1. Dr. S. Nishan Silva (MBBS)
Shoulder Region
Dr. S. Nishan Silva
(MBBS)

2. Why???

6. Shoulder Anatomy Bones Shoulder vs Shoulder Girdle Clavicle Scapula
Humerus
Shoulder vs Shoulder Girdle

7. Shoulder Anatomy
Joints
Sternoclavicular

8. Shoulder Anatomy
Joints
Sternoclavicular
Acromioclavicular

9. Distal Clavicle Coracoclavicular ligaments
“Suspensory ligaments of the upper extremity”
Two components:
Trapezoid
Conoid
Stronger than AC ligaments
Provide vertical stability to AC joint

10. Shoulder Anatomy Joints Sternoclavicular Acromioclavicular
Glenohumeral

11. Glenohumeral Joint Most common dislocated joint Lacks bony stability
Composed of:
Fibrous capsule
Ligaments
Surrounding muscles
Glenoid labrum

12. Shoulder Anatomy Ligaments Acromioclavicular Joint
Acromioclavicular Ligament

13. Shoulder Anatomy Ligaments Glenohumeral Joint Glenohumeral ligaments
Superior
Middle
Inferior

14. Glenohumeral joint
Humeral head coverage increased to 75% with glenoid labrum
25% humeral head surface in contact with glenoid

15. Shoulder Anatomy
Cartilage
Glenoid labrum

16. Glenoid Labrum

17. Radiographic Anatomy 17

19. Shoulder Anatomy
Shoulder Girdle Muscles
Trapezius

20. Major muscles of the trunk
Trapezius
Origin: superior nuchal line, external occipital protuberance, ligamentum nuchae and spinous processes of seventh cervical and all thoracic vertebrae
Insertion: lateral third of clavicle, acromion, and spine of scapulartery
Acton: upper fibers elevate scapula, lower fibers depress scapula; if scapula is fixed, one side acting along, draws head toward the same side, and turn face to opposite side; both sides together, draw head directly backward

21. Major muscles of the trunk
Latissimus dorsi
Origin: spinous processes of lower six thoracic and all lumbar vertebrae, median sacral crest, and posterior part of iliac crest.
Insertion: floor of intertubercular groove of humerus.
Action: trunk fixed, extends, adducts and medially rotates arm ; arm fixed, elevates trunk.

22. Shoulder Anatomy
Shoulder Girdle Muscles
Trapezius
Serratus Anterior

23. Serratus Anterior

24. Winged Scapula

25. Shoulder Anatomy Glenohumeral Muscles Rotator Cuff Suprispinatus
Infraspinatus
Teres Minor
Subscapularis

26. Rotator cuff
Subscapularis
Supraspinatus
Infraspinatus
Teres minor

27. Rotator cuff muscles
Supraspinatus, infraspinatus, teres minor, subscapularis
Form cuff around humeral head
Keep humeral head within joint (counteract deltoid)
Abduction, external rotation, internal rotation
Supraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.

28. Movement of RC Muscles
Subscapularis is an internal rotator of the arm.
Supraspinatus assists the deltoid in abducting the arm, with its greatest contribution being the initiation of abduction.
Infraspinatus and teres minor muscles both externally rotate the arm.

29. Supraspinatus “empty can sign”

30. Teres major Origin: dorsal surface of inferior angle of scapula
Insertion: crest of lesser tubercle of humerus
Action: medially rotates and adducts arm

31. Shoulder Anatomy Glenohumeral Muscles Latissimus Dorsi
Pectoralis Major

32. Pectoralis major
Origin: medial half of clavicle,sternum,1th-6th costal cartilages.
Insertion: crest of greater tubercle of humerus.
Action: flexes, adducts and rotates arm medially; arm fixed, elevates trunk; elevates ribs 1-6,aidding in forced inspiration.

