The shoulder is the most flexible joint in the body enabling a wide range of movements including, forward flexion, abduction, adduction, external rotation, internal rotation, and 360-degree circumduction.
Thus, the shoulder joint is considered the most insecure joint of the body but the support of ligaments, muscles and tendons function to provide the required stability.
Bones of the Shoulder
The shoulder is a ball and socket joint made up of three bones, namely the humerus, scapula and clavicle.
The end of the humerus or upper arm bone forms the ball of the shoulder joint. An irregular shallow cavity in the scapula called the glenoid cavity forms the socket for the head of the humerus to fit in. The two bones together form the glenohumeral joint, which is the main joint of the shoulder.
The scapula is a flat triangular-shaped bone that forms the shoulder blade. It serves as the site of attachment for most of the muscles that provide movement and stability to the joint. The scapula has four bony processes - acromion, spine, coracoid and glenoid cavity. The acromion and coracoid process serve as places for attachment of the ligaments and tendons.
The clavicle bone or collarbone is an S-shaped bone that connects the scapula to the sternum or breastbone. It forms two joints: the acromioclavicular joint, where it articulates with the acromion process of the scapula, and the sternoclavicular joint where it articulates with the sternum or breast bone. The clavicle also forms a protective covering for important nerves and blood vessels that pass under it from the spine to the arms.
Soft Tissues of the Shoulder
The ends of all articulating bones are covered by smooth tissue called articular cartilage which allows the bones to slide over each other without friction enabling smooth movement. Articular cartilage reduces pressure and acts as a shock absorber during movement of the shoulder bones.
Extra stability to the glenohumeral joint is provided by the glenoid labrum, a ring of fibrous cartilage that surrounds the glenoid cavity. The glenoid labrum increases the depth and surface area of the glenoid cavity to provide a more secure fit for the half-spherical head of the humerus.
Ligaments of the Shoulder
Ligaments are the thick strands of fibers that connect one bone to another. The ligaments of the shoulder joint include:
- Coraco-clavicular ligaments: These ligaments connect the collarbone to the shoulder blade at the coracoid process.
- Acromio-clavicular ligament: This connects the collarbone to the shoulder blade at the acromion process.
- Coraco-acromial ligament: It connects the acromion process to the coracoid process.
- Glenohumeral ligaments: A group of 3 ligaments that form a capsule around the shoulder joint, and connect the head of the arm bone to the glenoid cavity of the shoulder blade. The capsule forms a water-tight sac around the joint. Glenohumeral ligaments play a very important role in providing stability to the otherwise unstable shoulder joint by preventing dislocation.
Muscles of the Shoulder
The rotator cuff is the main group of muscles in the shoulder joint and is comprised of 4 muscles. The rotator cuff forms a sleeve around the humeral head and glenoid cavity, providing additional stability to the shoulder joint while enabling a wide range of mobility.
The deltoid muscle forms the outer layer of the rotator cuff and is the largest and strongest muscle of the shoulder joint.
Tendons of the Shoulder
Tendons are strong tissues that join muscle to bone allowing the muscle to control the movement of the bone or joint. Two important groups of tendons in the shoulder joint are the biceps tendons and rotator cuff tendons.
Bicep tendons are the two tendons that join the bicep muscle of the upper arm to the shoulder. They are referred to as the long head and short head of the bicep.
Rotator cuff tendons are a group of four tendons that join the head of the humerus to the deeper muscles of the rotator cuff. These tendons provide more stability and mobility to the shoulder joint.
Nerves of the Shoulder
Nerves carry messages from the brain to muscles to direct movement (motor nerves) and send information about different sensations such as touch, temperature and pain from the muscles back to the brain (sensory nerves). The nerves of the arm pass through the shoulder joint from the neck.
These nerves form a bundle at the region of the shoulder called the brachial plexus. The main nerves of the brachial plexus are the musculocutaneous, axillary, radial, ulnar and median nerves.
