SHOULDER COMPLEX

Components of shoulder complex

Integrated function
Motion of scapula
Applied aspects
Components of shoulder complex
Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
Scapulothoracic joint
Subacromial / suprahumeral joint
Sternoclavicular joint
Sternoclavicular articulating surfaces
Sternoclavicular disk
Joint capsule and ligaments
Sternoclavicular motions
Sternoclavicular stress tolerance
Sternoclavicular articulating surfaces
The structural attachment of scapula, clavicle
and upper limb to axial skeleton
Any motions in scapula result in motion of SC
joint
Plane synovial joint
3 rotatory and 3 translatory degrees of
freedom
Disk and clavicle, disk and manubrium,
costoclavicular joint
Cont..
2 two saddle shaped surfaces… one at sternal end/
medial end of clavicle and one at notch formed by
manubrium sternum and first costal cartilage
The proximal end of the clavicle articulates with
the clavicular notch of the manubrium of the
sternum and with the cartilage of the first rib
Little contact between manubrium sternum and
clavicle
Scapula attached to lateral end of clavicle
Movements of clavicle cause motion at SC joint
disk and manubriocostal cartilage
Sternoclavicular disk
SC joint has fibrocartilage disk or meniscus increasing
congruence between joint surfaces
Superior--- attached to postero superior clavicle
Lower --- attached to manubrium and first costal
cartilage
Divides SC joint into two cavities and act as pivot point
during clavicle motion
Elevation/depression= medial end of clavicle rolls and
slides on stationary disk, where upper disk as pivot point
Protraction/ retraction= SC disk and medial clavicle roll
together on manubrial facet, where lower disk as pivot
point

Cont..
Mechanical axis for this movement is not in
SC joint but in costoclavicular ligament
SC disk important in stability function by
increasing congruence and absorbing forces
transmitted along clavicle from lateral end .
This is due to its unique diagonal attachment
Sternoclavicular joint capsule & Ligaments
Strong fibrous capsule and 3 ligaments for majority of
support
1. Sternoclavicular ligament--- Anterior & Posterior SC
ligaments check A- P Translatory motion of medial
end of clavicle
2. Costoclavicular ligament --- strong, between clavicle
and first rib. Anterior laminae (lateral directed
fibres), posterior laminae (medially directed) checks
elevation of lateral end of clavicle. Medial fibres
resist medial movement of scapula
3. Interclavicular ligament --- resist excessive
depression of distal clavicle, hence protecting
brachial plexus and subclavian artery
Sternoclavicular motions
1. elevation/ depression
2. Protraction/retraction
3. Anterior/ posterior rotation of clavicle

Elevation/depression, protraction/retraction
visualise from lateral end of clavicle
Anterior /posterior in long axis of entire
clavicle
Cont..
 Elevation/ depression--- around A- P axis by convex
clavicular surface, concave manubrium, first costal cartilage
with axis at costoclavicular ligament. Elevation: lateral
clavicle rotates up, to 48*, full degree not utilised in
functional arm elevation
Depression : lateral clavicle rotates down to less than 15*
 Protraction/retraction---around vertical (superoinferior)
axis . Concave medial end of clavicle and convex manubrial
side.
Protraction: lateral clavicle rotates anteriorly & medial clavicle
slide over manubrium with 15 to 20*
Retraction: lateral clavicle rotates posteriorly with 20 – 30*
 Anterior/posterior rotation--- occurs as a spin between
saddle shaped surfaces of medial clavicle and
manubriocostal facet. From rest usually to
posterior/backward rotation (50*) then rotating back
anteriorly to resting position(less than 10*)
Sternoclavicular stress tolerance
Bony segements, ligaments and capsules, and
disk produce a joint that can produce both
mobility and stability function.
Purpose of joining upper limb to axial
skeleton contributing upper limb mobility and
withstanding stress
Disk and ligament reduce stress, prevent
intra- articular motion thus decreasing risk of
subluxation or dislocation.
Acromioclavicular joint
Acromioclavicular articulating surfaces
Acromioclavicular joint disk
capsule and ligaments
Acromioclavicular motions
Acromioclavicular stress tolerance

