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1. Anatomy And Bio-Mechanics of shoulder complex
2. Evaluation Of Shoulder Joint
3. Impingement Syndrome
4. Adhesive Capsulitis
5. Thoracic Outlet Syndrome
6. Fractures And Dislocations
7. Myofascial Pain Syndrome
8. Hemiplegic Shoulder
9. Throwing Athletic Injury
10. Brachial Plexus injury
ANATOMY AND BIO-MECHANICS
It is a complex joint consisting of gleno-humeral, Acromino-clavicular, Sterno-
clavicular, Scapulo-thoracic & the articulation between coraco-acromial arch and
greater tuberocity. Acromino-clavicular, Sterno-clavicular & Scapulo-thoracic joints
form a closed kinetic chain i.e. movement in one joint causes motion in the other.
It is a ball and socket type of synovial joint, formed by the articulation of
glenoid cavity of scapula and head of humerus. Glenoid cavity is part of a larger
sphere with the angular value of about 75°, whereas head of humerus is almost half of
a smaller sphere with angular value about 150°. From geometry it is clear that gleno -
humeral joint is incongruent. The shallow acetabelum is deepened by Glenoid labrum,
which is a fibrocatilagenous structure with triangular in cross section i.e. thicker at
periphery and thinner inwards. It somehow compensates the incongruicity.
Head of humerus makes an angle of about 45° with the shaft. Glenoid cavity
faces upwards, forward and outward, whereas head faces upward, backward and
The thin and lax joint capsule is attached to the margin of glenoid labrum
poximally and to the neck of humerus distally. It is loosely attached antero -inferiorly
and inferiorly forms a redundant fold which allows a wide range of abduction.
The ligaments are so loosely attached so that head can be distracted 2 cm outward
with the arm by the side. 55 of abduction,30 of horizontal flexion is referred as resting
position of the shoulder joint, where the joint space and volume are maximum, capsule -
ligamentous structures are maximally laxed and joint is least stable. At this position the
head of the humerus can be distracted by 3 cm outward. With the arm by the side
superior joint capsule remains taut, whereas remainder of the capsule twisted forward
and medially. The posterior capsule tightens when the arm rotates internally. External
rotation is limited by the anterior joint capsule, middle glenohumeral ligament, anterior
band of coracohumeral ligament and subscapularis muscle. The rotator cuff tendons
i.e. supraspinatus, Infraspinatus, Teres minor and Subscapularis blend with the fibres
of joint capsule. Stability sacrificed for mobility due to bony architecture and loosely
The capsule is reinforced by glenohumeral and coracohumeral ligaments. The
middle glenohumeral ligament reinforces the capsule anteriorly and checks external
rotation, whereas inferior glenohumeral ligament strengthen the capsule antro -inferiorly
preventing anterior sulaxation and dislocation. The coracohumeral ligament
strengthens the superior joint capsule. With the arm by the side the stability of the joint
is maintained by both superior joint capsule and coracohumeral ligament, provided the
glenoid cavity oriented normally i.e. faces upward and outward. The anterior band of
coracohumeral ligament checks external rotation and extension, whereas the posterior
band checks internal rotation and flexion. The transverse humeral ligament traverses
the bicipital groove preventing its displacement.
Clavicle is an S-shaped bone, the lateral third being concave anteriorly and
horizontally placed. The convex articulating surface of clavicle articulates with the
plane/concave articulating surface of acromion process, which faces anteromedially.
Acromioclavicular Joint is less mobile as it is a planer synovial joint.
It has a weak thin capsular ligament which is reinforced by strong superior and
inferior acromino-clavicular ligaments and coraco clavicular ligaments. Superior and
inferior acromino-clavicular ligaments prevent over-riding of clavicle on the
Coraco-clavicular ligament is very important in providing acromino-
clavicular joint stability. It has got two parts, horizontally oriented Trapezoid
ligament and vertically oriented Conoid ligament. The horizontally oriented
Trapezoid ligament checks over-riding or lateral movement of clavicle on the acromion.
It also check excessive narrowing of scpulo-clavicular angle as viewed from above.
The vertically oriented Conoid ligament checks superior movement of clavicle on the
acromion. It also check excessive widening of scpulo-clavicular angle as viewed from
above. As the arm abducts, scapula rotates outward increasing the distance between
the clavicle and coracoid process, pulling the conoid ligament taut. The tension of the
conoid ligament rotates the clavicle backward resulting into elevation of lateral end of
Convex clavicular surface articulates with sternum and the 1 st rib. Medial end
of clavicle is concave antero-posteriorly and convex vertically articulates with the
curved notch of manubrium of the sternum. It is a saddle shaped synovial joint, so
freely movable in almost all planes.
