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1. Shalini Gupta Diploma in Physiotherapy Shoul d er Jo i n t Glenohumeral Joint

2. SHOULDER JOINT The Glenohu m e r al Joi n t is S yno v ial ball and s oc k e t art i cul a tion – B e t w een • • • • It is The The the head of the hu m erus and g l enoid c a v i ty of t he s c apul a . m aj o r j o i n t c onnec t ing the upper the trunk. • l i mb t o

3. SHOULDER JOINT SHOULD E R J OINT is c ompone n t of SHOULD E R whi c h c omp r i s es of f i v e l in k a g es. G I RDLE 1. 2. G l enohume r al Sup r ahume r al art i cul a t i on: • Co r a c oac r omial a r ch ab o v e with head with subdel t oid bu r sa in b e t w e e n. of humerus bel o w 3. 4. 5. Ac r omiocl a v i cular S t ernocl a v i cular S c apulo t ho r acic (mu s cular)

4. TYPE • The shou l der j oi n t i s a bal l -an d -soc k e t type of s yno v ial joi n t . • • The head of humerus The g l enoid c a v i ty of soc k e t. is the bal l . the s c apula is – A dense fib r o c ar t ila g e n ous lip, c alled lab r um g l enoidale is a tt ac h ed t o the r i m the g l e noid c a v i ty and ma k es it wider & deepe r . of

5. SHOULDER JOINT The shou l der joi n t has the f ol lo w i ng cha r ac t er i s t i cs. It has a v e r y w i de r an g e of m o v eme n ts. • • – The shou l der joi n t is joi n t of the bod y . It is not a st able or a – It is mo s t c ommonly in the bod y . the mo s t m o v ab l e • secu r e joi n t. dislo c a t ed la r g e joi n t

6. LIGAMEN T S The li g ame n ts of the shoulder jo i n t a r e as f ol l o w s: 1. Ca p sular li g ame n t ( jo i n t c a p sule): 2. G l enohume r al l i g ame n ts: The r e a r e th r ee thic k enings the a n t er i or part of the fib r ous c a p sule; t o s t r en g then it. • • • in – – – Sup e rior , Middle , I n f er i or glen o hume r al li g ame n ts. • 3. Co r a c ohume r al l i g ame n t : It is a s t r ong band of fib r ous tissue th a t passes f r om the base of the c o r a c oid p r ocess t o the a n t er i or part of the g r e a t er tub e r cle of the humer u s. • 4. T r an s v e r se hume r al l i g ame n t: It is a b r oad fib r ous band, which spans the bicipi t al g r oo v e b e t w een the g r e a t er and lesser tub e r cles changing it the g r oo v e i n t o a c anal. – It p r o vides passa g e t o t he t endon of long head of biceps sur r o u nded b y a s yn o vial she a th.

7. A CC E S S O R Y LIGAME N T S Co r acoac r omi a l li g ame n t : It e x t ends b e t w een 1. c o r a c oid and ac r omion p r ocesses. It p r o t ects the supe r ior c ompone n t of the j oi n t. Co r acoac r omi a l a r ch: The c o r a c oac r o m ial a r ch is f ormed by c o r a c oid p r oces s , ac r omion p r oces s , and c o r a c oac r omial l i g ame n t b e t w een the m . • – This s t r ong tr i angular band f orms a p r o t ect i v e a r ch f or the head of hu m er u s ab o v e and p r e v e n ts i t s su p er i or d i sp l a c eme n t ab o v e the gleno i d c a v i t y . The sup r aspin a tus mus c le passes un d er th i s a r ch a nd e xi s ts deep t o the del t oid whe r e its t endon m i x es with the joi n t c a p su l e. –

8. The joi n t c a p sule The joi n t c a p sule is a f i b r ous she a th which encloses the s tr u ct u r es of t he joi n t. It e x t ends f r om t he an a t omi c a l neck of t he hume r us t o the bo r der of the g l enoid f ossa. The s y n o v ial me m b r ane l i nes the inner sur f ace of the joi n t c a p su l e, and p r oduces s yn o v i al f l uid t o r educe fr i ct i on b e t w een the art i cular su r f aces. • • • • Se v e r al s y n o v ial bu r sae a r e p r ese n t. – A bu r sa is a s y no v i al fl u id fi l led sa c , which a c ts as a cush i on b e t w een t en d ons and other joi n t s tr u ctu r es.

