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Shoulder
Glenohumeral joint
Rotator cuff
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Shoulder
Diagram of the human shoulder joint
Capsule of shoulder-joint (distended). Anterior aspect.
Latin articulatio humeri
Gray's subject #81 313 [1]
MeSH
Shoulder [2]
The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones
of the shoulder make up the shoulder joints. "Shoulder joint" typically refers to the glenohumeral joint, which is the
major joint of the "shoulder," but can more broadly include the acromioclavicular joint. In human anatomy, the shoulder joint comprises the part of the body where the humerus attaches to the scapula, the head sitting in the glenoid fossa.
[3]
The shoulder is the group of structures in the region of the joint.
[4]
There are two kinds of cartilage in the joint. The first type is the white cartilage on the ends of the bones (called articular cartilage) which allows the bones to glide and move on each other. When this type of cartilage starts to wear out (a process called arthritis), the joint becomes painful and stiff. The labrum is a second kind of cartilage in the shoulder which is distinctly different from the articular cartilage. This cartilage is more fibrous or rigid than the cartilage on the ends of the ball and socket. Also, this cartilage is also found only around the socket where it is attached.
[5]
The shoulder must be mobile enough for the wide range actions of the arms and hands, but also stable enough to allow for actions such as lifting, pushing and pulling. The compromise between mobility and stability results in a large number of shoulder problems not faced by other joints such as the hip.
1

Shoulder
There are three joints of the shoulder: The glenohumeral, acromioclavicular, and the sternoclavicular joints.
Glenohumeral joint
The glenohumeral joint is the main joint of the shoulder and the generic term "shoulder joint" usually refers to it. It is
a ball and socket joint that allows the arm to rotate in a circular fashion or to hinge out and up away from the body. It is formed by the articulation between the head of the humerus and the lateral scapula (specifically-the glenoid fossa of the scapula). The "ball" of the joint is the rounded, medial anterior surface of the humerus and the "socket" is formed by the glenoid fossa, the dish-shaped portion of the lateral scapula. The shallowness of the fossa and relatively loose connections between the shoulder and the rest of the body allows the arm to have tremendous mobility, at the expense of being much easier to dislocate than most other joints in the body. Approximately its 4 to 1 disproportion between the large head of the humerus and the shallow glenoid cavity.
The capsule is a soft tissue envelope that encircles the glenohumeral joint and attaches to the scapula, humerus, and head of the biceps. It is lined by a thin, smooth synovial membrane.
This capsule is strengthened by the coracohumeral ligament which attaches the coracoid process of the scapula to the greater tubercle of the humerus. There are also three other ligaments attaching the lesser tubercle of the humerus to lateral scapula and are collectively called the glenohumeral ligaments.
There is also a ligament called semicirculare humeri which is a transversal band between the posterior sides of the tuberculum minus and majus of the humerus. This band is one of the most important strengthening ligaments of the joint capsule. The shoulder is a vital joint and critical for movement.
Sternoclavicular joint
The sternoclavicular occurs at the medial end of the clavicle with the manubrium or top most portion of the sternum. The clavicle is triangular and rounded and the manubrium is convex; the two Anatomical studies of the shoulder by Leonardo da
Vinci c.1510
bones articulate. The joint consists of a tight capsule and complete intra-articular disc which ensures stability of the joint. The costoclavicular ligament is the main limitation to movement, therefore, the main stabilizer of the joint. A fibrocartilaginous disc present at the joint increases the range of movement. Sternoclavicular dislocation is rare,
[6] however it can be caused by direct trauma.
2

