i. Shoulder Complex a. Bones
b. The only bone that will connect the Upper extremities to the trunk: Clavicle ii. Clavicle
a. Orientation of clavicle, scapula and humerus
b. Convex medially 2/3 (vascular supply and blood vessels passes through), concave lateral 1/3(
common site of clavicle)
c. Slightly superior to horizontal plane, posterior to frontal plane.
iii. Scapula T2-T7
i. Medial (5-6cm or 2-3 fingerbreadths) ii. Lateral
iii. Superior border
iv. Rotated anteriorly to the frontal plane 35o (aka Scapular plane) v. Glenoid fossa: tilted upward 5-10o
1. Paralysis of upper trapezius, subluxation of humerus iv. Humerus
i. Anatomical neck
ii. Surgical neck – MC site of humeral fractures iii. Greater Tubercle – palpable by Internal rotation iv. Retroverted 20o posterior to frontal plane
v. Angle of inclination 125o v. Joints (3)
a. True joints
i. Sternoclavicular joint
1. Type: Saddle/ sellar type of joint, 3o of freedom
OPP arm by the side
CPP full elevation
CP pain @ extremes ROM, especially horizontal adduction and full elevation 2. Arthokinematics:
a. Sternal end of clavicle i. Vertical: convex ii. Horizontal: concave
Movement Roll Slide Ligament
Elevation Superior Inferior Costoclavicular ligament Depression Inferior Superior Interclavicular ligament Protraction Anterior Anterior Posterior SC ligament Retraction Posterior Posterior Anterior SC ligament Rotation Spins on articular disc Coracoclavicular ligament
3. Ligaments:
a. SC ligaments Anterior/ posterior
b. Interclavicular ligament, - prevent depression of the clavicle at the SC joint
c. Costoclavicular ligament – prevent elevation of clavicle 4. Movement
Movement Plane Axis ROM
Elevation-depression Frontal Z Elevation 30-45 Depression 5-10 Protraction-retraction Horizontal Y 15o Transverse, Upward rotation Horizontal Y 40o ii. Acromioclavicular joint
1. Plane type of joint 3o of freedom, 2. Ligaments
a. Acromioclavicular ligament b. Coracoclavicular ligament
i. Conoid (medial/center): taut in retraction and upward rotation ii. Trapezoid(lateral): taut in Protraction and Downward rotation 3. Movement
Movement Plane ROM
Upward and downward rotation Scapular plane 20-30o
Rotational adjustments Horizontal plane: Internal and external tilting
Sagittal plane: Anterior and Posterior tilting 10-30o
OPP arm by the side
CPP 90 abduction
CP pain @ extremes ROM, especially horizontal adduction and full elevation
4. AT what movement of the humerus will posterior tilting of the scapula occur.
Abduction and flexion iii. Glenohumeral joint
1. Ball and socket joint 3o of freedom
OPP 55o abduction 30o horizontal Adduction CPP Full abduction and lateral rotation
CP ER>ABD>IR
2. Ligaments
a. Coracohumeral ligament – provides passive stabilization at the GH joint i. Prevents the downward displacement of the head of the
humerus, AP stabilization, prevent excessive adduction b. Glenohumeral ligament
i. Superior
1. Prevent downward displacement, and AP movement of the humeral head.
ii. Middle
1. Becomes taut from 45-60o abduction and External rotation, excessive anterior displacement of humeral head
iii. Inferior
1. Taut @ 90o abduction
2. Prevent inferior displacement of humeral head 3. Parts:
a. Anterior band, prevent ER b. Axillary pouch
c. Posterior band, prevent IR iv. Points of weakness
1. Foramen of Weitbrecht between Superior and middle 2. Foramen of Ruvier between Middle and inferior c. Bursae Prevents friction and allows lubrication
i. Subacromial bursa ii. Subdeltoid bursae iii. Subcoracoid bursa d. Osteokinematics
i. Active abduction
1. If GH is in full IR: 60o of abduction
a. The greater tubercle will be exposed and hit the coracoacromial arch.
