Stabilization of GH joint:

• Given the incongruence of GH articular

surface, the bony surfaces alone cannot
maintain joint contact in a dependent
position-Static stabilization
• Joint has great mobility at the cost of
stability - Dynamic stabilization
Static stabilization of Dependent arm:
• Bony surfaces alone cannot maintain joint
contact in a dependent position (arm
hanging by the side)
• As the humeral head rests on the fossa,
gravity acts on the humerus parallel to the
shaft in a downward direction
• This requires a vertical upward force
(given by anterior deltoid, long head of the
biceps and triceps brachii) to maintain
equilibrium
• Muscles are electrically silent when arm is
unloaded and when tugged downward
• Mechanism of stabilization hence is
passive
• The line of pull of gravity lies slightly
away from the axis of rotation, hence
creating an adduction moment
(counterclockwise torque)
• Gravity has to be offset, by
a torque of equal magnitude
but opposite direction
• Such a force is applied by the structures
of the rotator interval capsule (superior
capsule, superior GH ligament and
coracohumeral ligament)
• These structures are taut when the arm is by the
side of the body
• Given the insertion of the interval capsule on
the greater tubercle, the moment arm (MA) of
this passive force is nearly twice that of more
centrally located force of gravity
• The action line of this force is upward offsetting
the downward translatory component of gravity
and into the glenoid fossa (joint compression)
• In a heavily loaded arm when the force of static
stabilization is not sufficient, supraspinatus is
recruited
• This is possible as the supraspinatus has
attachments on the rotator interval capsule
• In cases where there is paralysis or
dysfunction of supraspinatous it may lead to
gradual inferior subluxation of GH joint
• In such cases sustained load on the rotator
interval capsule causes these structures to
stretch and results in loss of joint stability
Dynamic Stabilization of GH joint:
• Gleno humeral joint has great mobility
at the cost of stability
• This is met by dynamic stabilization
• During various movements joint
depends on muscles for its control
Deltoid & GH Stabilization:
• Deltoid -prime mover for abduction
• Anterior deltoid -prime mover
for flexion
• Both abduction and flexion
are elevation activities
• Though the segments of deltoid
that participate vary with role and
function, understanding the resultant
action lines of deltoid in abduction can be
used to highlight the stabilization needs of
GH joint in elevation activities
• Action lines of three segments of deltoid
acting together coincide with the middle
fibers of deltoid

• Muscle action line FD is resolved into its

translatory (ftd) and rotatory (frd)
components, translatory component is by
far the larger
• As the translatory component is larger,
majority of the force of contraction of the
deltoid causes the humeral head to translate
superiorly
• Only a small proportion of the force causes
rotation (abduction) of the humerus
• As the articulating surface of humerus is not
in line with the shaft of humerus therefore a
force parallel to the bone creates a dislocating
rather than a stabilizing force
• The superior (caudal) translatory force of the
deltoid if unopposed would cause the humeral
head to impact the coracoacromial arch
before much abduction had occurred
• Once the inferiorly directed force of the
coracoacromial arch is introduced by humeral
head contact, rotation of humeral head could
theoretically, continue against the leverage
provided by the arch
• But pain from the impinged structures would
prevent much motion
• The inferior translatory pull of gravity cannot
offset ftd because the resultant force of the
deltoid must exceed that of gravity for any
rotation to occur
• Another set of forces must be introduced
• This is the major function of rotator/musculo
tendinous cuff
Rotator Cuff & GH Stabilization :
• Supraspinatus, infraspinatus, teres
minor and subscapularis compose the
rotator cuff
• All of them have action lines that
significantly contribute to dynamic
stabilization of GH joint
• When the force of these muscles are
resolved into its components it can be seen
that rotatory force (fr) not only tends to
cause at least some rotation of humerus
but it also compresses the head into the
glenoid fossa

• More important are the inferior translatory

forces (ft) of the three muscles
• Although rotator cuff are important GH
joint compressors, equally critical to their
stabilizing function is the inferior
translatory pull (ft) of the muscles
• Sum of three negative translatory
components of rotator cuff offsets the
superior translatory force of deltoid