It has capsular ligament which is reinforced by anterior and posterior
steroclavicular ligament, superiorly by inter-clavicular ligament, costo-clavicular
ligament and intra-articular disc. Intra-articular disc separates joint cavity into 2
compartments and checks medial displacement of clavicle. Costo-clavicular and
steroclavicular ligaments strongly anchor the medial end of clavicle to the sternum. The
short and strong costo-clavicular ligament provides stability to SC joint during
clavicular rotation associated with shoulder elevation. The anterior band of costo-
clavicular ligament is directed upward and laterally to check excessive upward rotation
of clavicle, whereas the posterior band of costo-clavicular ligament is directed upward
and medially to check excessive downward rotation of clavicle.
Scapulo thoracic joint is not a true anatomical joint because it has no usual joint
characteristics. It is a functional joint. The superior angle of scapula lies level
with T 2 spinous process, root of spine of scapula lies level with T 3 spinous process and
Inferior angle of scapula lies level with T 7 spinous process. Scapula makes an
angle of about 30° in the frontal plane and scapulo-clavicular angle is about 60°as
viewed from above with arm by the side. The vertebral border of scapula is parallel to
the spine and positioned approximately 3 inches from the midline of the thorax.
Suprahumeral joint is an articulation between the head of humerus and
coracoacromial arch. Coracoacromial arch forms an important protective arch over the
glenohumeral joint to prevent superior dislocation of head of humerus and protect the
glenohumeral joint from direct overhead trauma.It is the potential site for impingement
of suprahumeral structures like supraspinatus, infraspinatus, long head of bicepsand
Bursae: Bursa is a closed cavity, lined by synovium, present between two anatomical
structures to prevent friction during movements. There are about 8-9 bursae about the
shoulder joint, out of which only 2 are important clinically.
Subacromial / subdeltoid bursa lies over the supraspinatus tendon underneath the
acromion and deltoid muscle. It usually does not communicate with the joint cavity.
Rupture of calcific supraspinatus tendonitis communicate it with the joint cavity giving
rise to secondary bursitis. Inflammed bursa is susceptible to impingement underneath
the coraco-acromial arch.
Subscapularis bursa lies over the anterior joint capsule underneath the
subscapularis. It communicates with the joint cavity. So joint effusion manifest clinically
by anterior swelling.
The spinal roots supplying the rotator cuff and the articular structures are
C5,6,7. Ligaments, capsule and synovium are supplied by axillary, suprascapular, sub
scapular, thoraco-acromial and musculocutaneous nerves. Axillary artery, circumflex
humeral arteries supply to the shoulder joint and axillary vein is the main vein.
Blood supply of the rotator cuff tendons:
The rotator cuff tendons include supraspinatus, Infraspinatus, Teres minor and
Subscapularis blend with the fibres of joint capsule to form a continuous cuff
surrounding the posterior, superior and anterior aspects of the humeral head. It
provides dynamic stabilization for the joint.
The blood supply to the rotator cuff is derived from 6 vessels. Anterior Humeral
circumflex, the bony branch supplying Supraspinatus and Post circumflex humeral and
Suprascapular arties supplying Infraspinatus and teres minor are always present.
Thoracoacromial artery supplying Supraspinatus is sometimes absent. Supra humeral
and Subscapular arteries are often absent. The suprascapular and subscapular
arteries are muscular branches. In the dependant arm the arteries are elongat ed and
compressed, compromising the circulation. During arm elevation, abduction and flexion
contraction of rotator cuff compresses the arteries producing ischemia. The area within
the conjoint rotator cuff tendons is relatively avascular. and develops isc hemia, is
referred as critical zone. Blood supply to supraspinatus and to a lesser extent the
infraspinatus are relatively avascular....
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Anatomy of provocative tests for impingement.pdf (1113 KB)
On the pathogenesis of Shoulder Impingement Syndrome (2003).pdf (1191 KB)
Shoulder Kinematics and Impingement (2009).pdf (6134 KB)
A Review Of Diagnostic (1996).pdf (466 KB)
Chapter 7 - The Shoulder Complex.pdf (1379 KB)
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