2. If GH is in 90o of ER: 90o abduction ii. Passive abduction
1. Can reach up to 120o
Movement Planes of motion axis ROM (GH only) ROM (ST only) ROM (GH + ST)
Flexion-extension Sagittal X 120o 60 180
Abduction Frontal Z 120 60 0-180
ER-IR Forizontal Y - - ER: 0-90
IR: 0-70 Movement (OKC) Roll Slide
Abduction Superior Inferior
Adduction Inferior Superior
Flexion 140o
Flexion 140-180o Anterior
Posterior Posterior Anterior
Extension Posterior Anterior
External rotation Posterior Anterior Internal rotation Anterior Posterior
b. False joint
i. Scapulothoracic joint – motions occurring in SC and AC joint are composite of what?
1. Movable base for the humerus 2. Increases the ROM
3. Provides stability for GH joint
4. Provide shock absorption on an outstretched hand
5. Permits elevation of the body in closed chain activities: Depression
6. Movement: protraction, retraction, elevation depression, upward and downward rotation.
SC joint AC joint Elevation 30-45o Elevation: 20o Depression Depression 5-10o
Protraction 15o protraction Retraction 15 o retraction
Rotation 40o 20o
vi. Scapulohumeral rhythm
a. After 30o of abduction, there is 2:1 ratio between glenohumeral joint and scapulothoracic joint. 0-30o setting phase.>30o
vii. Six kinematic principles associated with full abduction of the should
Principle 1 Based on a generalized ration 2:1 scapulohumeral rhythm, active shoulder abduction of about 180o occurs as a result of simultaneous 120o of GH joint abduction and 60o of ST UR
Principle 2 The 60o of UR of the scapula during full shoulder abduction is the result of a simultaneous elevation at the SC joint with UR at AC joint
Principle 3 The clavicle retracts at the SC joint during shoulder abduction Principle 4 The scapula posteriorly tilts and ER during full shoulder abduction
Principle 5 The clavicle posteriorly rotates around its own axis during shoulder abduction Principle 6 The GH joint ER during shoulder abduction
viii. Companion motions of the shoulder girdle and GH joints
GH motion ST motion SC motion AC motion
Flexion UR, posterior tilting medial tilting followed by lateral tilting in higher ranges of flexion
Elevation Posterior rotation Protraction
Upward rotation Horizontal and Sagittal plane rotational adjustments
Extension Downward rotation, anterior tilting, Reverse of all triplanar motion occurring inflexion
Depression Anterior rotation Retraction
Downward rotation Horizontal and Sagittal plane
Rotational adjustments
Abduction UR, posterior tilting, medial tilting initially followed by lateral tilting in higher ranges of abduction
Elevation Posterior rotation Retraction
Upward rotation Horizontal and Sagittal plane
Rotational adjustments
Adduction Downward rotation, anterior tilting , lateral tilting initially followed by medial tilting when returning to anatomic position
Depression Anterior rotation Protraction
Downward rotation Horizontal and Sagittal plane rotational adjustments Lateral rotation and
horizontal abduction Retraction - -
Medial rotation and
horizontal adduction Protraction - -
ix. Phases of abduction a. 0-90
i. SC joint 25o elevation ii. AC joint: 5o upward rotation iii. GH joint: 60o
iv. Terminated by: hitting of greater tubercle with the glenoid b. 90-180
i. SC joint: 5o elevation; 35o posterior rotation of the clavicle ii. AC joint: 25o upward rotation
iii. GH joint: 60o
iv. Terminated by: resistance of adductor muscles E.g. Latissimus Dorsi x. Muscles
a. Responsible for movement and stabilization of the scapula during GH joint motion b. Originate on the thorax and on the scapula
i. Serratus anterior ii. Trapezius
iii. Rhomboids major and minor iv. Pectoralis minor
v. Levator Scapulae
