2 What is the importance of Shoulder Girdle Increase the ROM for Upper limb (up to 180°)Provide More space to reach for upper limbProvide an stable base for upper limb function
3 What are the Joints of the Shoulder girdle? Four interdependent linkages for Shoulder ComplexFunctional Articulation: Scapulothorasic Joint (STJ)Anatomical Articulation: Sternoclavicular Joint (SCJ)Anatomical Articulation: Acromioclavicular Joint (ACJAnatomical Articulation: Glenohumeral Joint (GHJ)
5 What is the role of Sternoclavicular Joint within shoulder girdle? Functional base for scapulaMovement in Clavicle and SCJMovement in Scapula Thoracic
6 Sternoclavicular Joint Can You Describe the Sternoclavicular Joint?Sternoclavicular JointConsists of two saddle-shaped surfaces butA plane Synovial Joint3 degree of freedomJoint Capsule3 Major LigamentsA Joint Disc4 joint’s area contactClavicleMovement in SCJ is due to the change in contact area betweenSternocalvicularDiscManuberium
7 Can you describe the function of Sternoclavicular Disc Joint? A fibrocartilage joint disk, or meniscus, that increases congruence between joint surfacesActs like a hinge or pivot point during clavicle motion.Act like axis in the SCJIn Elevation/DepressionClavicle move against Manuberium and DiscUpper part of Disc act like axis)In Protraction/RetractionDisc and Clavicle Move against ManuberiumLower part of Disc act like axis
8 the mechanical axis for these two movements located not at the SC joint itself but at the more laterally located costoclavicular ligament
9 How the disc Joint does provide stability for SCJ? Disc has an Important Role in Joint StabilityBy Creation congruent between Joint surfaceBy absorption coming stresses to the lateral end of clavicle
10 Three-Compartment SC Joint Anatomic examination of the SC articulation has led to the proposal that there are three functional unitsa lateral compartment between the disk and clavicle for elevation and depression;a medial compartment between the disk and manubrium for protraction and retraction;a costoclavicular joint for anterior and posterior long axis rotation.
11 Sternoclavicular Joint Capsule and Ligaments The SC joint is surrounded by a fairly strong fibrous capsule but must depend on three ligaments for the majority of its support. These are the sternoclavicular ligaments,
12 Can you name the Sternoclavicular Ligaments? Sternoclavicular Lig (Ant & Post)Costoclavicular Lig (Ant & Post)Inter Clavicular Lig
13 What is the function of Sternoclavicular Ligaments? Sternoclavicular (Ant & Post) LigStrengthening of Ant and Post part of JointPrevent of Ant and Post Movements of ClavicleCostoclavicular (Ant & Post parts) LigVery strong LigBoth parts resist against the 1) superior force from SCM and 2) against elevation of the lateral end of clavicleAt the limit reach, they are responsible for inferior gliding of claviclePost part prevent of inward movement of clavicle (absorb of forces acts on the Disc from arm)Inter Clavicular LigControl 1) Depression of clavicle, 2) superior gliding of clavicle and protect subclavian artery and Brachial plexus andWeight bearing of upper arm by help of upper capsule
14 Three Major functions for SCJ Integrity of These elementsClavicleSCJ DiscManuberiumLigamentsCapsulePROVIDSThree Major functions for SCJResist against Applied stress from Upper armProvide Mobility for Upper armProvide a Strength Base for Upper arm
15 What are the Sternoclavicular Movements? Motions of any joint are typically described by identifying the direction of movement of the portion of the lever that is farthest from the joint.Elevation/DepressionProtraction/RetractionAnterior/Posterior Rotation
16 Can you describe Elevation/Depression movements? Occur around the Ant-Post Axis which located in Costoclavicula LigIn the plan that convex surface of clavicle glide against concave surface of manubrium and DiskOpposite Movement of medial part of clavicleUp to 48 degree Elevation and 15 degree DepressionElevation of clavicle accompanied by elevation of scapula and its upward rotationSmall magnitudes of medial-lateral translation and superior/inferior translation in the medial aspect of clavicle
18 Can you describe the Protraction/Retraction movements? Occur vertical axis locate in costoclavicula LigIn the plan that concave surface of clavicle glide against convex surface of manubriumIn protraction, lateral end rotate anteriorly, and medial end slide anteriorlydegree Protraction and degree RetractionPro/Ret of clavicle is accompanied by Pro/Ret of scapula
20 Can you describe the Anterior/Posterior Rotation? Occur around the longitudinal axis of clavicle intersecting AC and SC JointAn Spin movement saddle surface of medial part of clavicle and manuberium/first costal cartilageMovement start from neutral position only toward posterior rotation35-55 ° Post Rot and 10 ° available Ant RotIt serve the last 30 degree of upward rotation of scapula.
