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Integrated functional anatomy of the shoulder girdle – Bones, joints, palpation, ligaments, nerves, joint anatomy, joint actions, arthrokinematics, muscles, fascia, and range of motion of the scapula, clavicle, and acromion. Highlighting the behaviors in postural dysfunction, shoulder pain, neck pain, and common interventions for the sternoclavicular, acromioclavicular, and scapulothoracic joints. 

Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

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Over the last years I've returned time and again to Brookbush Institute for stellar coursework as I've worked toward a Human Movement Specialist certification. (I'm currently ACE CPT, and in training with Anatomy Trains for Structural Integration Manual Therapy.) Every Brookbush Institute module is fantastic and each one includes detailed informational videos, written descriptions of how to-do, and, more importantly, why to-do!

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This course describes sternoclavicular joint anatomy (SC joint), acromioclavicular joint anatomy (AC Joint), and scapulothoracic joint anatomy (ST joint). These are the joints resulting from the approximation of the sternum (breastbone) with the medial clavicle (collar bone), the distal clavicle with the scapula (shoulder blade), and the scapula with the rib cage. These joints are also referred to as the shoulder girdle, and most often analyzed by referring to motion of the scapula. This course includes descriptions of the bones, synovial joints, joint actions, ligaments, bursae, relative location, the relationship between the bones of the clavicle, sternum, acromion, and thoracic spine, and the muscles that cross them. Further, this course discusses palpation and introduces sternoclavicular, acromioclavicular, and scapulothoracic joint (upper limb) specific exercises, manual techniques, and interventions for dysfunction, pain, posture, and movement impairment. The SC, AC, and ST joints often play a role in common dysfunctions and joint injuries of the shoulder including upper crossed syndrome, rounded shoulder posture, upper body dysfunction (UBD) (e.g. impingement syndrome), cervical spine dysfunction, forward head posture (e.g. chronic neck pain), thoracic spine dysfunction and thoracic kyphosis (e.g. upper back pain), sternocostal dysfunction and stiffness (e.g. costochondritis), and elbow dysfunction (e.g. lateral epicondylitis). Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) with advanced knowledge of the sternoclavicular, acromioclavicular, and scapulothoracic joints 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. assessment and treatment of joint injury, joint separation/dislocation, shoulder pain, shoulder separation, rotator cuff injury, type II acromion, ac joint sprain, and upper limb pain), the effect the SC, AC, and ST joints have on upper extremity (upper limb) and cervical spine alignment (e.g. a forward head position), and active and passive exercises for the shoulder girdle, including techniques to enhance sports performance (e.g. upper limb stability, strength, hypertrophy, and power).

Brookbush Institute's most recommended techniques for the SC, AC, and ST joints (see videos below):

Acromioclavicular (AC) Joint Cross Body Test

Thoracic Spine Mobilization: Posterior-to-Anterior

The acromioclavicular joint, joint capsule, ligaments, and cartilage surrounding the scapula

Course Description: Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)

Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy Study Guide

Study Guide: Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

Introduction

: "breastbone," 1660s, from Greek sternon "chest, breast, breastbone" (in Homer, only of males), also "the breast as the seat of affections," related to stornynai "to spread out," from PIE *ster-no- "to stretch, extend," from root *stere-, *ster- "to spread," related to stornynai "to spread out" (see 

 (n.)), on the notion of the chest as broad and flat, as opposed to the neck. Related: Sternal." (

: ""collarbone," 1610s, from Middle French clavicule "collarbone" (16c.), also "small key," from Medieval Latin clavicula "collarbone" (used c.980 in a translation of Avicenna), special use of classical Latin clavicula, literally "small key, bolt," diminutive of clavis "key" (see 

 (n.2)); in the anatomical sense a loan-translation of Greek kleis "key, collarbone." So-called supposedly from its function as the "fastener" of the shoulder. Related: Clavicular." (

