2 THE SHOULDER
Applied Anatomy
ACROMIOCLAVICULAR JOINT
The acromioclavicular (AC) joint is a spheroidal joint between the lateral end of the clavicle and the acromion process of the scapula (Figure 2-1). A small, intraarticular fibro cartilaginous disk divides the joint into two compartments. A subcutaneous, noncommunicating bursa may be present over the joint. The stability of the AC joint depends on the capsule and the superior and inferior AC ligaments. The coracoclavicular ligament (conoid and trapezoid parts) extends between the distal clavicle and the coracoid process of the scapula (Figure 2-2). It suspends the scapula, stabilizes both the clavicle and the scapula, and maintains a close relation between the two bones during shoulder movements, thus limiting scapular rotation around the AC joint. The AC and SC joints augment the range of shoulder movements, particularly abduction and rotation. The joints also allow slight axial rotation of the clavicle, as well as elevation/depression and forward/backward thrusting of the shoulder.
GLENOHUMERAL JOINT
The glenohumeral (GH) joint, the main articulation of the shoulder complex, is a multiaxial, ball-and-socket synovial articulation between the glenoid fossa of the scapula and the humeral head (Figure 2-1). The lax articular capsule and the small area of contact between the shallow glenoid fossa and the spheroidal humeral head permit a wide range of motion. The stability of the joint depends on a number of static and dynamic stabilizers. Static stabilizers include negative intraarticular pressure; GH bone geometry; the capsule; the glenoid labrum; the superior, middle, and inferior GH ligaments; and the coracohumeral ligament. The capsule, which fuses in part with the tendons of the rotator cuff, has two apertures: one for the long biceps tendon (origin from the supraglenoid tubercle) and one for the subscapularis bursa. The labrum, a ring of fibrocartilage that surrounds and deepens the glenoid cavity, contributes significantly to GH joint stability. Through a bumper effect, it functions as a “chock block” to prevent translational forces.
The coracoacromial arch—made up of the coracoid process, coracoacromial ligament, and acromion—acts as a protective, secondary socket for the humeral head, under which the rotator cuff tendons and long biceps tendon glide, with the subacromial bursa lying in between. The arch prevents upward displacement of the humeral head and protects the head and rotator cuff from direct trauma. The undersurface of the acromion is commonly flat (type 1); less frequently, it is downwardly curved (type 2) or hooked (type 3), but these conditions are more commonly associated with subacromial impingement.
The synovium of the shoulder lines the inner surface of the capsule. It has two extracapsular outpouchings, the tenosynovial sheath of the long biceps tendon and the bursa beneath the subscapularis tendon (Figure 2-2). A communicating infraspinatus bursa is sometimes present. The subcoracoid bursa lies between the shoulder capsule and the coracoid process, but it rarely communicates with the joint.
SCAPULOTHORACIC MOVEMENTS
The so-called scapulothoracic articulation is not a true joint but functions as an integral part of the shoulder complex. The scapula, which is connected to the posterior aspect of the chest wall by the axioappendicular muscles, provides the origin for the rotator cuff muscles and deltoid, and the trapezius inserts into its superior aspect. Scapulothoracic movements that include rotation, elevation, depression, protrusion, retraction, and circumduction are important for the normal functioning of the shoulder. The scapulothoracic bursa is located between the serratus anterior and the chest wall, just medial to the inferior angle of the scapula.
NERVE SUPPLY TO THE SHOULDER JOINT
The shoulder joint derives its nerve supply from three branches of the brachial plexus: suprascapular, axillary, and lateral pectoral nerves (C5/C6). The axillary nerve and the posterior circumflex humeral artery pass through the quadrilateral or quadrangular space, which lies inferoposterior to the GH joint, bounded by the teres minor superiorly, the teres major inferiorly, the long head of triceps medially, and the shaft of the humerus laterally (Figure 2-3).
SHOULDER PAIN AND HISTORY TAKING
Shoulder pain is a common symptom of diverse causes (Table 2-1). The pain may originate in the GH or AC joint or in periarticular structures, or it may be referred from the cervical spine, brachial plexus, thoracic outlet, or infradiaphragmatic structures. Important points in the history include age, hand dominance, occupational and sport activities involving heavy lifting or overhead repetitive movements, history of trauma, onset, location, character, duration, radiation of the shoulder pain, aggravating and relieving factors, presence of night pain, and the effect on shoulder function. Associated symptoms—shoulder stiffness, restriction of movement, grinding, clicking, instability, or weakness—may also provide useful diagnostic clues.
Articular Causes |
GH and AC arthritis: OA, RA, PsA, trauma, infection, crystal-induced |
Ligamentous and labral lesions |
GH and AC joint instability |
Osseous: fracture, osteonecrosis, neoplasm, infection |
Periarticular Causes |
Chronic impingement and rotator cuff tendinitis |
Bicipital tendinitis |
Rotator cuff and long biceps tendon tears |
Subacromial bursitis |
Adhesive capsulitis |
Neurological Lesions About the Shoulder |
Thoracic outlet syndrome |
Acute brachial plexus neuritis |
Quadrilateral space syndrome |
Suprascapular nerve entrapment syndrome |
Cervical radiculopathy |
Referred and Miscellaneous Causes |
Angina pectoris |
Diaphragmatic and infradiaphragmatic disorders: pericarditis, pleurisy, gallbladder disease, subphrenic abscess |
Axillary artery or vein thrombosis |
Reflex sympathetic dystrophy syndrome and shoulder–hand syndrome |
Polymyalgia rheumatica, myositis |
Diffuse fibromyalgia and myofascial pain syndrome |
Somatization disorder and psychogenic regional pain syndrome |
AC, acromioclavicular; GH, glenohumeral; OA, osteoarthritis; PsA, psoriatic arthritis; RA, rheumatoid arthritis
Common Disorders of the Shoulder
ROTATOR CUFF PATHOLOGY
In young persons, rotator cuff tendinopathy is often caused by a sport-related injury; for example, from use of the arm in an overhead position in baseball, racquetball, tennis, or swimming. In older individuals, an antecedent history of repetitive movements above the shoulder level or of strenuous or unaccustomed arm activity is common. Symptoms include aching pain in the shoulder, lateral aspect of the upper arm, and deltoid insertion; pain with movement, particularly abduction and internal rotation; night pain when rolling onto the affected side; restriction of shoulder movements; and sometimes weakness caused by a rotator cuff tear. The patient typically experiences shoulder pain on active abduction, especially between 60° and 120°, and difficulty with overhead work, lifting, or reaching behind the back when dressing. Clinical findings include a painful arc between 60° to 120° of abduction, limitation of active movement by pain, and tenderness localized to the rotator cuff and greater tuberosity. The supraspinatus test, Neer impingement test, Neer impingement sign, and Hawkins impingement sign (see Special Tests of Shoulder, p. 13) are often positive.