BIOMECH A NI C S OF

SH O U LD ER J O IN T
Y : SU BHASMITA NAY AK
PRESENTED B
GUIDED BY :SHRIYA MA’AM
18TH MARCH 2020
 INTRODUCTION
• The shoulder girdle is the link between the upper extremity and the trunk and is the most dynamic and mobile joint in
the body.

• It is composed of 3 independent joints:-

• Sternoclavicular joint
• Acromioclavicular joint
• Glenohumeral joint
And 2 functional joints:-

• Scapulothoracic joint
• Subacromial/suprahumeral joint or subacromial space
• The shoulder complex consists of four bones:-
• Sternum
• Clavicle
• Scapula
• Humerus
• The shoulder complex are designed primarily for mobility, allowing us to move and position the hand
through a wide range of space. The glenohumeral (GH) joint, which links the humerus and scapula,
has greater mobility than any other joint in the body.

• Shoulder complex constitute half of the mass of the entire upper limb, and they are connected to the
axial skeleton by a single joint, the sternoclavicular (sc) joint. As a result, 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.

• The articulation between the scapula and the thorax is often described as the scapulothoracic (ST)
“joint,” although it does not have the characteristics of a fibrous, cartilaginous, or synovial joint.
Instead, scapula motion on the thorax is a function of sternoclavicular, acromioclavicular, or
combined sternoclavicular and acromioclavicular joint motions. The scapulothoracic joint is
frequently described in the literature as a “functional joint.”
• An additional “functional joint” that is often considered part of the shoulder complex is the
subacromial (or suprahumeral) “joint.” ,is formed by movement of the head of the humerus below
the coracoacromial arch.The movement in this functional joint plays an important role in shoulder
function and dysfunction.

• Elevation of the upper extremity refers to the combination of scapular, clavicular, and humeral motion
that occurs when the arm is raised either forward or to the side (including sagittal plane flexion, frontal
plane abduction, and all the motions in between).

• Motion of the scapula on the thorax normally contributes about one third of the total shoulder complex
motion necessary for arm elevation, whereas the glenohumeral joint contributes about two thirds of the
total motion
 ROM OF SHOULDER COMPLEX
• Shoulder range of motion is traditionally,
 Flexion and extension (elevation of the humerus anteriorly or posteriorly away from the side of the
thorax in the sagittal plane)

 Abduction (elevation in the coronal plane)

 Internal-external rotation (rotation about the long axis of the humerus)
• Although forward elevation of 180° is theoretically possible, the average value in men is 167° and in
women it is 171°. Extension or posterior elevation averages 60° (boone and azen, 1979). These values
are limited by tension on the joint capsule. Abduction in the coronal plane is limited by bony
impingement of the greater tuberosity on the acromion. Forward elevation in the plane of the scapula,
therefore, is considered to be more functional because in this plane the inferior portion of the capsule
is most lax and the musculature of the shoulder is optimally aligned for elevation of the arm.
 STERNOCLAVICULAR JOINT
• The sternoclavicular (SC) joint is a complex articulation, involving the medial end of the clavicle, the
clavicular facet on the sternum, and the superior border of the cartilage of the first rib.

• The joint has a synovial capsule, a joint disc, and three major ligaments.
• The sternoclavicular joint is a plane synovial joint with three rotary and three translatory degrees of
freedom.

• Rotations at the sternoclavicular joint produce movement of both the clavicle and the scapula under
conditions of normal function, because the scapula is linked with the lateral end of the clavicle at the
acromioclavicular joint.

• Similarly, movement of the scapula often results in movement of the clavicle at the sternoclavicular joint.
 ARTICULAR SURFACE:- Click icon to add picture
• The sternoclavicular articulation consists of two shallow, saddle-
shaped surfaces, one at the medial end of the clavicle and one at the
notch formed by the manubrium of the sternum and first costal
cartilage.

• The medial end of the clavicle and the manubrium are incongruent,
with little direct contact between their articular surfaces.

• The superior portion of the medial clavicle does not contact the
manubrium at all but serves as the attachment for the
sternoclavicular joint disc and the interclavicular ligament.

• Movements of the clavicle in relation to the manubrium result in

changes to the areas of contact between the clavicle, the
sternoclavicular joint disc, and the manubriocostal cartilage.
The clavicular facet
on the sternum
typically is
reciprocally shaped,
with a slightly
concave longitudinal
diameter and a slightly
convex transverse
diameter.
STERNO-CLAVICULAR • The sternoclavicular joint has a fibrocartilage disc, or meniscus, that increases
congruence between the articulating surfaces.
DISC:-
• The upper portion of the sternoclavicular disc is attached to the postero-superior
clavicle (sternal end) and interclavicular ligament.

