國立台灣大學物理治療學系九十七學年度/ 肌動學 36

UPPER EXTREMITY – The Shoulder Complex

教學目標: 修習本課後, 學生應可

1. 區別肩帶與肩關節的基本構造, 包括關節型態、關節形狀與相關韌帶與肌肉
2. 描繪肩部的動作學、相關之肌肉活動、與牽制動作的因子
3. 理解肩部維持穩定及造成傷害的機轉
4. 分辨三自由度動作的關節與一自由度動作或二自由度動作的關節之異同
5. 瞭解肌肉間相互合作及單一肌肉損傷或肌力不足的影響

必讀書籍:

1. Neumann DA (2002).  Shoulder complex.  In Neumann DA: Kinesiology of the

Musculoskeletal System: Foundations for Physical Rehabilitation. Philadelphia: Mosby. 
Chapter 5, pp. 91-132
2. Smith LK, Weiss EL, Don Lehmkuhl L (eds, 1996). Brunnstrom's Clinical Kinesiology, 5th
ed.  Philadelphia, F.A. Davis. Chapter 5
3. Craig J et al. (2001).  Biomechanics of the shoulder.  In Nordin M & Frankel VH: Basic
Biomechanics of the Musculoskeletal System.  Philadelphia: Lippincott Williams &
Wilkins. Chapter 12, pp.318-339

Functions of the Shoulder

1. to link the upper extremity to the trunk

2. to provide mobility of the arm in space
3. to provide stability for elbow and hand skillful or forceful movements

Structures of the Shoulder Complex

A. Component of the shoulder joint and shoulder

girdle
1. glenohumeral joint (shoulder joint)
a. proximal component: concave glenoid fossa
covered with glenoid labrum
b. distal component: convex humeral head
c. joint type: ball-and-socket joint
d. motion: convex on concave
-- shoulder flexion/ extension with posterior/ anterior glide of the humeral head
-- shoulder abduction/ adduction with inferior/ superior glide of the humeral head
-- shoulder internal/ external rotation with posterior/ anterior glide of the humeral head

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UPPER EXTREMITY – The Shoulder Complex

e. DOF = 3
f. resting position: 70° of shoulder abduction and 30° of flexion (horizontal adduction)
g. closed packed position: 90° of shoulder abduction and full external rotation
2. sternoclavicualr joint
a. proximal component: saddle-shaped medial end of the clavicle
b. distal component: saddle-shaped sternal manubrium
c. joint type: saddle joint
d. motion: clavicle elevation/ depression
clavicle protraction/ depression
clavicle posterior rotation
e. DOF = 3
3. acromioclavicular joint
a. proximal component: convex lateral end of the clavicle
b. distal component: concave acromion of the scapula
c. joint type: nearly plane joint
d. motion: scapula winging – medial border of the scapular moves backwards
scapula tipping – inferior angle of the scapula moves backwards
scapula upward/ downward rotation – inferior angle of the scapula rotates upwards/
downwards
e. DOF = 3
4. scapulothoracic articulation
a. proximal component: convex rib cage
b. distal component: concave anterior surface of the scapula
c. motion: shoulder girdle motion; concave on convex
-- scapular elevation/ depression： whole scapula moves upwards/ downwards
-- scapular abduction/ adduction： medial border of the scapula moves away from/ toward
the spine
-- scapular upward/downward rotation： inferior angle of the scapula rotates
upwards/downwards
d. DOF = 3
e. functions of the scapulothoracic articulation
-- to provide movement base for the humerus
-- to maintain length-tension relationship for the deltoid muscle to function above 90º of arm
elevation
-- to provide stability of the GH joint working overhead
-- to absorb the shock for forces applied to the outstretched arm
-- to permit push-up during crutch walking
5. suprahumeral articulation (subacromial joint): not for joint stability

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UPPER EXTREMITY – The Shoulder Complex

