SHOULDER ANATOMY

I. INTRODUCTION

A.The shoulder or pectoral girdle consists of articulations between the

clavicle, scapula and the proximal end of the humerus. The sternoclavicular
articulation is the only bony link between the upper limb and the axial
skeleton. Movements at this joint are largely passive in that the occur as a
result of active movements of the scapula. Through the acromioclavicular
articulation, the clavicle can act as a strut maintaining the upper limb away
from the thorax permitting a greater range of upper limb motion. This joint
also helps provide static stability to the upper limb reducing the need to use
muscle energy to keep the upper limb in its proper alignment. The
glenohumeral articulation (shoulder joint) has the greatest range of motion of
any joint in the body. The mobility of the shoulder joint is necessary for
placement of the hand to maximize manipulation. The scapula is suspended
on the thoracic wall by muscle forming a "functional joint" called the
scapulothoracic joint. These muscles act to stabilize and/ or to actively move
the scapula. Active movements of the scapula help increase the range of
motion of the shoulder joint.
B.The student will be asked to demonstrate their understanding of shoulder
girdle anatomy by applying this information in the diagnosis of problems of
these often injured joints

II. COMPONENTS OF THE SHOULDER GIRDLE

A.Bones
1. Clavicle
2. Scapula
3. Proximal end of humerus
B.Articulations
1. Acromioclavicular Joint

a.Planar type joint between lateral portion of the clavicle and the
acromion of the scapula.
2. Sternoclavicular Joint

a.Sellar joint between the medial end of the clavicle and the
manubrium of the sternum.
2. 3. Glenohumeral ( Shoulder ) Joint

a.Ball and socket articulation between head of humerus and glenoid

cavity.
b.Favors mobility over stability
2. Scapulothoracic "Joint"

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 a.Scapula suspended on rib cage by muscles

i.highly mobile
b.capula movements increases range of motion at the
shoulder joint

III. MUSCLES ACTING ON THE SHOULDER GIRDLE

A.Extrinsic - Suspend scapula from the trunk .Stabilize and/or actively moves
scapula
1. Trapezius
2. Levator Scapulae
3. Rhomboid Major and Minor
4. Serratus Anterior
5. Pectoralis minor
B.Intrinsic - Attach scapula to humerus
1. Deltoid
2. Teres Major
3. Rotator Cuff (active stabilization of shoulder joint)

a.Supraspinatus
b.Infraspinatus
c.Teres Minor
d.Subscapularis
B.Attach trunk to humerus
1. Latissimus dorsi
2. Pectoralis Major
C.Attachments and Functions (See Chart 1)

IV. STABILITY OF THE SHOULDER GIRDLE

A.Acromioclavicular Joint
1. Ligaments

a.Acromioclavicular
b.Coracoclavicular
c.Conoid
d.Trapezoid
2. 2. Functions

a.Bind clavicle to scapula supporting weight of upper limb minimizing

use of muscle energy
2. 3. Shoulder Separation

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a.Tearing of acromioclavicular and /or coracoclavicular ligaments
b.Clavicle overrides acromion
c.Weight of upper limb pulls scapula and acromion inferiorly
below clavicle
B.Sternoclavicular Joint
1. Ligaments

a.Sternoclavicular
b.ianterior and posterior
c.Interclavicular
d.Costoclavicular
2. Fibrocartilage Disc

a.Strengthens articulation
B.Glenohumeral Joint
1. Capsule

a.Attaches from glenoid cavity to anatomical neck of humerus

b.Least amount of support inferiorly
2. Ligaments

a.Coracoacromial

i.Helps resist upward displacement of the head of the

humerus
b.Coracohumeral

i.Strengthens superior portion of capsule

ii.Some support during shoulder abduction
b.Transverse Humeral Ligament

i.holds long head of biceps in the groove

b.Glenohumeral Ligaments - 3 parts all attach from upper
margin of glenoid cavity and strengthen anterior portion
of capsule

i.Superior - over the humeral head to a depression above the

lesser tuberosity
ii.Middle - in front of humerus to lower lesser tuberosity
iii.Inferior - to lower part of the anatomical neck
2. Rotator Cuff Muscles

