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Integrated functional anatomy of the shoulder joint – Bones, joints, palpation, ligaments, nerves, joint anatomy, joint actions, arthrokinematics, muscles, fascia, and range of motion of the shoulder. Highlighting the behaviors in postural dysfunction, shoulder pain, shoulder impingement, rotator cuff injuries, upper cross syndrome, and common interventions for the glenohumeral/shoulder joint.

Shoulder Joint Anatomy (Glenohumeral Joint)

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This course describes shoulder joint anatomy, which includes the glenohumeral joint. This includes descriptions of the bones, synovial joints, joint actions, ligaments, bursae, relative location, the relationship between the bones of the shoulder/humerus, and the muscles that cross them. Further, this course discusses palpation and introduces shoulder joint specific exercises, manual techniques, and interventions for dysfunction, pain, posture, and movement impairment. The shoulder joint is included in the common compensation patterns known as rounded shoulder posture (RSP), upper-crossed syndrome (UCS), shoulder medial rotation syndrome (SMRS), and upper body dysfunction (UBD). Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) with advanced knowledge of the glenohumeral joint will improve their ability to analyze human movement and develop sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing injury prevention and physical rehabilitation/physical therapy (e.g. impingement syndrome, rotator cuff injury, scapula (shoulder blade) dysfunction, shoulder arthritis, shoulder replacement, forward head posture, thoracic kyphosis, sternocostal pain, and medial epicondylitis of the elbow), the effect the shoulder joint has on upper extremity alignment (e.g. excessive shoulder internal rotation), and shoulder joint specific techniques for enhancing sports performance (e.g. upper body (upper limb) stability, strength, hypertrophy, agility, and power).

Brookbush Institute’s most recommended techniques for the Shoulder Joint (see videos below):

Latissimus Dorsi, Rhomboids, Teres Major, and Posterior Deltoid Vibration Release

Latissimus Dorsi and Erector Spinae Static Stretch: Child's Pose

Shoulder External Rotator Isolated Activation

Shoulder (Glenohumeral) Joint Anterior to Posterior Mobilization

The shoulder joint with the ligaments, bones, and joint capsule labeled

Course Description: Shoulder (Glenohumeral) Joint

 Shoulder Joint Anatomy (Glenohumeral Joint)

Shoulder Joint Anatomy (Glenohumeral Joint) Course Study Guide

Study Guide: Shoulder Joint Anatomy (Glenohumeral Joint)

Introduction

: "Old English sculdor "shoulder," from West Germanic *skuldro (source also of Middle Dutch scouder, Dutch schouder, Old Frisian skoldere, Middle Low German scholder, Old High German scultra, German Schulter), of unknown origin, perhaps related to 

 (n.). Meaning "edge of the road" is attested from 1933." (

: Greek root meaning "socket of joint" (1).

 "1706, "bone of the upper arm," originally (14c.) "shoulder," from Latin humerus, a common spelling of umerus "shoulder," from PIE *om(e)so- "shoulder" (source also of Sanskrit amsah, Greek omos, Old Norse ass, Gothic ams "shoulder"). Blount's "Glossographia" (1656) has humerous (adj.) "That hath great shoulders." (

joint (n): "c. 1300, "an (anatomical) joint, a part of a body where two bones meet and move in contact with one another, the structure that holds such bones together," from Old French joint"joint of the body" (12c.), from Latin iunctus "united, connected, associated," past participle of iungere "join" (see 

Cross section of the glenohumeral joint (shoulder) of the body

Cross Section of the Glenohumeral Joint
By Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work, CC BY 3.0, http

The shoulder joint is comprised of the humerus and glenoid fossa of the scapula, hence the name glenohumeral joint (GH), and it is one of three articulations of the shoulder complex. The other two articulations are the acromioclavicular (AC) joint and sternoclavicular (SC) joint, which are commonly referenced relative to scapulothoracic motion and discussed in a separate article.

An illustration and X-ray of the glenohumeral joint with boney attachments

Illustration and X-Ray of Glenohumeral Joint - http://clinicalgate.com/wp-content/uploads/2015/03/B9780702051319000079_f007-025-9780702051319.jpg

: A convex surface that is approximately half of a full sphere facing superiomedially and slightly posteriorly. The slight posterior slant of the humeral head allows for more direct contact with the relatively small glenoid fossa of the scapula. The humeral head is lined with articular cartilage and tends to be 1.9 times larger longitudinally than the glenoid fossa.