9. Joi n t ca p sule The s ynov i al c a v i ty of t he joi n t sho w s the f oll o w i ng f e a tu r es: – It f orms t u b ular she a th a r ound the t endon of b iceps b r ac h ii whe r e it is lo ca t ed in the bicipi t al g r o o v e of the hu m eru s . – It c omm u ni c a t e s wi t h subs c ap u lar and i n f r aspin a t u s bu r sa e , a r ound the joi n t. Thus t he r e a r e th r ee apertu r es in the joi n t c a p sule. • •

10. Th r ee a pertu r es in the joi n t c a p sule 1. An openi n g b e t w een the tube r cles of the hu m erus f or t he passa g e of t endon of long head of b iceps b r ac h ii. An openi n g lo c a t ed a n t er i orly i n f er i or t o the c o r a c oid p r ocess t o allow i n t e r action b e t w een the s ynovial c a v i ty and sub s c ap u lar bu r sa. 2. 3. An openi n g lo c a t ed po s t er i orly t o c ommuni c a tion b e t w e e n s ynovial and i n f r aspi n a t u s b u r sa. allow c a v i ty

11. BU R S AE R E L A TED T O THE SHOULD E R JOINT Su b sc a pu l ar bu r sa: – I t lies b e t w een the t endon of su b sca p u l aris and the neck of the s c apula; and p r o t ects the t endon f r om frict i on f r om the neck. T h is b u r s a normal l y c omm u ni c a t es with t h e joi n t c a v it y . Sub a c r o m i a l bu r sa: – lies b e t w een the c o r a c oac r o m ial li g ame n t and ac r o m ion p r ocess ab o v e, and sup r aspin a t u s t end o n and joi n t c a p sule • • bel o w . It c o n tinues d o w n w a r ds bene a th the del t oid, hence is som e times also descr ib ed as subdel t oid bu r sa. It is t h e bi g g e s t s yn o vi a l b u r s a in t he bod y . I n f r asp i n a tus bu r sa: – I t lies b e t w een the t endon of i n f r aspin a tus and po s t e r ol a t e r al aspect of the joi n t c a p sule. It may s om e ti m e c omm u ni c a t e with t h e joi n t c a v it y . it •

12. Impor t a n t R el a tions • The s u b s c a pu l aris m u s c l e • De l t oid • The a xilla r y v e s s e l s and b r achial p l e x us A n t erior l y • The in f r as p in a t u s • T e r e s mi n or m u sc l e s P o s t erior l y • The s up r a s p i n a t u s m u sc l e , • S ub ac r omi a l bu r sa, • Co r a c oa c r om i al li g am e n t, • De l t oid m u sc l e Superiorly • The lo n g he ad of the tric e p s m u sc l e , • The a xilla r y n er v e • The p o s t e ri o r ci r c u m fl e x hu m e r al v e ssels • The t end o n of the lo n g he ad of the b ic e p s m u sc l e p ass e s t h r o u g h the joint and em e r g es b e ne a th the t r an s v e r se li g am e n t I n f eriorly

13. Neu r o v ascular Supply Ar t e r ial supp l y t o the gl e nohume r al joi n t is v i a – The a n t er i or and po s t erior ci r cu m fl e x h u me r al ar t er i e s , and – The sup r asc a p u lar ar t e r y . • • B r anches f r o m these ar t er i es f o rm the j o i n t. The joi n t i s su p p l i e d b y: an an a s t o motic n e t w o rk a r o und • – – – The a xil l a r y , T h e su p r asc a p u lar and T h e l a t e r al p e c t o r al ne r v es. • These ne r v es a r e d er i v ed f r o m r oo ts C5 and C6 of the b r achial pl e x us . – A n upper b r achial p l e x us inju r y ( Erb ’ s pal s y ) w i ll a f f ect shou l der jo i n t function.

14. Mo v eme n ts a t the sh o ulder • T w o types of mo v eme n ts: 1. Mo v eme n ts of t he shou l der joi n t: – T a k e place b e t w e e n h umerus & s c ap u la 2. Mo v eme n ts of the shou l der g i r dle: – I n v ol v e cl a v i cle & s c ap u la t o g e ther and occur a t the shou l d er joi n t

15. Mo v eme n ts of the sh o ulder j o i n t A n t e ri o r fib e r s of the de l t o i d P o s t er i or fibe r s of the d el t o i d De l t oid mi dd le fib r e s ( u p t o 90 ⁰) T e r es ma j or Abduction S up r as p i n a t u s ( u p t o 1 5 ⁰) T r ap e z i us & s e r r a tus a n t er i o r( ab ov e hea d ) Adduction P ec t o r al i s ma j or l a t i s s i mus do r si Co r a c ob r ach i al i s Subs c ap u l ar i s fl e xion P e c t o r a l is major(c l a v i cu l ar he ad) Co r a c o b r ach i al i s Bic e p s Ex t ension P ec t o r al i s ma j or ( s t erno c o s t al h e ad) T e r es ma j or L a t i s s i mus do r si

16. Mo v eme n ts of t h e sho u lder joi n t T e r es ma j or T e r es minor m ov em e n t of a l i mb th a t i nc l udes fl e xi o n, Ci r cumduction C i r c u md u c ti o n i s a c on e -sh a ped ab d uc ti on, e x t e n sion, and a d du c t i on. Medial r o ta tion P e c t o r a l is major L a tissi mu s d o r si A n t e ri o r fib e r s of the de l t o i d S u b s c apu l aris L a t e r al r o ta tion I n f r a s pin a tus P o s t er i or fibe r s of the d el t o i d