Muscle Origin Insertion Innervation Action Paralysis Serratus anterior
aka saw muscle Lowest 5 digitations:
strongest portion of the muscle
First 8-9 ribs Medial border
of scapula Long Thoracic Nerve and lower fiber inserts into limited to 120o and shifts the orientation of the glenoid fossa inferiorly
Rhomboids Minor
Ligamentum nuchae and
spines of C7-T1 Medial border
of the scapulae Dorsal scapular nerve
Retractions Scapula is placed in protracted position on the thorax
Rhomboids Major Spine of 2nd thoracic to T5
Lower Medial border of the
scapula Retraction
Pectoralis minor 3rd, 4th, 5th ribs Coracoid
process Medial pectoral nerve rotation of the scapula against resistance
Pectoralis major Lateral
Levator scapulae
Transverse process first 4 cervical to elevate and downwardly rotate the scapula Glenohumeral stabilizing muscles of the shoulder
Supraspinatus
“workhorse of abduction” max contract 90-180o, active all throughout ROM
Supraspinous
fossa Greater
tuberosity Suprascapular nerve
Infraspinatus Infraspinous
fossa Greater
tuberosity Suprascapular
nerve Laterally
rotates arm
lateral border of the scapula
Greater
tuberosity Axillary nerve
Subscapularis Subscapular
fossa Lesser
tuberosity Upper and lower subscapular nerve
Medially rotates arm and stabilizes the shoulder joint If in IR – adductor
If in ER – abductor
If overhead – assist in extension
Biceps Brachii
Supraglenoid tubercle and coracoids process of the scapula Triceps Brachii Infraglenoid
tubercle Olecranon
process Radial nerve Extensor Large muscle movers of the shoulder
Deltoid Anterior Middle (greatest activity 90-120o) posterior
Lateral third of the clavicle, acromion, and spine of the scapula
Deltoid
tuberosity Axillary nerve
Abduct shoulder Ant: flexes Post:
Extends
In paralysis of the
supraspinatus, the deltoid can abduct the arm in full range but
cartilages of the first 6 ribs Clavicular:
clavicle
Lateral lip of the bicipital groove
Medial and lateral pectoral nerves
Adducts arm and rotates it medially clavicular fibers also flex arm
Coracobrachialis Coracoid process
xi. Passive and dynamic stabilization of the glenohumeral joint a. Passive stabilizers:
i. Coracohumeral ligament ii. Superior GH ligament
iii. Negative atmospheric pressure within the capsule b. Dynamic stabilization
i. Rotator cuff muscles ii. Biceps brachii iii. Deltoid
xii. Antagonists and synergists of scapular upward rotation a. Synergists
i. Upper trapezius ii. Lower trapezius iii. Serratus anterior b. Antagonists
i. Rhomboids ii. Pectoralis minor iii. Levator scapulae xiii. Scapular retraction
a. Synergists
i. Rhomboids ii. Trapezius b. Antagonists
i. Pectoralis minor ii. Serratus anterior xiv. Scapular protraction
a. Synergists
i. Pectoralis minor ii. Serratus anterior b. Antagnosists
i. Rhomboids ii. Trapezius xv. Scapular elevation
a. Synergists
i. Upper trapezius ii. Rhomboid iii. Levator scapulae b. Antagonists
i. Pectoralis minor ii. Lower trapezius iii. Lower serratus anterior
xvi. Scapular depression a. Synergists
i. Pectoralis minor ii. Lower trapezius iii. Lower serratus anterior b. Antagonist
i. Upper trapezius ii. Rhomboids iii. Levator scapulae
Flexors Extensors Abductors Adductors ER IR
Pectoralis major Long head of triceps
brachii xvii. Force couple
a. Force couple is define in mechanical terms as two forces whose points of application occur on opposite sides of an axis and in opposite direction to produce rotation of the body
i. Scapular upward rotation 1. Synergists
a. Upper trapezius b. Lower trapezius c. Serratus anterior ii. Scapular downward rotation
1. Synergists
a. Rhomboid b. Pectoralis minor c. Levator scapulae iii. Shoulder elevation
1. Deltoid 2. Supraspinatus 3. Infraspinatus 4. Teres minor 5. Subscapularis