AME – Bhargavi Ravikhanth MPT (neuro)

Arunachala Medical Encyclopedia

Biomechanics - Shoulder complex
Structural components of shoulder complex
• The shoulder complex is composed of the bones humerus, scapula and
clavicle and the joints that link those bones.
• These three bones are linked by four
interdependent joints.
• One non anatomical/functional joint,
scapulothoracic joint.
• Three anatomical joints,
sternoclavicular joint,
acromioclavicular joint and
glenohumeral joint.
• These joints that compose the shoulder complex together contributes to
the various range of movements of upperlimb.
Scapulothoracic joint
• The scapulothoracic joint is formed by the articulation of scapula with the
thorax on which it sits.
Articulating surface
• Convex surface of the posterior thoracic cage
• Concave surface of the anterior scapula
• It is not a true anatomical joint, because it has no usual joint structures
such as capsular attachmet and ligaments.
• It depends on the anatomic joints, the acromioclavicular and
sternoclavicular joints.
• Any movement of scapula on thorax (scapulothoracic jont) will result in
movement in AC and SC joints and viceverca.
Scapulothoracic position and movements

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Position of scapula at rest
• 2 inches away from the midline
• Between the 2nd and 7th ribs
• 30 – 40 degree forward of the frontal plane and tipped anteriorly 10 – 20
degeree.
Scapulothoracic motions
• Elevation/depression
• Protraction/retraction
• Upward/downward rotation.
• Elevation and depression of the scapula are
translatory motions in which the scapula
moves upwards or downwards along the
ribcage from its position.
• Protraction and retraction of scapula are
translator motions in which the scapula
moves towards or away from the
vertebral coloumn.
• Upward and downward rotation of scapula are
rotatory movements in which the scapula rotates
in such a way the glenoid cavity faces upwards or
downwards.
• There are two other motions of scapula which
can be best understood while discussing
acromioclavicular joint.
Scapulothoracic stability
• Stability of scapula on thorax is provided by 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 movements of the scapula.

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• The ultimate function of scapular motion is to orient the glenoid fossa for
optimal contact with the maneuvering arm, to add rang of motion to
elevation of the arm and to provide a stable base for the controlled rolling
and sliding of the articular surface of the humeral head.
• As the scapula serves both stability and mobility functions, it is a premiere
example of dynamic stabilisation in human body.
Sternoclavicular joint
• The sternoclavicular joint is formed by the articulation of sternum with
clavicle.
• It is a plane synovial joint with 3 degeree of freedom of motion.
• It has a joint capsule, three major ligaments and a joint disc.
• Only structural attachment of scapula to the rest of the body is through
clavicle, thus any movement of clavicle in the sternoclavicular joint will
result in movement of scapula and viceversa.
Articulating surface
• Saddle shaped surface of the sternal end of clavicle
• Saddle shaped surface of the notch formed by the manubrium sternum
and the 1st rib.
• This is an incongruent joint, that is there is only a little contact between
the articular surfaces.

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Sternoclavicular disk
• When two articular surfaces of the bones are incongruent, there will be an
accessory joint structure interposed.
• Here in SC joint, a fibrocartilage joint disk or menisci is interposed between
the articular surfaces.
• The upper part of the disck is attached to the superior clavicle and the

lower part is attached to the manubrium and costal cartilage.

• Thus, the joint space is divided into two separate cavities.
• During elevation and depression, the medial end of the clavicle moves on
the stationary disc, thus the disc acts as a part of sternum here.
• During protraction and retraction, the medial end of the clavicle and the
inter articular disc moves together as same segment on the articular
surface of sternum, thus here the disc acts as a part of clavicle here.
• As the disc changes its participation from on segment to the other during
the movement of clavicle, mobility is well maintained when the stability is
enhanced.
• The disc also serves an important stability function by increasing the joint
congruence and by absorbing the force transmitted along the clavicle from
its lateral end.

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Sternoclavicular joint capsule and ligaments
• The SC joint is surrounded by joint capsule and three ligaments that
supports joint capsule.
• Sternoclavicular ligament
• Costoclavicular ligament and
• Interclavicular ligament

Sternoclavicular ligament
• Sternoclavicular ligament reinforces the capsule.
• The ligament is made up of two parts, anterior and posterior.
• These ligaments limits the anterior and posterior movements of head of
clavicle.

