A VERY NICE PRESENTAION CONCISE , ONE OF THE BEST PRESENTATION ON SHOULD JOINT AND APPLIED ASPECTS ITS A PRESENTAION FOR POST GRADUATE AND ITS FELOW MEMBERS AS HIGHLY RATED MATERAIAL, MOST ADVANCED TILL DATE ITYS A MATERIAL FOR MAJOR UNIVERSITIES FOR WORLD CLASS STUDENTS. TO BE PRECISE IN EVERYTHING. A WORLD OF PARAMOUNT IMPORTANCE A LUGGAGE FOR THE THE BEST OF THE STUDENTS. WORLD CLASS PRESENTAION FOR STUDENTS AND TEACHERS. FOR GENERAL STUDENTS CAN ALSO BENEFIT FRON THE PRESENTATION GLAD TO PRESENT OVER THIS TOPIC A VERY MINE BLOWING TOPIC A VERY ACCURATE DETAILS A MUST FOR MEDICAL GRADUATE EXPERIANCE FACULTIES FOR MEDICAL STUDENTS MEDICAL GRADUATE I M IN LOVE WITH THE CONTENT MUST FOR ALL LOVINGB THE IMAGES IMAFES FOR ALL. JOURNALS INCLUDED RECENT ADVANCED INCLUDED JBASJFKHSDJKJKSDHVJKDFHVKJDFHVJKVHSDKJVHDSJKVHJKVNSJKDVNSDJKVNDSJKVNSJKVNSJKDVNJKNVJKVNDJKNVJKVNKJVHJKHFIQOURDOIQWJDFKQWJDLKQNFLKWENNNNWJFLIOWJIOWJIWVJWKLVNWLKNVWLKGNWKLNGWKLNGWKLEFJIWEFJEWIOFJWIOEJUOWIEFJIOWEJFOIWENFLKWENFLKWEGJWEOIGJWEIOGJWIOEGJIOWEJGOIWEIFLKWEJFIOWEJGIOWEUJGFIOWEJFOIWEJFOIWEJFIOWEJFOIWEJFWLEFJWELGJLKWEFWEKLFMNWEKLGMWIOGJWIOGJWRIOGJWOIJGOPWEIR0QWFPOQIROPQWEJGLWENVLKSVNLIVJWIOBJIOWRJGOPWQHJFOIQWUJROPQWJFOPQKFPOWEJGOPWRJGOIWR LOVING IN MEMORY OF MY FATHER AND MOTHER A COPY FOR ALL VERY HIGHLY RATED FOR ALLA I M IN LOVR WITH THE CONTENTS AND TGEXT

1. SHOULDER JOINT AND ITS
APPLIED ASPECTS
Presenter- DR.Nipendra Kishore

2. Introduction
SHOULDER GIRDLE
● Sternoclavicular joint
● Acromioclavicular joint
● Glenohumeral joint(shoulder
joint)
● Scapulothoracic joint

3. Osteology
● Clavicle
● Scapula
● Humeral head

4. ● Humeral head version - (0-55 degree of retroversion)
● Glenoid version - 1.5 degrees of retroversion
Normal position of glenoid surface in relation to scapular body
ranged from 2 degree of anteversion to 7 degree retroversion

5. Articulations
Sternoclavicular joint
● Only true joint
● Anterior and posterior Sternoclavicular ligaments
● Costoclavicular ligament
● Posterior is strongest primary retsrains to anteroposterior stability
Acromioclavicular joint
● Diaryhroidal joint containing incomplete articular disc
● Facets are covered with fibrocartilage
● Acromioclavicular ligament(anterior,posterior,superior and inferior
ligaments)
Superior fibres blend with capsule of trapezius and deltoid
● When arm is maximally elevated about 5 to 8 degree rotation possible
● Corococlavicular ligament(conoid and trapezoid ligaments)

6. Scapulothoracic joint
● Medial border of scapula
articulates with posterier
aspect of second to
seventh rib
● Angled 30 degree
anteriorly and 3 degree
upward tilt