22 ■ Sternoclavicular Stress Tolerance The Complex of bony segments, Capsuloligamentous structure, and the SC disk produce a joint with dual functions of mobility and stability.The SC joint contribute to upper limb mobility, and withstanding imposed stresses.Although the SC joint is considered incongruent, the joint does not undergo the degree of degenerative change common to the other joints of the shoulder complex.Dislocations of the SC joint represent only 1% of joint dislocations in the body.
24 Acromioclavicular Joints CharacteristicsPlan Synovial Joint3 rotational and 3 transitional degrees of FreedomWeak capsular jointJoint DiscTwo Major LigamentsSuperior & Inferior Acromioclavicular ligamentsIntegration of joint surfaceProvide horizontal stabilityCoracoclavicular Lig.Its primary function included:
25 Primary function of ACJ Allow the scapula additional range of rotation on the thoraxAllow for adjustments of the scapula (tipping and internal/external rotation) in order to follow the changing shape of the thorax as arm movement occurs.Allows transmission of forces from the upper extremity to the clavicle.
26 Articular Surface and Joint Disc of ACJ The articular facets, considered to be incongruent, vary in configurationIntra-articular movements for this joint are not predictable.A Joint disk with variable in size between individuals exist in AC jointIt plays as a “meniscoid” fibrocartilage remnant within the joint to develop each articulating surface during upper extremitymovement
28 Acromioclavicular Capsule and Ligaments Capsule is weak and cannot maintain integrity of the joint without reinforcement by ligamentsThe superior acromioclavicular Lig are reinforced by aponeurotic fibers of the trapezius and deltoid muscles and assists capsule byApposing articular surfacesControlling A-P joint stability. The fibers of the superior AC ligament arethe superior joint support stronger than the inferior
30 Acromioclavicular Capsule and Ligaments Coracoclavicular Ligaments which divided into:Lateral portion, the trapezoid ligament,provides the primary restraint for the AC joint in the superior and inferior directionsMedial portion, the conoid ligament.Provides the majority of resistance to posterior translatory forces applied to the distal clavicle.They are separated by adipose tissue and a large bursaBoth portions of the coracoclavicular ligament limit upward rotation of the scapula at the AC jointTransfer Medially directed forces on humerus to the SCJTransfer the rotational force of scapula to the clavicle and then cause Posterior Rotation at SCJ
31 When a person bears weight on the arm, a medially directed force up the humerus (1) is transferred to the scapula (2) through the glenoid fossa and then to the clavicle (3) through the coracoclavicular ligament
32 Acromioclavicular Motions The primary rotatory motions of AC joint areInternal/external rotation,Anterior/ posterior tipping or tilting,Upward/downward rotationThese motions occur around axes that are oriented to the plane of the scapula rather than to the cardinal planes.Small translatory motions of AC joint included:Anterior/Posterior,Medial/Lateral,Superior/Inferior.
34 What movement does occur in the Acromioclavicular joint? 1- Internal and External Rotation
35 Internal and External Rotation Occurs around an approximately vertical axis through the AC jointTo Maintain contact of the scapula to horizontal curvature of the thorax during Protraction and RetractionTo orient the glenoid fossa toward the plan of humeral elevation30 degree the total ROMAn Anterior/Posterior translatory movement
36 Internal and External Rotation at AC joint Glenoid Fossa is the reference for naming the movementBecause of the thorax curvature, Internal/External Rotation is a necessary movement for protraction and Retraction
37 Anterior and Posterior Tipping Occurs around an oblique “coronal” axis of jointAnt. tipping will result in the acromion tipping forward and the inferior angle tipping backward during downward rotation and also Elevation of scapulaPosterior tipping will rotate the acromion backward and the inferior angle forward. during upward rotation and also Depression of scapulaTo Maintain contact of the scapula with the contour of the rib cage and orient the glenoid fossa during arm flexion and abduction30-40 degree the total ROMA Superior/posterior translatory movement
38 Anterior and Posterior Tipping The superior aspect of scapula is the reference of naming the movementThe acromion has slightly translatory anteriorly/posteriorly movement
39 Upward and Down Ward Rotation at AC Joint Around an A-P axis (perpendicular to scapula)Direction of Glenoid Fossa is the reference for the naming the movementAcromion has a small medial/lateral Translatory movement
40 3-Scapula Upward and Downward Rotation Help to orient the glenoid fossa upward or downwardCoraco-Clavicular Ligament limit this movementPosterior rotation of clavicle lax the ligSo upward rotation can be done in the AC Joint30 degree Upward Rot17 degree Downward Rot
41 Acromioclavicular Stress Tolerance AC joint is extremely susceptible to both trauma and degenerative change due to theits small and incongruent surfacesDegenerative change is common from the second decade with narrowed joint space by the sixth decade.Treatment of sprains, subluxations, and dislocations of this joint occupies a large amount of the literature on the shoulder complex
42 Acromioclavicular Stress Tolerance Various classification of injury commonlyType I injuries consist of a sprain to the AC ligaments,Type II injuries typically have ruptured AC ligaments and sprained coracoclavicular ligamentsType III injuries result in rupture of both sets of ligaments,Types I, II, and III AC separations all involve inferior displacement of the acromion in relation to the clavicle caused by the loss of support from the coracoclavicular ligaments
43 Acromioclavicular Stress Tolerance Various classification of injury commonlyType IV injuries have a posteriorly displaced lateral clavicle, often pressing into the trapezius posteriorly, with complete rupture of both the AC and coracoclavicular ligamentsType V injuries also involve an inferior displacement of the acromion and complete rupture of both sets of ligaments and are distinguished from type III by a severity of between three and five times greater coracoclavicular space than normal.Type VI injuries have an inferiorly displaced clavicle in relation to the acromion, with complete ligament rupture and displacement of the distal clavicle into a subacromial or subcoracoid position.