• The lower portion is attached to the manubrium (lateral edge of clavicular facet) and
first costal cartilage, as well as to the anterior and posterior aspects to the fibrous
sternoclavicular capsule.

FUNCTION :

i. Provides stability by increasing joint congruence and by absorbing forces transmitted

along the clavicle .
ii. The unique diagonal attachment of the sternoclavicular disc helps limit medial
movement of the clavicle,
iii. The disc also has a substantial area of contact with the medial clavicle, which helps
dissipate medially directed forces, protecting the small manubrial facet from high
concentrations of pressure.
• During elevation and depression of the clavicle, the
medial articular surface rolls and slides on stationary
disc.
• During protraction and retraction of the clavicle,
the sternoclavicular disc and medial articular surface
roll and slide together on the manubrial facet.The
disc, therefore, is considered part of the manubrium
during elevation and depression and part of the
clavicle during protraction and retraction.
• Anterior and posterior rotation are occur between a
portion of the disc over the first rib on the
anteroinferior edge of the articular surface of the
medial clavicle.
STERNO-CLAVICULAR CAPSULE & LIGAMENTS:-
• The sternoclavicular joint is surrounded by a fairly strong fibrous capsule but depends on 3 ligament complexes
for the majority of its support:

 The anterior and posterior sternoclavicular ligaments : check anterior and posterior translatory
movement of the medial end of the clavicle.
 The bilaminar costoclavicular ligament : a very strong ligament between the clavicle and the first rib and
has two segments, or laminae. Both laminae limit elevation of the lateral end of the clavicle . also limits
the superiorly directed forces applied to the clavicle by the sternocleidomastoid and sternohyoid muscles.
 The interclavicular ligament: limits excessive depression of the distal clavicle and superior gliding of the
medial clavicle on the manubrium. The limitation of clavicular depression by the interclavicular ligament
by protecting structures such as the brachial plexus and subclavian artery, which pass under the clavicle
and over the first rib.
Sterno-clavicular motion-

• The 3 rotary degrees of freedom at the sternoclavicular joint are

• Elevation/depression
• Protraction/retraction
• Anterior/posterior rotation of the clavicle.
• Translations of the medial clavicle on the manubrium are usually defined as occurring in:-
• Anterior/posterior
• Medial/lateral
• Superior/ inferior directions
Elevation / depression
• The motions of elevation and depression occur around an
approximately anteroposterior (A-P) axis between a convex
clavicular surface and a concave surface formed by the manubrium
and the first costal cartilage.

• With elevation, the lateral clavicle rotates upward; with depression,

the lateral clavicle rotates downward.

• The convex surface of the clavicle slide inferiorly on the concave

manubrium and first costal cartilage during elevation, in a direction
opposite to movement of the lateral end of the clavicle.

• The clavicular elevation has been described as up to 48°, whereas

passive depression is limited, on average, to less than 15°.
Protraction/retraction

• Protraction and retraction of the clavicle occur at the

sternoclavicular joint around an approximately vertical axis.

• With protraction, the lateral clavicle moves anteriorly, with

retraction, the lateral clavicle moves posteriorly.

• During protraction, the medial clavicle is expected to slide

anteriorly on the manubrium and first costal cartilage.

• There is about 15° to 20° protraction and 30° or greater

retraction of the clavicle available
Axial rotation
• Anterior/posterior, or long axis, rotation of the clavicle occurs as a
spin between the saddle-shaped surfaces of the medial clavicle and
manubriocostal facet.

• The clavicle rotates posteriorly from neutral, bringing the inferior

surface of the clavicle to face anteriorly. This has also been referred
to as backward or upward rotation rather than posterior rotation.

• From its fully rotated position, the clavicle can rotate anteriorly
again to return to neutral.

• Available anterior rotation past neutral is very limited, generally

described as less than 10°. The range of available clavicular
posterior rotation may be as much as 50°.
STERNOCLAVICULAR STRESS

• Although the sternoclavicular joint is considered incongruent, it does not undergo the
degree of degenerative change common to the other joints of the shoulder complex.

• Strong force-dissipating structures such as the sternoclavicular disc and the

costoclavicular ligament minimize articular stresses and also prevent excessive intra-
articular motion, which could lead to subluxation or dislocation.

• Dislocations of the sternoclavicular joint represent only 1% of joint dislocations in the

body and only 3% of shoulder girdle dislocations.
 ACROMIOCLAVICULAR JOINT
• The acromioclavicular joint attaches the scapula to the clavicle that is the joint is the articulation between the
lateral end of the clavicle and the acromion of the scapula which is a plane synovial joint with three degrees of
freedom.

• Joint surfaces vary, however, from flat to slightly convex or concave. Because of the predominantly flat joint
surfaces, roll-and-slide arthrokinematics are not described.