: A shallow concave surface angled superiorly and either anterolaterally (anteverted) or posterolaterally (retroverted); 6º-7º of retroversion is typical (3). The surface of the glenoid fossa is longer (superior to inferior) than it is wide (anterior to posterior) and varies considerably in size between individuals (3). The articular cartilage of the glenoid fossa is thicker around the edges than it is in the middle, which increases the surface contact area with the much larger humeral head. The shallowness of the glenoid fossa allows for greater mobility but offers minimal stability. The joint capsule does not enhance the stability significantly as it is relatively thin with a slackened inferior portion named the axillary pouch, allowing for significant inferior translation during movement. Therefore joint stability is primarily accomplished via musculature, of particular importance to joint stability are the rotator cuff muscles (

To increase congruence with the humeral head, the scapula rests on the thorax tilted anteriorly approximately 10º, upwardly rotated approximately 5-10º, and internally rotated approximately 35º, forming the scapular plane angle.

Dissection of the shoulder (glenohumeral joint) in a cadaver

Glenoid Fossa Inclination Angle (Frontal Plane)

Angle formed by a line parallel to the floor of the supraspinatus fossa and a line from superior to the inferior ridge of the glenoid fossa.

Normal: Glenoid inclination was 15.7° ± 5.1° superiorly (15)

Glenoid Fossa Retroversion Angle (Tranverse Plane)

Angle formed by a line parallel to the floor of the supraspinatus fossa and a line from the anterior to the posterior ridge of the glenoid fossa.

Normal: Retroversion of 4.9° ± 6.1° (15)

An X-ray of the glenoid fossa showing the inclination angle in the frontal plane

Glenoid Fossa Inclination Angle (Frontal Plane) on X-ray

Torsion is defined as a state of longitudinal twisting or spiraling of the shaft of a long bone and can be measured as the difference between the joint axis of proximal and distal ends of the bones. Angle formed by a line bisecting the humeral head and the medial-lateral axis through the condyles at the elbow.

Normal: 30º of retroversion (of the humeral head when compared to the axis of the elbow)

Humeral head Inclination Angle (Frontal Plane)

Angle formed by a line through the long axis of the humeral shaft and a line bisecting the humeral head

A representation of humeral torsion angle between the scapula and humerus

s://commons.wikimedia.org/w/index.php?curid=27796970

Introduction to the Shoulder (Glenohumeral) Joint

Palpation

Note it is helpful to learn the palpations below in the order listed:

Each scapula rests on the posterior aspect of the ribcage, spanning from the level of T2 to about T7, 2 - 5 centimeters lateral the thoracic spine. Trace the borders of each scapula and observe its triangular shape. Place one hand on each of your partner's scapula and ask your partner to shrug and depress their scapula. Note how the scapula can slide on the ribcage without any spinal motion.

Now shift focus to one scapula. Palpate the broad surface of the scapula from superior to inferior. The scapula is nearly a triangle, being much narrower at the bottom than at the top. Find the most inferior aspect of the scapula; a rounded point between the axillary and medial borders. This rounded point is referred to as the 

and is a reference point typically used when assessing scapulothoracic motion during elevation of the arm.

Return to the inferior angle of the scapula. Ask your partner to let their arm hang from the table. Now follow the inferior angle back toward the shoulder, along the lateral edge of the scapula. This is the lateral /axillary border of your scapula. You may have to palpate a bit deeper as the muscles that attach to the lateral border of the scapula are fairly thick (

). It may be helpful to try and approach the lateral border from underneath these soft tissues (on the anterior side).

: Return to the inferior angle and follow the contour of the scapula on the side closest to the spine superiorly. This is the vertebral or 

 attach along this border then travel medially to their proximal attachment on the spine, and the 

 also attaches here and travels laterally, underneath the scapula to attach to the lateral ribcage. If you need help finding or identifying the medial border, palpate 2 – 4″ lateral to the spinous process, use your other hand to scoop underneath the shoulder, and use that shoulder to passively retract and protract the scapula. You should feel the medial border slide into your fingers. In fact, with a little exploring, you may note that you can get your fingers underneath the medial border when the scapula is passively retracted.

: Return to the medial border of the scapula, this time following the medial border to its superior end. In essence, the 

 is the superior/medial corner of the triangle of the scapula. Note, the superior end is more difficult to identify, as it is buried under the 

. The superior angle is also less “sharp” than the inferior angle, curving more gradually into the superior border of the scapula.

Posterior view of the scapula with boney landmarks labeled

Posterior View of Scapula - By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 203, Public Domain, https://commons.wikimedia.org/w/index.php?curid=307344

 of the scapula by following the contour of the scapula laterally from the superior angle (underneath the 

). Again, it may be helpful to use your other hand to cup underneath the shoulder and passively move the scapula underneath your fingers.