• In addition to their stabilizing role teres
minor and infraspinatous contribute to
abduction by providing the lateral
rotation necessary to prevent the greater
tubercle from impacting the acromion
Force Couple:
• Definition : Force couple is defined as two
forces whose points of application occur on
opposite sides of an axis and in opposite
directions to produce rotation of the body
• Forces in a couple combine to produce a
turning effect on the body
• Axis of motion of the body
will be midway between
the two forces
• Example- two hands on a
steering wheel
* If all forces in a force system extend in the
same direction the resultant cannot be a
couple
* Pure rotation cannot take place unless there
is a couple
* Couple acting on a body will always cause
rotation of the body,or will tend to make the
body rotate if it is being held at rest by
opposing forces
Force Couple in GH joint:
• The action of deltoid along with the
combined action of infraspinatus, teres
minor and sub scapularis form a force
couple
• In a force couple the divergent pull of
the forces create a pure rotation
• The divergent muscles almost create a
‘pure spin’ of the humeral head around
a fixed joint axis
Examples of force couples:
• Strenocleidomastoid and contralateral
splenius capitus muscles act together to
rotate the head about axis between the first
and second cervical vertebrae
• External oblique and contralateral
latissimus dorsi rotate the thorax on pelvis
• Horizontal component of upper trapezius
pulls together with serratus anterior
to rotate the scapula upward in arm
elevation
Supraspinatus and GH stabilization
• Supraspinatus also forms a part of the rotator
cuff
• But its action line has a superior translatory
component rather than the inferior found in
other muscles
• Hence it cannot offset the translatory force of
deltoid
• The muscle is still effective as a stabilizer
of the GH joint because its rotatory
component generates a strong compressive
force
• Gravity also assists in stabilizing the joint
by offsetting the small translatory upward
pull of the muscle
• The net effect of gravity and supraspinatus
is such that it allows the head of the
humerus to glide inferiorly during
complete abduction and prevents the
abnormal upward displacement (Vertical
steerers)
Steerers:
• A muscle which causes a change over of
surfaces within the joint, usually by gliding,
and directs the articular surfaces to the
appropriate points of contact
• Gravity and suprspinatous act as vertical
steerers,the resultant of the two forces
causes an inferior gliding of humeral head
during abduction allowing full articulation
of the surfaces and preventing superior
displacement
• Role of sub scapularis in posteriorly
steering the head of humerus
Biceps and GH stabilization
• Long head runs superiorly from the
anterior shaft of the humerus through the
bicipital groove between the greater and
lesser tubercles to attach to supraglenoid
tubercle above the glenoid fossa
• It enters the joint
capsule through an
opening between the
supraspinatous and
subscapularis muscles
• With in the groove the long head is
enveloped by a tendon sheath and tethered
by a transverse humeral ligament
• Because of its position long head is
considered part of rotator interval capsule
and is sometimes considered to be part of
the reinforcing cuff
• The muscle is capable of carrying out
flexion and can, if the arm is laterally
rotated, contribute to force of abduction
• Long head contributes to GH stabilization
by centering the head in the fossa
• The long head helps to
c. Reduce the vertical translations
d. Reduce the anterior translations
• Relevance of long head at the shoulder
may have more to do with dysfunction
than with function,that is, its contribution
to normal GH motion has less impact than
its contribution to shoulder problems
• When ever humerus elevates in flexion and
abduction whether biceps is contributing to the
motion actively or passively the tendon must slide
with in the groove and under the transverse
humeral ligament
• If the tendon sheath is worn or inflamed, the
gliding mechanism may be interrupted and pain
produced
• A tear in transverse humeral ligament results in
tendon popping in and out of the groove with
rotation of humerus,a potentially wearing and
painful microtrauma
• The tendon hypertrophies with rotator cuff tears
helps to suggest that it is involved in GH
stabilization
Costs of dynamic stabilization:
• Equilibrium at any point in the GH range is
a function of
c. Force of prime movers
d. Force of gravity
e. Force of compressors and steerers
f. Force of friction and joint reaction force
• Requirements for dynamic stability of GH
joint vary somewhat through out the range