a.Active stabilizers of shoulder joint

i.act throughout entire range of motion at shoulder

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 b.Depress head of humerus in glenoid cavity when
humerus moves

i.Prevents compression of structures between humeral head

and acromion
b.Muscles also help rotate shoulder (See Chart:
"Movements of Glenohumeral Joint" )
B.D.Scapulothoracic Articulation
1. 1. Stability

a.Dependent upon activity of extrinsic muscles

b.Winged scapula
2. 2. Alignment

a.Upwardly rotated and elevated position of scapula at rest

i.action of trapezius muscle

V. MOVEMENTS OF THE STERNOCLAVICULAR JOINT

A.Passive movements.
1. Acromial end moves as consequence of movements of the scapula
2. Sternal end of clavicle moves in a direction opposite from that of
the scapula.
B.Types of Movements
1. Protraction - scapula is retracted causing the sternal end to move
forward
2. Retraction - scapula is protracted causing the sternal end to move
backward
3. Elevation - scapula is depressed causing the sternal end to move
upward
4. Depression - scapula is elevated causing the sternal end to move
downward
C.Muscles Acting on Sternoclavicular Joint
1. The muscles acting on the Sternoclavicular joint are outlined in
Chart 1. These are the same muscles that act on the scapula.
2. Movements of the Sternoclavicular joint and the muscles producing
these movements are outlined in Chart 2. Remember the SC joint
moves in a direction opposite from the way in which the scapula
moves.

VI. MOVEMENTS OF THE SCAPULA

A.Types
1. Elevation - moving the superior border of the scapula and the
acromion in an upward direction.

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 2. Depression - moving the superior border of the scapula and the
acromion in an downward direction.
3. Upward Rotation - Moving the scapula so that the glenoid cavity
faces upward.

a.Increased the ranges of motion during abduction and/or

flexion of the shoulder.
2. Downward Rotation - moving the scapula so that the glenoid cavity
faces inferiorly.

a.Increases range of motion during extension and / or adduction of the

shoulder.
2. Protraction ( Abduction) - moving the scapula away from the midline
3. Retraction (Adduction) - moving the scapula toward the midline
B.Muscles Acting to Move Scapula
1. Very mobile

a.Muscles suspend scapula from vertebral column and chest

wall
b.Axis around which scapulae move changes
c.Muscles attach to scapula obliquely

i.Produce many motions

2. Movements

a.See chart Movements of the Scapula

2. Muscle Synergy at the Shoulder Joint

a.Retraction of the Scapula

i.Trapezius -- retract and rotates upward

ii.Rhomboids -- retract and rotate downward
b.Upward rotation of the Scapula

i.Serratus anterior -- protracts and rotates upward

ii.Trapezius -- Retract and rotates upward

VII. MOVEMENTS OF THE GLENOHUMERAL JOINT

A.Properties
1. Movements of the shoulder joint (glenohumeral joint) usually
involve moving the humerus on the scapula.
2. All movements are to be studied starting from the ANATOMICAL
POSITION

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 3. Axis of motion

a.Flexion - Extension

i.Coronal axis through head of humerus

b.Abduction /Adduction

i.Sagittal axis through humeral head

b.Rotation

i.Longitudinal axis through shaft of humerus

B.Types of Movements
1. Flexion moving the humerus forward and upward in the sagittal
plane.
2. Extension - bringing the arm down to the side in the sagittal plane.

a.Hyperextension - moving the arm in the sagittal plane behind

the body.
2. Abduction - moving the arm in the coronal plane away from the
midline

a.Stages

i.initiate -supraspinatus
ii.90 - deltoid
iii.180 - deltoid with upward rotation of scapula
2. Adduction - moving the arm in the coronal plane towards the
midline.
3. Inward Rotation - rotating the arm in a transverse plane so that the
anterior surface of the bone turns inward.
4. Outward Rotation - rotating the arm in a transverse plane so that
the anterior surface of the bone turns outward.
B.Scapulohumeral Rhythm
1. Coordinated movements of the scapula and the humerus
increasing the range of motion at the glenohumeral joint

a.Most noticeable during complete flexion and abduction of the

shoulder
b.2 - 30 of humeral abduction is associated with 1 - 20 of
scapula rotation
B.Movements of the Shoulder Joint
1. Chart 3 - MOVEMENTS of the SHOULDER JOINT indicates which
muscles interact to produce a given movements of the shoulder