• The primary rotary motions that take place at the acromioclavicular joint are internal/external rotation,
anterior/posterior tilting or tipping, and upward/ downward rotation.

• It has a joint capsule, two major ligaments, and a joint disc that may or may not be present.
• The primary function of the acromioclavicular joint is to allow the scapula to rotate in three dimensions during
arm movement so that upper extremity motion is increased.

• The acromioclavicular joint also allows transmission of forces from the upper extremity to the clavicle.
 ACROMIOCLAVICULAR ARTICULATING SURFACES

• The acromioclavicular joint consists of the articulation between the lateral end of the clavicle and a
small facet on the acromion of the scapula.

• The articular facets are considered to be incongruent and vary in configuration.

• They may be flat, reciprocally concave-convex, or reversed (reciprocally convex-concave).
• The vertical inclination of the articulating surfaces varies from individual to individual varying
between 16° and 36° from vertical and suggested that the closer the surfaces are to vertical, the more
prone the joint is to the wearing effects of shear forces.

• However, greater arthritic changes are not apparent in acromioclavicular joints with more vertical
orientations.
.
 ACROMIOCLAVICULAR JOINT DISC Click icon to add picture
• The articular surfaces at the AC joint are lined with a layer of fibrocartilage and
often separated by a complete or incomplete articular disc.

• The disc of the acromioclavicular joint may vary in size between individuals,
within an individual as they age, and between shoulders of the same individual.

• Through 2 years of age, the joint is actually a fibrocartilaginous union. With use
of the upper extremity, a joint space develops at each articulating surface that
may leave a “meniscoid” fibrocartilage remnant within the joint.

• An extensive dissection of 223 sets of AC joints revealed complete discs in only

about 10% of the joints. The majority of joints possessed incomplete discs,
which appeared fragmented and worn.

• According to depalma, the incomplete discs are not structural anomalies but
rather indications of the degeneration that often affects this joint.
 ACROMIOCLAVICULAR CAPSULE AND LIGAMENTS

• The capsule of the acromioclavicular joint is weak and cannot maintain integrity of the joint without the reinforcement of the
superior and inferior acromioclavicular ligaments and the coracoclavicular ligaments.

• The acromioclavicular ligaments assist the capsule in apposing the articular surfaces while the superior acromioclavicular is the main
ligament limiting movement caused by anterior forces applied to the distal clavicle.

• The fibers of the superior acromioclavicular ligament are reinforced by aponeurotic fibers of the trapezius and deltoid muscles,
making the superior joint support stronger than the inferior.

• The coracoclavicular ligament, although not belonging directly to the anatomic structure of the acromioclavicular joint, firmly unites
the clavicle and scapula and provides much of the joint’s superior and inferior stability.

• This ligament is divided into a medial portion, the conoid ligament, and a lateral portion, the trapezoid ligament.The conoid
ligament, medial and slightly posterior to the trapezoid, is more triangular and vertically oriented. The trapezoid ligament is
quadrilateral in shape and is nearly horizontal in orientation.

• The two portions are separated by adipose tissue and a large bursa.
• The conoid portion of the coracoclavicular ligament provides the primary restraint to translatory motion caused by superior-
directed forces applied to the distal clavicle (or, conversely, to translatory motion caused by inferiordirected forces applied to the
acromion).

• The trapezoid portion of the coracoclavicular ligament provides more restraint than the conoid portion to translatory motion
caused by posterior-directed forces applied to the distal clavicle.
• In addition, both portions of the coracoclavicular ligament limit upward rotation of the scapula at
the acromioclavicular joint.

• When medially directed forces on the humerus are transferred to the glenoid fossa of the scapula,
medial displacement of the scapula on the clavicle is prevented by the coracoclavicular ligament
complex, in particular the horizontal trapezoid portion.

• These medial forces are transferred to the clavicle and then to the strong sternoclavicular joint.
• One of the most critical roles played by the coracoclavicular ligament in integrated shoulder
function is to couple the posterior rotation of the clavicle to scapula rotation during arm elevation.
Acromioclavicular motions
• The articular facets of the acromioclavicular joint are small, afford limited motion, and have a wide range of
individual differences.

• The primary rotary motions that take place at the acromioclavicular joint are internal/external rotation,
anterior/posterior tilting or tipping, and upward/ downward rotation.

• These motions occur around axes that are oriented to the plane of the scapula rather than to the cardinal planes.
• Although internal/external rotation occurs around an essentially vertical axis, anterior/ posterior tilting occurs
around an oblique “coronal” axis, and upward/downward rotation around an oblique “a-p” axis.

• In addition, translatory motions at the acromioclavicular joint can occur, although, as in the case of the
sternoclavicular joint, these motions are typically small in magnitude.