Primary function is to allow scapula,

additional range of rotation on thorax (for
adjustments, changing shape of thorax during
arm movement)
Acromioclavicular articulating surfaces
Lateral end of clavicle and small facet on
acromion of scapula
Flat, reciprocally concave- convex
Inclination varies from individual to
individual (16* - 30*)
Transmission of force from upper extremity
to clavicle
 if vertical inclination of surface is more, then
more prone to wearing of shear force
Acromioclavicular joint disk
Variable in size between individuals, between
sides, between ages of individual
Through 2 yeears is fibrocartilagenous union,
then with use of UE’s, then meniscoid
fibrocartilage remnant within joint
Acromioclavicular Capsule and Ligaments
Capsule is weak and hence can maintain integrity of
joint with reinforcement from Ligaments
1. Superior Acromioclavicular ligament --- assist capsule
in opposing articular surfacesand in controlling A- P
joint stability. Reinforced by aponeurotic fibres of
trapezius and deltoid
2. Inferior Acromioclavicular ligament --- less stronger
than superior
3. Coracoclavicular Ligament ---- unites clavicle&
scapula. Two parts: lateral portion (trapezoid), medial
portion (conoid). Separated by adipose tissue and large
bursa. Both attached in under surface of clavicle. Limit
upward rotation of scapula at AC joint
Cont…
Trapezoid ligament ---
- Quadrilateral in shape , horizontal orientation
- Resistance to posterior translatory forces applied
in distal clavicle
Conoid ligament ---
- Triangular in shape, vertically oriented
- Restraint for AC joint in superior, inferior
direction
Critical role by Coracoclavicular ligament in
coupling posterior rotation of clavicle to scapula
rotation during elevation
Acromioclavicular Motions
Internal/ external rotation
Anterior / posterior tipping/tilting
Upward/downward rotation
Cont..
Internal/ external rotation
- Vertical axis
- Glenoid fossa of scapula anteromedially and
posterolaterally
- These occur to maintain contact of scapula
with horizontal curvature of thorax as clavicle
protracts and retracts
- Difficult to measure the available range
Cont..
Anterior / Posterior Tipping
- Oblique coronal axis
- ANT – acromion tipping forward and inferior
angle tipping backward
- POS- rotate acromion backward , inferior angle
forward
- To maintain contact of scapula with contour of
rib cage and orient glenoid fossa. Maintain
vertical curvature of ribs
- Available passive is 60* but with normal
flexion/extension tipping is 30- 40*
Upward/ downward rotation
- Oblique A- P axis
- Upward--- tilt glenoid fossa upward 30*,
coracoid process and superior border move
away from clavicle
- Downward --- tilt glenoid fossa downward 17*
- Motions are limited by attachment of
coracoclavicular ligament
Acromioclavicular stress tolerance
Extremely susceptible to trauma and
degenerative change due to
small/incongruent surfaces
Degeneration from second decade and
narrowed by sixth decade
Subluxations, sprains common with shoulder
complex
Scapula thoracic joint
Articulation of scapula with thorax
Not a true anatomic joint
Any movement on scapula on thorax result in
movement of AC/ SC joints
-- resting position of scapula
-- motions of scapula
-- scapulo thoracic stability
Resting position of scapula
 Rest on posterior thorax approx 2 inches from midline, between
2nd to 7 th ribs
 Scapula internally rotated 30* to 45* from coronal plane, tipped
anteriorly approx 10* to 20* from vertical and upward rotated
10 – 20* from vertical
 Vertebral or medial border used as reference axis, then
magntude of upward rotation is 2 – 3* from vertical
 Though normal values cited, it varies among healthy individuals
 Primary scapular motions– upward and downward rotation
(observable)
 Secondary scapular motions – internal/external rotation,
anterior/posterior tipping
 Translatory motions--- elevation/depression,
protraction/retraction
 Linkage of scapula to AC joint, SC joint ,… movements of
scapula co- occur in combinations on thorax
Motions of scapula
Upward/ downward rotation– upward (60*
available) is principal motion of scapula and
significant role in elevation of arm. Closed
chain between SC, AC and ST joints,
prportions of up/downward rotations
contribute to other motions
Elevation/ depression– scapular eelvation/
depression.. Shrugging shoulder up/
depressing shoulder down. Translatory
motions .. Move cephalad up or caudally
down along rib cage. Elevation of clavicle co-
occurs
Cont..
 Protraction/retraction– translatory motion. Away from
(protraction– glenoid fossa face laterally, vertebral border in
contact with rib) or toward (retraction) vertebral column.
Scapula follows contour of ribs with combination of clavicle
protraction/retraction at AC joint

 Internal/ external Rotation – not identifiable. Accompany

with protraction/retraction of clavicle at SC joint. Internal---
result in prominence of vertebral border, loss of contact on
thorax (winging of scapula). Excessive indicate pathology

 Anterior/posterior tipping--- not obvious on observation.