Costoclavicular ligament
• This strong ligament lies between the clavicle and the first rib.
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• It has 2 segments/lamina, anterior lamina and posterior lamina.
• The anterior lamina has medially directed fibers and posterior lamina has
laterally directed fibers.
• It limits the elevation of clavicle and contributes to the downward gliding
of medial end of clavicle.
• It also counteracts some of the superiorly directed forces applied on the
clavicle by some muscles.
• Posterior lamina limits the medial movement of clavicle, prevents the
forces acting on sternoclavicular disc.
Interclavicular ligament
• It limits the excessive depression or downward glide of the clavicle.
• Preventing these movements of clavicle is necessary to protect the
brachial plexus and subclavian artery.
• When the clavicle is depressed the interclavicular ligament is taut and it
can support the entire weight of the upperlimb.
Sternoclavicular movements
• The movements that occur in the sternoclavicular joint are
• Elevation / Depression of clavicle
• Protraction / Retraction of clavicle
• Anterior / Posterior rotation of
clavicle
• The movements elevation /
depression and protraction /
retraction should be visualized by
referencing the movements of the
lateral end of clavicle.
• The movements anterior / posterior rotation of clavicle by referencing the
movement of entire clavicle

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Elevation / Depression of clavicle
• The movement elevation and
depression of the clavicle occurs
when the convex surface of
clavicle slides on the concave
surface formed by the
manubrium and the first coastal
cartilage.
• The sliding occurs in a direction opposite to the movement of lateral end
of clavicle.
• Therefore, elevation results in downward sliding of medial end of clavicle
and depression results in upward sliding.
• The average range of clavicular elevation is about 45 degeree and
depression is about 15 degeree.
• As the acromion process of scapula is attached to the lateral end of clavicle
the elevation / depression of clavicle are invariably associated with
scapular movements(elevation / depression and upward / downward
rotation).
Protraction / retraction of clavicle
• The movement protraction and retraction of the clavicle occurs when the
concave surface of clavicle slides on the convex surface formed by the
manubrium and the first coastal cartilage.
• The sliding occurs in the same direction to the movement of lateral end of
clavicle.
• Therefore, protraction of clavicle results in anterior sliding of medial end of
clavicle and retraction causes posterior sliding.
• The average range of clavicular protraction and retraction is about 15
degeree.
• Again here these clavicular movements are invariably accompanied by
scapular movements as the scapula is attached with the lateral end of
clavicle.
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Anterior and posterior rotation of clavicle
• Rotations of clavicle occurs as a spin between the saddle shaped articular
surfaces of medial end of clavicle and manubrium.
• Unlike other joints, clavicle can only rotate in one direction from its resting
position.
• The clavicle can only rotate posteriorly from its neutral position, bringing
its inferior surface anteriorly.
• From its fully rotated position, clavicle can rotate anteriorly to return to
neutral.
• The average range of clavicular rotation is about 30 to 55 degeree.
• Again here these clavicular movements are invariably accompanied by
scapular movements.
Acromioclavicular Joint
• This joint attaches the clavicle to the scapula.
• It is a plane synovial joint with 3 degree of freedom.
• During the early stage of elevation of upper limb, this joint maintains the
relationship between the scapula and the clavicle and during the mater
stages of elevation of upper limb, this joint allows scapular rotation on
thorax to provide additional range of motion for the
elevation of upper limb.
Acromioclavicular articulating surfaces
• Lateral end of the clavicle
• Facet on the acromion process of the scapula.
• The articular facets are incongruent and vary in configuration.
• They may be flat or reciprocally concave convex, which varies from
individual to individual.
Joint capsule and ligaments
• AC joint have one joint capsule and two ligaments.

