Shoulder (Glenohumeral) Joint Heather, Riley, Tonia, and Jo

Surface Anatomy Anterior axillary fold - The inferior border of the pectoralis major muscle forms the anterior axillary fold Clavicular head of pectoralis major - The clavicular head is the smaller top section of the bare-chested upper-torso Clavipectoral triangle - The clavipectoral triangle (deltopectoral triangle) is the depressed area just inferior to the lateral part of the clavicle, bounded by the clavicle superiorly, the deltoid laterally, and the clavicular head of the pectoralis major medially. Sternocostal head of pectoralis major - The sternal-costal head consists of more muscle mass. It originates at the sternum and six sternum costal cartilages

Surface Anatomy Clavicle - can be felt from end to end (subcutaneous) since they produce horizontal ridges visible at the junction of the neck to the thorax Manubrium – the upper segment of the sternum in which the clavicles and upper two ribs articulate

Surface Anatomy Parts of the Deltoid : •clavicular part ( or anterior): originates on the lateral third of the clavicle •acromial part (or middle): originates on the acromion process •spinal part (or posterior): originates on the scapular spine

Surface Anatomy Posterior Axillary Fold – formed by the latissimus dorsi winding around the lateral border of the teres major muscle Triangle of auscultation - The space bounded by the lower border of the trapezius, the latissimus dorsi, and the medial margin of the scapula, used to listen to (auscultate) the lungs because the stethoscope can be placed close to the thoracic wall at this location Three areas of the Trapezius Muscle : Descending Part of Trapezius (the superior region or Upper fibers) - which functions to support the weight of the arm Ascending Part of Trapezius (the inferior region or Lower Fibers) - which function to rotate and or lower the scapulae. Middle Part of the Trapezius (the intermediate region or middle fibers) - which function to draw or pull the scapulae  inwards closer to the spine

BONES OF THE SHOULDER JOINT Made up of three bones: Clavicle Humerus Scapula

CLAVICLE Sternal end 2. Acromial end 3. Conoid tubercle

HUMERUS Greater Tubercle Lesser Tubercle Head Anatomical Neck Intertubercular Sulcus Head Anatomical Neck Surgical Neck Deltoid Tuberosity

SCAPULA Angles (Superior and Inferior) Subscapular Fossa Infraspinatous Fossa Supraspinatous Fossa Spine Glenoid Fossa (Cavity) Acromion Process Coracoid Process Borders (superior, vertebral, and axillary

Shoulder Ligaments Coracohumeral ligament Coracoclavicular ligament Transverse humeral ligament Acromioclavicular ligament Glenohumeral ligaments - superior - middle - inferior Coracoclavicular ligament - Trapezoid ligament - Conoid ligament Superior transverse scapular ligament

Shoulder Bursae A bursa is a sac between two moving surfaces that contains a small amount of lubricating fluid, and they reduce friction where two body parts are moving against one another and there is no joint.

CARTILAGE Labrum: is a type of cartilage found in the shoulder, found only around the socket where it is attached. This cartilage is more fibrous and rigid Articulating Cartilage: white cartilage found on the ends of bones, which allows the bones to glide and move on each other. When this type of cartilage starts to wear out you get arthritis.

Articular Capsule Synovial Membrane: Layer of connective tissue that lines the joints, tendon sheaths, and bursae and makes synovial fluid, which has a lubricating function.

THE ROTATOR CUFF: Group of muscles and tendons that surround the shoulder joint Keep the head of your upper arm bone firmly within the shallow socket of the shoulder. 

ROTATOR CUFF MUSCLES Supraspinatus Infraspinatous Teres Minor Subscapularis ROTATOR CUFF MUSCLES

CLINICAL CONCERNS ROTATOR CUFF INJURY SYMPTOMS: Dull ache deep in the shoulder Disturb sleep, particularly if you lie on the affected side Difficult to comb your hair or reach behind your back Arm weakness http://link.brightcove.com/services/player/bcpid1709592238001?bckey=AQ~~,AAABjg7u0WE~,1M0n70-zc746ABCoBjqsbGI_EgtRkuwu&bctid=2549400139001

ROTATOR CUFF INJURY TYPES: CAUSE: Partial tear: damages the soft tissues but does not completely sever it Full thickness tear or a complete tear: splits the soft tissue into two pieces. CAUSE: Injury: Falling on an outstretched hand or lifting something too heavy are two common injuries associated with rotator cuff tears. Degeneration: Repetitive stress, lack of blood supply, and bone spurs are factors that contribute to degeneration.