-- coracoacromial arch: composed of the coracoacromial ligament

-- spraspinatus tendon passing underneath this arch
-- subacromial bursa
-- shoulder impingement occurs if the subacromial space is insufficient
6. bicipital groove covered with transverse humeral ligament
-- groove between greater and lesser tuberosities of the humerus covered with transverse
humeral ligament
-- passing tendon of long head of biceps brachii
-- intra-articular but extra-synovial

B. Plane of scapula
1. the plane at the angle of 30º anterior to the frontal plane
2. capsules in the loose-packed position
3. no impingement in the suprahumeral joint if shoulder motions occurs in the plane of scapula

C. Dependent arm position

-- the position that the arm is hanging down by the side of the trunk

Kinematics of the Shoulder Complex

A. Shoulder flexion/ extension in the sagittal plane

1. joint involved: GH (principal joint), SC, and AC joints and ST articulation
2. axis: transverse axis through the center of the humeral head
3. osteokinematic movements
-- range: 0-180 for flexion and 0-45 or 60 for extension
-- closed kinematic chain motions:
4. arthrokinematic movements
-- posterolateral glide of the humeral head on the glenoid cavity with shoulder flexion
-- anteromedial glide of the humeral head on the glenoid cavity with shoulder extension
5. factors limiting shoulder flexion
-- inferior glenohumeral ligament (most important)
 -- tightness of the posterior joint capsule
6. factors limiting shoulder extension
-- superior and middle glenohumeral ligament (most important)

B. Shoulder abduction/ adduction in the frontal plane

1. shoulder abduction = arm elevation

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UPPER EXTREMITY – The Shoulder Complex

2. joint involved: GH (principal joint), SC, and AC joints and ST articulation

3. axis of rotation
GH joint: sagittal axis through the center of the humeral head
SC joint: sagittal axis through the center of the medial end of the clavicle
4. osteokinematic movements
-- range of motion (ROM)
total range: 0-165 or 175º
GH joint: 0-120º of shoulder abduction
0-60º with full internal rotation of humerus
0-90º with full external rotation of humerus
SC joint: 0-30 or 45º, most occurring in 1st 90º of arm elevation
-- scapulohumeral rhythm
Inman et al. (1944): measured frontal plane motion
• GH: ST = 2:1 after 30º of abduction
Bagg and Forrest (1988): measured plane of scapula motion
• GH: at the beginning and the end
• ST: 80-140 º of abduction
• averaged ratio: 1.25:1
-- Codman’s paradox:  conjunct rotation occurs during sequential motion
5. arthrokinematic movements
-- shoulder abduction
inferior glide of the humeral head on the glenoid cavity
inferior glide of the clavicle on the sternum in most people
6. factors limiting shoulder abduction
a. inferior glenohumeral ligament (most important)
b. tightness of the inferior joint capsule of the glenoumeral joint
c. tightness of the costoclavicular and interclavicular ligaments and the subclavicius muscles
at the SC joint
7. factors limiting shoulder adduction : trunk

C. Shoulder external/ internal rotation

1. joint involved: glenohumeral joint
2. axis of rotation: vertical axis through the center of the humeral head
3. osteokinematic movements
-- range of motion (ROM)
 shoulder internal rotation: 0-70º as the arm at 90º of shoulder abd and 90º elbow flexion
shoulder external rotation: 0-90º as the arm at 90º of shoulder abd and 90º elbow flexion
If the elbow is extended, shoulder rotation occurs simultaneously with forearm rotation.

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UPPER EXTREMITY – The Shoulder Complex

4. arthrokinematic movements
posterolateral glide of the humeral head on the glenoid cavity with shoulder internal rotation
 anteromedial glide of the humeral head on the glenoid cavity with shoulder external rotation

5. factors limiting shoulder internal rotation: posterior capsule

6. factors limiting shoulder external rotation
-- coracohumeral ligament
-- glenohumeral ligaments

