SHOULDER

COMPLEX
 Shoulder joint
• Structural components
– Sternoclavicular joint
– Acromioclavicular joint
– Scapulothoracic joint
– Glenohumeral joint (static / dynamic stabilization: Action lines)

• Functions
– ST : GH contribution
– SC : AC contribution
– Structural dysfunctions

• Muscles of elevation / depression

• Applied aspects
 Introduction
• Shoulder complex, composed of the clavicle, scapula, and humerus, is an
intricately designed combination of three joints linking the upper extremity to
the thorax.

• Articular structures of the shoulder complex are designed primarily for mobility,
allowing us to move and position the hand through a wide range of space.

• Joint which has a high degree of mobility but not without compromising
stability
• Involved in a variety of overhead activities relative to making various functional
activities in daily living skills.

• Movement and stabilization of the shoulder requires integrated function of the

rotator cuff muscles, joint capsule and scapula stabilizing muscles.
 Cont…

• Glenohumeral (GH) joint, linking the humerus and scapula, has

greater mobility than any other joint in the body.

• Although the components of the shoulder complex constitute half

of the mass of the entire upper limb, the components are

connected to the axial skeleton by a single joint the

(sternoclavicular [SC] joint).

• Muscle forces serve as a primary mechanism for securing the

shoulder girdle to the thorax and providing a stable base of support

for upper extremity movements.

 Joints surrounding shoulder joint

⮚ Sternoclavicular joint

⮚ Acromioclavicular joint

⮚ Glenohumeral joint

⮚ Scapulothoracic joint
 Interclavicular ligament

Clavicle
Clavicle
Articular disk
Sternoclavicular ligament
Costal cartilage
Costoclavicular ligament (1st rib)
Sternum
 Sternoclavicular Joint
• Sternoclavicular joint: Joint between proximal clavicle and
manubrium of the sternum. SC joint is a plane synovial joint with
three rotatory and three translatory degrees of freedom.
• This joint has a synovial capsule, a joint disk, and three major
ligaments.
• Provides major axis of rotation for movement of clavicle and
scapula.
• Allows some forward and backward rotation.

• Any motions of the scapula must result in motion at the SC joint

 Sterno
clavicular disks

Costo
clavicular
ligaments
 Sterno-clavicular Articulating Surfaces and disks

• The SC articulation consists of surfaces, one at the sternal

or medial end of the clavicle and one at the notch formed
by the manubrium of the sternum and first costal
cartilage.
• SC disk is generally true at an incongruent joint, the SC
joint has a fibro cartilage joint disk, or meniscus, that
increases congruence between joint surfaces.
• 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.
 Sterno clavicular
ligament

Inter clavicular
ligament

Posterior costoclavicular
ligament

Anterior costoclavicular
ligament
 Sternoclavicular Joint Capsule and Ligaments

• The SC joint is surrounded by a fairly strong fibrous capsule but

must depend on three ligaments for the majority of its support.
These are the sterno-clavicular ligaments, the costo-clavicular
ligament, and the inter-clavicular ligament.

• The anterior and posterior SC ligaments reinforce the capsule

and function primarily to check anterior and posterior
translatory movement of the medial end of the clavicle.
 Cont….
• Costo-clavicular ligament is a very strong ligament found between the
clavicle and the first rib.
• Costoclavicular ligament is also positioned to counter the superiorly
directed forces applied to the clavicle by sternocleidomastoid and
sternohyoid muscles.

• Interclavicular ligament resists excessive depression of the distal clavicle

and superior glide of the medial end of the clavicle.

• 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.
 Sterno-clavicular Motions

• Elevation and Depression of the Clavicle

• Anterior and Posterior Rotation of the Clavicle

• Protraction and Retraction of the Clavicle

 Acromio clavicular joint
• The AC joint attaches the scapula to the clavicle. It is generally
described as a plane synovial joint with three rotational and three
translational degrees of freedom.

• It has a joint capsule and two major ligaments; a joint disk may or
may not be present.