• Anterior stability is considered to be a
function of subscapularis while
infraspinatus and teres minor muscles
protect the humeral head posteriorly
High incidence of shoulder pain with increasing age
• Although little superior gliding of humeral head
occurs during normal elevation activities, there are
substantial changes that occur in the pressure with
in the subacromial bursa as the humerus moves
through its ROM
• These pressures are related to both arm positions
and load with greater pressures evidenced as arms
are loaded and maintained in elevated positions
• Elevated subacromial pressure and the coincident
poor vascularization of supraspinatus tendon that
lies beneath the bursa may be responsible for
degenerative changes seen in tendon with
increasing age
• Degeneration results in tendon tears with
increasingly minor trauma as one ages –
this may explain high incidence of shoulder
pain as one ages
• Pain may also be due to narrowed AC joint
spaces found with increasing age
Rotator cuff tears
• Most rotator cuff tears are seen in ages
beyond 70
• Tears in supraspinatus show earlier before
other tendons
• Frequency of supraspinatus lesion may be
due to not only to its limited vascularity but
also to its role both in moving the arm and
in sustaining weight of the dependent
extremity
• Supraspinatus is either contracting or
passively tensed in almost all positions of
GH joint
• Over time the stresses of dynamic
stabilization process leads to
degenerative changes at the GH joint
• Small gliding movements may be
responsible for an increase in pressure
in the subacromial bursa
• If this pressure increases it can narrow
the suprahumeral space blocking the
blood supply to the tendon leading to
supraspinatus tears with minor trauma
• Rotator cuff lesions typically produce
pain in the range of 60-120° of elevation,
this is termed as ‘Painful Arc Syndrome’
• AC joint pain occurs when the arm is
raised beyond the painful arc
• A tear in the transverse humeral ligament,
or an inflamed or hypertrophied biceps
tendon leads to pain the anterosuperior
part of the shoulder
Integrated function of shoulder complex:
• Shoulder complex acts in a coordinated fashion
to provide smoothest and greatest ROM
possible to upper limb
• Motion available at the GH joint would not
allow for full range of elevation available to
the humerus
• The reminder is contributed by the scapluo
thoracic joint through the AC and SC linkages
• Under normal and unconstrained
conditions,each joint makes its contribution not
only in a fairly consistent,but following a
pattern of concomitant and coordinated
movement known as scapulohumeral rhythm
 Scapulohumeral Rhythm
• Combination of concomitant GH and ST motion
• GH joint contributes to 120° flexion & 90-120 °
of abduction
• The scapula moves with the humerus to provide a
maximum range (2° of GH to 1° of ST motion)
• Scapulo-humeral rhythm
allows shoulder to move
through its full ROM &
allows the head of humerus
to be centered within the
glenoid fossa
• For every 15° of shoulder abduction, 10°
occurs at the GH and 5° occurs at the ST
• For 180° of shoulder abduction, 120°
occurs at the GH and 60 ° occurs at the ST
• If there are changes to the scapulo-humeral
rhythm, head of the humerus does not
remain centered and it can lead to problems
with the rotator cuff tendons such as
tendonitis or rotator cuff impingement
I. Scapulothoracic & Glenohumeral contributions:
• Scapulothoracic joint contributes to
both flexion and abduction of humerus
by upwardly rotating the glenoid fossa
60° from its resting position
• GH joint contributes 120° of flexion
and any where from 90° to 120° of
abduction
• Combination of scapular and humeral
movement results in maximum range of
elevation to 180° and in an overall ratio
of 2° of GH to 1° of scapulothoracic
motion
• Combined Scapulo humeral motion helps
in:
b) Distributing the motion between two joints
permitting a larger ROM with less
compromise on stability
c) Mainating glenoid fossa in an optimal
position to receive the head of humerus
increasing joint congruency and decreasing
shear forces
d) Permitting muscles acting on the humerus
to maintain a good length-tension relation
while minimizing or preventing active
insufficiency of GH muscles
• During initial 60° of flexion or initial 30° of
abduction of humerus an inconsistent amount
and type of scapular motion takes place relative
to GH motion
• During this period the scapula seeks a position
of stability in relation to the humerus- setting
phase
• In this early phase motion occurs primarily at
the GH joint
• With increasing range the scapula increases its
contribution approaching a 1:1 ratio with GH
movement.