33. Shoulder Anatomy Glenohumeral Muscles Latissimus Dorsi
Pectoralis Major
Deltoid

34. Major muscles of upper limb
Deltoid
Origin: lateral third of clavicle, acromion, and spine of scapula
Insertion: deltoid tuberosity of humerus
Action: abducts，flexes and medically rotates, extends, and laterally rotates arm

36. Shoulder Anatomy Glenohumeral Muscles Latissimus Dorsi
Pectoralis Major
Deltoid
Biceps

37. Biceps strength testing
Arms outstretched with palms up at level of shoulder
Forced supination of hand with elbow flexed at 90 degrees
Bicipital tendonitis – pain at long head of the biceps.s

38. Shoulder Anatomy Glenohumeral Muscles Latissimus Dorsi
Pectoralis Major
Deltoid
Biceps
Triceps

39. Shoulder Anatomy
Other structures
Brachial Plexus
Brachial Artery

40. Brachial plexus Formation:
Five roots: formed by anterior rami of C5-C8 and T1 spinal nerves, roots C5～C7give rise to long thoracic n.
Three trunks
The upper trunk is formed by the joining of root C4,C5,C6.
The middle trunk is the continuation of root C7.
The lower trunk is formed by the joining of root C8 and T1.
Six divisions: above clavicle, trunks form anterior and posterior divisions
Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a.

41. Position: Main branches
passes through the scalene fissure to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords
Main branches
Lateral cord
Musculocutaneous n.
Lateral root to median n.
Medial cord
Medial root to median n.
Ulnar n.
Medial brachial cutaneous n.
Medial antebrachial cutaneous n.

42. Posterior cord
radial n.
axillary n.
thoracodorsal n.

43. Axillary artery
Continuation of subclavian artery at lateral border of first rib
Becomes brachial artery at lower border of teres major
Divided into three parts by overlying pectoralis minor
First portion, above muscle－gives rise to thoracoacromial a.
Second portion, behind muscle－gives rise to lateral thoracic a.
Third portion, below muscle－gives rise to subscapular a. anterior and posterior humeral circumflex a.; the former then divides into throcodorsal a. and circumflex scapular a.

44. Axillary a.
Thoracoacromial a.
Lateral pectoral n.
Musculocutaneous n.
Medial antebrachial cutaneous n.
Median n.
Ulnar n.
Medial brachial cutaneous n.
Long thoracic n. & lateral thoracic a.
Intercostobrachial n.
Thoracodorsal n. & a.

45. Integrated Action

46. Practice Name the muscles for Horizontal Adduction Pect Major (both)
Corachobrachialis
Deltoid (anterior)
Name the muscles for Horizontal Abduction
Deltoid (post)
Infraspinatus
Teres minor
Lats

47. Practice List the muscles that do flexion of the shoulder
Coracobrachialis
Pectoralis major (upper to 60°)
Anterior Deltoid
List the muscles that do extension of the shoulder
Latissimus dorsi
Teres major
Posterior deltoid
Pectoralis major (lower fibers to neutral)

48. Practice List the muscles that do adduction of the shoulder
Pectoralis major (lower and upper below 90°)
Coracobrachialis
Latissimus dorsi
Teres major
List the muscles that do abduction of the shoulder
Deltoid (all sections)
Supraspinatus
Pectoralis major (upper past 90°)

49. Practice List the muscles that do internal rotation of the shoulder
Subscapularis
Latissimus dorsi
Teres major
Anterior deltoid
Pect. major
List the muscles that do external rotation of the shoulder
Infraspinatus
Teres minor
Posterior deltoid

