Shoulder Joint

the shoulder joint is the main joint of the shoulder. It is a ball and socket joint that allows the arm to
rotate in a circular fashion or to hinge out and up away from the body. The joint capsule is a soft tissue
envelope that encircles the glenohumeral joint and attaches to the scapula, humerus, and head of the
biceps. It is lined by a thin, smooth synovial membrane. The rotator cuff is a group of four muscles that
surround the shoulder joint and contribute to the shoulder's stability. The muscles of the rotator cuff are
supraspinatus, subscapularis, infraspinatus, and teres minor. The cuff adheres to the glenohumeral
capsule and attaches to the humeral head.

The shoulder must be mobile enough for the wide range actions of the arms and hands, but stable
enough to allow for actions such as lifting, pushing, and pulling.
The rotator cuff is an anatomical term given to the group of four muscles and their tendons that act to
stabilize the shoulder.[3] These muscles are the supraspinatus, infraspinatus, teres minor and
subscapularis and that hold the head of the humerus in the glenoid cavity during movement.[3] The cuff
adheres to the glenohumeral capsule and attaches to the head of the humerus.[3] Together, these keep
the humeral head in the glenoid cavity, preventing upward migration of the humeral head caused by the
pull of the deltoid muscle at the beginning of arm elevation. The infraspinatus and the teres minor, along
with the anterior fibers of the deltoid muscle, are responsible for external rotation of the arm.[6]

The four tendons of these muscles converge to form the rotator cuff tendon. This tendon, along with the
articular capsule, the coracohumeral ligament, and the glenohumeral ligament complex, blend into a
confluent sheet before insertion into the humeral tuberosities.[7] The infraspinatus and teres minor fuse
near their musculotendinous junctions, while the supraspinatus and subscapularis tendons join as a
sheath that surrounds the biceps tendon at the entrance of the bicipital groove.[7

Muscles from the shoulder region

In addition to the four muscles of the rotator cuff, the deltoid muscle and teres major muscles arise and
exist in the shoulder region itself.[3] The deltoid muscle covers the shoulder joint on three sides, arising
from the front upper third of the clavicle, the acromion, and the spine of the scapula, and travelling to
insert on the deltoid tubercle of the humerus.[3] Contraction of each part of the deltoid assists in
different movements of the shoulder - flexion (clavicular part), abduction (middle part) and extension
(scapular part).[3] The teres major attaches to the outer part of the back of the scapula, beneath the
teres minor, and attaches to the upper part of the humerus. It helps with medial rotation of the
humerus.[3]

Joint Capsule and Bursae

The joint capsule is a fibrous sheath which encloses the structures of the joint.

By TeachMeSeries Ltd (2019)

Fig 1.0 – The articulating surfaces of the shoulder joint.

It extends from the anatomical neck of the humerus to the border or ‘rim’ of the glenoid fossa. The joint
capsule is lax, permitting greater mobility (particularly abduction).

The synovial membrane lines the inner surface of the joint capsule, and produces synovial fluid to reduce
friction between the articular surfaces.

To reduce friction in the shoulder joint, several synovial bursae are present. A bursa is a synovial fluid
filled sac, which acts as a cushion between tendons and other joint structures.

Ligaments

In the shoulder joint, the ligaments play a key role in stabilising the bony structures.

Glenohumeral ligaments (superior, middle and inferior) – the joint capsule is formed by this group of
ligaments connecting the humerus to the glenoid fossa. They are the main source of stability for the
shoulder, holding it in place and preventing it from dislocating anteriorly. They act to stabilise the
anterior aspect of the joint.

Fig 1.2 – The ligaments of the shoulder joint. The transverse humeral ligament is not shown on this
diagram

Coracohumeral ligament – attaches the base of the coracoid process to the greater tubercle of the
humerus. It supports the superior part of the joint capsule.

Transverse humeral ligament – spans the distance between the two tubercles of the humerus. It holds
the tendon of the long head of the biceps in the intertubercular groove.]
Coraco–clavicular ligament – composed of the trapezoid and conoid ligaments and runs from the clavicle
to the coracoid process of the scapula. They work alongside the acromioclavicular ligament to maintain
the alignment of the clavicle in relation to the scapula. They have significant strength but large forces
(e.g. after a high energy fall) can rupture these ligaments as part of an acromio-clavicular joint (ACJ)
injury. In severe ACJ injury, the coraco-clavicular ligaments may require surgical repair.

The other major ligament is the coracoacromial ligament. Running between the acromion and coracoid
process of the scapula it forms the coraco-acromial arch. This structure overlies the shoulder joint,
preventing superior displacement of the humeral head.

Movements

As a ball and socket synovial joint, there is a wide range of movement permitted:

Extension (upper limb backwards in sagittal plane) – posterior deltoid, latissimus dorsi and teres major.

Flexion (upper limb forwards in sagittal plane) – pectoralis major, anterior deltoid and coracobrachialis.
Biceps brachii weakly assists in forward flexion.

Abduction (upper limb away from midline in coronal plane):

The first 0-15 degrees of abduction is produced by the supraspinatus.

The middle fibres of the deltoid are responsible for the next 15-90 degrees.

Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by the
trapezius and serratus anterior.

Adduction (upper limb towards midline in coronal plane) – pectoralis major, latissimus dorsi and teres
major.

Internal rotation (rotation towards the midline, so that the thumb is pointing medially) – subscapularis,
pectoralis major, latissimus dorsi, teres major and anterior deltoid.

External rotation (rotation away from the midline, so that the thumb is pointing laterally) – infraspinatus
and teres minor
Movements

As a ball and socket synovial joint, there is a wide range of movement permitted:

Extension (upper limb backwards in sagittal plane) – posterior deltoid, latissimus dorsi and teres major.

Flexion (upper limb forwards in sagittal plane) – pectoralis major, anterior deltoid and coracobrachialis.
Biceps brachii weakly assists in forward flexion.

Abduction (upper limb away from midline in coronal plane):

The first 0-15 degrees of abduction is produced by the supraspinatus.

The middle fibres of the deltoid are responsible for the next 15-90 degrees.

Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by the
trapezius and serratus anterior.

Adduction (upper limb towards midline in coronal plane) – pectoralis major, latissimus dorsi and teres
major.
Internal rotation (rotation towards the midline, so that the thumb is pointing medially) – subscapularis,
pectoralis major, latissimus dorsi, teres major and anterior deltoid.

External rotation (rotation away from the midline, so that the thumb is pointing laterally) – infraspinatus
and teres minor

Pathology
Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder.
They act as cushions between bones and the overlying soft tissues, and help reduce friction between the
gliding muscles and the bone.

Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can
become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may
become difficult.

tendinitis

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the
tendon.

Generally, tendinitis is one of two types:

Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute
tendinitis.

Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic
tendinitis.

impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the
underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion
rubs, or "impinges" on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis,
causing pain and limiting movement.

fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus
(upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger
patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or
contact sports injury.

Fractures often cause severe pain, swelling, and bruising about the shoulder.