of the biceps
brachii.
2. The coracohumeral ligament:

• It extends from the root of the

coracoid process

• to the neck of the humerus opposite

the greater tubercle.

• It gives strength to the capsule.

3. Transverse humeral ligament:

• It bridges the upper part of the bicipital

groove of the humerus (between the

greater and lesser tubercles).

• The tendon of the long head of the

biceps brachii passes deep to the

ligament.
 4. The glenoidal labrum:
• brocartilaginous rim

• which covers the margins of the glenoid

cavity,

• thus increasing the depth of the cavity.

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 Bursae related to the Joint:

1. The subacromial (subdeltoid) bursa

2. The subscapularis bursa, communicates with

the joint cavity.

• The subacromial bursa and the subdeltoid bursae

are commonly continuous with each other

• may be separate.
• Collectively they are called the subacromial bursa,
which separates the acromion process and the
coracoacromial ligaments from the supraspinatus
tendon and permits smooth motion.

Any failure of this mechanism can lead to

in ammatory conditions of the supraspinatus
tendon.
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Bursae related to the Joint:

3. The infraspinatus bursa, may

communicate with the joint cavity.
Relations:

• Superiorly: Coracoacromial arch,

subacromial bursa, supraspinatus and deltoid

• Inferiorly: Long head of the triceps brachii,

axillary nerves and posterior circum ex
humeral artery.
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Relations:

• Anteriorly: Subscapularis,
coracobrachialis, short head of biceps
brachii and deltoid.

• Posteriorly: Infraspinatus, teres minor

and deltoid.

• Within the joint: Tendon of the long head

of the biceps brachii.
Blood Supply:
1. Anterior circum ex humeral vessels.
2. Posterior circum ex humeral vessels.
3. Suprascapular vessels.
4. Subscapular vessels.
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Nerve Supply:
1. Axillary nerve.
2. Musculocutaneous nerve.
3. Suprascapular nerve.
Movements of Shoulder Joint:

• has great freedom of mobility at the cost of

stability.

• There is no other joint in the body which is more

mobile than the shoulder joint.

This wide range of mobility is due

• to laxity of its brous capsule, and

• the four times large size of the head of the
humerus as compared with the shallow glenoid
cavity.
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The range of movements is further increased by concurrent movements of the shoulder girdle

However, this large range of motion makes glenohumeral joint more susceptible to

• dislocations,
• instability,
• degenerative changes and
• other painful conditions specially in individuals who perform repetitive overhead motions eg.,cricketers.
• Movements of the shoulder joint
are considered in relation to the
scapula rather than in relation to
the sagittal and coronal planes.
• When the arm is by the side (in
the resting position) the glenoid
cavity faces almost equally
forwards and laterally; and the
head of the humerus faces
medially and backwards.
• Keeping these directions in
mind, the movements are as
follows.
1. Flexion and extension:
• During exion the arm moves
forwards and medially, and
• during extension the arm
moves backwards and
laterally.
• Thus exion and extension
take place in a plane parallel
to the surface of the glenoid
cavity
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 Movement Main Muscles Accessory muscles

1. Clavicular head of the pectoralis

1. Coracobrachialis
major
Flexion 2. Anterior bres of deltoid
2. Short head of biceps brachii

1. Teres major
2. Long head of triceps brachii
1. Posterior bres of deltoid
Extension 3. Sternocostal head of the pectoralis
2. Latissimus dorsi
major
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2. Abduction and adduction:

• take place at right angles to the plane of exion

and extension,

• In abduction, the arm moves anterolaterally away

from the trunk.

• This movement is in the same plane as that of the

body of the scapula
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 Accessory
Movement Main Muscles
muscles

Abduction 1. Supraspinatus
0°- 90° 2. Deltoid

Abduction 1. Serratus anterior

90° - 180° 2. Upper & lower bres of trapezius

1. Pectoralis major
2. Latissimus dorsi Teres Major
Adduction
3. Short head of biceps brachii Coracobrachialis
4. Long head of triceps brachii
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3. Medial and lateral rotations:

• are best demonstrated with a mid exed

elbow.

• In this position, the hand is moved medially

across the chest in medial rotation, and

• laterally in lateral rotation of the shoulder

joint

• Takes place around a vertical axis from

centre of head to centre of capitulum
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 Movement Main Muscles Accessory Muscles

1. Pectoralis Major
2. Anterior bres of deltoid
Medial rotation 1. Subscapularis
3. Latissimus dorsi
4. Teres major

1. Posterior bres of deltoid

Lateral rotation 2. Infraspinatus
3. Teres major
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4. Circumduction:

is a combination of different movements as a result

of which the hand moves along a circle.