50. Name the muscle.
Coracobrachialis
Name the action
Adduction of the shoulder
Also, flexion and hor. add.

51. Name the muscle.
Subscapularis
Name the action
Internal rotation of the shoulder

52. Name the muscle.
Deltoid
Name the action
Abduction of shoulder

53. Name the muscle.
Infraspinatus
Name the action
External rotation

54. Name the action
Name the muscle.
Adduction of scapula
Teres Major

55. Name the muscle.
Teres Minor
Name the action if the humerus move directly to the posterior
Extension of the shoulder

56. Name the muscle.
Supraspinatus
Name the action
Abduction of the shoulder

58. Coracobrachialis
Pect. Major
Subscapularis
Deltoid

59. Supraspinatus
Teres Major
Infraspinatus
Teres Minor

60. What position are her shoulders in?
Flexion

61. What position is his right shoulder in?
Horizontal Abduction and
External Rotation

62. What rotation action is his shoulder performing as he continues to through the ball?
Internal Rotation

63. What position are her shoulders in?
Flexion

64. What position are his shoulders in?
Horizontal abduction or Extension

65. Position of their shoulders?2. 1.
Extension
Flexion

66. What is the position of shoulders?
Extension

67. Major Muscles of the Shoulder
Pectoralis major
Push-ups
Pull-ups
Bench press
Throwing
Tennis serve
Latissimus dorsi
Chinning
Robe climb
Dips on parallel bars
Pullover exercises
Pulldown exercises
Rowing

68. Shoulder action = ? Shoulder muscle(s) = ? Deltoid Abduction
Supraspinatus
Abduction

69. Shoulder action = ? Shoulder muscle(s) = ? Flexion Ant Deltoid
Upper Pect Major
Coracobrach.

70. Shoulder action = ? Shoulder muscle(s) = ? Ant. Deltoid
Pect. Major (both)
Coracobrachialis
Horizontal Add.

71. Shoulder action = ? Shoulder muscle(s) = ? Horizontal Abduction
Latissimus Dorsi
Post. Deltoid
Teres Minor
Infraspinatus

72. Shoulder action = ? Shoulder muscle(s) = ? Adduction
Pect. Major (both)
Coracobrachialis
Latissimus Dorsi
Teres Major

73. Shoulder action = ? Shoulder muscle(s) = ? Horizontal Add Ant. Deltoid
Pect. Major (both)
Coracobrachialis

74. Shoulder action = ? Shoulder muscle(s) = ? Extension Lats Teres Major
Post. Deltoid Pectoralis Major (lower)
Infraspinatus Teres minor

75. Shoulder action = ? Shoulder muscle(s) = ? External Rotation
Infrspinatus
Teres Minor
Post. Deltoid

76. Name a shoulder muscle isolated with the following exercises.
Side arm dumbbell raises
Deltoid
Push-ups
Pectoralis major
Rowing and pull-overs
Latissimus dorsi

77. What is the action to the left? What muscles perform that action?
External Rotation
Internal Rotation
Internal Rotation
Subscapularis, Ant. Deltoid, Pect, Major, Lats. And Teres Major

78. Rotator Cuff Exercises
External Rotation
Internal Rotation
External Rotation
Abduction (to work the supraspinatus)

79. Shoulder Dysfunction and Injury
Factors Predisposing to Shoulder Pain
Instability of glenohumeral joint
Weakness in scapular stabilizing muscles
Previous injury (dislocation of glenohumeral joint, separation of AC joint)
Hypomobility of cervical or thoracic spine
Postural dysfunction
Muscle imbalances

80. Shoulder Dysfunction and Injury (cont’d)
Differentiation of Shoulder Pain
Active inflammation: pain that occurs or increases at night
Irritation of a sensory nerve root: sharp pain, numbing, & tingling in a dermatome
Rotator cuff injury: pain at lateral portion of upper arm, painful limitation when elevating arm overhead
Bicipital tendinitis: well-localized pain at anterior portion of head of humerus & aggravation with Speed’s test
Adhesive capsulitis: stiffness in shoulder, dramatic loss of arm motion (especially external rotation)

81. Shoulder Dysfunction and Injury (cont’d)
Differentiation of Shoulder Pain
Impingement: pain over anterior humerus, loss of internal rotation, & painful Neer’s test
Instability: clunking in shoulder with active circumduction & excessive joint play in passive motion test for glenohumeral joint
Pain originating in glenohumeral joint: rarely felt at joint, but over lateral brachial region

82. Shoulder Dysfunction and Injury (cont’d)
Characteristics of Shoulder Pain (vs. neck pain)
Elicited or increased from active shoulder motion & relieved by rest
Isometric challenge will be painful with localized lesion
Painless weakness in arm & shoulder muscles from motor nerve root problem in cervical spine