17. D El e v a tion Shou l der Gi r dle Mo v eme n ts Abduction Adduction ep r essi o n

18. Mo v eme n ts • El e v a t i on – U p w a r d or su p er i or m o v eme n t, shou l de r s as in sh r u g ging • Dep r ess i on – D o w n w a r d m o v eme n t, or as i n f er i or in r e tur n i n g t o normal pos i tion

19. Mo v eme n ts • Ab d uct i on (p r ot r action) – S c apu l a m o v es l a t e r al l y a w a y f r om sp i nal c ol u mn • Ad d uct i on ( r e t r actio n ) – S c apu l a mo v es med i al l y t o w a r d sp i nal c ol u mn

20. Mo v eme n ts • U p w a r d r o t a tion – T urning glenoid f ossa u p w a r d & m o ving i n f er i or angle supe r ol a t e r ally a w a y c olumn f r om spinal • Dow n w a r d r o t a tion – R e tur n ing i n f er i or angle i n f e r o m edially t o w a r d spinal c olumn & glenoid f ossa t o n ormal p o sition

21. Glenoid f aces d o wn Glenoid f aces up

22. M o v eme n ts of the sho u lder g i r dle U p w a r d r o ta tio n( gl en o id f ac e s up ) L ow er T r ape zi us Upp e r T r ape zi us Ser r a tus A n t er i or ( l ow er part) D o w n w a r d r o t a t i on L e v a t or S c apula ( glenoid f aces d o wn) Rhomboids L a t i s s i mus Do r si P r ot r action ( p ull i n g f o r w a r ds) Ser r a tus A n t er i or P ec t o r al i s M i nor R e t r ac ti on (pu lli ng back w a r d s ) M i dd l e T r ape zi us Rhomboids El e v a tion ( s h ru g g i n g s h o u ld e r s) Upp e r T r ape zi us L e v a t or S c ap u l a Dep r e s sion(d r ooping s h oulde r s) P ec t o r al i s Major P ec t o r al i s M i nor L a t i s s i mus Do r si

23. Mobility and S t ability The shou l der joi n t is o ne of the mo s t mob i le in the bod y , the e xpense of s t abi l it y . F ac t o r s th a t c o n tribu t e t o mobility: • a t • – T ype of joi n t – It is a b all and soc k e t joi n t. – B o n y sur f aces – Shallow g l e noid c a v i ty and la r g e h u me r al head • The r e is a 1 : 4 di s p r oport i on in s u r f ace s . – L a xity of the joi n t c a p sul e .

24. Mobility and S t ability • F ac t o r s th a t c o n tribu t e t o s t abil i ty: – R o tat or cuff muscles: – Glenoid labrum : – Li g ame n ts: • The li g ame n ts act t o r e i n f o r ce the joi n t c apsule, and f orms t he c o r a c o -ac r omial a r ch.

25. Clini c al R ele v ance: Common Injuries Dis l o c a tion of the Shoulder Joi n t: – Disl o c a ti o ns a t the sh o ul d er a r e describ e d b y whe r e the hume r al head li e s in r el a tion t o the i n f r ag l eno i d tube r cle. An a nt erior disl o ca tion is u sual l y c aused b y e x ces s i v e e x t ension and l a t e r al r o t a ti o n of the hu m erus . The h u me r al head is f o r ced • • a n t eriorly and i n f eriorly the joi n t c a p sul e . i n t o the w ea k e s t part of • The a xi l la r y ne r v e runs in cl o se p r o xim i ty t o the should e r joi n t, and c an be d ama g ed in t h e disl o ca tio n . Inj u r y t o

26. CLINICAL C OR R EL A TION • A portion o f epip h y seal line p r o ximal humerus i s i n t r a c a p sula r , of • Sept i c arth r itis of the shou l der joi n t m a y occur f ollo w ing m e t ap h y seal o s t eo m y e l itis.

27. R o tat or Cuff

28. R o tat or Cuff T endonitis T endoni t is r e f e r s t o i n flamm a tion of the mu s cle t endons – us u al l y due t o o v eru s e. Th i s m a y c ause de g en e r a ti v e chan g es in the subac r omial bu r sa, and the sup r asp i n a tus t endon. – This i n c r eases fr i ction b e t w een t h e s tr u ctu r es of the joi n t. The cha r ac t er i s t i c s i gn of r o t a t or cu f f t endoni t is is the ͚ pai n f u l a r c ͛ – pain in the mid d le of abduc t ion, whe r e the a f f ec t ed a r ea c omes i n t o c o n t act w i th the ac r omio n . • •

29. Suba c r omial bu r sitis, sup r aspin a tus t endinitis, or pe r i c a p sulitis sh o wing the painful a r c in the middle r an g e of abduction, when the diseased a r ea impin g es on the l a t e r al ed g e of the a c r omio n .