2. Shoulder joint is a complex joint composed of
clavicle, scapula & humerus.
It links the upper extremity to the thorax or
axial skeleton.
It is a ball and socket type of joint.
Shoulder joint consists of :
Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
INTRODUCTION:
3. Osteology
The scapula is a triangular-shaped bone that functions mainly
as a site for muscle attachment.
Four rotator cuff muscles that act on the shoulder take their
origin from the scapula. These are the supraspinatus,
infraspinatus, teres minor, and subscapularis
Additionally, the trapezius, serratus anterior, rhomboids, and
levator scapulae insert on the scapula and are responsible for
scapular mobility and stability. The scapula is freely moveable,
because it is suspended by these muscles.
The scapula has 4 processes, the spine, the acromion, the
coracoid, and the glenoid. The glenoid cavity (or, alternatively,
the glenoid fossa) is set on the expanded aspect of the lateral
angle of the scapula.
The glenoid cavity is an irregularly shaped oval and has been
compared to an inverted comma shape. It articulates with the
head of the humerus, forming the glenohumeral joint, which
serves as the main joint of the shoulder.
scapula
4. Clavicle
The clavicle is an S-shaped bone that forms the anterior portion of
the shoulder girdle that keeps the arm away from the trunk, allowing
it to move freely. The clavicle has 2 articulations, the sternoclavicular
joint and the acromioclavicular joint.
Humeral head
The proximal articular surface of the humerus is termed the humeral
head. The humeral head articulates against the shallow glenoid
cavity. Only 25% of the humeral head surface makes contact with
the glenoid cavity. The glenoid labrum, a fibrocartilaginous ring
attached to the outer rim of the glenoid cavity, provides additional
depth and stability.
5. Articulations
Joint between medial end of clavicle and superolateral aspect of manubrium.
Links the upper extremity directly to thorax.
▸ True synovial joint.,has a fibrocartilagenous articular disc which divides it into 2
compartments.
Stabilizers of SC Joint:
-Costoclavicular ligament
-Interclavicular ligament-Sternoclavicular ligaments
▸ Articular disc .
Sternoclavicular ligaments-prevents anterior and posterior dislocations.
Costoclavicular ligament-limits upward a posterior displacement of clavicle.
Interclavicular ligaments-restraint SC Joint superiorly
Sternoclavicular joint
6. Acromioclavicular joint
Joint between lateral end of clavicle & acromion of scapuia.
Synovial joint
Articular Disc present.
ACROMIO-CLAVICULAR LIGAMENT:
-Superior AC Ligament
-Inferior AC Ligament
-coracoclavicular ligament
Glenohumeral joint
▸ Joint between glenoid fossa of scapula and head of humerus.
Ball and socket joint.
Glenoid fossa faces slight anteriorly.
The glenoid labrum is a ring composed of mostly dense fibrous tissue. The average depth of the glenoid cavity is 2.5 mm, but
the labrum serves to increase this depth. Although the labrum increases the depth and volume of the glenoid cavity, it does
not seem to increase the stability of the glenohumeral joint.
7. Ligaments
Coracoclavicular
ligament
The conoid and
trapezoid ligaments
comprise the
coracoclavicular
ligaments (CCLs) .
They function to
maintain the
articulation of the
clavicle with the
coracoid process of
the scapula.
Glenohumeral
ligament
Three glenohumeral
ligaments exist:
(1) the superior
glenohumeral ligament
(SGHL),
(2) the middle
glenohumeral ligament
(MGHL), and
(3) the inferior
glenohumeral ligament
(IGHL).
Coracohumeral
ligament
The coracohumeral
ligament (CHL)
originates on the
base and lateral
border of the
coracoid process of
the scapula and
inserts on the
greater tubercle.
8. Rotator cuff
The supraspinatus, infraspinatus, teres minor, and subscapularis muscles
comprise the rotator cuff .
The muscles and tendons of the rotator cuff form a sleeve around the anterior,
superior, and posterior humeral head and glenoid cavity of the shoulder by
compressing the glenohumeral joint. In addition to stabilization, the rotator cuff
provides the shoulder with tremendous mobility.
Subacromial bursa
The subacromial bursa lies on the superior aspect of the
supraspinatus tendon . The bursa acts to cushion and reduce
friction during motion between the overlying bone of the
acromion and the soft rotator cuff muscles below. It often
extends laterally to be continuous with the subdeltoid bursa.