• These translations are usually defined as anterior/posterior, medial/lateral, and superior/ inferior.
 Click icon to add picture
Internal and external rotation
• Internal/external rotation of the scapula in relation to the clavicle
occurs around an approximately vertical axis through the
acromioclavicular joint.

• Internal and external rotation at the acromioclavicular joint can best be

visualized as bringing the glenoid fossa of the scapula anteromedially
and posterolaterally, respectively.

• These motions occur in part 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.
• These motions also “aim” the glenoid fossa toward the plane of humeral elevation. The orientation of the
glenoid fossa is important for maintaining congruency with the humeral head; maximizing the function of
glenohumeral muscles, capsule, and ligaments; maximizing the stability of the glenohumeral joint; and
maximizing available motion of the arm.

• The available range of motion (rom) at the acromioclavicular joint is difficult to measure. Dempster
provided a range of 30° for combined internal and external ROM in cadaveric acromioclavicular joints
separated from the thorax. Smaller values (20° to 35°) have been reported in vivo during arm motions,
although up to 40° to 60° may be possible with full-range motions reaching forward and across the body.
 Click icon to add picture
ANTERIOR AND POSTERIOR TILTING
• The second acromioclavicular motion is anterior/posterior
tilting or tipping of the scapula in relation to the clavicle
around an oblique “coronal” axis through the joint.

• Anterior tilting results in the acromion tilting forward and the

inferior angle tilting backward.

• Posterior tilting rotates the acromion backward and the

inferior angle forward.

• Scapular tilting, like internal/external rotation of the scapula,

occurs in order to maintain the contact of the scapula with the
contour of the rib cage and to orient the glenoid fossa.
• Elevation of the scapula on the thorax, such as occurs with a shoulder
shrug, can result in anterior tilting. The scapula does not always follow the
curvature of the thorax precisely.

• During normal flexion or abduction of the arm, the scapula posteriorly tilts
on the thorax as the scapula is upwardly rotating.

• Available passive motion into anterior/posterior tilting at the

acromioclavicular joint is 60° in cadaveric acromioclavicular joint
specimens separated from the thorax. The magnitude of anterior/ posterior
tilting during in vivo arm elevation has been quantified as approximately
20º, although up to 40° or more may be possible in the full range from
maximum flexion to extension.
UPWARD/DOWNWARD ROTATION
• The third acromioclavicular joint motion is upward/ downward
rotation of the scapula in relation to the clavicle about an oblique “A-
P” axis approximately perpendicular to the plane of the scapula,
passing midway between the joint surfaces of the acromioclavicular
joint.

• Upward rotation tilts the glenoid fossa upward , and rotation is the
opposite motion.

• In order for upward rotation to occur at the acromioclavicular joint,

the coracoid process and superior border of the scapula need to move
inferiorly away from the clavicle.
• However, dempster described 30˚ of
available passive ROM into
upward/downward rotation. Conway
describes 30° of upward rotation and 17°
of downward rotation actively at the
acromioclavicular joint.

• Because of the attachment of the

coracoclavicular ligaments to the
undersurface and posterior edge of the
clavicle, posterior rotation of the clavicle
releases tension on the coracoclavicular
ligaments and “opens up” the
acromioclavicular joint, allowing upward
rotation to occur.
Acromioclavicular stress
• Unlike the sternoclavicular joint, the acromioclavicular joint is susceptible to both trauma and
degenerative changes.

• Trauma to the acromioclavicular joint most often occurs in the first three decades of life, during
either contact sports or a fall on the shoulder with the arm adducted. Typically the result of high
inferior forces on the acromion, trauma results in acromioclavicular joint disruption ranging from
sprains and subluxations to dislocations.

• Degenerative change is common from the second decade on,16 with the joint space frequently
narrowed by the sixth decade. Acromioclavicular joint degeneration is likely due to small and
incongruent articular surfaces that result in high forces per unit area.
 SCAPULOTHOACIC JOINT

• The scapulothoracic “joint” is formed by the articulation of the scapula with the thorax as the two surfaces do not make
direct contact; rather, they are separated by muscles, such as the subscapularis, serratus anterior, and erector spinae.

• It is not a true anatomic joint because it is not a union of bony segments by fibrous, cartilaginous, or synovial tissues.
• By contrast, the articulation of the scapula with the thorax depends on the integrity of the anatomic acromioclavicular
and sternoclavicular joints.

• Any movement of the scapula on the thorax must result in movement at the acromioclavicular joint, the sternoclavicular
joint, or both.

• This makes the functional scapulothoracic joint part of a true closed chain with the acromioclavicular and
sternoclavicular joints and the thorax.

• Observation and measurement of individual sternoclavicular and acromioclavicular joint motions are more difficult than
observing or measuring motions of the scapula on the thorax.
Resting position of the scapula
• The scapula rests on the posterior thorax approximately 5cm from the midline
between the second through seventh ribs.