The range of any movement depends on the

availability of an area of free articular surface on the
head of the humerus.
Mechanism of elevation of arm
above the head
• Elevation of arm through 180° from dependent
position to vertical position can take place in
abduction or in exion
Elevation in abduction
• Out of 180° elevation, humerus moves
• 120°at shoulder joint
• Remaining 60°is done by scapula at the joints of
shoulder girdle
• In every 15° elevation, shoulder joint contributes
10° and girdle joints 5° (2:1)
• This is scapula-humeral rhythm
• This rhythm starts concurrently except in the
initial 25 -30°, when only humerus move at the
shoulder joint
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 Abduction:
• Performed by ve muscles
• Two prime movers - supraspinatus, middle
bres of deltoid
• Three - synergists - subscapularis,
infraspinatus & trees minor
• Abduction in scapular plane is restricted upto
90°

• Further 30° ( range of 120°) is made by lateral

rotation of humerus
A. To overcome the impingement of greater
tubercle against the acromial process
B. To bring more available articular surface of
humeral head for moving over glenoid fossa
C. Infraspinatus & teres minor perform this
movement of lateral rotation
D. Long head of biceps helps at this stage
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Scapular movement:
• Contribute 60° of elevation
• Takes place at acromioclavicular and
sternoclavicular joint
• Initial elevation of acromial end of
clavicle followed by axial rotation of
clavicle
• Elevation of clavicle ranges about 30°
• Acromioclavicular joint permits slight
elevation
• but main movement take place by the
downward swing of sternal end of
clavicle at the meniscoclavicular
compartment of sternoclavicular joint
• Produced by Upper bres of trapezius &
levator scapulae
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• Further elevation is checked by tension of
coracoclavicular ligament
• Hence scapular rotation is associated with
axial rotation of clavicle
• At sternoclavicular joint
• Permits further 30° elevation
• Glenoid cavity faces vertically upward
• Performed by
1. upper & lower bres of trapezius
2. Lower 5 digitation of serrates anterior
muscle
• The middle bres of trapezius stabilise the
scapula during abduction
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 Elevation in exion

• Full exion of humerus at right angle

to scapular plane ranges upto 90°

• Further elevation is not possible

unless the exed humerus abducts to
the scapular plane

• Elevation of exed humerus in sagittal

plane becomes full & straight without
lateral rotation of humerus
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Clinical Anatomy:

1. Dislocation:
The shoulder joint is more prone to dislocation than any
other joint.
•due to laxity of the capsule and
•the disproportionate area of the articular surfaces.
•Dislocation usually occurs when the arm is abducted.
•In this position, the head of the humerus presses
against the lower unsupported part of the capsular
ligament.
•almost always the dislocation is primarily subglenoid.

•Dislocation endangers the axillary nerve which is

closely related to the lower part of the joint capsule
2. Optimum attitude:
• In order to avoid ankylosis, many diseases of the shoulder joint are treated in an optimum
position of the joint.
• In this position, the arm is abducted by 45-90 degrees.
3. Shoulder tip pain:
• Irritation of the peritoneum underlying
diaphragm from any surrounding
pathology causes referred pain in the
shoulder.

• This is so because the phrenic nerve

carrying impulses from peritoneum and the
supraclavicular nerves which supplies the
skin over the shoulder, both arise from
spinal segments C3, C4
4. The shoulder joint is most commonly approached
(surgically) from the front.
For aspiration
• the needle may be introduced either anteriorly through
the deltopectoral triangle (closer to the deltoid), or
• laterally just below the acromion
 5. Frozen shoulder:
This is a common occurrence.
Clinically,
•the patient (usually 40-60 years of age)
•complains of progressively increasing pain in the shoulder,
sti ness in the joint and
•restriction of all movements particularly external rotation,
abduction and medial rotation.
As the contribution of the glenohumeral joint is reduced,
the patient shows altered scapulo-humeral rhythm
due to excessive use of scapular motion while performing
overhead exion and abduction.
The surrounding muscles show disuse atrophy.
The disease is self-limiting and the patient may recover
spontaneously in about two years and much earlier by
physiotherapy.
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• Shoulder joint disease can be excluded if the patient can raise both his arms above the head and bring the
two palms together.
• Deltoid muscle and axillary nerve are likely to be intact.
•