An image of the clavicle and sternoclavicular joint

: "shoulder blade," 1570s, Modern Latin, from Late Latin scapula "shoulder," from Latin scapulae (plural) "shoulders, shoulder blades," perhaps originally "spades, shovels," on the notion of similar shape, but animal shoulder blades might have been used as scraping tools in primitive times, from PIE *skap-, variant of *skep- "to cut, scrape" (see 

Acromion (n): "from the Greek akros, meaning topmost, highest" (

: "chest of the body," late 14c., from Latin thorax "the breast, chest; breastplate," from Greek thorax (genitive thorakos) "breastplate, chest," of unknown origin." (

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 

A superior view of the clavicle with attachments of the pectorlais major and SCM

Clavicle (Superior View) - By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 200, Public Domain, https://commons.wikimedia.org/w/index.php?curid=792173

Bones, Articulating Surfaces and Joint Types

An image of the sternoclavicular joint with the adjacent bones and ligaments 

An image of the acromioclavicular joint with bones and ligaments labeled

Position of the humerus relative to the ribcage and scapula

Glenoid fossa inclination angle (in the frontal plane) on X-ray

Palpation

The manubrium sitting at the top of the sternum, between the acromioclavicular joint

An image of the scapula with the boney landmarks highlighted

The clavicle, 1st rib, sternum, ligaments, and boney landmarks

Palpation 

Capsule, Ligaments, and Menisci

The shoulder joint, acromioclavicular joint, sternoclavicular joint, and ligaments

SC, AC, & ST Connective Tissue: Capsule, Ligaments, and Menisci

Bursae

The location of the scapulothoracic bursa, subscapularis muscles, and supraserratus bursa

SC, AC, & ST Bursae

Nerves

The branches of the brachial plexus running to the upper body extremities

SC, AC, & ST Nerves

Introduction to Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)

Osteokinematics

Before discussing movement at the sternoclavicular (SC) and acromioclavicular (AC) joints, it is important to acknowledge the intimate relationship between these joints and the 

. This group of joints has been referred to as the "shoulder joint complex" (3, pg 232). Each joint can be thought of as a link in a chain, as motion of one joint does not generally occur without motion of the others. Motion of the "shoulder joint complex" is usually simplified to include movement of the scapula (scapulothoracic joint) and humerus, excluding consideration of the SC and AC joints independently, and referred to as scapulohumeral rhythm. Scapulohumeral rhythm is easiest to describe during flexion and/or abduction of the shoulder (often referred to as upper extremity "elevation" in research); as the shoulder complex moves into elevation, there is approximately 1° of scapular motion for every 2° of 

Motion of the scapula, referred to as scapulothoracic joint motion (ST) is dependent on the coordinated motion of the SC and AC joints. These two joints provide the bony connections between the scapula and the thorax. SC and AC joint motion may be additive where both joints contribute to the same net direction of ST motion. SC and AC joint motions may also work in opposition to each other, where larger motions of the SC joint are opposed by the AC joint to maintain congruence between the scapula and the ribcage.

SC, AC, and ST joint motion are not typically measured independently, but in conjunction with the full range of motion of the "shoulder joint complex" (24). Individual SC and AC joint motion can be more challenging to observe and quantify (25). Even ST joint motion, which is easily observed visually, is tough to measure reliably. This results in a tendency for more variability in the ranges of motion reported for the SC, AC, and ST joints in the body of research and texts.

See Kinesiology of the shoulder and scapula for a list of prime movers, synergists, antagonists, neutralizers, stabilizers and fixators for all joint actions.

An image of scapular depression and accompanying SC and AC joint arthrokinematics 

Scapular depression and accompanying SC and AC joint Arthrokinematics - Cynthia C. Norkin, Pamela K. Levangie, Joint Structure and Function: A Comprehensive Analysis: Fifth Edition © 2011 F.A. Davis Company

SC Joint Kinematics

Sternoclavicular (SC) Joint Kinematics

AC Joint Kinematics

Acromioclavicular (AC) Joint Kinematics

ST Joint Kinematics

Scapulothoracic (ST) Joint Kinematics

Arthrokinematics

A cross section of the shoulder joint showing the attachments of the muscles and bones of the shoulder

SC, AC, & ST Joint Actions

Integrated Function

Motion of the AC, SC, and ST joints is influenced by muscles, fascia, and nerves that cross multiple joints. Further, the motion of 

 joints may influence the position of bones, force vectors, moment arms, and the dissipation of force.