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• They are
1. Superior & Inferior acromioclavicular ligament
2. Coracoclavicular ligament
Joint capsule
• Joint capsule of this
joint is very weak
and cannot maintain
the integrity of the
joint without
reinforcement of
the ligaments.
Superior & inferior
acromioclavicular
ligament
• It assists the joint capsule in apposing the articular surfaces and in
controlling horizontal stability.
The superior part of the ligament is reinforced by the aponeurotic fibers of
trapezius and deltoid, making the superior joint more stronger than the inferior.
Coracoclavicular ligament
• Although it doesn't belong to the AC joint, it provided stability by firmly
uniting the clavicle and scapula.
• The ligament is divided into two parts
• The lateral part - trapezoid ligament.
• The medial part - conoid ligament
• Trapezoid ligament is quadrilateral in shape and horizontally oriented.
• The conoid ligament is triangular in shape and vertically oriented.
• The two ligaments are separated by adipose tissue and bursa.
• Displacement of AC joint is restricted by this ligament and it also prevents
upward rotation of the scapula at AC joint.
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Acromioclavicular motions
• As the articular surfaces configuration of this joint varies from individual to
individual, the motion occurs in this joint and its ROM also varies from
individual to individual.
• The primary motions at this joints are
1. Medial / lateral rotation of scapula
Anterior / posterior tipping of scapula
Medial and lateral rotation of scapula
• Medial and lateral rotation occurs at the AC joint brings the glenoid cavity
of scapula anteriorly or posteriorly when the scapula is protracting or
retracting.

• Without AC joint motion, protraction and retraction of scapula can only

make the glenoid fossa to face laterally.
• AC joint medial and lateral rotation motions enhances the protraction and
retraction of scapula by making the glenoid cavity face anteriorly and
posteriorly which is necessary for various upperlimb motions and to
prevent dislocations.
• While protraction and retraction scapula traces the horizontal curvature of
the rib cage with the help of the medial and lateral rotation movements
permitted in the AC joint.
Anterior and posterior tipping of scapula
• Anterior tipping moves the superior border of the scapula anteriorly and
the inferior angle posteiorly.
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• Posterior tipping moves the superior border
of scapula posteriorly and inferior angle
anteriorly.
• Like medial and lateral rotation of scapula
helps the scapula to trace the horizontal
curvature of ribcage, anterior and posterior
tipping of scapula helps it to trace the
vertical curvature of ribcage during elevation
and depression of scapula.
• Apart from that when the clavicle is rotating posteriorly, if there no
movement permitted in AC joint, it will make the scapula to rotate along
with clavicle and the inferior angle of scapula will hit the ribcage and will
restrict the movement.
• But now, as the AC joint provides tipping movements , while clavicle is
rotating posteriorly the joint allows the scapula to remain in its place.
Glenohumeral Joint
• Articulation between the glenoid fossa of scapula and the head of
humerus is called as GH joint.
• GH joint is a ball and socket joint with 3° of freedom.
• Any movement of scapula and it's interlinked SC and AC joints will affect
the GH joint function.
• GH joint sacrificed it's congruency to serve mobility.
Glenohumeral Articular Surfaces
• Glenoid fossa of scapula.
• Head of humerus.
• The glenoid fossa is very shallow compared to the head of humerus.
• The curvature of the fossa is greater in lengthwise and lesser width wise.
• The head of the humerus faces medially, superiorly and posteriorly with
respect to the shaft and condyles of humerus.

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• An axis through the humeral head and
longitudinal axis of humeral shaft may form an
angle of 130° - 150°.
• This is known as angle of inclination of
humerus.
• The axis through the humeral head and an axis
through the condyles of humerus form an
angle 30°.
• This is known as angle of torsion.
• Normal posterior position of the humeral
head with respect to the condyles are
termed as posterior torsion or
retrotorsion of humerus.
Glenoid Labrum
• The articular surface of glenoid fossa is
enhanced by the glenoid labrum.
• The labrum surrounds the periphery of the
fossa enhancing the depth or
curvature of the fossa.
Glenohumeral Capsule and ligaments
• The GH joint is surrounded by a loose capsule and three
glenohumeral ligaments.
Joint capsule
• GH joint capsule is large, loose capsule
that surrounds the joint.
• It is taut superiorly and slack inferiorly
when the arm is in resting position.
• The capsule is double the size of the head
of humerus and allows 1 inch of