• ST:GH=1:1
• In later part of the range GH joint contribution
increases
• Overall 2° of GH motion takes for every 1° of
ST motion GH:ST=2:1
I. Sternoclavicular & Acromioclavicular Contributions
• As scapulothoracic joint is part of a
closed chain, movement of the scapula
occurs only with motion at one or both
the AC and SC joints
• The 60°arc of upward rotation through
which the scapula moves during
elevation of the arm can be attributed
primarily to SC and secondary to AC
motion produced by force couple of the
trapezius and serratus anterior
• These are the only two muscles capable
of upwardly rotating the scapula
Phase I:
• Upper portion of the trapezius elevates
the clavicle, the lower portion of the
trapezius along with the upper and lower
fibers of serratus anterior produce an
upward rotatory force on the scapula
• Although the upward rotation of scapula
would appear to occur
at the AC joint,tension
in conoid and trapezioud
parts of CC ligament
prevents this
• Upward rotation of scapula at AC joint would
result in movement of coracoid process inferiorly
• Since the coracoid process is tied to the clavicle
by the CC ligament,movement of scapula is
prevented
• Upward rotatory force
on scapula continues,
however, as the trapezius
& serratus anterior contract;
the muscles produce
movement at the next
available joint-SC joint
• Pull of trapezius and serratus anterior on the
scapula force the clavicle to elevate
• Clavicular elevation
carries the scapula
through 30° of upward
rotation as the scapula
rides on the lateral end
of the rising clavicle
while maintaining relatively
fixed scapuloclavicular angle
• Elevation of clavicle is checked when CC
ligament becomes taught
• Since scapulothoracic and clavicular
motions occur concurrently with GH
motion, the GH joint will have
simultaneously elevated about 60° ( using
overall 2:1 ratio)
• Given 30° of ST upward rotation and 60° of
GH flexion or abduction the arm will be
raised to 90 - 100° from the side (30° ST +
60° GH)
Phase II:
• Lower trapezius and serratus anterior
continue to generate an upward rotatory force
on scapula, upward rotation at the AC joint is
still restrained by the CC ligament while the
SC joint is now constrained by tension in the
CC ligament
• With no other available motion to dissipate
the upward rotatory force being created by
the trapezius and the serratus tension in the
CC ligament builds (especially the conoid
portion)
• Coracoid process of scapula gets pulled down
• Tensed conoid ligament draws its
posteroinferior clavicular attachment
forward and down as the coracoid process
drops causing the clavicle to posteriorly
rotate
• Posterior rotation of clavicle will flip the
lateral end of crank-shaped clavicle up
with out causing further elevation at the
SC joint
• Magnitude of posterior rotation of clavicle
may be anywhere from 30° - 55°
• Due to this scapula attached at lateral end
of the clavicle will be carried through an
additional 30° of upward rotation
• In 180° of flexion and abduction
• raising arm to horizontal involves 60° of
GH motion and 30° of ST motion with
scapular contribution produced by
clavicular elevation at the SC joint
• raising the arm from horizontal to vertical
involves an additional 60° of GH motion
and 30° of ST movement produced
clavicular rotation and AC motion
Scapulohumeral rhythm serves two purposes:
b. It preserves the length-tension relationships of the
glenohumeral muscles; the muscles do not
shorten as much as they would without the
scapula's upward rotation, and so can sustain their
force production through a larger portion of the
range of motion.
c. It prevents impingement between the humerus
and the acromion. Because of the difference in
size between the glenoid fossa and the humeral
head, subacromial impingement can occur unless
relative movement between the humerus and
scapula is limited. Simultaneous movement of the
humerus and scapula during shoulder elevation
limits relative (arthrokinematic) movement
between the two bones.
Structural Dysfunction:
• Completion of range of elevation of arm is
dependent on the ability of GH,
scapulothoracic,SC and AC joints each to
make the needed contributions
• Disruption of movement in any of the
participating joints will result in a loss of
ROM