Thoracic spine: In a study by Ottowa et al. thoracic kyphosis was correlated with shoulder impingement syndrome (SIS) (41). It is likely that scapular dyskinesis is correlated, or may be the bridge between thoracic kyphosis and shoulder joint dysfunction.

Cervical spine: Studies have shown that forward head 

 alters muscle recruitment in overhead tasks, including a reduction in the activity of the 

 in those with chronic cervical pain (28-30).

Glenohumeral joint: The relationship between the glenohumeral and scapulothoracic joint is well documented, going back to a study by Inman et al. in 1944 (23). Several studies have correlated shoulder impingement/pain with scapular 

 tipping and upward rotation and an increase in scapular internal rotation (27, 35 - 41).

Radioulnar joint: Two studies have demonstrated that dysfunction of the elbow and forearm may alter scapular muscle activity and endurance (42, 43).

All muscles crossing the shoulder and scapula (as described throughout the article)

: Links the glenohumeral joint, scapula, lumbar spine, sacroiliac joint, and pelvis

: Links the shoulder to the sternoclavicular and sternocostal joints

Sternocleidomastoids: Links the cervical spine and the SC joints

: may link the scapula and the lumbar spine via the thoracolumbar fascia

Thoracolumbar fascia (TLF): The TLF, as the central structure of the 

, may transmit force and sensory information to the investing fibers of the 

 (56). This would add to the influence the TLF has on the scapula by transmitting force between the 

The torso fascia: The fascia of the torso runs nearly continuously from clavicle to pelvis, and wraps around the torso to invest in the subscapularis and axillary fascias. Starting with the pectoral fascia, the pectoral fascia is a thin lamina covering the surface of the 

 and sending numerous extensions between fascicles. This fascia originates from the sternum and 

 (underneath the platysma (2)) and courses in multiple directions, running continuous with the fascia of the shoulder and biceps, axilla, and abdomen (56). Undercover the muscle at the lateral border of the 

and runs continuous with the clavipectoral fascia. The axillary fascia (a blending of the pectoral and clavipectoral fascial sheaths) splits at the 

, one layer coursing superficial all the way to the spinous processes of the thoracic spine, the other ducking under the 

, and potentially doubling back on itself to encase the 

. At the lower part of the thoracic region, the deep pectoral fascia is well-developed and is continuous with the fibrous sheaths of the 

 muscles have synergistic functions, when we examine all of the muscles mentioned in the description of the "torso fascia" we can start to see a pushing/throwing/spiral synergy of muscle that builds on the 

The motor and sensory nerves of the arm and shoulder joint originate from the c4 – c7 nerve roots and 

 the brachial plexus, before diverging into individual nerves. The suprascapular, thoracodorsal, long thoracic, 

 pectoral nerves do not cross the shoulder. Dysfunction involving these nerves may be specific to SC, AC, and ST joint dyskinesis (this is not implying that these joints are the only joints that may contribute, but that they may be the primary reason). The axillary, musculocutaneous, upper, and lower subscapular nerves all cross the shoulder after passing underneath the clavicle and 

. The median, ulnar and radial nerves continue to cross the elbow and wrist. Upper extremity neural dysfunction may be a sign of dysfunction of the cervical spine, sternoclavicular joint, acromioclavicular joint, scapular dyskinesis, as well as 