VIII. CLINICAL ANATOMY OF THE SHOULDER JOINT

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A.Dislocation
1. Weakness of rotator cuff tendons and / or trauma
2. Head of humerus subluxes (separated ) from glenoid cavity of
humerus
3. Usually occurs when humerus is in position of abduction or flexion

a.Least amount of contact between apposing bony surfaces

2. Occurs in an inferior direction

a.Weakest region of capsule

b.Humerus pulled either anterior to or posterior to shoulder joint
depending upon which rotator cuff muscles are injured.
2. Arm hangs limp at side with a prominent "step deformity" (space)
between acromion and humeral head
B.Impingement Syndrome
1. Weakness or fatigue of rotator cuff muscles
2. Activity of shoulder joint accompanied by intense pain

a.Movements of abduction and flexion usually more painful

b.Painful arc

i.Very painful abducting from neutral position to

horizontal. Then pain subsides
2. Compression of supraspinatus tendon between head of humerus
and acromion.
B.Nerve Lesions
Lesions to components of the brachial plexus, especially those components
associated with the C 5 and/or C 6 nerve roots, will have and major effect on
the ability of the shoulder girdle to carry out normal functions. Often, the signs
and symptoms concerning loss or reduction in function can be used to
localize the site of the nerve lesion. The effects of various types of nerve
lesions can have on the shoulder girdle is summarized below:
1. Accessory nerve - innervates the trapezius muscle. Paralysis of this
muscle will result in a marked drooping and down turning of the
affected shoulder at rest because of the loss of the ability of the
trapezius to elevate and upwardly rotate the scapula. The latter loss
will also prevent the patient from abducting their arm above the
horizontal ( shoulder level).
2. Dorsal Scapular nerve - innervates the rhomboideus muscles. Any
attempt to retract the scapula will be accompanied by a marked
upward rotation of the shoulder because the rhomboideus can no
oppose the upward rotation on the scapula exerted by the
trapezius. The patient will have difficulty retracting the scapula
against resistance on the affected side.
3. Long thoracic nerve - Innervates the serratus anterior muscle.
Active contraction of this muscle results in scapula protraction and

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 upward rotation. When the scapula is passively protracted by action
of the pectoralis major muscle on the humerus , the serratus
anterior acts to stabilize the scapula and keep it applied to the
thoracic wall. Such action occur when a boxer throws a jab or a
cross. Paralysis of the serratus anterior prevents the scapula from
moving smoothly across the thoracic wall resulting in a bowing out
of the medial border of the scapula. This condition is called
"winged" scapula. In addition, the ability to actively upwardly rotate
the shoulder is diminished and the patient can not abduct the
humerus above the horizontal.
4. Suprascapular nerve - innervates the supraspinatus and
infraspinatus muscles. Paralysis of this nerve will result is
weakness of the rotator cuff muscles resulting in pain form
impingement and an inability of the patient to begin shoulder
abduction. Such patients tend to swing the affected limb away from
their side in order to provide momentum to start abduction.
5. Axillary nerve - innervates the deltoid and teres minor muscles.
Since the deltoid plays a major role in movement of the
glenohumeral joint, paralysis will cause a loss &/or weakness of
most shoulder functions. Symptoms of deltoid paralysis include:

a.loss or roundness to the shoulder and a very visible acromion

process
b.inability to abduct the glenohumeral joint more than a few
degrees away from the side.
c.inability to laterally rotate the humerus
d.weakened movements of glenohumeral flexion and extension
e.loss of sensation just below the point of the shoulder
2. C5, C6 root damage ( Erb's palsy) - axons from the C5 and C6
ventral rami innervate the following muscles acting on the shoulder
girdle:
deltoid, supraspinatus, infraspinatus , teres minor, subscapularis.
Lesion to these roots will result in paralysis of these muscles. The
symptoms of such a lesion are outlines in the chart below.

