Anatomy of G-H Joint

Stability & Instability

Glenohumeral joint
Capsule/Ligaments/Glenoid
Instability/Impingement/RC tears

Components of Stability
Concept: Considerable individual
variations in capsuloligamentous
anatomy, inherent shoulder laxity
Laxity: Asymptomatic passive translation
of the humeral head on the glenoid
Instability: Pathologic condition manifest
as pain in association with excessive G-H
movement.

Articular Surface
Geometry
Glenoid surface is
small articular surface
area, Roll/Spin/Slide
important
Humeral head to
glenoid 3:1
Golf ball sitting on a tee
Shape of the articular
surfaces altered by
varying thickness of
labrum

Glenoid Labrum
Fibrocartilaginous
structure
Attachment superior
glenoid rim loose good
mobility
Inferior attachment firm
poor mobility
Blocks humeral head
translations
Increased area of
articulation 9mm sup/inf
5mm ant/post

Suction Cup - Matsen

G-H joint compressive
force of the head of the
humerus into the socket
expels the synovial fluid to
create a suction that
resists distraction.
Negative Inter-articular
pressure is produced by
the limited volume of fluid
Compressive load
produced by dynamic
action of muscle
contraction

Shoulder Capsule
Large, loose
redundant for large
ROM
Variable thickness of
layers with discrete
thickening capsular
ligaments
Anterior glenohumeral
ligaments include:
Superior/ Middle/
Inferior

G-H Ligaments
Coracohumeral ligament is
the strongest supporting
ligament
Portions of the
Coracohumeral ligament
form a tunnel for the
biceps tendon
Portion of the Rotator Cuff
Interval
Superior G-H ligament and
the coracohumeral limits
external rotation and
abduction of the humerus

Anterior G-H Ligaments

Superior glenohumeral
ligament forms the anterior
cover around the long
head of the biceps and part
of RCI
Middle glenohumeral
ligament blends with
portions of the
subscapularis tendon and
is taut at 45E abd, 10E
extension and external
rotation Anterior stability
between 45E and 60E

Inferior glenohumeral
Hammock like
structure with
attachments to the
anterior labrum
Most important
stabilizer against
anterior inferior
dislocation

Rotator Cuff Interval

RCI region of the shoulder plays a role in
the pathomechanics and intervention of
patients with shoulder instabilities.
Anteriorsuperior aspect of the shoulder
Defects are associated with large sulcus
sign combined with anterior instability
Harryman 92, Rowe 81, JBJS defects in
the RCI significant factor in instability

Rotator Cuff Interval

Bordered by the
supraspinatus and
subscapularis
Capsular tissue
covers it and
reinforced by the
coracohumeral lig.
& the deepest
segment of the
SGL

Isolated Closure of RCI Defects

for Shoulder Instability
Field, Warren, OBrien,
Altchek et al Am J
Sports Med
RCI bordered by
Supraspinatus and
Subscapularis
Harryman et al RCI
significant increases
in anterior, posterior
and inferior humeral
translations

Role of G-H Capsular

Ligaments Int & Ext rotation
Branch et al. Am J Sports Med 95
Six Cadaveric shoulders
Increased flexibility of the anterior capsule
is most effected by external Rot
Increased flexibility of the posterior
capsule is most effected by internal Rot.
Both share in limiting rotation at a number
of positions

Guanche et al. Am J Sports

Med. 95
Synergistic action of the capsule and
shoulder muscles
Stimulation of the Anterior and inferior
axillary articular nerves / Elicited EMG
activity of the
-Biceps, Subscapularis,
-Supraspinatus, and Infraspinatus
Posterior axillary nerve = EMG activity of
the Deltoid

Dynamic Stability of the G-H

joint Via 4 mechanisms
1. Joint compression RC and
biceps increases the conforming fit
of the humeral head into glenoid /
Suction cup
2. Coordinated contraction of the RC
muscles = Force couple control the
translations of the humeral head

Dynamic Stability of G-H

3. Synergistic action of capsular
mechanoreceptors and the RC
muscles- Guanche
4. Glenohumeral Joint and
Scapulothoracic must function in a
coordinated manner. Stable base
allows glenoid to adjust to changing
arm positions.