OTHER COMMON INJURIES TO THE SHOULDER Labrum Tear Instability- One shoulder joint moves or is forced out of its normal position. This condition can result in a dislocation of one of the joints in the shoulder. Impingement- Caused by excessive rubbing of the shoulder muscles against the top part of the shoulder blade (acromion) OTHER COMMON INJURIES TO THE SHOULDER CLINICAL CONCERNS

Cervical Plexus Accessory (Spinal) Nerve

Brachial Plexus Nerves Medial Cord Lateral Cord Posterior Cord Lateral Pectoral Medial Pectoral Long Thoracic Dorsal Scapular Musculocutaneous Thoracodorsal Axillary Subscapular Suprascapular

Arteries Subclavian Axillary Transverse Cevical Dorsal Scapular Lateral Thoracic Posterior Circumflex Deep Scapular Suprascapular Circumflex Scapular Subscapular Brachial

Upper Trapezius Origin: Superior line of the occipital bone, ligamentum nuchae, and cervical vertebrae Insertion: Lateral 1/3 of clavicle and acromion process Action: Scapular elevation and upward rotation Innervation: Spinal Accessory nerve Roots C3 and C4 Synergists: -Elevation : Levator Scapulae -Upward Rotation: Upper and Lower Trapezius Antagonists: -Adduction: Rhomboids Major and Minor, Middle Trapezius -Downward Rotation: Levator Scapula, Rhomboids Major and Minor.

Middle Trapezius Origin: Spinous Processes of C7 to T3 Insertion: Scapular Spine Action: Scapular Adduction (retraction) Innervation: Spinal Accessory Nerve Roots C3 and C4 Synergists: Adduction: Rhomboids Major and Minor Antagonists: Serratus Anterior, Pectoralis Minor

Lower Trapezius Origin: Spinous Processes of Middle and Lower Thoracic Vertebrae Insertion: Base of the scapular Spine Action: Scapular depression and upward rotation Innervation: Spinal Accessory Nerve Roots C3 and C4 Synergists: -Depression: Pectoralis Minor -Upward Rotation: Upper Trapezius, Serratus Anterior Antagonists: -Elevation: Levator Scapulae, Upper Trapezius, Rhomboids Major and Minor -Downward Rotation: Rhomboids Major and Minor, Levator Scapulae

Levator Scapulae: Origin: Transverse process of first four cervical vertebrae Insertion: Vertebral border of scapula between the superior angle and the spine Action: Scapular elevation and downward rotation (Inferior rotation of Glenoid Cavity) Innervation: Dorsal Scapular and Cervical nerves and Dorsal scapular artery Roots: Dorsal Scapular C5 -Cervical C3 and C4 Synergists: -Elevation: Upper Trapezius, Rhomboids Major and Minor -Inferior Rotation: Rhomboid Major and Minor, Pectoralis Major Antagonists: -Depression: Lower Trapezius, Pectoralis Minor -Superior Rotation: Upper and Lower Trapezius, Serratus Anterior

Pectoralis Minor Origin: Anterior Surface, third through fifth Ribs Insertion: Coracoid process of the scapula Action: Ribs Fixed: Draws scapula forward (abducts) and rotates scapula downward against the thoracic wall Scapula fixed: Elevates the rib cage. Innervation: Medial pectoral nerve, Axillary artery Synergists: Abduction: Serratus Anterior Respiration: Sternocleidomastoid, Scalenes Antagonists: Adduction: Rhomboids major and minor, Middle Trapezius Respiration: Rectus Abdominus