C5, C6 Nerve Root Lesion (Erb's Palsy)

MOTOR SENSORY NERVES

DEFICITS DEFICIT
Loss of Posterior and Axillary,
abduction, lateral aspect of Suprascapular,
flexion and arm - axillary n. Upper and Lower
rotation at subscapular
shoulder ;

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 Weak
shoulder
extension -
deltoid,
rotator cuff
Very weak Radial side of Musculocutaneous ;
elbow Forearm- Radial N. brs. to
flexion and musculocutaneous supinator &
supination n. Thumb and 1st brachioradialis
of finger - superficial muscles
radioulnar br. of radial; digital
joint- biceps brs. - Median n.
brachii &
brachialis
Susceptible Suprascapular,
to shoulder Upper and Lower
dislocation - subscapular
loss of
rotator cuff
muscles
"Waiters
Tip"position

Chart 1 - Muscles Acting On The Shoulder Girdle

MUSCLE PROXIMAL DISTAL NERVE FUNCTIONS
Extrinsic: Attach scapula to neck and trunk
Trapezius 1. Ext 1. Lat. 1/3 Spinal portion Retracts and
Occipital of clavicle of XI upwardly
Protuberance (upper) rotates
scapula
2. Lig . 2.
nuchae Acromion
(middle)
3. Lower
cervical & 3. Spine
thoracic of
spines scapula
(lower)
Levator Transverse Upper Cervical Elevation and
Scapulae processes of medial Plexus downward

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 C 1 to or 4 border of rotation of the
the C3&C4 scapula
scapula
Rhomboid 1. Medial Dorsal 1. Retraction,
Major & Minor Ligamentum border of Scapular downward
nuchae, the rotation, some
scapula; (Nerve to elevation of
2. spinous from the Rhomboids) the scapula,
processes of root of
C7 to T 5 the spine C 4; (C5) 2. Fixes the
to the scapula
inferior against the
angle trunk
Serratus Outer surface Anterior Long Thoracic 1.Protraction
Anterior of ribs surface of and upward
the ( C 5,6,7) rotation of
1-8 medial scapula
border of
the 2. Fixes
scapula scapula
against the
thoracic wall
Pectoralis Ribs 3, 4, & 5 Coracoid Medial Protract,
Minor process Pectoral Nerve downward
of (C8,T1) rotation o f
scapula scapula
Intrinsic: Rotator Cuff ( Active stabilization of shoulder joint by
preventing downward displacement of the humerus)
Supraspinatus Supraspinous Superior Suprascapular Starts
fossa of facet of shoulder
scapula the (C 5,6) abduction
greater
tubercle
of
humerus
Infraspinatus Infraspinous Middle Suprascapular Lateral
fossa of facet of shoulder
scapula the (C 5,6) rotation
greater
tubercle
of
humerus
Teres Minor Lateral border Inferior Axillary (C 5,6) Lateral

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 of scapula, fact of the shoulder
superior to greater rotation
Teres Major tubercle
of the
humerus
MUSCLE PROXIMAL DISTAL NERVE FUNCTIONS
Subscapularis Subscapular Lesser Subscapular 1. Medial
fossa of the tubercle of Nerves (C 5,6) shoulder
scapula humerus rotation
Intrinsic: Attach humerus to scapula
Deltoid 1. Lateral one Deltoid Axillary (C 5,6) Anterior
third of clavicle tuberosity portion -
flexes,
2. Acromion on the medially
humeral shaft rotates
3. Spine of the shoulder
scapula
Middle portion
- abducts the
shoulder

Posterior
Portion -
extends,
laterally
rotates the
shoulder
Teres major Dorsal scapula Crest of the Lower 1. Adduction
near inferior lesser tubercle Subscapular and medial
angle of humerus rotation of the
(C 5,6) shoulder

2. Stabilizes
shoulder
during
abduction

3. Extend
shoulder from
flexed position
Attach humerus to trunk ( Act primarily on humerus; scapula moves
passively in response to movement of humerus)
Latissimus 1. Floor of Thoracodorsal 1.Extend,