• The scapula is internally rotated 35° to 45° from the coronal plane, is tilted
anteriorly approximately 10° to 15° from vertical, and,is upwardly rotated 5° to
10° from vertical.

• Thismagnitude of upward rotation has as its reference a “longitudinal” axis

perpendicular to the axis running from the root of the scapular spine to the
acromioclavicular joint.

• If the vertebral (medial) border of the scapula is used as the reference axis, the
magnitude of upward rotation at rest is usually described as 2° to 3° from vertical.

• 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
• The motions of the scapula from the resting position include three rotations that have already been
described because they occur at the acromioclavicular joint.

• These are upward/downward rotation, internal/external rotation, and anterior/posterior tilting.

• Of these three acromioclavicular joint rotations, only upward/downward rotation is easily observable at the
scapula, and it is therefore considered for our purposes to be a “primary” scapular motion.

• Internal/external rotation and anterior/posterior tilting are normally difficult to observe and are therefore
considered for our purposes to be “secondary” scapular motions.

• The scapula presumably also has available the translatory motions of scapular elevation/depression and
protraction/ retraction.

• These “primary” (readily observable) scapular motions are typically described as if they occur
independently of each other.
Upward/downward rotation
• Upward rotation of the scapula on the thorax is the principal motion of the scapula observed during active elevation of the arm and plays a significant
role in increasing the arm’s range of elevation overhead. Approximately 50° to 60° of upward rotation of the scapula on the thorax is typically
available.

• Given the closed-chain relationship between the sternoclavicular, acromioclavicular, and scapulothoracic joints, differing proportions of
upward/downward rotation of the scapula are contributed by sternoclavicular joint posterior/anterior rotation, by sternoclavicular joint
elevation/depression, and by acromioclavicular joint upward/ downward rotation.

• If the long axis of the clavicle were parallel to the plane of the scapula such that acromioclavicular joint internal rotation was 0° , sternoclavicular
joint elevation would directly result in or couple with scapulothoracic upward rotation.

• If the long axis of the clavicle were perpendicular to the plane of the scapula such that acromioclavicular joint rotation was 90°, sternoclavicular joint
posterior rotation would directly result in or couple with scapulothoracic upward rotation.

• The average angle of acromioclavicular joint internal rotation is 58° to 68°, or about two thirds of a 90° acromioclavicular joint internal rotation
position.

• Consequently, two thirds of the motion of sternoclavicular joint posterior rotation will translate into or couple with scapulothoracic upward rotation,
while only one third of clavicular elevation will result in scapulothoracic upward rotation.
ELEVATION/DEPRESSION
• Scapular elevation and depression can be isolated by shrugging
the shoulder up and depressing the shoulder downward.

• Elevation and depression of the scapula on the thorax are

commonly described as translatory motions in which the scapula
moves upward (cephalad) or downward (caudal) along the rib
cage from its resting position.

• Scapular elevation, however, occurs through elevation of the

clavicle at the sternoclavicular joint and may include subtle
adjustments in anterior/posterior tilting and internal/external
rotation at the acromioclavicular joint in order to keep the scapula
in contact with the thorax.
PROTRACTION/RETRACTION
• These theoretical translatory motions have also been termed scapular abduction and adduction.
• However, if protraction or abduction of the scapula on the thorax occurred as a pure translatory
movement, the scapula would move directly away from the vertebral column, and the glenoid fossa
would face laterally.

• Protraction and retraction of the scapula on the thorax are often described as translatory motions of
the scapula away from or toward the vertebral column, respectively.

• In reality, full scapular protraction results in the glenoid fossa facing anteriorly, with the scapula in
contact with the rib cage.

• The scapula protracts and retracts through sternoclavicular joint protraction and retraction and
follows the contour of the ribs by rotating internally and externally at the acromioclavicular joint
INTERNAL/EXTERNAL ROTATION
• The scapular motions of internal and external rotation are normally not overtly identifiable on
physical observation but are critical to movement of the scapula along the curved rib cage.

• Approximately 15° to 16° of internal rotation occurs at the acromioclavicular joint during normal
elevation of the arm.

• A larger amount of internal rotation of the scapula on the thorax that is isolated to (or occurs
excessively at) the acromioclavicular joint results in prominence of the vertebral border of the
scapula as a result of loss of contact with the thorax.

• This is often referred to clinically as scapular winging. Excessive internal rotation may be indicative
of pathology or poor neuromuscular control of the scapulothoracic muscles.
ANTERIOR/POSTERIOR TILTING
• As is true for internal/external rotation, anterior/posterior tilting is normally not overtly obvious on
clinical observation and yet is critical to maintaining contact of the scapula against the curvature of the
rib cage.