Shoulder
The muscles and joints of the shoulder allow it to move through a remarkable range of motion, making it one of the most mobile joints in the human body. The shoulder can abduct, adduct (such as during the shoulder fly), rotate, be raised in front of and behind the torso and move through a full 360° in the sagittal plane. This tremendous range of motion also makes the shoulder extremely unstable, far more prone to dislocation and injury than other joints [7]
The following describes the terms used for different movements of the shoulder: [8]
Name
Scapular retraction
[] (aka scapular adduction)
Description
The scapula is moved posteriorly and medially along the back, moving the arm and shoulder joint posteriorly. Retracting both scapulae gives a sensation of "squeezing the shoulder blades together."
Scapular protraction [] (aka scapular abduction)
The opposite motion of scapular retraction. The scapula is moved anteriorly and laterally along the back, moving the arm and shoulder joint anteriorly. If both scapulae are protracted, the scapulae are separated and the pectoralis major muscles are squeezed together.
Scapular elevation []
The scapula is raised in a shrugging motion.
Scapular depression
[]
The scapula is lowered from elevation. The scapulae may be depressed so that the angle formed by the neck and shoulders is obtuse, giving the appearance of "slumped" shoulders.
Arm
Arm
Arm
Arm abduction adduction flexion extension
Medial rotation the arm [] the arm[]
[]
[]
[]
[]
Lateral rotation of of
Muscles rhomboideus major, minor, and trapezius serratus anterior (prime mover), pectoralis minor and major levator scapulae, the upper fibers of the trapezius pectoralis minor, lower fibers of the trapezius, subclavius, latissimus dorsi
Arm abduction occurs when the arms are held at the sides, parallel to the length of the torso, and are then raised in the plane of the torso.
This movement may be broken down into two parts: True abduction of the arm, which takes the humerus from parallel to the spine to perpendicular; and upward rotation of the scapula, which raises the humerus above the shoulders until it points straight upwards.
True abduction: supraspinatus (first 15 degrees), deltoid; Upward rotation: trapezius, serratus anterior
Arm adduction is the opposite motion of arm abduction. It can be broken down into two parts: downward rotation of the scapula and true adduction of the arm.
Downward rotation: pectoralis minor, pectoralis major, subclavius, latissimus dorsi (same as scapular depression, with pec major replacing lower fibers of trapezius); True Adduction: same as downward rotation with addition of teres major and the lowest fibers of the deltoid
The humerus is rotated out of the plane of the torso so that it points forward (anteriorly).
The humerus is rotated out of the plane of the torso so that it points backwards (posteriorly) pectoralis major, coracobrachialis, biceps brachii, anterior fibers of deltoid.
latissimus dorsi and teres major, long head of triceps, posterior fibers of the deltoid
Medial rotation of the arm is most easily observed when the elbow is held at a 90-degree angle and the fingers are extended so they are parallel to the ground. Medial rotation occurs when the arm is rotated at the shoulder so that the fingers change from pointing straight forward to pointing across the body.
subscapularis, latissimus dorsi, teres major, pectoralis major, anterior fibers of deltoid
The opposite of medial rotation of the arm.
infraspinatus and teres minor, posterior fibers of deltoid
Arm circumduction []
Movement of the shoulder in a circular motion so that if the elbow and fingers are fully extended the subject draws a circle in the air lateral to the body. In circumduction, the arm is not lifted above parallel to the ground so that "circle" that is drawn is flattened on top.
pectoralis major, subscapularis, coracobrachialis, biceps brachii, supraspinatus, deltoid, latissimus dorsi, teres major and minor, infraspinatus, long head of triceps
The scapula is lowered from elevation. The scapulae may be depressed so that the angle formed by the neck and shoulders is obtuse, giving the appearance of "slumped" shoulders. Arm abduction occurs when the arms are held at
3

Shoulder the sides, parallel to the length of the torso, and are then raised in the plane of the torso. This movement may be broken down into two parts: True abduction of the arm, which takes the humerus from parallel to the spine to perpendicular; and upward rotation of the scapula, which raises the humerus above the shoulders until it points straight upwards.
Major muscles
The muscles that are responsible for movement in the shoulder attach to the scapula, humerus, and clavicle. The muscles that surround the shoulder form the shoulder cap and underarm.
Name serratus anterior subclavius
Attachment
Originates on the surface of the upper eight ribs at the side of the chest and inserts along the entire anterior length of the medial border of the scapula.
Function
It fixes the scapula into the thoracic wall and aids in rotation and abduction of the shoulders.
Located inferior to the clavicle, originating on the first rib and inserting (penetrating) on the subclavian groove of the clavicle.
It depresses the lateral clavicle and also acts to stabilize the clavicle.
pectoralis minor sternocleidomastoid levator scapulae rhomboid major and rhomboid minor (work together)
Arises from the third, fourth, and fifth ribs, near their cartilage and inserts into the medial border and upper surface of the coracoid process of the scapula.
Attaches to the sternum (sterno-), the clavicle (cleido-), and the mastoid process of the temporal bone of the skull.
Arises from the transverse processes of the first four cervical vertebrae and inserts into the medial border of the scapula.
This muscle aids in respiration, medially rotates the scapula, protracts the scapula, and also draws the scapula inferiorly.
Most of its actions flex and rotate the head. In regards to the shoulder, however, it also aids in respiration by elevating the sternoclavicular joint when the head is fixed.
It is capable of rotating the scapula downward and elevating the scapula.
They arise from the spinous processes of the thoracic vertebrae T1 to T5 as well as from the spinous processes of the seventh cervical. They insert on the medial border of the scapula, from about the level of the scapular spine to the scapula's inferior angle.
They are responsible for downward rotation of the scapula with the levator scapulae, as well as adduction of the scapula.
trapezius Arises from the occipital bone, the ligamentum nuchae, the spinous process of the seventh cervical, and the spinous processes of all the thoracic vertebrae, and from the corresponding portion of the supraspinal ligament. It inserts on the lateral clavicle, the acromion process, and into the spine of the scapula.
Different portions of the fibers perform different actions on the scapula: depression, upward rotation, elevation, and adductions.
deltoid, anterior fibers Arises from the anterior border and upper surface of the lateral third of the clavicle.
The anterior fibres are involved in shoulder abduction when the shoulder is externally rotated. The anterior deltoid is weak in strict transverse flexion but assists the pectoralis major during shoulder transverse flexion / shoulder flexion (elbow slightly inferior to shoulders).
deltoid, middle fibers Arises from the lateral margin and upper surface of the acromion.
The middle fibres are involved in shoulder abduction when the shoulder is internally rotated, are involved in shoulder flexion when the shoulder is internally rotated, and are involved in shoulder transverse abduction (shoulder externally rotated) -but are not utilized significantly during strict transverse extension (shoulder internally rotated).
4