Occurs at AC joint accompany anterior/posterior rotation of
clavicle at SC joint. Anterior tipping– prominence of inferior
angle of scapula in isolated indicate pathology or in abnormal
posture
Scapulothoracic stability
By structures that maintain integrity linked AC and
SC joints
Muscles maintain contact during movements
Stabilization in addition provided by ST
musculature by pulling or compressing scapula to
thorax
Function of scapula is to orient glenoid fossa for
optimal contact for manuevering arm , to addd
range on elevation and provide stable base for
contolled motions between glenoid and humerus
Associated muscleand linkage provide stability and
mobility
GLENOHUMERAL JOINT
 Ball and socket synovial joint
 3 rotational/translational degrees of freedom
 It has capsule, ligaments and bursae
 Glenoid fossa is proximal segment and any motion of scapula
influence GH motions
 Sacrificed articular congruency to serve mobility needs of hand
 - GH articulting surfaces
 - glenoid labrum
 - Glenohumeral Capsule and ligaments
 - coracoacromial arch
 - bursae
 - GH motions
 Static stabilization
 Dynamic stabilization
GH articulating surfaces
Shallow concavity glenoid fossa
Glenoid fossa tilted slightly up/down when arm
is at side
Not lie on plane in perpendicular of scapula, it
may be anteverted (Gl Fo face slightly
anterior) /retroverted (Gl Fo face slightly
posterior)upto 10* with 6 – 7* retroversion
Radius of curvature of fossa increased by
articular cartilage, thinner in middle thicker on
periphery increasing
Cont
 The angle of inclination --- by an axis through humeral
head and neck in relation to a longitudinal axis through the
shaft of the humerus and is normally between 130° to 150°
in the frontal plane
The angle of torsion -- by an axis through the humeral head
and neck in relation to an axis through the humeral
condyles---- transverse plane approximately 30° posterior
The posterior orientation of the humeral head with regard to
the humeral condyles is also called posterior torsion,
retrotorsion, or retroversion of the humerus. When the
arms hang dependently at the side, the two articular surfaces
of the glenohumeral joint have little contact; the inferior
surface of the humeral head rests on only a small inferior
Glenoid Labrum
 Articular surface enhanced by glenoid labrum
 Accesory structure increasing depth and concavity of glenoid
fossa by 50% as ring surrounding surface
 The core of the labrum is composed of densely packed
fibrous connective tissue
 It is covered by superficial mesh consistent with
cartilaginous tissue, with fibrocartilage at the attachment of
the labrum to the periphery of the fossa.
 Serve as attachment to ligaments and long head of biceps
The functions include
 -resistance to humeral head translations,
 -protection of the bony edges of the labrum,
 -reduction of joint friction, and
 -dissipation of joint contact forces.
Glenohumeral Capsule and LIgaments
The glenohumeral joint is surrounded by a large, loose
capsule that is taut superiorly and slack anteriorly
The capsule tightens when the humerus is abducted and
laterally rotated, making this the close-packed position
for the glenohumeral joint.
The capsular surface area is twice that of the humeral
head, and more than 2.5 cm of distraction of the head
from the glenoid fossa is possible in the loose-packed
position.
The relative laxity of the glenohumeral capsule is
necessary for the large excursions of the joint but
provides little stability without the reinforcement of
ligaments and muscles
Cont..
Ligaments (vary in size in individuals)
Superior (anterior and inferior joint stability)
Middle(anterior joint stability)
Inferior Glenohumeral ligaments (thsese are
thickened tissue within the capsule itself)
Coracohumeral ligaments
In all positions of humeral abduction, lateral
or medial rotation of the humerus tightens
the capsule and glenohumeral ligaments and
increases glenohumeral joint stabilization.
Rotator cuff muscles
They provide dynamic reinforcement to the
capsule through their anatomical proximity to
the joint and because the tendons insert
directly onto and blend into the glenohumeral
capsule
Coraco Acromial Arch
 The coracoacromial (or suprahumeral) arch is formed by the
coracoid process, the acromion, the coracoacromial ligament,
and the inferior surface of the acromioclavicular Joint.
 The coracoacromial arch forms an osteoligamentous vault over
the humeral head and the region between the arch and the
humeral head is called the subacromial space.
 The subacromial bursa, the rotator cuff tendons, and a
portion of the tendon of the long head of the biceps brachii lie
within the subacromial space and are protected superiorly from