Rotator Cuff Pathology

A.
B.
C.
D.
E.

Classification:
Primary Compressive Disease
Secondary Compressive Disease
Tensile injury
Macrotrauma
Anterior and Posterior Impingement

A:Primary Compressive
Impingement direct result of
compression of
suprahumeral structures
Forces during elevation .42 X
BW and 10.2 X wt of the limb
Poppen and Walker / Lucas
Bigliani 1991, types of
acromions type I (flat) type II
(curved) and type III (hooked)
Type III acromion found in
70% of cadaveric shoulders
with full thickness tears of
the Rotator cuff.

B: Secondary Compressive
Disease Underlying Instability of
G-H Jt.
Budoff, Nirschl et al JBJS 1998 Debridement of
partial-thickness tears RC without acromioplasty.

Supraspinatus is small and relatively weak

susceptible to overuse and trauma
Eccentric overload weakens
musculotendinous rotator cuff unit
Unable to oppose superior migration
causing secondary impingement.

Pathological Changes
Deltoid retains
strength longer than
RC loss of depressor
effect on humeral hd.
During elevation
Reactive and
degenerative osseous
changes/ Osteophytic
spurring causing a
weakened cuff to
rupture resulting from
impingement

Type III acromion

Tendinosis

Acromioplasty
Surgery results most predictable for
pain relief/less for increased strength
Disrupts periosteum and cortical
bone of acromion, predisposes to
extensive scar
Subacromial decompression-partial
thickness tears relief from pain due
to Post-op rest and denervation

Functional Arch
Harryman believes the
function of the shoulder may
eventually become dependent
on the arch for functional
stability Comtemp Orthop 1995
Williams stated patients with a
marginally functional torn RC
need the coracoacromial arch.
If removed the shoulder may
become completely nonfunctional
Franklin states the arch
provides restraint to anterior
and anterosuperior migration
of the humerus

C:Tensile Overload
Repetitive intrinsic

tension overload. Heavy

repetitive eccentric forces
incurred by the posterior RC
during deceleration and followthru of overhead sport activities
can lead to tendon failure.
Pathologic changes
degenerative process dense
fibroblasts and disorganized
collagen absence of
inflammatory cells

Force 1090N to the RC

during arm deceleration
phase of throwing

D:Macotraumatic Tendon Failure

Single event that create
forces greater than the
tendon can tolerate
Full- thickness tears of the
RC with bony avulsions of
the greater tuberosity
Classification:
Partial thickness Superior
surface/Bursal impinge
Undersurface tensile strength
less

E: Internal Impingement
Impingement of deep surface of the subscap tendon
and the reflection pulley on the ant/sup glenoid rim:
Gerber et al J Sh/Elbow Surg 2000.

Increased internal rotation with 100 deg Flexion

the lesser tuberosity and biceps tendon are
brought closer to the ant/sup glenoid rim and the
superior GH lig becomes lax.
At 90 deg flexion and internal rotation the deep
surface of the subscap is impinging against the
glenoid rim

Posterior G-H pain in overhead

throwing athletes
Superior Glenoid Impingement Jobe,
Clin Ortho 1996
External rotation 90 deg.
Abduction and horizontal
extension ( early part of the
acceleration phase of
overhead throwing)
Impingement of inner fibers
of the RC & post sup. labrum
between the grt. tub and
post.sup glenoid
Secondary to lack of
resistance from the
subscapularis causing
angulation of the humeral
head instead of translation

Scapula Asymmetry
Warner et al Clin
Ortho Rel Res 1992
Asymmetry of scapula
in 32-57% of shoulder
instability and
impingement groups
Cooper J, Physical
Therapy of the Sh.
Donatelli (Eds) 2003
Scapula asymmetry