45 Rotation at AC JointSCJ Elev/Dep and ACJ Rotation are necessary movements for Scapula Elevation and Depression
46 ACJ Rotation and SCJ Elev and Post Rotation are the necessary movements for Scapular upward Rot
47 Resting Position of scapula Position of Scapula on the Thorax2 inches from the midlineBetween 2nd and 7th ribs30-45 degree internally rotated from the coronal plane10-20 degree anteriorly tipping from vertical10-20 degree upward rotation, it is different among the individuals
49 What is the Movement of Scapula? Elevation/DepressionProtraction/RetractionUpward Rotation/Downward Rotation
50 Scapula Upward and downward Rotation Upward rotation of the scapula plays a significant role in increasing the range of elevation of the armApproximately 60º of upward rotation is available.Considering the closed-chain relationship between the SC, AC, and ST joints, they contribute to scapula upward/downward rotation by:SC joint elevation/depression,SC joint posterior/anterior rotationAC joint upward/downward rotationMost often, scapular upward/downward rotation results from a combination of the SC and AC motions.
52 Scapula Elevation/Depression Scapular elevation and depression can be isolated by shrugging the shoulder up and depressing the shoulder downward.It is described as translatory motionsScapular elevation, occurs by elevation of the clavicle at the SC joint and requires Scapula adjustments inanterior/posterior tippinginternal/external rotation at the AC jointto maintain the scapula in contact with the thorax
54 Scapula Protraction/Retraction Scapula Protraction and retraction are described as translatory motions of the scapula away from or toward the vertebral column, respectively.However, if protraction occurred as a pure translatory movement, only the vertebral border of the scapula would remain in contact with the rib cage.In reality during protraction, scapula follows the contour of the ribs byrotating internally and externally at the AC joint andclavicular protraction and retraction at the SC jointSo, glenoid fossa facing anteriorly with the full contact of scapula with the rib cage
56 Scapula Internal/External rotation Scapular internal and external rotation arenormally not overtly identifiable on physical observationbut are critical to its movement along the curved rib cage.The Movement normally accompany protraction/ retraction of the clavicle at the SC jointIsolated Scapula Int rotation at the AC joint, causeProminence of the vertebral border of scapulaLoss of contact of scapula with the thorax.Which is referred to clinically as scapular “winging”Excessive Int rotation may be indicative of pathology or poor neuromuscular control of the ST muscles.
58 Scapula Anterior/Posterior Tipping Anterior/Posterior tipping isnormally not obvious on clinical observation andyet is critical to maintaining contact of the scapula against the curvature of the rib cageMovement occurs at the AC jointnormally will accompany anterior/posterior rotation of the clavicle at the SC jointIsolated excessively Ant/Post Tipping at the AC joint will resultin prominence of the inferior angle of the scapulaAnt. tipped scapula may occur in pathologic situations (poor neuromuscular control) or in abnormal posture.
60 What are the Scapulathorasic Functions? Final function of this JointAdjustment of gelenoid directionTo Increased ROM for upper armTo Provide an Strong Base to control Rolling and gliding Movements for Humorous Surface
61 Scapulothorasic Stability Scapula Stability on the thorax is provided byThe structures that maintain integrity of the linked AC and SC joints such as ligaments, capsule and joint disc.The muscles that attach to both the thorax and scapula maintain contact between these surfacesThese muscles also provide stabilization by pulling or compressing the scapula to the thorax.The scapula, with its associated muscles and linkages, performs mobility and stability functions so well that it serves as a premier example of dynamic stabilization in the human body