Serratus Anterior: Origin: Lateral Surface of the Upper eight ribs Insertion: Anterior surface of the vertebral border of the scapula Action: Scapular protraction and Upward Rotation, holds scapula against thoracic wall Innervation: Long thoracic nerve, Lateral thoracic artery Roots C5-C7 Synergists: -Abduction: Pectoralis Minor -Upward Rotation: Upper and lower Trapezius Antagonists: -Adduction: Rhomboids Major and Minor, Middle Trapezius -Downward Rotation: Levator Scapulae, Rhomboids Major and Minor

Rhomboid Major: Origin: Spinous processes of T2 - T5 Insertion: Vertebral border of the scapula between the spine and inferior angle Action: Adducts (retracts) Scapula, Depresses Glenoid Cavity, Stabilizes scapula Innervation: Dorsal Scapular Nerve and Dorsal Scapular Artery Synergists: -Adduction: Middle Trapezius -Downward Rotation: Levator Scapulae, Pectoralis Minor Antagonists: -Abduction: Serratus anterior, Pectoralis Minor -Upward Rotation: Upper and lower Trapezius, Serratus Anterior

Rhomboid Minor: Origin: Nuchal Ligament and spinous process of C7 and T1 Insertion: Vertebral border of scapula superior to spine Action: Adducts (retracts) Scapula, Depresses Glenoid Cavity, Stabilizes scapula Innervation: Dorsal Scapular Nerve and Dorsal Scapular Artery Synergists: -Adduction: Middle Trapezius -Downward Rotation: Levator Scapulae, Pectoralis Minor Antagonists: -Abduction: Serratus anterior, Pectoralis Minor -Upward Rotation: Upper and lower Trapezius, Serratus Anterior

Deltoids Anterior (Clavicular) Origin: Lateral 1/3 of Clavicle Action: Shoulder Abduction, Flexion, Medial rotation, Horizontal Adduction Middle (Acromial) Origin: Acromion process Action: Shoulder Abduction   Posterior (Spinal) Origin: Scapular Spine Action: Shoulder Abduction, Extension, Hyperextension, Lateral Rotation, Horizontal Adduction All 3 Deltoids Insert on the Deltoid Tuberosity and are Innervated by the Axillary Nerve with Roots C5-C6 All 3 Deltoids have the Supraspinatus as a Synergist when performing Abduction

Pectoralis Major Origin: (clavicular head) Medial third of the clavicle, (sternal head) sternum, costal cartilage of first six ribs and the aponeurosis of the External Oblique Insertion: Lateral lip of bicipital groove of humerus Action: Shoulder Adduction, Medial Rotation, Draws Scapula anteriorly and inferiorly, Clavicular Head Flexes Humerus, Sternal Head Extends Humerus Innervation: Lateral and Medial Pectoral Nerve Roots: Clavicular C5-C6, Sternocostal C7-C8 Synergists: -Adduction: Latisumus Dorsi, Teres Major -Medial Rotation: Latissumus Dorsi, Anterior Deltoid, Teres Major -Extension: Posterior Deltoid, Latissimus Dorsi, Teres Major Antagonists: -Abduction: Deltoids, Supraspinatus -Lateral Rotation: Infraspinatus, Teres Minor, Posterior Deltoid -Flexion: Anterior Deltoid

Latissimus Dorsi Origin: Spinous Processes of T7 through L5 (via dorsolumbar fascia), posterior surface of sacrum, iliac crest, and lower 3 ribs Insertion: Medial lip of Intertubercular sulcus of humerus Action: Shoulder extension, adduction, medial rotation, hyperextension Innvervation: Thoracodorsal nerve Roots: C6-C8 Synergists: -Extension: Posterior Deltoid, Teres Major, Pectoralis Major -Adduction: Teres Major, Pectoralis Major -Medial Rotation: Teres Major, Petoralis Major, Subscapularis, Anterior Deltoid Antagonists: -Flexion: Anterior Deltoid, Pectoralis Major -Abduction: Deltoids, Supraspinatus -Lateral Rotation: Infraspinatus, Teres Minor, Posterior Deltoid