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distraction of the head of humerus and glenoid fossa.
• The laxity of the GH capsule is necessary for mobility of the joint.
• Also the capsule provides stability with the reinforcement of ligaments and
muscles.
• When the humerus is abducted and laterally rotated the joint capsule
twists on itself and become taut.
Ligamets
• The GH joint capsule is reinforced by four ligaments, three glenohumeral
ligaments and one coracohumeral
ligament.
• They are
1. Superior GH ligament
2. Middle GH ligament
3. Inferior GH ligament
Coracohumeral ligament
• Anteriorly, the capsule is reinforced by
supple- mental bands called the superior, middle and inferior
glenohumeral ligaments.
• The area between the superior and
middle gleno- humeral ligament is a
point of weakness in the capsule
(foramen of Weitbrecht) which is a
common site of anterior dislocation of
humeral head.
• Although reinforced by the
subscapularis tendon, foramen of
weitbrecht is the site of weakness
where anterior dislocation of humerus occurs.
• Coracohumeral ligament connects the tip of coracoid process with the
head of humerus.
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• It has two bands, which forms a tunnel for the passage of biceps tendon.
Bursae
• Several bursae are associated with
the shoulder complex, the most
important are subacromial and
subdeltoid bursa.
• These two bursae are usually fused
together and collectively called as
subacromial bursa.
• They separate supraspinatus tendon
and the head of humerus from the acromion, coracoid processes and
coracoacromial ligament.
• Subacromial bursa permits smooth gliding between the humerus and its
surrounding structures.
• Inflammation of subacromial bursa is called as subacromial bursitis.
• Subacromial bursitis causes interruption or failure of gliding mechanism
and will result in pain and limitation of GH motion.
Coracoacromial arch
• Coracoacromial arch is also called as supra humeral arch.
• It is an arch like structure formed by the following three structures.
• The acromion process
• The coracoid process and
• The coracoacromial ligament that connects both the coracoid and
acromion processes.
Advantages of coracoacromial arch
• The coracoacromial arch forms an osteoligamentous vault, which covers
the humeral head and creates a space within which the subacromial bursa,
supraspinatus tendon and the long head of biceps lies.

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• The arch protects the structures beneath it from direct trauma that can
occur through daily activities such as carrying heave sling bags over the
shoulder.
• The arch prevents the superior dislocation of humerus, if there's no
coracoacromial arch, the humerus may easily dislocate superiorly as there
is no other structure to counteract the force pushing the humerus
superiorly.

Disadvantages of coracoacromial arch

• While preventing the superior dislocation of humerus, the impact of
humeral head can cause painful impingement of the structures lying in
between the humeral head and the arch.
• Apart from this, the suprahumeral space may become narrow due to
various factors such as changes in the shape of acromion process, changes
in the slope of acromion process, changes in the size of subacromial bursa,
acromial bone spurs and thick coracoacromial ligament.
• When the suprahumeral space is narrowed due to any factors, it will result
in painful moments and limited range of motion due to impingement of
those structures.
Glenohumeral motions
Osteokinematics
• The glenohumeral joint is having 3 degree of freedom of motion.

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• That is it have flexion/extension, abduction/adduction and medial/lateral
rotation.
• The joint is considered to have 120 degree of flexion and about 50 degree
of extension.
• The range of medial and lateral rotation varies with the position of
humerus.
• With the arm at the side the medial and lateral rotation is limited as 50
degree of combined motion.
• Abducting the humerus to 90 degree increases the range of motion to 120
degree.
• The restriction of medial rotation when the arm is by the side is because of
the impact of lesser tubercle on the anterior glenoid fossa.
• The restriction of lateral rotation when the arm is by the side is because of
the impact of greater tubercle on the acromion.
• When the arm is abducted, these bony restrictions plays a little role, so the
restrictions of motion is only capsular and muscular.
• The range of abduction will be diminished when the humerus is in medial
rotation or in neutral.
• When the humerus is in neutral position, only about 90 degree of GH
abduction can be done and when the humerus is medially rotated, only 60
degree of abduction can be done.
• The restriction here is due to the impingement of greater tubercle on
coracoacromial arch.
Arthrokinematics
• The glenoid fossa and the humeral head are incongruent surfaces, the
convex humeral head is substantially larger than the shallow concave
glenoid fossa.
• Because of this incongruence, rotation in this joint do esnot occurs as pure
spin, but with changing centres of rotation and contact pattern within the
joint.
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• Elevation of humerus requires that the humeral head glides inferiorly in a
direction opposite to the movement of the shaft of humerus.
• For example – abduction of humerus would cause, inferior glide of the
humeral head on the glenoid fossa.
Functions of shoulder complex
• Shoulder complex provides smoothest and greatest ROM available to the
upper limb.
• Combination of contribution from GH, AC, SC and ST joints contributes to
the full ROM of elevation of humerus with more stability.
• Combined movements of all these joints maintains the optimal position of
scapula for the movements.
• Involvement of all these joints also minimize or prevent the active
insufficiency of GH muscles.
Static stabilisation of GH joint
• Because of incongruent joint
surfaces the GH joint, maintenance
of position of head of humerus is
impossible only with bony surfaces.
• Gravity acting on the shaft of
humerus causes an adduction
moment on the humerus.
• Gravity must be offset by a force
that can apply a torque of equal
magnitude in the direction of
abduction.
• Such force is applied by the rotator interval capsule (superior capsule,
superior glenohumeral ligament and coracohumeral ligament) that are
taut when the arm is by the side.