direct trauma by the coracoacromial arch
 When the subacromial space decreases even more than what
has been measured in healthy subjects, the likelihood of
impingement of the rotator cuff tendons and subacromial
bursa during elevation of the arm increases.
Bursae
 Although all bursae at the shoulder contribute to function, the
most important are the subacromial and subdeltoid bursae
 These bursae separate the supraspinatus tendon and head of
the humerus from the acromion, coracoid process,
coracoacromial ligament, and deltoid muscle.
 These bursae may be separate but are commonly continuous
with each other and are collectively known as the subacromial
bursa
 The subacromial bursa reduces friction to permit smooth
gliding between the humerus and supraspinatus tendon and
the surrounding structures.
 Interruption or failure of this gliding mechanism is a common
cause of pain and decreased glenohumeral motion, although it
rarely occurs as a primary problem
Glenohumeral motions
Intra-articular Contribution to
Glenohumeral Motions
Full ROM of the glenohumeral joint is, to a
reasonable
degree, a function of the intra-articular
movement of the
incongruent articular surfaces.
The convex humeral head is a substantially
larger surface and may have a different radius
of curvature than the shallow concave fossa.
Cont
Static Stabilization of the Glenohumeral Joint
in the Dependent Arm
 Given the incongruence of the glenohumeral articular
surfaces, bony geometry alone cannot maintain joint
stability with the arm relaxed at the side, requiring the
contribution of other mechanisms.
 With the humeral head resting on the fossa, gravity imparts
a caudally directedtranslatory force on the humerus.
 To maintain equilibrium, a cranially directed force is
needed and couldbe supplied by active contraction or
passive tension of muscles such as the deltoid,
supraspinatus, or the long heads of the biceps brachii and
triceps brachi
Dynamic stabilization of glenohumeral joint
Deltoid
Rotator cuff
Supraspinatus
Long head of biceps
Integrated function of shoulder complex
Motion available to the glenohumeral joint alone will not
allow full ROM of humerus
CONTRIBUTIONS
- Scapulothoracic contribution
- sternoclavicular Joint contribution
- acromioclavicular joints.
Combined scapulohumeral motion is necessary for
(1) Distributing the motion between joints, large ROM with
less stability
(2) maintaining glenoid fossa in optimal position in relation to
the head of the humerus, increasing joint congruency while
decreasing shear forces
(3) to maintain a good length-tension relationship while
minimizing or preventing active insufficiency of the
glenohumeral muscles.
ST & GH contributions
An overall ratio of 2° of glenohumeral to 1° of
scapulothoracic motion during arm elevation
is commonly referred to as scapulohumeral
rhythm.
Flexion or abduction of 90° in relation to the
thorax would be accomplished through
approximately 60° of glenohumeral and 30°
of scapulothoracic motion.
The trunk may laterally flex or extend to gain
additional range for the arm
cont
The humerus can move independently on the
glenoid fossa.
The glenohumeral joint contributes 100° to
120° of flexion and 90° to 120° of abduction.
But The combination of scapular and
humeral movement results in additional
maximum range of elevation of 150° to 180°
The scapula posteriorly tilt on thorax during
elevation of arm
SC & AC Joint contributions
Elevation of the arm in any plane involves motion of
the sternoclavicular and acromioclavicular joints to
produce scapulothoracic motion.
The initiation of scapulothoracic upward rotation as
the arm is flexed or abducted appears to couple
with clavicular posterior rotation and elevation at
the sternoclavicular joint
This scapular upward rotation occurs around an
oblique A-P axis, passing through the
costoclavicular ligament (sternoclavicular joint
motion) and projecting backward through the root
of the scapular spine (scapulothoracic motion)
Cont
Tension in coracoclavicular ligament (especially
the conoid portion) during --- coracoid process of
the scapula gets pulled downward with muscle
forces to upward rotate the scapula at the
acromioclavicular joint.
The tightened conoid ligament pulls its
posteroinferior clavicular attachment forward and
down as the coracoid process drops, causing the
clavicle to posteriorly rotate.
Posterior rotation of the clavicle around its
longitudinal axis will result in additional
scapulothoracic upward rotation
Muscles
Elevation
Depression
Applied
Post – mastectomy / radiation--- secondary
muscular and soft tissue fibrosus
Joints hypomobility in pain
Muscles overuse (trapezius )
subluxation/dislocation
Ageing and shoulder joint