7. Shoulder joint
● It is a synovial joint of ball
and socket varietty
● Glenohumeral articulation
● Weak joint(Glenoid cavity
is too small and shallow)
● Greatest range of motion
in body
● Stability due to STATIC
and DYNAMIC stabilisers

8. Static stabilisers
● Articular anatomy
● Glenoid labrum
● Glenohumeral ligaments
● Capsule and negative intra
articular pressure
Dynamic stabilisers
● Rotator cuff and biceps
tendon
● Scapulothoracic mechanics

9. Capsule
● Loose and permits free range of movements
● Least supported inferiorly
● Medially attached to scapula beyond supra glenoid tubercle
and margins of labrum
● Laterally to anatomical neck of humerus with exceptions (
inferiorly extends down to surgical neck )
● Superiorly deficient for passage of long head of biceps
● Capsuloligamentus structures is the primary static stabiliser
of shoulder

10. LIGAMENTS
Glenohumeral ligaments
● Discrete capsular thickenings
● 3 weak Bands
(superior,middle,inferior)of fibrous
tissue that strengten the anterior
capsule
Transverse humeral ligaments
● Bridges upper part of bicipital
groove of humerus
● Tendon of long head of biceps

11. Coracohumeral ligament
● From root of corocoid process to
neck of humerus
● It strengten the capsule
Coracoacromial ligament
● Extends between corocoid
process of scapula and acromion
● Ligament is a constraint to
superior escape of humeral head
● Key component of
corocoacromial arch

13. Musculotendinous cuff of shoulder
● Fibrous sheath
● Formed by 4 flattened
tendons(subscapularis
,supraspinatus,infraspinatus
and teres minor) blend with
capsule of joint
● Acromion, coracoacromial
ligament and coracoid process
form coraco acromial arch
(secondary socket for head of
humerus)

14. ROTATOR INTERVAL:- Triangular space between anterior
border of supraspinatus and superior border of subscapularis
Base of triangle is formed by coracoid
Contents :- SGHL,CHL and Biceps tendon
Tightening this interval can decrease the inferior translation
BICEPS PULLEY : SGHL, CHL, Subscapularis form an anterior
pulley to keep biceps tendon located in joint / bicepetal groove

15. ROTATOR CABLE :-
● Curved structure , which is an extension of
corocohumeral ligament in anterior
direction
● It blends with anterior subscapularis and
supraspinatus tendon
● Cable runs from anterior to posterior under
the supraspinatus tendon and
infraspinatus tendon to blend with
posterior infraspinatus and teres minor
tendons
● Connects supraspinatus and infraspinatus
to head of humerus and function to
transmit forces across rotator cuff complex

16. Muscles around
Shoulder
Intrinsic group
● Rotator cuff muscles
● Deltoid
● Pectoralis major
● Teres major
● Latismus dorai
● Biceps brachii

17. Extrinsic group
● Rhomboids
● Levator scapulae
● Trapizius
● Serratus anterior

18. Muscles connecting upper limb to
vertebral column :Trapizius ,latissimus
dorsai, both rhomboids muscles and levator
scapulae
Muscles connecting upper limb to
thoracic wall : both pectoralis muscle
,subclavius , and serratus anterior
Suprascapularnotch:- suprascapular
ligament converts notch into foramen
Suprascapular nerve passes below the
ligament ,and artery and vein above
ligament
Splinoglenoidnotch:- splenoglenoid
ligament that bridges the notch

20. Movements of shoulder Girdle
● Elevation - by upper fibres of Trapizius and levator scapulae
● Depression-by lower fibres of serratus anterior and pectoralis
minor
● Protraction - serratus anterior and pectoralis major
● Retraction- by Rhomboids and middle fibres of Trapizius

24. Spaces around scapula
● Quadrangular space
● Triangular space
● Triangular interval

25. Blood supply
● Posterior circumflex
Humeral vessels
● Anterior circumflex
Humeral vessels
● Suprascapular vessels
● Subscapular artery
Nerve supply
● Axillary nerve
● Musculocutaneous nerve
● Suprascapular nerve