Return to the superior angle and drop inferiorly approximately one inch along the medial border to locate the raised and thickened 

. This landmark is about level with the spinous process of the T3 vertebra. Alternatively, you can run your fingers down from the 

 muscles until you feel a superficial bony ridge running from medial to lateral. Palpate the ridge of the 

 as it travels laterally and gradually enlarges to become the prominent acromion process which wraps anteriorly and then medial to meet the clavicle forming the AC joint.

Return to the spine of the scapula, this time with the intent of exploring the full breadth of the top side of the spine of the scapula. Sink your fingers into the tissue above the spine of the scapula; notice how the top of the spine of the scapula creates a “trough”. Follow that trough to the root of the spine of the scapula at the medial border, and then follow the trough laterally and note how it disappears under the acromion shelf. This trough is your supraspinous fossa (depression superior to the spine of the scapula) where you can palpate the 

Now allow your fingers to sink into the tissue underneath the spine of the scapula. Trace the trough on the underside of the spine of the scapula from its medial to lateral edge. This is the superior border of the infraspinous fossa (depression below the spine of the scapula). The infraspinous fossa extends from this trough all the way to the inferior angle, filling in all the space from the medial to the lateral border. This depression is masked by the muscle originating on this fossa – the 

: If you follow the axillary border to where the scapula meets the humerus (the glenohumeral joint), you should notice a fairly distinct bump or rough "patch" just before coming into contact with the inferior glenoid rim and humerus. This is the infraglenoid tubercle, the attachment site of the long head of your triceps.

An anterior view of the scapula with boney landmarks labeled

Anterior view of the Scapula By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 202, Public Domain, https://commons.wikimedia.org/w/index.php?curid=307340

The coracoid process feels like a hard bony button, just inferior to the clavicle and deep to the tissues of the deltopectoral groove. Likely the most confusing palpation, as this is part of the scapula palpated on the front of the body. With your partner in supine, locate the deltopectoral groove (the line between the 

 muscle). Place your thumb on the intersection between the deltopectoral groove and the clavicle. If you fall off the clavicle inferiorly (no more than a couple of centimeters) and press just deep to the soft tissue, you should note a hard bony projection. This projection is your coracoid process. Explore the rounded beak, like a hemispherical button under your finger.

Have your partner lie supine. Cradle their arm and gently pull them into as much protraction as you can with a bit of shoulder flexion to promote upward rotation of the scapula. You want as much of the anterior surface of the scapula pulled away from the rib cage as can be maintained comfortably. Use the thumb of the other hand to explore the posterior wall of the axilla (armpit). You can find the 

 by dropping off medially, from the laterally located fibers of the 

. If you press down (toward the table) into the posterior wall of the axilla, through the soft tissue you will hit the solid anterior face of the scapula. Virtually the entire anterior face of the scapula is the subscapular fossa. The subscapular fossa may also be reached by curling the fingers underneath the medial/vertebral border of the scapula. This is easiest if done in side-lying position, pulling the top arm into protraction, finding the medial side of the inferior angle of the scapula (triangle of auscultation) where no muscles attach, and then retracting the scapula over the fingers. Once the fingers are under the scapula the rest of the medial border may be explored.

With your partner in supine locate the acromion shelf. Just inferior to the acromion shelf you can palpate the humeral head, although this may require a little gentle digging. The humeral head is covered by the 

 and the tendons of various muscles coursing into and over it (

). Using your other hand, gently rotate the arm back and forth (internal and external rotation) and continue to explore. You should start to identify the bumpy "roundish" thickening of the humerus that is the humeral head.

Once you feel comfortable with palpation of the humeral head, place your thumb over the anterior portion of the humeral head. Gently explore deep to the soft tissue and try to identify bumps/ridges. It's tough to identify anything specific... but here's a little trick. Keep your thumb in place over the bumpy part of the anterior surface of the humerus, now slowly roll the humeral head (passively internally and externally rotate your partner's arm) under your thumb. As you slowly roll back and forth and adjust your thumb, you will start to notice ridges and a valley. The lateral ridge is your greater tubercle, the medial ridge is your lesser tubercle and the valley is the intertubercular (bicipital groove).

The deltoid tuberosity is the site of attachment for your 

. It is a small bump that lies about halfway between the acromion shelf and the elbow on the lateral side of the humerus. Trace the deltoid to the point of insertion, gently palpate in a small circle around that point and you should find this landmark.