Blood vessels of the Shoulder
Blood vessels travel along with the nerves to supply blood to the arms. Oxygenated blood is supplied to the shoulder region by the subclavian artery that runs below the collarbone. As it enters the region of the armpit, it is called the axillary artery and further down the arm, it is called the brachial artery. The main veins carrying de-oxygenated blood back to the heart for purification include:
- Axillary vein: this vein drains into the subclavian vein
- Cephalic vein: this vein is found in the upper arm and branches at the elbow into the forearm region. It drains into the axillary vein.
- Basilic vein: this vein runs opposite the cephalic vein, near the triceps muscle. It drains into the axillary vein.
Rotator Cuff Tear
The rotator cuff is a group of tendons in the shoulder joint providing support and enabling a wide range of motion. Major injury to these tendons may result in tear of these tendons, a condition called rotator cuff tear.
Rotator cuff tear results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted.
Pain in the shoulder suggests a shoulder injury which is more common in athletes participating in sports such as swimming, tennis, pitching and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.
In addition to pain, shoulder injuries also cause stiffness, restricted movements, difficulty in performing routine activities and popping sensation.
The shoulder joint is a ball and socket joint. A 'ball' at the top of the upper arm bone (the humerus) fits neatly into a 'socket', called the glenoid, which is part of the shoulder blade (scapula). The term SLAP (superior –labrum anterior-posterior) lesion or SLAP tear refers to an injury of the superior labrum of the shoulder. The labrum is a ring of fibrous cartilage surrounding the glenoid for stabilization of the shoulder joint. The biceps tendon attaches inside the shoulder joint at the superior labrum of the shoulder joint.
Frozen shoulder, also called adhesive capsulitis, is a condition characterized by pain and loss of motion in the shoulder joint. It is more common in older adults aged between 40 and 60 years and is more common in women than men.
Frozen shoulder is caused by inflammation of the ligaments holding the shoulder bones to each other.
Shoulder Labrum Tear
Traumatic injury to the shoulder or overuse of shoulder (throwing, weightlifting) may cause labral tear. In addition, ageing may weaken the labrum leading to injury.
Shoulder labral tear injury may cause symptoms such as:
A break in a bone that makes up the shoulder joint is called a shoulder fracture.
The clavicle and end of the humerus closest to the shoulder are the bones that usually get fractured. The scapula on the other hand is not easily fractured because of its protective cover by the surrounding muscles and chest tissue.
Biceps Tendon Rupture
The biceps tendon is a tough band of connective fibrous tissue that attaches your biceps muscle to the bones in your shoulder on one side and the elbow on the other side.
Overuse and injury can cause fraying of the biceps tendon and eventual rupture.
A superior labrum anterior and posterior tear or SLAP tear is an injury to the labrum. This injury may also involve the biceps tendon, which is attached to the top part of the labrum. The injury occurs from repeated use of the shoulder while throwing or a fall onto the shoulder. A SLAP tear can be treated through an arthroscopic surgical procedure called a SLAP repair.
A superior labrum anterior and posterior tear or SLAP tear is an injury to the labrum.
Shoulder Labrum Reconstruction
Traumatic injury to the shoulder or overuse of the shoulder by excessive throwing or weightlifting can cause a labral tear. In addition, the ageing process may weaken the labrum, leading to injury secondary to wear and tear.
A shoulder labral tear injury can cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability.
The shoulder joint provides a wide range of movement to the upper extremity, but overuse or trauma can cause instability to the joint. The Latarjet procedure is a surgical procedure performed to treat shoulder instability by relocating a piece of bone with an attached tendon to the shoulder joint.
Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation. The repeated dislocation of the humerus out of its socket is called chronic shoulder instability. A tear in the labrum or rotator cuff and ligament tear in the front of the shoulder (a Bankart lesion) may lead to repeated shoulder dislocations.
Rotator Cuff Repair
The rotator cuff is a group of tendons and muscles in the shoulder joint providing support and enabling a wider range of shoulder motion. Injury to the rotator cuff may occur due to pressure on the rotator cuff from part of the shoulder blade (scapula). It may occur due to repeated use of the arm for overhead activities or while playing sports. A forceful injury such as trauma can cause one or more of these tendons to tear, a condition called rotator cuff tear.