• Anterior/posterior tilting of the scapula on the thorax occurs at the acromioclavicular joint.
• Because of the differing sternoclavicular and acromioclavicular axis alignment as described above,
scapulothoracic anterior/posterior tilting can also couple with elevation/depression of the clavicle at the
sternoclavicular joint.

• Anterior tilting beyond resting values will result in prominence of the inferior angle of the scapula.
• An anteriorly tilted scapula may occur in pathologic situations (poor neuromuscular control) or in
abnormal posture.
 GLENOHUMERAL JOINT
• The glenohumeral joint is a ball-and-socket synovial joint with three degrees of freedom.
• The glenohumeral (gh) : articulation formed between the large convex head of the humerus and the
shallow concavity of the glenoid fossa.

• This joint operates in conjunction with the moving scapula to produce an extensive range of motion
of the shoulder.

• The glenohumeral joint has sacrificed articular congruency to increase the mobility of the upper
extremity and hand and is therefore susceptible to degenerative changes, instability, and
derangement.
GLENOHUMERAL ARTICULATING SURFACES
PROXIMAL ARTICULATING SURFACE:-
• The glenoid fossa of the scapula serves as the proximal articular surface for the glenohumeral joint.
• The orientation of the shallow concavity of the glenoid fossa in relation to the thorax varies with the resting
position of the scapula on the thorax and with motion at the sternoclavicular and acromioclavicular joints.

• The glenoid fossa may be tilted slightly upward or downward when the arm is at the side, although
representations most commonly show a slight upward tilt.

• Similarly, the fossa also does not always lie in a plane perpendicular to the plane of the scapula; it may be
anteverted or retroverted up to 10°, with 6° to 7° of anteversion most typical.

• The concavity of the fossa is increased by articular cartilage that is thinner in the middle and thicker on the
periphery, which improves congruence with the humeral head.
DISTAL ARTICULATING SURFACE:-
• The humeral head is the distal articular surface of the glenohumeral joint and has an articular
surface area that is larger than that of the glenoid articular surface, forming onethird to one half of a
sphere.

• In an anatomical position, the head faces medially, superiorly, and posteriorly with regard to the
shaft of the humerus and the humeral condyles.
 The angle of inclination is formed by an axis through the humeral Click icon to add picture
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 is formed by an axis through the humeral head

and neck in relation to an axis through the humeral condyles. This
transverse plane angle varies but is 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 portion of
the glenoid fossa.
GLENOID LABRUM
• The total available articular surface of the glenoid fossa is enhanced by the glenoid labrum.
• This accessory structure surrounds and is attached to the periphery of the glenoid fossa, enhancing the
depth or concavity of the fossa by approximately 50%.

• The core of the labrum is composed of densely packed fibrous connective tissue covered by a fine
superficial mesh consistent with cartilaginous tissue, with fibrocartilage at the attachment of the labrum to
the periphery of the fossa.

• The composition of the labrum allows it to perform a variety of functions, including resistance to humeral
head translations, protection of the bony edges of the labrum, reduction of joint friction, and dissipation of
joint contact forces.

• The glenoid labrum serves as the attachment site for the glenohumeral ligaments and the tendon of the long
head of the biceps brachii.
GLENOHUMERAL CAPSULE
• The glenohumeral joint is surrounded by a large, loose capsule fibrous capsule that is taut superiorly
and slack anteriorly and inferiorly with the arm dependent at the side.

• The capsule attaches along the rim of the glenoid fossa and extends to the anatomic neck of the
humerus.

• 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 capsule is reinforced by the superior, middle, and inferior glenohumeral ligaments and by
the coracohumeral ligament.
 Click icon to add picture
A synovial membrane lines the inner wall of the joint capsule.
An extension of this synovial membrane lines the intracapsular portion
of the tendon of the long head of the biceps brachii.

This synovial membrane continues to surround the biceps tendon as it

exits the joint capsule and descends into the intertubercular
(i.E.,Bicipital) groove.

The head of the humerus and the glenoid fossa are both lined with
articular cartilage.

In the anatomic or adducted position, the inferior portion of the capsule
appears as a slackened or redundant recess called the axillary pouch.
Glenohumeral ligament

•The superior, middle, and inferior glenohumeral ligaments are thickened regions within the capsule tissue itself
attaching distally to the humerus or the capsule itself.

•The superior glenohumeral ligament : from the superior glenoid labrum to the upper neck of the humerus deep
to the coracohumeral ligament. The superior glenohumeral ligament and its associated rotator interval capsule
structures contribute most to anterior and inferior joint stability by limiting anterior and inferior translations of the
humeral head when the arm is at the side (0° abduction).

