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The shoulder joint: anatomy and relevant conditions Farhan A Z Chughtai iBSc (Hons) F.Chughtai1@uni.bsms.ac.uk Brighton & Sussex Medical SchoolThanks to our partners!Contents Anatomy • Bones of the shoulder • Anterior shoulder compartment • Posterior shoulder compartment • Shoulder muscle properties Clinical applications • Examining the shoulder • Common shoulder presentations: musculoskeletal • Common shoulder presentations: rheumatological© The Skeletal System 2024© Wikipedia 2024© Wikipedia 2024Shoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Shoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Shoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Shoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Shoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6) Shoulder muscles: key pointers Muscle Origin Insertion Neurovasculature Function Lateral clavical Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Acromion process tuberosity of axillary - Shoulder flexion humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability • Teres minor tubercle of the humerus holdtubercle ofouldeand post. circumflex humeral - Lateral/external border of scapula muscles humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation • The axillary artery is the most significant supply to the shoulder - External rotation muscles Infraspinous fossa Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus • Injury to C5-6 can cause complete loss of shoulder function Lesser A: Axillary, subscapular and Subscapularis Subscapular tubercle of suprascapular - Shoulder adduction fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Examining the shoulder With any orthopaedic examination: LOOK, FEEL, MOVE, SPECIAL TESTS In the shoulder: - Look for obvious dislocation, erythema, swelling, bruising, pallor - Feel for swelling, muscle tension, tenderness - Move: flexion, extension, abduction, adduction, internal/external rotation © Healthline 2024 - Special tests: • Jobe test (empty can): check for supraspinatus tendinopathy • Wall push-up test: check for scapular winging • Medial winging: serratus anterior pathology • Lateral winging: trapezius or rhomboid pathologyShoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder conditions: rheumatological Conditions Pathophysiology Clinical findings Management - Pain worse after exercise/better with rest - Pain worse in evening/better in morning st Unilateral arthralgia - Typically associated with old age, sickle cell disease 1 : topical NSAIDs Osteoarthritis isolated to Shoulder XR: LOSS 2 : oral analgesia (paracetamol, of the glenohumeral joint codeine, co-codamol) shoulder - Loss of joint space 3 : shoulder replacement surgery if “Wear and tear” - Osteophyte margins extensive degeneration - Subchondral cysts - Subchondral sclerosis Bilateral arthralgia, - Pain better after exercise/worse with rest Acute: oral corticosteroids may be extra- - Pain better in evening/worse in morning Requires rheumatology referral Rheumatoid articular involvement - Can present at any age 1 : DMARDs arthritis of - Shoulder XR may be NORMAL - methotrexate the shoulder Always symmetrical Investigations: - hydroxychloroquine UNLESS psoriatic - Anti-cyclic citrullinated peptide (CCP) Ab - leflunomide/sulfasalazine arthritis - Rheumatoid factor 2 : biologics e.g. infliximab 1 : analgesia +/- physio Adhesive Inflammation of the 2 : intra-articular steroids capsulitis shoulder bursa - Restricted movements in flexion, extension and - Methylprednisolone abduction of shoulder (frozen causing pain and - Internal and external - Triamcinolone shoulder) stiffness 3 : hydrodilation 4 : manual manipulationShoulder conditions: rheumatological Conditions Pathophysiology Clinical findings Management - Pain worse after exercise/better with rest - Pain worse in evening/better in morning st Unilateral arthralgia - Typically associated with old age, sickle cell disease 1 : topical NSAIDs Osteoarthritis isolated to Shoulder XR: LOSS 2 : oral analgesia (paracetamol, of the glenohumeral joint codeine, co-codamol) shoulder - Loss of joint space 3 : shoulder replacement surgery if “Wear and tear” - Osteophyte margins extensive degeneration - Subchondral cysts - Subchondral sclerosis Bilateral arthralgia, - Pain better after exercise/worse with rest Acute: oral corticosteroids may be extra- - Pain better in evening/worse in morning Requires rheumatology referral Rheumatoid articular involvement - Can present at any age 1 : DMARDs arthritis of - Shoulder XR may be NORMAL - methotrexate the shoulder Always symmetrical Investigations: - hydroxychloroquine UNLESS psoriatic - Anti-cyclic citrullinated peptide (CCP) Ab - leflunomide/sulfasalazine arthritis - Rheumatoid factor 2 : biologics e.g. infliximab 1 : analgesia +/- physio Adhesive Inflammation of the 2 : intra-articular steroids capsulitis shoulder bursa - Restricted movements in flexion, extension and - Methylprednisolone abduction of shoulder (frozen causing pain and - Internal and external - Triamcinolone shoulder) stiffness 3 : hydrodilation 4 : manual manipulationShoulder conditions: rheumatological Conditions Pathophysiology Clinical findings Management - Pain worse after exercise/better with rest - Pain worse in