9. MOVEMENT Plane of motion AXIS Muscles Rom
Flexion Sagittal Transverse
Pectoralis major,Anterior fibres of
Deltoid,Coracobrachialis,
Short head of Biceps
0-90 deg
Extension Sagittal Transverse
Posterior fibres of Deltoid,Lattisimus Dorsi,Teres
Major,Sternocostal head of Pectoralis major
0-45 deg
Abduction Frontal Sagittal
Deltoid(Middle fibres)
Supraspinatus
Serratus Anterior
Upper & lower fibres of Trapezius.
175 degree
Adduction Frontal Sagittal
Pectoralis major,Lattisimus dorsi,Long head of
Triceps,Teres major,Coracobrachialis
Internal
rotation
Transverse Vertical
Pectoralis major,Anterior fibres of
Deltoid,Lattisimus Dorsi,Teres major,Subscapularis
0-70 deg
External
rotation
Transverse Vertical
Posterior fibres of Deltoid,Infraspinatus,Teres
minor
0-90 deg
Muscles And Movements
10. Circumduction :
A combination of flexion, abduction, extension,
and adduction or in the reversed sequence
o glenohumeral joint : flexion → abduction → extension → adduction
o glenohumeral joint (reversed ): extension abduction → flexion → adduction
14. Inspection
Anterior side
Deltoid -Atrophy
Pain at insertion site mostly
referred from rotator cuff
pathology:rarely due to
deltoidtendinitis
Subacromial region:
swelling- bursitis
Biceps tendon rupture-
Popeyebulge
15. Scapula Position : high sprengel's
Fossae : supraspinatus & infraspinatus atrophy.
Borders of scapula :lateral - prominent in LD
atrophy , superior - prominent insupraspinatus
&trapezius atrophy , Vertebral - prominent in
serratus ant weakness/winging
Posterior side
Tenderness
Swelling
Palpable gap in muscles
PALPATION
16. Movements
Active
Patient attempts to touch
the oppositescapula thus
testing abduction & ER and
adduction & IR.
Good screening test for
ROM assessment .
Apley's scratch test
19. 1. Instability
Glenohumeral Dislocation
Anterior dislocation
Hamilton Ruler test
Duga's test
Callaway's test
Posterior dislocation
ER restricted
Prominence in posterior deltoid
Light bulb sign
20. Chronic Shoulder Instability
Unidirectional- anterior, posterior, inferior
Multidirectional (MDI) - anterior &/ or posterior + inferior
CHRONIC UNIDIRECTIONAL INSTABILITY
PROVOCATIVE TESTS
to document the presence & direction of instability
Anterior Instability
Crank test
Fulcrum test
Jobes's relocation test
posterior instability
Jerk test
Circumduction test
QUANTITATIVE TESTS
To quantitate the amount of laxity
Drawer's test
load and shift test
21. IMPINGEMENT
Shoulder impingement syndrome is a painful condition of the upper
extremity resulting from a structural narrowing of the subacromial
space.
O'BrienTest
Neer
impingement
sign
22. Rotator cuff tear
Inability to abduct or flex foreward
Atrophy of supra & infraspinatus fossae
Empty can test - for supraspinatus
ER at arm at side with elbow flexed- for infraspinatus
Lift off test/ abdominal compression test - for subscapularis
Drop Arm sign
External rotation lag sign
23. BICEPS TENDINITIS
Biceps tendonitis describes a clinical condition of inflammatory
tenosynovitis, most commonly affecting the tendinous portion of
the LHB as it travels within the bicipital groove in the proximal
humerus.
Yergassons
test
Speeds test
24. AC joint problems
Cross Body Adduction test (also called Cross chest adduction test or scarf
test) is used to check for Acromioclavicular Joint pathology.
With the patient sitting or standing, the 90° abducted arm on the affected
side is forcibly adductd across the chest toward the normal side.
Pain in the acromioclavicular joint suggests Acromioclavicular joint
pathology, anterior impingement, or suprascapular nerve entrapmentsyndrome.
(Absence of pain after injection of an anesthetic is a sign of joint disease.)
25. STIFF SHOULDER
Restriction of all range of motion, esp Abduction & ER
Pain on attempted movements.
ER restriction occurs in 2 conditions only
1. Stiff shoulder
2. Posterior dislocation
Overhead athletes may have restriction of IR due to posterior capsular tightness