•The middle glenohumeral ligament :runs obliquely from the superior anterior labrum to the anterior aspect of
the proximal humerus below the superior glenohumeral ligament attachment. The middle glenohumeral ligament
contributes primarily to anterior joint stability by limiting anterior humeral translation with the arm at the side
and up to 60° of abduction.

•The inferior glenohumeral ligament is described as having three components and thus has been termed the
inferior gh ligament complex (ighlc). The three components of the complex are the anterior and posterior
ligament bands and the axillary pouch in between.
• With abduction beyond 45° or with combined abduction and rotation, the IGHLC plays the major
role of joint stabiliztion.

• With abduction, the axillary (inferior capsule) slack is taken up, and the ighlc resists inferior humeral
head translation.

• The coracohumeral ligament originates from the base of the coracoid process and has two bands.
• The first band inserts into the edge of the supraspinatus and onto the greater tubercle, joining the
superior glenohumeral ligament.

• The second band inserts into the subscapularis and lesser tubercle.
• The two bands form a tunnel through which the tendon of the long head of the biceps brachii passes.
• In addition, the coracohumeral ligament resists humeral lateral rotation with the arm adducted.
GLENOHUMERAL MOTIONS
•The GH joint is considered a universal joint because movement occurs in all 3
degrees of freedom.

•The primary motions at the gh joint are flexion and extension, abduction and
adduction, and internal and external rotation.

•Often, a fourth motion is defined at the GH joint: horizontal flexion and extension
(also called horizontal adduction and abduction). The motion occurs from a
starting position of 90 degrees of abduction.

•The humerus moves anteriorly during horizontal flexion and posteriorly during
horizontal extension.
FLEXION AND EXTENSION
• Flexion and extension at the GH joint are defined as a rotation of the humerus within the near sagittal plane
around a near medial-lateral axis of rotation that is about a coronal axis passing through the center of the
humeral head.

• The arthrokinematics involve primarily a spinning motion of the humeral head around the glenoid fossa.
• The spinning of the humeral head draws most of the surrounding capsular structures taut. Tension within the
stretched posterior capsule may cause a slight anterior translation of the humerus at the extremes of flexion.

• At least 120 degrees of flexion are available to the gh joint. Flexing the shoulder to nearly 180 degrees
includes an accompanying upward rotation of the scapulothoracic joint.

• Full extension of the shoulder occurs to a position of about 65 degrees actively (and 80 degrees passively)
behind the frontal plane of which 50° of extension occurs at the glenohumeral joint.

• The extremes of this passive motion likely stretch the capsular ligaments, causing a slight anterior tilting of
the scapula. This forward tilt may enhance the extent of a backward reach.
INTERNAL AND EXTERNAL ROTATION
• From the anatomic position, internal and external rotation at the GH joint is defined as an axial
rotation of the humerus in the horizontal plane.

• Medial and lateral rotation occur about a long axis parallel to the shaft of the humerus and passing
though the center of the humeral head.

• The arthrokinematics of external rotation :

Take place over the transverse diameters of the humeral head and the glenoid fossa.
The humeral head simultaneously rolls posteriorly and slides anteriorly on the glenoid fossa.

• The arthrokinematics for internal rotation :

are similar, except that the direction of the roll and slide is reversed.
the simultaneous roll and slide of internal and external rotation allows the much larger transverse
diameter of the humeral head to roll over a much smaller surface area of the glenoid fossa.
•If, for example, 75 degrees of external rotation occur by a posterior roll without a
concurrent anterior slide, the head displaces posteriorly, roughly 38 mm. This amount
of translation completely disarticulates the joint because the entire transverse
diameter of the glenoid fossa is only about 25 mm (about 1 inch).

•Normally, however, full external rotation results in only 1 to 2 mm of posterior

translation of the center of the humeral head, demonstrating that an “offsetting”
anterior slide accompanies the posterior roll.

•From an adducted position, about 75 to 85 degrees of internal rotation and 60 to 70

degrees of external rotation are usually possible, but much variation can be expected.

•In a position of 90 degrees of abduction, the external rotation range of motion usually
increases to near 90 degrees.
• From the anatomic position, full internal and
external rotation of the shoulder includes
varying amounts of scapular protraction and
retraction, respectively.

• Rotation of the gh joint from a position of

about 90 degrees of abduction, however,
requires primarily a spinning motion
between a point on the humeral head and the
glenoid fossa.
ABDUCTION AND ADDUCTION
• Abduction/adduction of the glenohumeral joint occur around an A-P axis passing through the humeral head
center and are traditionally defined as rotation of the humerus in the near frontal plane around an axis oriented
in the near anterior-posterior direction.

• Normally, the healthy person has about 120 degrees of abduction at the GH joint, although a range of values
has been reported.

• There is general consensus, however, that the range of abduction of the humerus in the frontal plane (both
active or passive) will be diminished if the humerus is maintained in neutral or medial rotation.