26. Bursae related to joint
● Subacromial
bursa(subdeltoid bursa)
● Subscapular bursa
● Infraspinatus bursa

27. Examination of shoulder joint
History:-
● Age and chief complaints
● Instability , acromioclavicular joint injuries ,and distal clavicle
osteolysis are common in young patinets
● Rotator cuff tears , arthritis ,and proximal humerus fractures are
common in older people
● Direct blow are usually responsible for acromioclavicular
separations
● Instability occurs with injury to abducted extrernally rotated arm
● Chronic overhead pain and night pain are associated with rotator
cuff tears

29. CODMAN’S METHOD
● Method of palpation of shoulder joint
● Exeminers left hand used for right shoulder
● Thumb lies below the spine of scapula to palpate posterior
aspect of shoulder
● Tip of index finger is used placed anterior to acromium to
feel superior aspects and anterior aspects of shoulder and
other 3 fingers are placed on clavicle to hold it
● Examiners right hand grasps the patients flexed elbow and
patient arm is moved gently backwards and forwards and
shoulder joint is carefully palpated

30. Examination of shoulder joint
● Neer impingement sign and impingement test:-
Affected arm ( Forward elevation )+stabilising scapula
Causing the greater tuberosity to impinge against the
acromium
● Impingement test with use of subacromial injection
of 10 ml of 1 % lidocaine . Pain caused by
impringement is significantly reduced

31. ● HAWKINS -KENNEDY TEST:-
Forward flexing humerus to 90 degrees+ forcible internal rotation of
the shoulder
● JOBE TEST :-
Shoulder in 90 degree of abduction and 30 degrees of forward flexion
and internal rotation . Supraspinatus testing against resistance shows
weakness or insufficiency owning to tear or pain associated with
rotator cuff impingement
● INTERNAL ROTATION RESISTANCE STRESS TEST:-
Zaslav described this test.To differentiate between internal and classic
oulet impingement.Patients arm in 90 degrees of abduction the coronal
plane and 80 degrees of external rotation.A manual isometric mucle test
is performed for external rotation and compared with one for internal
rotation in same position

32. ● PAINFUL ARC TEST :-
Arm in full elevation and slowly bring down arm to side.In
between 90 degrees and 120 degrees the patient feels pain
test is considered positive
● GERBER SUBCORACOID IMPINGEMENT TEST
To identify impingement between rotator cuff and coracoid
process.Arm is forward flexed 90 degrees and abducted 10 to
20 degrees across the body to bring the lesser tuberosity into
contact with coracoid
Pain indicates coracoid impingement

34. ● JOBE APPREHENSION -RELOCATION TEST:-
To distinguish between primary and secondary
impingement.Patient supine ,arm abducted 90 degrees and
externally rotated produces pain. Application of posteriorly
directed force to humeral head ,relocating it in glenoid does
not change the pain in patients with secondary impingement
● SPEED TEST:-
Flex shoulder 90 degrees with elbow extended and forearm
supinated.Resistance applied to forearm, positive result
produce pain in bicipital groove

35. ● YERGASON SIGN:-
Elbow flexed to 90 degrees ,the forearm pronated .The
patient attempt to supinate forearm activly against
resistance
● LIFT OFF TEST:-
For detection of isolated rupture of subscapularis
tendon.With patient seated/standing arm is internally
rotated dorsum of hand is placed against Lower back.If
test is positive unable to lift the hand.