D. Shoulder horizontal abduction/ adduction

1. shoulder flexion/ extension at 90º of shoulder abduction
-- horizontal abduction: arm moves backward with the arm at 90º of shoulder abduction
-- horizontal adduction: arm moves forward with the arm at 90º of shoulder abduction
2. joint involved: GH, SC, and AC joints as well as ST articulation
3. plane of motion: transverse plane
4. axis of rotation: vertical axis through the center of the humeral head
5. arthrokinematic movements
-- anteromedial glide of the humeral head on the
glenoid cavity with shoulder horizontal depression
abduction
-- posterolateral glide of the humeral head on the
glenoid cavity with shoulder horizontal
elevation
adduction

E. Shoulder girdle elevation/ depression

1. elevation: ST elevation associated with SC elevation and AC tipping
2. depression: STdepression associated with SC depression
3. range: 0-30 or 45º for clavicle elevation and 0-15º for clavicle depression
4. sagittal axis of the SC joint

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UPPER EXTREMITY – The Shoulder Complex

F. Shoulder girdle protraction/ retraction

1. 0-15º for protraction and 0-15º for retraction
2. clavicular protraction associated with scapular abduction
3. clavicular retraction associated with scapular adduction
4. vertical axis of the sternoclavicular joint protraction

G. Scapulothoracic upward rotation

1. fisrt 30º: elevation of the clavicle through the axis at the
base of the spine of scapula
2. last 30º: posterior rotation of the clavicle and scapular retraction
rotation around AC joint downward
rotation

H. Scapulothoracic winging
1. posterior movement of the vertebral (medial) border of the
scapula, coupled with scapular abduction
2. vertical axis at the acromioclavicular joint upward
rotation

Joint stability

A. Stability of glenohumeral joint deltoid SIT

1. glenoid labrum
2. coracohumeral ligament supraspinatus
3. superior capsule
infraspinatus
4. inactive supraspinatus
5. dynamic stability of the rotator cuff subscapularis
teres minor

B. Stability of sternoclavicular joint

1. saddle-shaped articular surface
2. anterior and posterior sternoclavicular ligament
3. costoclavicular ligament
4. interclavicular ligament

C. Stability of acromioclavicular joint

1. acromioclavicular ligament

D. Scapulothoracic articulation:

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UPPER EXTREMITY – The Shoulder Complex

1. atmosphere pressure
2. serratus anterior
3. structures which hold acromioclavicular and sternoclavicular joints
Muscle Action

A. Muscles for shoulder girdle elevation

prime mover: levetor scapula, upper trapezius, and rhomboids
against resistance: sternocleidomastoid

B. Muscles for shoulder girdle depression

prime mover: lower trapezius

C. Muscles for shoulder girdle protraction

prime mover: serratus anterior and pectoralis minor

D. Muscles for shoulder girdle retraction

prime mover: rhomboid and middle trapezius, and
coupled motion of upper and lower trapezius

E. Muscles for shoulder girdle upward rotation

prime mover: serratus anterior and upper trapezius

F. Muscles for shoulder girdle downward rotation

prime mover: levetor scapula and rhomboid

G. Muscles for shoulder flexion

glenohumeral flexion with shoulder girdle elevation
prime mover: anterior deltoid and clavicualr portion of the pectoralis major
against resistance: coracobrachialis and biceps brachii

H. Muscles for shoulder extension

glenohumeral extension with scapular tipping
prime mover: posterior deltoid, latissimus dorsi
against resistance: teres major

I. Muscles for shoulder abduction

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UPPER EXTREMITY – The Shoulder Complex

glenohumeral abduction with glenohumeral inferior glide and shoulder girdle upward rotation
prime mover: deltoid and supraspinatus for glenohumeral abduction
rotator cuff for inferior glide
serratus anterior and upper trapezius for scapular upward rotation

J. Muscles for shoulder adduction

prime mover: latissmus dorsi, sternal part of pectoralis major
against resistance: teres major

K. Muscles for shoulder external rotation

glenohumeral external rotation with shoulder girdle adduction
prime mover: infraspinatus and teres minor

L. Muscles for shoulder internal rotation

glenohumeral internal rotation with shoulder girdle abduction
prime mover: subscapularis, latismus dorsi, anterior deltoid, pectoralis major
against resistance: teres major

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