Loehr & Uhthoff 306

cadaveris RC
-Most degenerative tears originated on
articular side supraspinatus near insertion
-Poor blood supply-unable to repair itself
-Pain develops if the degeneration of tissue
becomes inflamed
-No evidence that full thickness tear heals
-Small tears usually get larger
-Pain not associated to tear size/ strength is
related to size of tear

Poor Blood Supply

Supraspinatus
Opaque dye into micro blood vessels
Arm in 30E abd
Arm in adduction

Rotator Cuff Partial Thickness

Tear Bursal Surface
Internal rotation and
flexion of the sh.

Hawkins & Dunlop Full Thickness

Tears, Clin Orthop 1995
33 patients full thickness tears RC
14 patients dissatisfied with exercises/
elected to have surgery to repair tendon
19 patients were satisfied with exercise
program.
Criteria for patient satisfaction NO PAIN,
carry objects 10-15 lbs, eat using utensils

Patient Prognostic Factors

Poor outcomes associated with:
1. Tear greater than 1 cm
2. History of symptoms greater
than one year
3. Significant functional
impairment

Surgical Repair vs Rehab

Faltow et al Prospective patient
study surgery vs exercise
68% of the surgical patients
66% of the exercise patients were
successful F/U 6 mo. 2.6 years
2% of the exercise group and 50% of
the placebo group had surgery

Open RC Repair vs Arthroscopic

Debridement and Decompression
Burkart Orthop Clin North Am 1993
25 patients Debridement and
Decompression
30 mo F/U 80% pts. Good or excellent
results
Montgomery J Sh Elbow Surg 1994
87 patients Full thickness RC tears
2-5 year F/U open repair superior results
as compared to arthroscopic group

Impingement Syndrome

Treatment approach

Bang M & Deyle G Comparsion of supervised

exercise with & without manual PT for patients with
shoulder impingement syndrome JOSPT 2000
N=52 2x/wk for 3 weeks
Both groups had the same exercise regime
Manual therapy group (Maitland) Superior to
exercise group only
Manual therapy group had significant increase in
strength, ROM, and decreased pain

Scapular Kinematics:
Strengthening & Stretching
Wang et al Arch Phys Med Reb 1999
20 asymptomatic subjects with forward
shoulder posture
Stretching for pects & strengthening
exercises of scapula retractors 3xs per
week 6 wks
Scapula showed significantly (p<.01) less
upward rotation and superior translation
after exercise program

Treatment Approach to
RC Tears
Reduce pain and
restore scapula
mobility and
strength
Restoration of G-H
joint ROTATION,
arthrokinematics
Increase strength
and balance of
local muscles

Scapula Mobilization

Scapula Rotator - Exercises

Decker et al AJSM 1999
Dynamic Hug greatest
EMG activity of
Serratus anterior
Lear & Gross JOSPT 98
Increase EMG for
serratus and upper
traps with push-up
with a plus and
elevation of the feet

Scapula Strengthening
Dynamic Hug

Summary
Anatomy Of Shoulder Instability
Labrum, Capsule, Ligaments
Suction Cup, RCI, Sup, Mid, Inf
Proprioceptors link to Dynamic
Stabilizers
Instability, Impingement, RC tears
Surgery
Rehab Concepts

Case Presentation
Impingement Syndrome
History of thyroid resection
secondary to cancer of the thyroid
Unable to palpate
sternocleidomastoid, Anterior
scalene
Forward head posture Poor
scapula rotator strength

Before

After

Before

After

Scapula Rotator Weakness

Exercises

Case study Football Player

Impingement Diagnosis
Before
After

Strengthening Exercises

Strength Training

Summary
Anatomical factors stability and instability
eg. Central position of humerus on glenoid
Dynamic stability importance of the rotator
cuff and scapula rotators
Rotator Cuff Disease is results from
instability, impingement, RC tear
Muscle activity can cause instability and
compressive force to the joint. Improper
exercise may cause shoulder dysfunction