An image comparing forward head posture and neutral posture

Postural Dysfunction

The scapula (and AC and SC joints) has a propensity toward a 

 often described as part of rounded shoulder 

 (RSP), upper-crossed syndrome (USD), or referred to specifically as downward rotation syndrome or scapular dyskinesis (56 - 62). These patterns are often correlated with the commonly diagnosed shoulder impingement syndrome (SIS) (39 - 41). A study by Lawrence et al. (40), likely does the best job identifying the common pattern of SC, AC, and ST joint dysfunction, noting inadequate upward rotation, posterior tilting and external rotation of the scapula, and inadequate elevation and posterior rotation of the clavicle during elevation of the arm. For ease of analysis, we will consider inadequate motion to be the same as excessive motion in the opposite direction. That is, the soft tissues that would restrict motion in one direction are the same that would contribute to motion in the opposite direction. The inverse of the Lawrence et al. study (along with the texts from respected clinicians/researchers (56-62)) defines the osteokinematic model of scapula and clavicle dysfunction: excessive downward rotation, anterior tipping and internal rotation of the scapula, and excessive anterior roll and depression of the clavicle.

These changes may result in, or be the result of altered length and activity of one, or many of the muscles crossing the clavicle or scapula, and further, result in maladaptive changes in length and/or 

 of passive soft tissues (capsule, ligaments, and fascial structures). Although this section will describe dysfunction from the perspective of the scapula (and clavicle); it is worth noting that scapular dyskinesis often results in 

 or cervical pain, and should likely be considered as a component of 

; not as an isolated dysfunction. Careful 

 of the shoulder, thoracic spine, and cervical spine should be included for every patient/client exhibiting signs of scapular dysfunction.

All of the muscles that move the scapula have an effect on AC and SC joint 

, but the relationships are indirect and may vary depending on the intended motion, synergies recruited, 

 present, and potentially individual differences in the shape of joint surfaces (40). However, based on common dysfunction, clinically effective mobilization techniques, and EMG studies we may be able to presume that 

 motion of the acromion on the clavicle follows convex on concave rules in the sagittal plane (

), concave on convex in the frontal plane (

 tipping and internal rotation of the scapula are common in those individuals with 

 (40, 56 - 62), EMG studies support these findings demonstrating increased activity of downward rotators and anterior tippers, and decreased activity of upward rotators and posterior tippers (35-38, 63), and to aid in correcting impairment at the AC joint many clinician’s use 

 clavicle. This could imply that the acromion has a propensity toward 

 on the clavicle relative to stable scapula results in better congruence. Further, the study by Lawrence et. al, demonstrated less relative 

 rotation and elevation of the clavicle, which may imply an increase in 

 of the acromion restricting end range posterior rotation of the clavicle, as well as dysfunction of the SC joint. As the SC joint is a 

, convex on concave rules apply in the frontal plane (

), and concave on convex rules applied in the transverse plane (

 follows roll) (3). This would suggest that inadequate elevation would be accompanied by inadequate inferior glide, and this may be supported by the propensity of the sternocleidomastoid (SCM) to become over-active (64-67). Admittedly, research is needed to determine if this increase in SCM activity also accompanies 

/scapula dysfunction. Superior to inferior glides are commonly used by clinicians to alleviate stiffness of the SC joint. Posterior rotation of the clavicle and posterior rotation of the clavicle on the manubrium are the same motion; implying that the inadequate posterior rotation of the clavicle also implies inadequate arthrokinematic spin. In summary, a 

 for the AC joint may include inadequate inferior and anterior glide of the clavicle on the acromion and for the SC joint inadequate inferior glide and posterior spin. It should also be noted that additional compensatory patterns exist and are 

 to practice; however, in this article, focus will be given to this pattern, which is presumed to be “most common."

Clavicle on Manubrium (Inadequate Motion)

Common changes in Muscle Activity and Length:

These muscles are listed because of their influence on the clavicle and AC joint, they do not contribute to the motion of the scapula directly.

Shoulder Dysfunction Relative to Predicitive Models of Dysfunction

Shoulder Dysfunction Relative to Postural Dysfunction

Postural Dysfunction and the Sternoclavicular, Acromioclavicular & Scapulothoracic Joints

Techniques and Ending Info

Overhead Squat Assessment: Upper Body Dysfunction

Serratus Anterior Manual Muscle Testing for an Active Population

Serratus Anterior Isolated Activation

Lower Trapezius Manual Muscle Testing

Lower Trapezius Activation

Videos

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins

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

Petersson, C. J. (1983). Degeneration of the acromioclavicular joint: a morphological study. Acta orthopaedica Scandinavica, 54(3), 434-438.