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Dorsi Thoracolumbar bicipital Adduct, and
fascia groove (also (C 6,7,8) Medially
called rotate the
2. Sacrum, iliac intertubercular shoulder
crest sulcus)
2. Depress
3. Spinous and
processes of T downward
6 to L5 rotation of
scapula
Pectoralis 1. Medial 1/2 of Lateral lip of Lateral and 1. Adduction,
Major the clavicle the bicipital Medial Flexion,
groove (also Pectoral Medial
2. Sternum, called the nerves (C6- Rotation of
costal intertubercular T1) the shoulder
cartilages of sulcus)
ribs 2 6 2. Horizontal
Adduction

3. Protraction
of scapula

Chart 2 - MOVEMENTS OF THE SCAPULA

Motion Prime Movers Nerve Critical
Segment
Elevation Trapezius- upper Accessory
Levator scapulae N. to L. C 3,4
scapulae
Rhomboideus major* Dorsal scapular C (4),5
Rhomboideus minor* Dorsal scapular C (4),5
Depression Latissimus dorsi1 Thoracodorsal C 7
Pectoralis major - Pectoral C 6, 7,8
sternal head1 Nerves
Pectoralis minor Medial pectoral C 8, T1
Upward Serratus anterior Long thoracic C 5, 6, 7
Rotation Trapezius-Upper & Accessory
Lower

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 Downward Latissimus dorsi1 Thoracodorsal C 7
Rotation Pectoralis major - Pectoral C 6, 7,8, 1
sternal head1 Nerves
Pectoralis minor Medial pectoral C 8, T1
Levator scapulae N. to L. C 3,4
scapulae
Protraction Serratus anterior Long thoracic C 5, 6, 7
Pectoralis minor Medial pectoral C 8, T 1
Pectoralis major 1 Pectoral C 6, 7,8, 1
Nerves
Retraction Trapezius Accessory
Rhomboideus major Dorsal scapular C (4),5
Rhomboideus minor Dorsal scapular C (4),5

* When the rhomboids assist in elevation, the resultant movement is a

combination of elevation and retraction.

1 Muscles passively move scapula through their active action on the humerus

Chart 3 -MOVEMENTS OF THE GLENOHUMERAL JOINT

Motion Prime Movers Nerve Critical
Segments
Flexion Deltoid - anterior Axillary C5
Pectoralis major - Lateral Pectoral C 5, 6
clavicular head
Coracobrachialis* Musculocutaneous C 5, 6, 7
Extension Deltoid - posterior Axillary C5
Latissimus dorsi Thoracodorsal C7
Teres major Lower subscapular C 5, 6
Abduction Supraspinatus1 Suprascapular C 5, 6
Deltoid - anterior Axillary C5
Adduction Latissimus dorsi Thoracodorsal C7
Pectoralis major - Pectoral nerves C 6, 7, 8, 1
sternal head
Inward Subscapularis Upper subscapular C 5, 6
Rotation Deltoid - anterior Axillary C5

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Outward Infraspinatus Suprascapular C 5, 6
Rotation Teres minor Axillary C5
Deltoid - posterior Axillary C5

Figure 1
SCAPULA
MOVEMENTS

Retraction means the scapula is drawn

towards the midline; protraction is
movement away from the midline.
Elevation is raising the entire scapula
upwards as in shrugging ones shoulder;
depression is lowering the scapula.

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 Figure 2
SCAPULA
ROTATION

Upward Rotation of the scapula involves

rotating the glenoid cavity upward while
moving the inferior angle laterally;
downward rotation involves rotating the
glenoid cavity downward while the inferior
angle moves medially. Upward rotation
occurs during flexion and abduction of the
shoulder to increase the range of motion
when the humerus moves on the scapula.
Downward rotation is used to increase the
range of motion of the humerus when it
moves on the scapula during shoulder
extension and adduction.

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 Figure 3
Shoulder
Girdle -
Anterior

1. Name the bony features of the shoulder

girdle indicated by each number

2. Draw in the ligaments the support the

joints of the shoulder girdle

Figure 4.
Shoulder
Girdle -
Posterior

1. Name the bony components of the shoulder girdle

indicated by each number.

2. The dashed line is the

__________________________________. What
structure attaches here?

3. What are the names and functions of the muscles

inserting at the dark rectangles?

4. What is the name and function(s) of the muscle

inserting along the bones labeled 3, 4, 5?
From Gray Anatomy

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