evening/better in morning st Unilateral arthralgia - Typically associated with old age, sickle cell disease 1 : topical NSAIDs Osteoarthritis isolated to Shoulder XR: LOSS 2 : oral analgesia (paracetamol, of the glenohumeral joint codeine, co-codamol) shoulder - Loss of joint space 3 : shoulder replacement surgery if “Wear and tear” - Osteophyte margins extensive degeneration - Subchondral cysts - Subchondral sclerosis Bilateral arthralgia, - Pain better after exercise/worse with rest Acute: oral corticosteroids may be extra- - Pain better in evening/worse in morning Requires rheumatology referral Rheumatoid articular involvement - Can present at any age 1 : DMARDs arthritis of - Shoulder XR may be NORMAL - methotrexate the shoulder Always symmetrical Investigations: - hydroxychloroquine UNLESS psoriatic - Anti-cyclic citrullinated peptide (CCP) Ab - leflunomide/sulfasalazine arthritis - Rheumatoid factor 2 : biologics e.g. infliximab 1 : analgesia +/- physio Adhesive Inflammation of the 2 : intra-articular steroids capsulitis shoulder bursa - Restricted movements in flexion, extension and - Methylprednisolone abduction of shoulder (frozen causing pain and - Internal and external - Triamcinolone shoulder) stiffness 3 : hydrodilation 4 : manual manipulation@supta_uk @SUPTAUK www.supta.uk Thank you! Any questions, ask or email: F.Chughtai1@uni.bsms.ac.uk Supplementary slides after this for revisionShoulder muscles Muscle Origin Insertion Neurovasculature Function Deltoid A: Thoracoacromial branch of - Shoulder abduction Deltoid Lateral clavicle tuberosity of axillary - Shoulder flexion Acromion process humerus N: Axillary (C5-6) - Shoulder extension Greater A: Subscapular, circumflex scapular - Glenohumeral stability Teres minor Posterolateral tubercle of and post. circumflex humeral - Lateral/external border of scapula humerus N: Axillary (C5-6) rotation Greater A: Suprascapular and dorsal - Shoulder abduction Supraspinatus Supraspinous tubercle of scapular - Rotator cuff stability fossa of scapula humerus N: Suprascapular (C5-6) - Prevent subluxation - External rotation Greater A: Suprascapular and circumflex - Scaption (scapular Infraspinatus Infraspinous fossa tubercle of scapular plane elevation) of scapula humerus N: Suprascapular (C5-6) - Lateral rotation of humerus A: Axillary, subscapular and Subscapular Lesser suprascapular - Shoulder adduction Subscapularis tubercle of fossa humerus N: Upper and lower subscapular - Internal rotation (C5-6)Shoulder injuries: musculoskeletal Injury Injured/threatened Mechanism Clinical findings Management components Injured: any part may - Physical relocation Shoulder be injury Trauma or joint Inability to abduct, flex or extend shoulder - Surgery dislocation Threatened: axillary instability Extreme, shooting pain down arm - Physiotherapy artery and nerve - +/- analgesia Shoulder Injured: rotator cuff Achy pain, worse on internal/external - Physiotherapy impingement tendon around greater Trauma rotation of shoulder - Analgesia tubercle of humerus Injured: any rotator cuff Achy pain, worse on internal/external - Rest Rotator cuff tear Trauma rotation of shoulder, and shoulder - Analgesia +/- physio muscle abduction up to 20 o - Surgery if severe Severe pain localised to clavicular area - Conservative (sling) Injured: clavicle - Analgesia Fracture of the Threatened: subclavian Trauma May be swelling/erythema/contusion - Surgery if clavicle artery → axillary artery Passive shoulder function usually severe/neurovascular preserved compromise Injured: humerus - Conservative (brace) Threatened: Severe pain localised to humeral area - Analgesia Fracture of the - surgical neck: axillary Trauma May be swelling/erythema/contusion - Surgery if humerus nerve Passive shoulder function usually affected severe/neurovascular May be neurovascular compromise (!!!) - midshaft: radial nerve compromiseShoulder conditions: rheumatological Conditions Pathophysiology Clinical findings Management - Pain worse after exercise/better with rest - Pain worse in evening/better in morning st Unilateral arthralgia - Typically associated with old age, sickle cell disease 1 : topical NSAIDs Osteoarthritis isolated to Shoulder XR: LOSS 2 : oral analgesia (paracetamol, of the glenohumeral joint codeine, co-codamol) shoulder - Loss of joint space 3 : shoulder replacement surgery if “Wear and tear” - Osteophyte margins extensive degeneration - Subchondral cysts - Subchondral sclerosis Bilateral arthralgia, - Pain better after exercise/worse with rest Acute: oral corticosteroids may be extra- - Pain better in evening/worse in morning Requires rheumatology referral Rheumatoid articular involvement - Can present at any age 1 : DMARDs arthritis of - Shoulder XR may be NORMAL - methotrexate the shoulder Always symmetrical Investigations: - hydroxychloroquine UNLESS psoriatic - Anti-cyclic citrullinated peptide (CCP) Ab - leflunomide/sulfasalazine arthritis - Rheumatoid factor 2 : biologics e.g. infliximab 1 : analgesia +/- physio Adhesive Inflammation of the 2 : intra-articular steroids capsulitis shoulder bursa - Restricted movements in flexion, extension and - Methylprednisolone abduction of shoulder (frozen causing pain and - Internal and external - Triamcinolone shoulder) stiffness 3 : hydrodilation 4 : manual manipulation