• Primary function of the AC joint is:

• To allow the scapula additional range of rotation on the thorax and

allow for adjustments of the scapula (tipping and internal/external
rotation) follow the changing shape of the thorax as arm movement
 Acromio-clavicular Capsule and Ligaments
• Capsule of the AC joint is weak and cannot maintain integrity of
the joint without reinforcement of the superior and inferior
acromio-clavicular and coraco-clavicular ligaments.
• Superior acromio-clavicular ligament assists the capsule in
apposing articular surfaces and in controlling A-P joint stability.
• Coraco- clavicular ligament- This ligament is divided into a lateral
portion, the trapezoid ligament, and a medial portion, the
conoid ligament
Superior acromio clavicular Trapezoid ligament
ligaments
Conoid ligament

Acromio clavicular
capsules
 Acromio-clavicular Motions

• Primary rotatory motions that take place at the AC joint

are internal/external rotation, anterior/ posterior
tipping or tilting, and upward/downward rotation.
Internal and External Rotation:
• Internal and external rotation at the AC joint can best be
visualized as bringing the glenoid fossa of the scapula
antero-medially and postero- laterally, respectively
• These motions 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.

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;

• maximize available motion of the arm.

 Anterior and Posterior Tipping
• 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, like internal / external rotation of the scapula, occurs to

maintain the contact of the scapula with the contour of the rib cage and
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
During normal flexion or abduction of
the arm, the scapula posteriorly tips
on the thorax as the scapula is
upwardly rotating.

Available passive motion into

anterior/posterior tipping
at the AC joint is 60
• The amount of available passive motion into upward/downward
rotation specifically at the AC joint is limited by the attachment
of the coraco - clavicular 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 away from the clavicle, a motion restricted by
tension in the coraco-clavicular ligaments.

• Dempster et al., has described that 30 degree of shoulder

movements in passive ROM depends into upward/downward
rotation.
 Scapulothoracic Joint
• The ST “joint” is formed by the articulation of the scapula
with the thorax. It is not a true anatomic joint because it
has none of the usual joint characteristics (union by
fibrous, cartilaginous, or synovial tissues).
• The SC and AC joints 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.
 Resting Position of the Scapula
• Normally, the scapula rests at a position on the posterior thorax
approximately 2 inches from the midline, between the second
through seventh ribs.
• In view, it can be seen that the scapula rests in an internally
rotated position 30 to 45 degree anterior to the coronal plane
• Scapula is tipped anteriorly approximately 10 to 20 degree from
vertical , and is upwardly rotated 10 to 20 degree from vertical.
 Cont….
• Although these “normal” values for the resting scapula
are cited, substantial individual variability exists in
scapular rest position, even among healthy subjects.

• Motions of the scapula are

⮚ upward/downward rotation,

⮚ internal/external rotation, and

⮚ anterior/posterior tipping.
A. Superior View: The scapula rests in an internally

rotated position, 35° to 45° anterior to the coronal

plane.

B. Side View: The scapula at rest is tilted anteriorly,

approximately 10° to 15° to the vertical plane.

C. Posterior View: The longitudinal axis of the scapula

(90° to an axis through the spine) is upwardly rotated 5°

to 10° from vertical.

 Cont….
• Of these three AC joint rotations, only upward/downward

rotation is readily observable at the ST - “primary” scapular

motion.

• Internal/external rotation and anterior/posterior tipping are

normally difficult to observe - “secondary” scapular motions.

• Scapular motions on the thorax must occur in combinations,

such as the simultaneous upward rotation, external rotation,

and posterior tipping that occur when the arm is abducted.

Winging of scapula
 Scapulo-thoracic Stability

• Muscles that attach to both the thorax and scapula maintain contact

between the articular surfaces while producing the movements of the

scapula.

• In addition, stabilization is provided through the ST musculature by

pulling or compressing the scapula to the thorax.

• Ultimate functions of scapular motion are to orient the glenoid fossa for

optimal contact to add range to elevation of the arm, and to provide a

stable base for the controlled motions between the humeral head and

glenoid fossa.
 Scapulo-humeral rhythm
During humeral elevation (flexion, abduction) scapula and

humerus must move in synchronous fashion which is

often termed “scapulo-humeral rhythm”

• Total range 180°: 120° @ GH joint, 60° of scapular mvmt

• Ratio of 2:1, degrees of GH movement to scapular movement

after 30 degrees of abduction and 45 to 60 degrees of flexion

• Maintain joint congruency

• Length-tension relationship for numerous muscles

• Adequate subacromial space

 Scapulohumeral rhythm
During humeral elevation
• Scapula upwardly rotates

• Posteriorly tips

• Externally rotates

• Elevates & Retracts

– Alterations in these movement patterns can

cause a variety of shoulder conditions
 Gleno - humeral Joint
• GH joint is a ball-and-socket synovial joint with three rotational and
three translational degrees of freedom.