DePalma AF: Degenerative changes in sternoclavicular and acromioclavicular joints in various decades. Springfield, Ill, 1957, Charles C Thomas.

Stein, B. E. S., Wiater, J. M., Pfaff, H. C., Bigliani, L. U., & Levine, W. N. (2001). Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. Journal of Shoulder and Elbow Surgery, 10(3), 204-208.

Petersson, C. J., & Redlund-Johnell, I. (1983). Radiographic joint space in normal acromioclavicular joints. Acta Orthopaedica Scandinavica, 54(3), 431-433.

Colegate-Stone, T., Allom, R., Singh, R., Elias, D. A., Standring, S., & Sinha, J. (2010). Classification of the morphology of the acromioclavicular joint using cadaveric and radiological analysis. Bone & Joint Journal, 92(5), 743-746.

Mall, N. A., Foley, E., Chalmers, P. N., Cole, B. J., Romeo, A. A., & Bach Jr, B. R. (2013). Degenerative joint disease of the acromioclavicular joint: a review. 

Capsule, Ligaments and Menisci (Non-contractile/passive tissue)

Nakazawa M., Nimura A, Mochizuki T, Koizumi M, Sato T, Akita K. (2016). The orientation and variation of the acromioclavicular ligament: An anatomic study. Am J Sports Med. 44(10):2690-2695.

Stine IA, Vangsness CT Jr. (2009). Analysis of the capsule and ligament insertions about the acromioclavicular joint: a cadaveric study. Arthroscopy. (9):968-74.

Kuhne, M., Boniquit, N., Ghodadra, N., Romeo, A. A., & Provencher, M. T. (2009). The snapping scapula: diagnosis and treatment. 

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Kuhn, J. E., Plancher, K. D., & Hawkins, R. J. (1998). Symptomatic scapulothoracic crepitus and bursitis. 

Journal of the American Academy of Orthopaedic Surgeons

Merolla, G., Cerciello, S., Paladini, P., & Porcellini, G. (2013). Snapping scapula syndrome: current concepts review in conservative and surgical treatment. 

MLTJ Muscles, Ligaments and Tendons Journal

Manske, R. C., Reiman, M. P., & Stovak, M. L. (2004). Nonoperative and operative management of snapping scapula. 

Resnick D. Diagnosis of bone and joint disorders. 3rd edition. Philadelphia: WB Saunders Company; 1995

Banneheka, S. (2008) Anatomy of the ansa cervicalis: nerve fiber analysis. Anat Sci Int. 83(2):61-7. doi: 10.1111/j.1447-073X.2007.00202.x.

Hassett, G. and Barnsley, L. (2001) Pain referred from the sternoclavicular joint: A study in normal volunteers 

Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

Related Courses:

Course Description: Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)

Study Guide: Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

Introduction to Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)
5 Sub Sections

SC, AC, & ST Joint Actions
4 Sub Sections

Integrated Function

Postural Dysfunction and the Sternoclavicular, Acromioclavicular & Scapulothoracic Joints
1 Sub Section

Videos
5 Sub Sections

Bibliography

Related Courses:

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Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

Related Courses:

Course Description: Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)

Study Guide: Sternoclavicular (SC), Acromioclavicular (AC), and Scapulothoracic (ST) Joint Anatomy

Introduction to Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)5 Sub Sections

SC, AC, & ST Joint Actions4 Sub Sections

Integrated Function

Postural Dysfunction and the Sternoclavicular, Acromioclavicular & Scapulothoracic Joints1 Sub Section

Videos5 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Introduction to Shoulder Girdle Anatomy: Sternoclavicular Joint (SC), Acromioclavicular Joint (AC), and Scapulothoracic Joints (ST)
5 Sub Sections

SC, AC, & ST Joint Actions
4 Sub Sections

Postural Dysfunction and the Sternoclavicular, Acromioclavicular & Scapulothoracic Joints
1 Sub Section

Videos
5 Sub Sections