37. ● BELLY PRESS TEST:-
Patient presses abdomen with flat of the hand and
attempts to keep the arm in maximal internal rotation
If strength of subscapularis is impaired , maximal internal
rotation cannot be maintained
● EXTERNAL ROTATION STRESS TEST:-
To test integrity of Infraspinatus and Teres minor.With the
arm side in neutral flexion and abduction , shoulders are
externally rotated 45 to 60 degrees.Examiner applies force
against dorsum of hand,attempting to rotate shoulder
internally back to neutral while patient is asked to resist

38. ● EXTERNAL ROTATION LAG SIGN:-
To test the integrity of supraspinatus and infraspinatus
tendons.elbow passivly flexed to 90 degrees ,and the
shoulder is held at 20 degrees of elevation and near
maximal external rotation by the examiner The patient
asked to maintain external rotation .The sign is positive
when a lag or angular drop occurs
● PATTE SIGN:-
To determine the strength of the teres minor.Patient
standing examiner elevates patients arm to 90 degrees in
scapular plane and flexes elbow to 90 degrees .Patient
asked to laterally rotate shoulder

39. ● DROP SIGN:-
To test the integrity of Infraspinatus .The affected arm held in 90
degrees of elevation in scapular palne and at almost full external
rotation with elbow flexed at 90 degrees.The patient asked to mainatin
position activly as examiner releases the wrist while supporting the
elbow ,which is mainly function of Infraspinatus
● INTERNAL ROTATION LAG SIGN:-
To test the integrity of subscapularis tendon
Affected arm is held in maximal internal rotation
Elbow flexed to 90 degrees ,shoulder held at 20 degrees of elevation
and 20 degrees of extension.Dorsum of hand is partially lifted away from
lumbar region until almost full internal rotation is reached

42. APPLIED ASPECTS OF SHOULDER JOINT
ADHESIVE CAPSULITIS ( FROZEN SHOULDER )
● It describes contracted ,thickened joint capsule that seemed to be
drawn tightly around humeral head with relative absence of synovial
fluid and chronic inflammatory changes within the subsynovial layer
● Pathologic changes in adhesive capsulitis are synovial inflammation
with sussequent reactive capsular fibrosis
● RISKFACTORS - female gender , age above 50 yrs ,DM, Prolonged
immobilisation, Hyperthyroidism, Stroke or Myocardial
infarction,Presence of autoimmune diseases and trauma
● Frozen shoulder -PRIMARY OR SECONDARY(based on inciting
event present or not)

43. ● There is no universal accepted criteria to diagnose Frozen
shoulder
● Internal rotation is lost initially,followed by loss of flexionand
external rotation
● Clinical caurse of primary frozen shoulder consists of 3 phases
Secondary may not exhibit all 3 phases
● PHASE 1 - PAIN (gradual onset of diffuse shoulder pain)
progresses over weeks to months .Pain usually worse at night
and exacerbated by lying on affected side
● PHASE 2 - STIFFNES, usually lasts for 4 to 12 months .Patient
describes difficulty with activity
● PHASE 3 - THAWING , Usually lasts for weeks or months ,as
motion increases , pain diminishes

44. Treatment :-
● Self limiting condition lasting 12 to 18 months
● Treatment options include benign neglect,supervised
physical therapy ,NSAIDS,oral
corticosteroids,intraarticular steroid injections,distention
arthrography,closed manipulation,open surgical release
and arthroscopic capsular release

45. CALCIFIC TENDINITIS:-
● Painful,self limited disorder of rotator cuff in which tendons are
infiltrated with calcium deposits
● Most common site of occurance supraspinatus tendon( 1.5 to
2 cm away from tendon insertion on greater tuberosity)
● Women between ages of 30 and 60 years are most
freequently affected (women are affected more than men)
● Most patients are asymptomatic ,but pain is intense in
symptomatic patients ( subacromial pain)
● Hypoperfusion…calcification(vascular etiology with degeration
of tendon fibres preceding calcification)

46. ● CALCIFIC TENDINITIS follows a definite progression
PHASE 1 :- PRECALCIFICATION STAGE .Site undergoes
fibrocartilaginous metaplasia (Asymptomatic stage )
PHASE 2:- CALCIFICATION STAGE . Calcium deposit into
matrix vessels ,excreted by cells and coalesce to larger
calcium deposits. Phase of Formation……Resting phase
…...Resorptive phase
● PHASE 3:- POST CALCIFICATION STAGE

47. TREATMENT:-
Non operative - physical therapy,exercises ,Anti Inflammatory
medications and corticosteroid injections
Surgical treatment -
Indications - symptom progression, constant pain that interferes
with activities of daily living and absence of improvement after
conser vative methods