A frontal section and lateral section of the structures and tissues surrounding the shoulder joint 

Shoulder (Glenohumeral) Joint Palpation

Capsule and Ligaments

Open Pack Position: 40° of abduction in the scapular plane

Close Pack Position: Full abduction and external rotation

The shoulder (glenohumeral) joint with boney landmarks and ligaments

Glenohumeral Ligaments - Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 326

An anterior view of the shoulder capsule with boney landmarks and ligaments labeled

Shoulder Capsule and Ligaments - Netter Atlas of Human Anatomy

Shoulder Joint Connective Tissues: Capsule and Ligaments

Bursae

The bursae of the glenohumeral joint are often continuous with one another, and function to reduce friction between tendons, the humeral head, and the surrounding structures (coracoacromial arch, coracoid process, 

 tendon and inferior to the acromion process (in the subacromial space). Functions to reduce friction during elevation of the arm as the 

 contracts and the tendon slides beneath the coracoacromial arch.

; continuous with the subacromial bursa. Functions to reduce friction during elevation of the arm between the 

Extension of the glenohumeral synovial membrane, located posterior to the 

 tendon on the anterior shoulder capsule. Functions to reduce friction between the 

, superior to the tendon of the short head of the biceps brachii, and 

. Functions to reduce friction between the 

, and short head of the biceps tendons, during shoulder motion.

Located superior to the acromion process this bursa generally does not communicate with the sub-acromial bursa (18). Likely function is to serve as a barrier between the bony superior surface of the acromion, the skin, and external loads (for example, a backpack or purse)

A drawing of the subacromial-subdeltoid bursa, subscapular recess, subcoracoid bursa, coracoclavicular bursa, supra-acromial bursa and medial extension of the subacromial-subdeltoid bursa.

Diagram of normal bursae surrounding the shoulder joint: (1) subacromial-subdeltoid bursa, (2) subscapular recess, (3) subcoracoid bursa, (4) coracoclavicular bursa, (5) supra-acromial bursa and (6) medial extension of subacromial-subdeltoid bursa.
By Zameer Hirji - Zameer Hirji, Jaspal S Hunjun, Hema N Choudur (2011). "Imaging of the Bursae". Journal of Clinical Imaging Science 1 (1): 22. DOI:10.4103/2156-7514.80374. ISSN 2156-7514.Figure 1, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=25309551

Nerves

The axillary and suprascapular nerves which innervate the shoulder joint

Shoulder (Glenohumeral) Joint Nerves

Shoulder (Glenohumeral) Joint Bursae

Joint Actions

Open Chain Kinematics: Humerus on Scapula

, inferior joint capsule, posterior joint capsule, coracohumeral ligament (posterior cord), clavipectoral fascia, pectoral fascia, axillary fascia, brachial plexus

Optimal Range of Motion (ROM): 120° (180° with full scapular upward rotation) (

 (clavicular head), anterior joint capsule, coracohumeral ligament, clavipectoral fascia, pectoral fascia, deltoid fascia, brachial plexus, and nerves of the arm

, posterior capsule, inferior capsule, glenohumeral ligament (superior and inferior), posterior deltoid fascia, brachial plexus

Optimal ROM: 60-70° (with 90° of abduction) (

, anterior capsule, inferior capsule, glenohumeral ligaments (superior, middle, and inferior), coracohumeral ligament, clavipectoral fascia, pectoral fascia, brachial plexus

Optimal ROM: 90-95° (with 90° of abduction) (

, inferior capsule, glenohumeral ligaments (superior and inferior), coracohumeral ligament, the lower portion of brachial plexus (C8-T1)

Optimal ROM: 120° (180° with full scapular upward rotation) see 

, biceps brachii (short head), triceps brachii (long head), posterior 

, joint capsule, possibly coracohumeral ligament, upper portion of brachial plexus (C5-6)

, assuming (glenoid labrum, anterior joint capsule, glenohumeral ligaments (superior and middle), clavipectoral fascia, pectoral fascia, brachial plexus)

, assuming (posterior joint capsule posterior deltoid fascia)

See Kinesiology of the Shoulder for a list of prime mover, synergists, antagonists, neutralizers, stabilizers, and fixators for all joint actions.

