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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

The Shoulder Girdle Dr Youssef Masharawi

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

The 4 Joints
Acromio-Clavicular Sterno-Clavicular Scapular-Thoracic Gleno-Humeral

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Acromioclavicular Joint
Clavicular shape Ligaments
AC lig. Trapezoid lig. Coracoacromial lig.

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Sternoclavicular Joint
Ball & Socket
Rotation in long axis

Interspace meniscus Sternoclavicular lig. Costoclavicular lig.

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

ST joint
Passive stabilizer AC joint Dynamic stabilizers
Trapezius Serrantus anterior Rhomboids Levator scapula
6 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

ST joint functions
To orient the glenoid fossa for optimal contact with the humeral head To increase the range of arm elevation To provide a stable base for the RC muscle activity
7 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Glenohumeral Joint
Passive System
OSSEOUS MORPHOLOGY
Ball & Socket type

Glenoid labrum

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Dr Youssef masharawi emai: yossefm@post.tau.ac.il

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Passive System
Capsuloligamentous mechanism Passive muscle tension Negative intra-articular pressure

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Dynamic System
Dynamic stability = muscle activity
(Richardson 1992)

The RC tendons are blended into the capsule and ligaments

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Dynamic System
They circumduct the humeral head Adjust tension in passive structures Create a compressive vector on the humeral head

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

<>

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Neural System
Facilitates normal interaction between the passive and active system Static stabilizers have to work in synergy with the dynamic stabilizers (Lippit & Matson, 1993, Peat, 1986) Strength alone is not sufficient (Matson et al 1990) A reflex arch from the GH capsule to several muscles crossing the GH joint has been described by Guanche et al (1995) in cats
17 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Joint Stability Panjabis concept (1992)

Passive system Neural system Dynamic system

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Functional Anatomy in Scaption - Abduction

Scaption Abduction

Setting phase Setting phase 0 --30 0 30

Middle phase 30 - 140

Final phase 140 - 180

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Setting Phase ( 00 - 300)

GH joint contributes most of the motion Type and amount of movement in the ST joint differs between individuals ICR of the scapula anywhere in its lower-mid portion Strongly influenced by motion at the SC joint
(Norkin & Levangie, 1992)
20 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Setting Phase Muscle function

Middle deltoid action counteracted by RC activity Disagreement to the relative contribution of scapular rotator muscles Different theories about the force couples between upper and lower trapezius, and serratus anterior
(Basmajan & De Luca, 1985, Kapandji, 1982, Poppen &Walker, 1976).
21 Dr Youssef masharawi emai: Dvir & Berme, 1978, Inman et al, 1944, Johnson et al, 1994). yossefm@post.tau.ac.il

(Johnson et al, 1994, Dvir& Berme, 1978, Bagg & Forrest, 1986, Ludewig et al, 1996).

(Bagg & Forrest, 1986,

Middle Phase
SHR ratio 1:1

0 (30

0) 140

AC joint elevation & protraction Scapula ICR is now located at the AC joint After 600 the humeral head glide downward and rotate externally (Donatelli, 1997; Kapandji, 1982)
22 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Middle Phase Muscle function

The most powerful phase at the GH joint This resistance is overcome by activation of the scapular rotator muscles (Doody
et al., 1970)

The Deltoid and Supras. reached their peak activity around 900 (De Luca & Forrest, 1973; Dvir & Berme, 1978)

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Muscle function
Different reports of scapular rotators muscle activity in the literature (Bradly & Tibone, 1991; Inman et al., 1944, Ludewig et al., 1996) A change in muscle task from scapula stabilizer to prime mover (Bagg & Forrest, 1986) Ludewig et al., 1996 described 3 possible patterns of upper and lower trapezius activity
Dr Youssef masharawi emai: yossefm@post.tau.ac.il

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Final Phase

0 (140

0) 180

SHR varies between 3:1 to 7:1 Tightness of the AC joint caused by tightness in the coracoclavicular ligaments The flexibility of the Latiss., Pect.Maj., Subs., Ter.Maj can affect the ROM in Abd. (Donatelli, 1997)
25 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Final Phase Muscle function

Trapezius muscle function is controversial Increase/Decrease activity (Bagg & Forrest, 1986; Brandell & Wilkinson,
1991; Guazzelli et al, 1991; Ludewig et al., 1996)

Serrat.ant activity remain high Decrease activity of the RC, and mid. Delt.
1. Outer range = active insufficiency 2. GHJ at a closed pack position less dynamic stabilisation is needed
(Inman et al., 1944; Kronberg et al., 1990)
26 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

SHR roles
Prevent impingement Optimize length/tension relationship Optimize contact between humeral head and glenoid help to stabilize GH joint
27 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Three SHR patterns

(Bagg & Forrest, 1988)

1. The most common

Each phase has a different SHR, Mid.phase ST > GH

2. Only 2 phases 1.8:1 up to 1300

7.5 :1 up to 1800

3. Only 2 phases 2:1 up to 1600

7:1 up to 1800
Dr Youssef masharawi emai: yossefm@post.tau.ac.il

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SHR conclusions
SHR is variable between subjects SHR change during arm elevation Scapular ICR is not fixed Average contribution to arm elevation ST about 600, GH about 1000
29 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

The Vicious Cycle

Shoulder impingement
Pain inhibition of the R.C. muscle Abnormal kinematics Muscle imbalance around the shoulder

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Abnormal Decrease in SHR Dr Youssef masharawi emai: subacromial space

yossefm@post.tau.ac.il

Secondary Impingement
Minor instability: Static stabilisers, dynamic stabilisers Muscle imbalance: Abnormal function of the RC, Abnormal function of the scapula rotators

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Primary Impingement
Intrinsic factors: Degenrative changes, Tendinitis Extrinsic factors: Osteophytes, coracoacromial arch Abnormality, capsule tightness
32 Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Shoulder Impingement
Possible Etiology
Shoulder impingement

Secondary (younger population)

Primary (older population)

GH joint hypermobility
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Muscle imbalance
Dr Youssef masharawi emai: yossefm@post.tau.ac.il

Extrinsic

Intrinsic

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Dr Youssef masharawi emai: yossefm@post.tau.ac.il