Supraspinatus: Origin: Supraspinous fossa of the scapula Insertion: Greater Tubercle of the humerus Action: Initiates and Assists the Deltoid Abduct the arm Innervation: Suprascapular nerve Root: C5 and C6 Synergist -Abduction: Deltoids Antagonist -Adduction: Pectoralis Major, Teres Major and Latissimus Dorsi

Teres Major Origin: Dorsal surface of inferior angle of the scapula Insertion: Medial lip of intertubercular groove of humerus Action: Adducts and medially rotates Innervation: Lower subscapular nerve Root: C6 and C7 Synergist -Adduction: Pectoralis Major, Teres Major, Latissimus Dorsi -Medial Rotation: Latissimus Dorsi, Teres Major, Subscapularis, and Pectoralis Major Antagonist: -Abduction: Deltoids and Supraspinatus -Lateral Rotation: Infranspinatus, Teres Minor, and Posterior Deltoid

Subscapularis Origin: Subscapular fossa of the scapula Insertion: Lesser tubercle of the humerus Action: Shoulder Medial Rotation and adduction, also helps hold Humeral Head in Glenoid Cavity Innervation: Subscapular nerve and Subscapular Artery Roots: C5-C7 Synergists: -Adduction: Pectoralis Major, Teres Major, Latissumus dorsi -Medial Rotation: Latissimus dorsi, Teres Major, Pectoralis Major, Anterior Deltoid Antagonists: -Abduction: Deltoid, Supraspinatus -Lateral Rotation: Teres Minor, Posterior Deltoid

Coracobrachialis Origin: Coracoid process of the scapula Insertion: Medial 1/3 of the humerus Action: Helps adduct the shoulder joint Innervation: Musculocutaneus nerve Roots: C6-C7 Synergists: -Arm Flexion: Biceps Brachii, Anterior Deltoid -Adduction: Subscapularis, Teres major, Pecotalis Major Antagonists: -Forearm extension: Triceps Brachii, Posterior Deltoid -Abduction: Deltoids, Supraspinatus

Infraspinatus Origin: Infraspinous fossa of the scapula Insertion: Greater tubercle of the humerus Action: External (lateral) Rotation  Innervation: Suprascapular nerve Root: c5 and c6 Synergist: -Lateral Rotation: Teres Minor and Posterior Deltoid Antagonist: -Medial Rotation: Latissimus Dorsi, Teres Major, Subscapularis, Pectoralis Major and Anterior Deltoid

Teres Minor Origin: Superior lateral border of the scapula Insertion: Greater tubercle of the humerus Action: External Rotation, weak rotation Innervation: Axillary nerve Root: c5 and c6 Synergist -Lateral Rotation: Infraspinatus and the Posterior Deltoid Antagonist: -Medial Rotation: Latissimus Dorsi, Teres Major, Subscapularis, Pectoralis Major, and Anterior Deltoid

Overview of the Muscles of the SHOULDER/GLENOHUMERAL region

References http://teachmeanatomy.info/upper-limb/misc/surface-anatomy/surface-anatomy-of-the-axilla- anterior-and-posterior-axillary-folds/ http://uni-doctors.blogspot.com/search?q=clavipectoral+triangle https://web.duke.edu/anatomy/Lab10/Lab11_preLab.html http://www.science-art.com/image/?id=2961#.VF7jXtEtDVI https://web.duke.edu/anatomy/Lab10/images/Grant's%20Atlas%206.30%20(1).jpg http://www.musclesused.com/wp-content/uploads/2012/08/Trapezius-Muscle-3.jpg http://med.uc.edu/labmanuals/ga/HEMATOLOGY%20AND%20CARDIOVASCULAR/ Clemente, Carmine D. Atlas, A regional Atlas of the Human Body. 6th edition. 2011  https://www.google.com/search?q=levator+scapulae&biw=1301&bih=641&source=lnms&tbm=i sch&sa=X&ei=kD9hVJy7JsTuoASNp4CoBg&sqi=2&ved=0CAYQ_AUoAQ#tbm=isch&q=pectoralis+ major+images&imgdii=_ BLEVINS, GARY THE OFFICIAL MUSCLE SHEET. 2014