• It has a capsule and several associated ligaments and bursae.

• Because the glenoid fossa of the scapula is the proximal segment of the
GH joint, any motions of the scapula (and its interdependent SC and AC
linkages) may influence GH joint function.

• GH joint has taken up role to serve the mobility needs of the hand and is
subsequently has higher chances to have degenerative changes,
instability.
 Glenohumeral Capsule and Ligaments
• 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.

• The capsule is reinforced by the superior, middle, and inferior

GH ligaments, as well as by the coracohumeral ligament.

• However, a thin area of capsule between the superior and the

middle GH ligaments (known as the foramen of Weitbrecht) is a

particular point of weakness in the capsule.

 Importance of ligaments

• The 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.
• With abduction beyond 45 degree or with combined
abduction and rotation, the IGHLC plays the major role
of stabilization.
 Cont…
• With humeral abduction and medial rotation the
posterior band of the IGHL fans out and provides
posterior stability and resistance to posterior humeral
translation.
• In all positions of humeral abduction, the capsule and GH
ligaments tighten with rotation of the humerus,
producing tension and consequently increasing GH
 Static Stabilization of the Glenohumeral
Joint in the Dependent Arm
• As the humeral head rests on the fossa, gravity acts on the humerus parallel
to the shaft in a downward direction.
• This appears to require a vertical upward pull to maintain equilibrium.

• Such a vertical force could be supplied by muscles such as the deltoid,

supraspinatus, or the long heads of the biceps brachii and triceps.
• Degree of glenoid inclination influences the stability of the GH joint with the
arm in the dependent position.
• If there is a slight upward tilt of the glenoid fossa either anatomically in the
structure of the scapula or through scapular upward rotation, the tilt of the
fossa will produce a partial bony block against humeral inferior translation.
 Cont…
• When the available passive forces are inadequate for static
stabilization, as may occur in the heavily loaded arm, activity of the
supraspinatus is recruited.
• Although the supraspinatus may not be active when the arm is
hanging at the side, paralysis or dysfunction in the supraspinatus may
lead to gradual inferior subluxation of the GH joint, which results in a
loss of joint stability.
• Inferior GH subluxation is commonly encountered in patients with
diminished rotator cuff function caused by stroke or other brain injury.
Static Stabilization of the Glenohumeral
Joint in the Dependent Arm
Mechanism for stabilization of the dependent
arm. With the arm relaxed at the side, the downward pull of gravity
on the arm is opposed by the passive tension in the rotator interval
capsule. The resultant of these opposing forces stabilizes the humeral
head on the glenoid fossa.
Dynamic Stabilization of the Glenohumeral Joint

Deltoid and Glenohumeral Stabilization

• Deltoid muscle is a prime mover (along with the supraspinatus)

for GH abduction especially anterior deltoid.

• Majority of the force of contraction of the deltoid causes the

humerus and humeral head to translate superiorly;

• Only a small proportion of force is applied perpendicular to the

humerus and directly contributes to rotation (abduction) of the
humerus.
 Rotator Cuff and Glenohumeral Stabilization

• Rotator cuff muscles along with long head of the biceps provide dynamic
stability
– control the position of humeral head
– Prevent excessive displacement or translation of humeral head relative
to glenoid
• Co-activation of rotator cuff muscles function to compress humeral
head into glenoid for stability, as well as depress humeral head
– counteracts contraction of deltoid which is elevating humeral
head
» Imbalance between muscle components will create
abnormal GH mechanics and injury
•Although the infraspinatus, teres minor, and subscapularis muscles of the rotator
cuff are important GH joint compressors, equally (or perhaps more) critical to the
stabilizing function of these particular muscles is the inferior downwards pull of
the joint.

The teres minor and infraspinatus muscles, in addition to their stabilizing role,
contribute to abduction of the arm by providing the external rotation that
typically occurs with elevation of the humerus
Supraspinatus as an Independent Abductor
• Supraspinatus muscle is a particularly key structure in
dynamic stabilization. The supraspinatus is either
passively stretched or actively contracting when the arm
is at the side (depending on load); it also participates in
humeral elevation throughout the ROM.

• Mechanical compression and impingement of the

stressed supraspinatus tendon can occur when the sub
acromial space is reduced by osteo ligamentous factors.
Applied Aspects
 Painful arc syndrome
• Supraspinatus tendon is the most vulnerable of the cuff muscles due to the overuse and

potential impingement issues. Rotator cuff tendinitis or tears typically produce pain

between 60 and 120 of humeral elevation in relation to the trunk. This range constitutes

what is known as the painful arc.