An X-ray of the shoulder (glenohumeral) joint

Shoulder X-Ray - By RSatUSZ - PACS UniversitätsSpitalZürich, GFDL, https://commons.wikimedia.org/w/index.php?curid=11258999

Arthrokinematics

Shoulder cross section with muscles, ligaments, and boney landmarks labeled

Integrated Function

The brachial plexus and nerves that run through the shoulder joint

Shoulder (Glenohumeral) Joint Actions

Movement Impairment (Postural Dysfunction)

The shoulder has a propensity toward a compensation pattern often described as rounded shoulder posture (RSP), upper-crossed syndrome (USD), or shoulder medial/internal rotation syndrome, and these patterns often match the altered muscle activity and arthrokinematics, and osteokinematic restrictions exhibited by individuals with shoulder impingement syndrome (SIS) in research (1, 6-11, 23-26). This movement impairment is a combination of joint restrictions and actions – 

excessive internal rotation during static and dynamic postures, often in conjunction with restrictions in end range flexion, external rotation and internal rotation, and potentially an increase in the anterior and inferior glide of the humeral head on the glenoid fossa

 (1, 7-10, 23-26). Clinically and in review of applicable research, the Brookbush Institute has noted that shoulder (glenohumeral joint) impairment almost always involves scapular dyskinesis (article coming soon), and often involves dysfunction of the thorax and cervical spine. These changes may result in or be the result of altered length and activity of one, or many of the muscles crossing the shoulder joint, and further, result in maladaptive changes in length and/or extensibility of passive soft tissues (capsule, ligaments, and fascial structures). Although this section will describe dysfunction from the perspective of the shoulder; the shoulder could be viewed as the most common "victim" or "pain generating site" in those exhibiting 

. That is, changes in upper body alignment and optimal muscular recruitment may result in excessive stress (tissue damage) to any and all tissues of the upper body, but the shoulder joint is often the first to develop considerable inflammation, nociception, and the perception of pain in the shoulder. Perhaps the increased stress placed on the shoulder for activities of daily living results in a faster rate of tissue damage and inflammation. Careful assessment of the scapula, thoracic spine, and cervical spine should be included for every patient/client exhibiting signs of shoulder dysfunction. It should also be noted that additional compensatory patterns exist and are relevant to practice; however, in this article, the focus will be given to this pattern, which is presumed to be “most common.”

Common Osteokinematic Dysfunction (6-11):

Excessive anterior glide of the humeral head on the glenoid fossa

Excessive inferior glide of the humeral head on the glenoid fossa

Maladaptive Decrease In Length/Extensibility 

Restricts posterior glide of the humeral head on the glenoid fossa – posterior capsule, inferior glenohumeral ligament

Restricts superior glide of the humeral head on the glenoid fossa – coracohumeral ligament and 

Shoulder Dysfunction

A cadaver image of the muscles crossing the shoulder joint

Shoulder Dysfunction and Signs of Dysfunction

Postural Dysfunction and the Shoulder Joint

Self-administered Joint Mobilization for the Shoulder

Manual Joint Mobilization for the Shoulder

Videos

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition 

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Colby, Lynn Allen; Carolyn Kisner. Therapeutic Exercise: Foundations and Techniques (Therapeutic Exercise: Foundations & Techniques) (Kindle Locations 20651-20653). F A Davis Co. Kindle Edition.

Shoulder Joint Anatomy (Glenohumeral Joint)

Related Courses:

Course Description: Shoulder (Glenohumeral) Joint

Study Guide: Shoulder Joint Anatomy (Glenohumeral Joint)

Introduction to the Shoulder (Glenohumeral) Joint

Shoulder (Glenohumeral) Joint Palpation

Shoulder Joint Connective Tissues: Capsule and Ligaments

Shoulder (Glenohumeral) Joint Bursae
1 Sub Section

Shoulder (Glenohumeral) Joint Actions
2 Sub Sections

Postural Dysfunction and the Shoulder Joint
1 Sub Section

Videos
2 Sub Sections

Bibliography

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Shoulder Joint Anatomy (Glenohumeral Joint)

Related Courses:

Course Description: Shoulder (Glenohumeral) Joint

Study Guide: Shoulder Joint Anatomy (Glenohumeral Joint)

Introduction to the Shoulder (Glenohumeral) Joint

Shoulder (Glenohumeral) Joint Palpation

Shoulder Joint Connective Tissues: Capsule and Ligaments

Shoulder (Glenohumeral) Joint Bursae1 Sub Section

Shoulder (Glenohumeral) Joint Actions2 Sub Sections

Postural Dysfunction and the Shoulder Joint1 Sub Section

Videos2 Sub Sections

Bibliography

Related Courses:

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Shoulder (Glenohumeral) Joint Bursae
1 Sub Section

Shoulder (Glenohumeral) Joint Actions
2 Sub Sections

Postural Dysfunction and the Shoulder Joint
1 Sub Section

Videos
2 Sub Sections