• The restriction to abduction in medial or neutral rotation is commonly attributed to impingement of the greater
tubercle on the coracoacromial arc and therefore avoid jamming against the contents within the subacromial
space, most notably the supraspinatus tendon..

• When the humerus is laterally rotated 35° to 40°, the greater tubercle will pass under or behind the arch so that
abduction can continue.
• The roms for abduction of the glenohumeral joint (if impact of the greater tubercle is avoided) are reported to be anywhere from
90° to 120°.

• Full abduction of the shoulder complex requires a simultaneous approximate 60 degrees of upward rotation of the scapula.
• The available passive range for abduction in the scapular plane may be slightly greater than for abduction in the frontal plane.
• When the humerus is elevated in the plane of the scapula (referred to as abduction in the plane of the scapula, scapular
abduction, or scaption in clinical jargon), there is presumably less restriction to motion because the capsule is less twisted than
when the humerus is brought further back into the frontal plane.

• Although it has been proposed that abduction in the scapular plane does not require concomitant lateral rotation to achieve
maximal range, this premise has also been disputed.

• During active arm elevations in all planes of elevation, glenohumeral lateral rotation has been demonstrated.
• The arthrokinematics of abduction involve the convex head of the humerus rolling superiorly while simultaneously sliding
inferiorly.
• Roll-and-slide arthrokinematics occur along, or close to, the
longitudinal diameter of the glenoid fossa. With regard to
arthrokinematics, adduction is similar to abduction but occurs in
a reverse direction.

• In addition to producing abduction, the active muscular

contraction pulls the superior capsule taut, thereby protecting it
from being pinched between the humeral head and undersurface
of the acromion process.

• The muscular force also adds to the dynamic stability of the

joint.

• As abduction proceeds, the prominent humeral head unfolds and

stretches the axillary pouch of the inferior capsular ligament.

• The resulting tension within the inferior capsule acts as a

hammock or sling, which supports the head of the humerus.
BURSAE

•Multiple separate bursa sacs exist around the shoulder.

•Some of the sacs are direct extensions of the synovial membrane of the gh joint, such as the
subscapular bursa, whereas others are separate structures.

•All are situated in regions where significant frictional forces develop, such as between tendons, capsule
and bone, muscle and ligament, or two adjacent muscles.

•Two important bursa sacs are located superior to the humeral head.
•The subacromial bursa lies within the subacromial space above the supraspinatus muscle and below
the acromion process.

•This bursa protects the supraspinatus muscle and tendon from the rigid under surface of the acromion.
•The subdeltoid bursa is a lateral extension of the subacromial bursa, limiting frictional forces between
the deltoid and the underlying supraspinatus tendon and humeral head.
(1) AND (6) SUBACROMIAL-
SUBDELTOID BURSA
(2) SUBSCAPULAR RECESS,
(3) SUBCORACOID BURSA,
(4) CORACOCLAVICULAR BURSA,
(5) SUPRA-ACROMIAL BURSA
 CORACOACROMIAL 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 is 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.

• The arch also acts as a physical barrier to superior translatory forces acting on the humeral head,
preventing it from dislocating superiorly.

• Although beneficial to joint stability, contact of the humeral head with the undersurface of the arch can
simultaneously cause painful impingement of the structures within the subacromial space.
• The subacromial space, also referred to as the suprahumeral space or supraspinatus outlet .
• This interval averages 10 mm in healthy subjects with the arm adducted at the side and decreases to
about 5 mm during elevation of the arm.

• As the acromiohumeral interval decreases, it must accommodate the soft tissue structures within it, as
well as the articular cartilage and the capsuloligamentous structures.

• Recent 3-d imaging has determined that anatomical approximation of the supraspinatus tendon with the
acromion occurs at humeral elevation angles below 60°, while the smallest acromiohumeral interval is
between the acromion and the greater tuberosity of the humerus at approximately 90° of elevation.

• This anatomical relationship suggests that normal decreases in the acromiohumeral distance during arm
elevation may not impact the rotator cuff at elevation angles higher than 60°.
• 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.

• The space can decrease by anatomical factors such as changes in the shape or slope of the acromion,
acromial bone spurs, acromioclavicular joint osteophytes, a large coracoacromial ligament, or a
disproportionately large humeral head.

• Abnormal scapular or humeral motions can also functionally reduce the size of the subacromial space.
• Inadequate posterior tilting or inadequate upward rotation of the scapula during arm elevation or
excessive superior or anterior translation of the humeral head on the glenoid fossa are believed to bring
the humeral head in closer proximity to the acromion, increasing the risk of impingement.

• Finally, repetitive impingement may lead to inflammation, fibrosis, and thickening of the soft tissues,
further reducing the subacromial space during arm elevation.