• It is within this ROM that the tendons of the rotator cuff are passing beneath the coraco

acromial arch. Beyond 120, the tendons have rotated past the overlying arch structures.

• Degenerative changes in the AC joint may result in pain in the same area of the shoulder

as pain from supraspinatus or rotator cuff lesions.

• Pain due to AC degeneration is more typically found when the arm is raised beyond the

painful arc or when the arm is adducted across the body, compressing the AC joint

surfaces.
• Bicipital tendon sheath is worn or inflamed, or if the tendon is
hypertrophied  Gliding mechanism may be interrupted and
pain produced.

• A tear in the transverse humeral ligament Tendon of long

head popping in and out of the bicipital groove with rotation of
the humerus  a potentially wearing and painful micro trauma
called bicipital tendonitis
 Dislocation
• A shoulder that dislocates comes all the way out of the joint.

• Significant trauma is usually required to cause a shoulder to dislocate.

• The usual direction of dislocation is the front or anterior.

• Anterior dislocations often occur when the arm is outstretched and is forced
backwards.

• It is usually quite painful and there may be partial numbness of the shoulder, arm and
hand.

• Minimum treatment for the first time dislocation should be immobilization in a sling
for 2 – 3 weeks. In spite of this treatment, the recurrence range is still fairly high.
 Subluxation

• A shoulder that subluxes is one that comes part of the way out of the joint,

but not all the way and then goes back in, usually on its own.

• This occurs with less significant trauma than a dislocation. Subluxation, like

dislocation, often occurs when the arm is outstretched .

• It is painful and often the arm feels weak, numb or “not there”. The first

time a shoulder subluxes is usually rather painful and the shoulder may be

sore for several days.

• Immobilization should be done for 2 - 3 weeks

 Acromioclavicular Joint

• Injury to the AC joint is most commonly the result of direct force

produced by the patient falling on the point of the shoulder onto the

ground or a firm object with the arm at the side in the adducted position.

• There may be an additional anteroposterior direction to the force. AC

joint injuries vary along a continuum of ligament injuries, beginning with

a mild sprain of the AC ligaments and progressing through AC ligament

tears, followed by stresses on the coracoclavicular ligament.

• Type I: Direct force to the shoulder produces a minor strain to the fibres

of the AC ligaments.
• Type II: In type II injuries, a greater force to the point of the shoulder is severe

enough to rupture the AC ligaments yet not severe enough to rupture or affect

the coracoclavicular ligaments.

• Type III: This injury involves complete disruption of both AC and coracoclavicular

ligaments without significant disruption of the deltoid or trapezoid fascia.

• UE is usually held in an adducted position with the acromion depressed, while

the clavicle appears “high riding.”

• Clavicle is unstable in both the horizontal plane and the vertical plane, and stress

views on radiographic examination are abnormal.

• Pain on movement is severe, typically for the first 1–3 weeks.

• Neuromuscular control issues:

 Impaired nerve function (e.g., nerve entrapments) can lead to altered muscle

activation patterns, resulting in aberrant movements.

• Scapular Dyskinesis: This refers to abnormal movement or positioning of the

scapula. Since the scapula provides the foundation for glenohumeral motion,

its improper movement can lead to:

 Altered force couples: Muscles that control scapular movement (e.g., serratus

anterior, trapezius) work in force couples. An imbalance in their activity can

lead to abnormal scapular rotation, tipping, or winging.

 Reduced subacromial space: Improper scapular positioning can decrease the

space under the acromion, increasing the risk of impingement of the rotator

cuff tendons and bursa.

• Impingement Syndromes: This occurs when soft tissues (like rotator cuff tendons

or the bursa) are compressed in the subacromial space during arm movements.

It's often a consequence of other biomechanical dysfunctions, such as:

– Scapular dyskinesis.

– Rotator cuff weakness or tendinopathy.

– Poor posture.

• Adhesive Capsulitis (Frozen Shoulder): While the exact cause can be complex, it

involves thickening and contraction of the joint capsule, leading to significant loss

of both passive and active range of motion.

• Degenerative Changes: Over time, abnormal stresses due to biomechanical

dysfunctions can lead to wear and tear of articular cartilage (e.g., osteoarthritis)

and soft tissues.