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• When the passive force of rotator capsule structures is inadequate for
static stabilisation such as heavy loaded arm, the activity of supraspinatus
is recruited.
Dynamic stabilisation of GH joint
Deltoid and GH stabilisation
• Deltoid is the prime mover for GH
elevation.
• The force exerted by the all the
three segments of deltoid is the
translatory force that would cause
superior translation of humeral
head if unopposed, so deltoid
doesn’t play a major role in dynamic
GH stabilisation.
• The upward translatory force of the
deltoid on humerus is counteracted by the downward translatory pull by
the rotator cuff muscles which results in shoulder abduction.
Rotator cuff and GH stabilisation
• Supraspinatus, infraspinatus, teres minor and subscapularis muscles
compose the rotator cuff or musculotendinous cuff.
• In addition to providing inferior translatory pull on the humeral head to
oppose the superior translatory pull exerted by the deltoid, the rotator cuff
muscles also exerts compressive force on the head of the humerus
compressing it into the glenoid fossa which plays a major role in dynamic
stabilisation of the joint.
• The forces exerted by the rotator cuff muscles combines together to
maintain the head of humerus in position.
• Thus these muscles are called as steerers.
• Steering muscle can cause changeover of surfaces within the joint by
gliding and directing the articular surfaces in appropriate direction.

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Supraspinatus and GH stabilisation
• Although supraspinatus is a part of rotator cuff muscles, it doesn’t provide
inferior translatory force to offset the force of deltoid.
• It offers compressive force and superior translatory force that stabilises as
well as abducts the humerus.
• Gravity and supraspinatus alone act together to cause abduction of
humerus as they are both acting as vertical steerers.
Long head of biceps and GH stabilisation
• The position and attachment of long head
of biceps plays a major role in
strengthening the joint capsule and
stabilising the head of the humerus in
position.
• It also contributes in elevation of humerus
depending upon the position of humerus.
Costs of dynamic stabilisation
1. Force of prime movers
2. Force of gravity
3. Force of compressors and steerers
4. Articular surface and geometry
5. Passive capsuloligamentous forces
Scapulothoracic and glenohumeral
contribution
• The scapulothoracic joint contributes to
both flexion and elevation of humerus
by upwardly rotating the glenoid fossa
to 60 degree from its resting position.