48. IMPINGEMENT SYNDROME:-
● In 1972 ,Neer described impingement syndrome
characterised by a ridge of proliferative spurs and
excrescences on the undersurface of anterior process of
acromium apparently caused by repeated impingement of
rotator cuff and humeral head with coracoacromial ligament
● Supraspinus insertion into greater tuberosity that passes
beneath the coracoacromial arch during forward flexion of
shoulder are succeptible to impingement syndrome
Four types of impingement :- PRIMARY
,SECONDARY,SUBCORACOID AND INTERNAL
IMPINGEMENT

50. ROTATOR CUFF TEAR
● Loss of continuity of rotator cuff can be described in
● ACUTE OR CHRONIC
● PARTIAL OR FULL THICKNESS
● TRAUMATIC OR DEGENERATIVE

51. ● Majority of tear involves supraspinatus and infraspinatus
● Tears associated with chronic impingement syndrome typically
begin on the bursal surface or within tendon substance
● Tears occur in articular surface because of tension failure in
younger patients participating in overhead activities
● Patient typically presents with an insidious onset of pain
exacerbated by overhead activities
● Complaints of night discomfort,pain in deltoid region,muscle
weakness and difference in active and passive range of motion
are common
● Acute pain and weakness may be seen after traumatic rotator
cuff rupture

52. TREATMENT
● Non operative :-asymptomatic full thickness tear, non
complaint patients ,medical contraindications to surgery
● Activity modification ,stretching and strengthening exercises
antiinflammatory medications
● Operative :-significant pain, chronic full thickness tear that
failed to respond to non operative methods

53. GLENOHUMERAL INSATABILITY:-
● Symptomatic and pathologic condition in which humeral head
does not remain centered in the glenoid fossa
OTA Classification :-in the system shoulder region is 10
A letter used to identify specific joint
(A- Glenohumeral ,
B - Sternoclavicular etc)
Followed by another number
(1- Anterior,2- posterior,3-lateral
4- medial,5 - inferior)

54. ANTERIOR INSTABILITY:-
● Most common type of shoulder instability
● Typically the result of trauma to arm when in abducted and
external rotated position
● Highly painful
POSTERIOR INSTABILITY:-
● The result of trauma when arm in adduction and internal
rotation
● Minimally painful
● Epilepsy and electric shock are freequent causes
INFERIOR INSTABILITY:-
● LUXATIO ERECTA
● Hyperabduction injuries

55. Surgical approaches to shoulder joint
Anterior approach :-
Anterior incision - Make 10- 15 cm straight incision following
lines of deltopectoral groove ( incision should begin above
coracoid process)
Axillary incision - make vertical incision 8 to 10 cm long starting
from midpoint of anterior axillary fold and extending posteriorly
to axilla
-After skin incision and subcutaneous dissection ,the interval
between Anterior deltoid and pectoralis major muscle is
identified (deltopectoral interval)
-Cephalic vein is taken laterally

56. -underlying clavipectoral fascia can be incised at the lateral edge of
coracobrachialis
-conjiont tendon is pulled medially giving exposure of Subscapularis
muscle and tendon
-subscapularis muscle and tendon may split iwith it's fibres 1 cm
medial to insertion of insertion and reflected medially
-capsule can be incised a number of ways preferably T incision
Posterior approach :-
Incision:- linear incision along the entire length of scapular
spine,extending to the posterior corner of acromion
.Alternatively make a 10 to 15 cm longitudnal incision centered on a
point 2 cm inferomedial to the posterior corner of acromium

57. -intravenous plane between teres minor and infraspinatus muscle
- identify origin of deltoid on scapular spine and detach it
-identify intravenous plane between infraspinatus and teres minor
muscle
-retract infraspinatus superiorly and teres minor inferiorly to reach
posterior region of glenoid cavity and neck of scapula
-Posterioinferior corner of shoulder joint capsule is exposed
-Incise it longitudnally ,close to scapula