83. Shoulder Dysfunction and Injury (cont’d)
Common Dysfunctions and Injuries of the Shoulder
Rotator cuff tendinitis (supraspinatus tendinitis)
Infraspinatus tendinitis
Subscapularis tendinitis
Adhesive capsulitis (frozen shoulder)
Impingement syndrome
Instability syndrome of the glenohumeral joint

84. Shoulder Dysfunction and Injury (cont’d)
Common Dysfunctions and Injuries of the Shoulder
Bicipital tendinitis
Subacromial (subdeltoid) bursitis
Acromioclavicular ligament sprain
Suprascapular nerve entrapment
Costoclavicular syndrome (part of thoracic outlet syndrome)
Pectoralis minor syndrome (part of thoracic outlet syndrome)

85. Impringement Syndrome
Abduction/adduction
Painful arc of abduction – sensitive, not specific
Impringement of inflammed sub-acromial bursae / biceps tendon etc underneath
Flexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing).
Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.

86. Anterior shoulder dislocation
Fig :

87. Shoulder - summary

88. Name
Description
Muscles
Scapularretraction [7] (aka scapular adduction)
The scapula is moved posteriorly and medially along the back, moving the arm and shoulder joint posteriorly. Retracting both scapulae gives a sensation of "squeezing the shoulder blades together."
rhomboideus major, minor, and trapezius
Scapularprotraction[7](aka scapular abduction)
The opposite motion of scapular retraction. The scapula is moved anteriorly and laterally along the back, moving the arm and shoulder joint anteriorly. If both scapulae are protracted, the scapulae are separated and the pectoralis major muscles are squeezed together.
serratus anterior (prime mover), pectoralis minor and major
Scapularelevation [8]
The scapula is raised in a shrugging motion.
levator scapulae, the upper fibers of the trapezius
Scapulardepression [8]
The scapula is lowered from elevation. The scapulae may be depressed so that the angle formed by the neck and shoulders is obtuse, giving the appearance of "slumped" shoulders.
pectoralis minor, lower fibers of the trapezius, subclavius, latissimus dorsi
Arm abduction [9]
Arm abduction occurs when the arms are held at the sides, parallel to the length of the torso, and are then raised in the plane of the torso. This movement may be broken down into two parts: True abduction of the arm, which takes the humerus from parallel to the spine to perpendicular; and upward rotation of the scapula, which raises the humerus above the shoulders until it points straight upwards.
True abduction: supraspinatus (first 15 degrees), deltoid; Upward rotation: trapezius, serratus anterior
Arm adduction[10]
Arm adduction is the opposite motion of arm abduction. It can be broken down into two parts: downward rotation of the scapula and true adduction of the arm.
Downward rotation: pectoralis minor, pectoralis major, subclavius, latissimus dorsi (same as scapular depression, with pec major replacing lower fibers of trapezius); True Adduction: same as downward rotation with addition of teres major and the lowest fibers of the deltoid
Arm flexion [11]
The humerus is rotated out of the plane of the torso so that it points forward (anteriorly).
pectoralis major, coracobrachialis, biceps brachii, anterior fibers of deltoid.
Arm extension[11]
The humerus is rotated out of the plane of the torso so that it points backwards (posteriorly)
latissimus dorsi and teres major, long head of triceps, posterior fibers of the deltoid
Medial rotation of the arm [12]
Medial rotation of the arm is most easily observed when the elbow is held at a 90-degree angle and the fingers are extended so they are parallel to the ground. Medial rotation occurs when the arm is rotated at the shoulder so that the fingers change from pointing straight forward to pointing across the body.
subscapularis, latissimus dorsi, teres major, pectoralis major, anterior fibers of deltoid
Lateral rotationof the arm[12]
The opposite of medial rotation of the arm.
infraspinatus and teres minor, posterior fibers of deltoid
Armcircumduction[13]
Movement of the shoulder in a circular motion so that if the elbow and fingers are fully extended the subject draws a circle in the air lateral to the body. In circumduction, the arm is not lifted above parallel to the ground so that "circle" that is drawn is flattened on top.
pectoralis major, subscapularis, coracobrachialis, biceps brachii, supraspinatus, deltoid, latissimus dorsi, teres major and minor, infraspinatus, long head of triceps