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• Combination of both scapulothoracic as well as glenohumeral motion
causes full range of elevation of humerus.
• The ratio of GH is 2 and ST motion is 1.
• The combination of concomitant GH and ST motion is called as
scapulohumeral rhythm.
• This rhythm varies among individual and also varies with external
constraints.
Sternoclavicular and acromioclavicular contribution
• ST joint is a part of closed chain with other joints such as SC and AC joints.
• The 60 degree upward rotation of scapula during elevation of the arm can
be attributed with movements at SC joint primarily and AC joint
secondarily.
• Trapezius and serratus anterior are the only two muscles that are capable
of producing upward rotation of scapula.
Elevation and depression are the two primary movements of shoulder complex.
Muscles of Elevation
• The completion of normal elevation depends on
1. Freedom and integrity of the SC, AC, GH and ST joints
2. Appropriate strength of the muscles producing and controlling movement.
Deltoid Muscle Function
• Deltoid’s angle of pull will result in
superior translatory pull on the
humerus with an active contraction.
• With an appropriate inferior pull from
the infraspinatus, teres minor, and
subscapularis muscles, deltoid can
produce flexion and abduction.
• Deltoid activity depends on intact
rotator cuff muscles.
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• With complete derangement of the cuff, a
contraction of the deltoid results in a shrug of
the shoulder (scapular upward rotation and
upward translation of the humerus) rather than
in abduction of the humerus from the side.
Supraspinatus Muscle Function
• The activity of the supraspinatus is the same as
in the deltoid
• When the deltoid is paralyzed, the
supraspinatus alone can bring the arm
through most if not all of the GH range,
but the motion will be weaker.
• The secondary functions of the
supraspinatus is to compress the GH joint,
and to assist in maintaining the stability of
the dependent arm.
Infraspinatus, Teres Minor, and Subscapularis Muscle Function
• Infraspinatus, teres minor, and
subscapularis muscles, contribute
from 0 to 115 elevation.
• Total activity of flexion was slightly
greater than that in abduction.
Trapezius and Serratus Anterior Muscle Function
• The trapezius and serratus anterior
muscles creates a balance of forces
that drives the scapula in elevation
of the arm.
• These two muscle segments, along
with the levator scapula muscle,
also support the shoulder girdle
against the downward pull of gravity.
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Rhomboid Muscle Function
• The rhomboid major and minor muscles
are active in elevation of the arm,
especially in abduction.
• These muscles serve a function as
stabilizing synergists to the muscles that
upwardly rotate the scapula.
• Paralysis of these muscles causes
disruption of the normal scapulohumeral
rhythm.
Muscles of depression
Latissimus Dorsi and Pectoral Muscle Function

• When the upper extremity is free to move in space, the latissimus dorsi
muscle may produce adduction, extension, or medial rotation of the
humerus.
• When the hand is fixed, the latissimus dorsi muscle will pull pelvis toward
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.
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AME – Bhargavi Ravikhanth MPT (neuro)
Pectoralis major
• The clavicular portion of the
pectoralis major muscle can assist
the deltoid in flexion of the GH
joint, but the sternal and
abdominal portions are primary
depressors of the shoulder
complex.
• The depressor function of these
muscles is further assisted by the
pectoralis minor muscle.
Teres Major and Rhomboid Muscle Function
• The teres major muscle, like the latissimus dorsi, adducts, medially rotates,
and extends the humerus.
• Function of the teres major muscle is strongly dependent on activity of the
rhomboid muscles.
• Without stabilization, the teres major muscle would upwardly rotate the
lighter scapula rather than move the heavier humerus.

• The rhomboid muscles, as downward rotators of the scapula, offset the

undesired upward rotatory force of the teres major muscle.
• By fixing the scapula as the teres major muscle contracts, the rhomboids
allow the teres major muscle to move the heavier humerus.

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AME – Bhargavi Ravikhanth MPT (neuro)
• The rhomboids are assisted in stabilization of the scapula during humeral
extension or adduction by the anteriorly located pectoralis minor muscle.

Previously asked questions

Shoulder complex essay

1. What is Scapulo-humeral rhythm? Explain the phases of scapulo-humeral rhythm in detail with neat diagram.

2. Compare and contrast biomechanics of Hip and Shoulder Joint.

3. Discuss in detail the Kinematic variables that describe the motion of Scapulothoracic and Glenohumeral joint.

Shoulder complex 5 marks

1. Scapulo humeral rhythm

2. Rotator cuff stabilization.

3. Clavicular contribution to elevation of arm

4. Advantages and disadvantages of Coracoacromial arch

5. Winging of scapula

6. Compare action of anconeus and triceps.

7. Anconeus and Triceps.

8. Shoulder joint stability.

9. Reverse scapulohumeral rhythm.

10. Pathomechanics of supraspinatus impingement.

11. Describe dynamic stabilization of glenohumeral joint.

12. Describe the role of sternoclavicular joint in shoulder movements.

13. Describe scapula humeral rhythm and codman’s paradox.

14. Explain the structure and function of scapulothoracic joint.

Shoulder complex 2 marks

1. What is scaption?

2. Scapulo humeral rhythm.

3. Coracoacromial arch.

4. Muscles of elevation of shoulder.

5. Subacromial space.

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