Shoulder deltoid, posterior fibers Arises from the lower lip of the posterior border of the spine of the scapula, as far back as the triangular surface at its medial end.
The posterior fibres are strongly involved in transverse extension particularly since the latissimus dorsi muscle is very weak in strict transverse extension. The posterior deltoid is also the primary shoulder hyperextensor.
5
Rotator cuff
The rotator cuff is an anatomical term given to the group of muscles and their tendons that act to stabilize the
shoulder. It is composed of the tendons and muscles (supraspinatus, infraspinatus, teres minor and subscapularis) that hold the head of the humerus (ball) in the glenoid fossa (socket).
Two filmy sac-like structures called bursae permit smooth gliding between bone, muscle, and tendon. They cushion and protect the rotator cuff from the bony arch of the acromion.
Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well. Major injuries to the shoulder include rotator cuff tear and bone fractures of one or more of the bones of the shoulder.
Shoulder fractures include:
•• Clavicle fracture
•• Scapular fracture
• Proximal humerus fracture
Tetrapod forelimb are characterised by a high degree of mobility in the shoulder-thorax connection. Lacking of a solid skeletal connection between the shoulder girdle and the vertebral column, the forelimb's attachment to the trunk is instead mainly controlled by serratus lateralis and levator scapulae. Depending on locomotor style, a bone connect the shoulder girdle to the trunk in some animals; the coracoid bone in reptiles and birds, and the clavicle in primates and bats; but cursorial mammals lack this bone. In primates, the shoulder shows characteristics the differs from other mammals, including a well developed clavicle, a dorsally shifted scapula with prominent acromion and spine, and a humerus featuring a straight shaft and a spherical head.
[9]

Shoulder
The left shoulder and acromioclavicular joints, and the proper ligaments of the scapula
Instrumented shoulder endoprosthesis, with a 9-channel telemetry transmitter to measure six load components in vivo. (cut model)
[1] http:/ / education.
yahoo.
com/ reference/ gray/ subjects/ subject?id=81#p313
[2] http:/ / www.
nlm.
nih.
gov/ cgi/ mesh/ 2011/ MB_cgi?mode=& term=Shoulder http:/ / www.
prlog.
org/
12015359-acromioclavicular-arthritis-by-dr-les-bailey-phddoacopmapta-int-part-dr-les-bailey.
html
• Video of the shoulder carriage in motion (http:/ / chrisevans3d.
com/ research.
htm)
• NIH (article includes text from this source) (http:/ / www.
niams.
nih.
gov/ hi/ topics/ shoulderprobs/ shoulderqa.
htm)
• University of Michigan Medical School module on movements of the shoulder, arm, forearm, and hand (http:/ / www.
med.
umich.
edu/ lrc/ coursepages/ M1/ anatomy2010/ html/ modules/ upper_limb_module/ upper_limb_01.
html)
6

Glenohumeral joint
The right shoulder and
Glenohumeral joint
Latin Articulatio humeri
Gray's subject #82 315 [1]
MeSH
Glenohumeral+Joint [2]
The glenohumeral joint , (from ancient Greek glene , eyeball, puppet, doll + oid , 'form of', + Latin humerus , shoulder) or shoulder joint , is a multiaxial synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula (shoulder blade) and the head of the humerus (upper arm bone). Due to the very limited interface of the humerus and scapula, it is the most mobile joint of the human body.
The glenoid fossa is shallow and contains the glenoid labrum which deepens it and aids in stability. With 120 degrees of unassisted flexion, the glenohumeral joint is the most mobile joint in the body.
Scapulohumeral rhythm helps to achieve further range of movement. The Scapulohumeral rhythm is the movement of the scapula across the thoracic cage in relation to the humerus. This movement can be compromised by anything that changes the position of the scapula. This could be an imbalance in the muscles that hold the scapula in place which are the upper and lower trapezius. This imbalance could cause a forward head carriage which in turn can affect the range of movements of the shoulder.
The rotator cuff muscles of the shoulder produce a high tensile force, and help to pull the head of the humerus into
the glenoid fossa.
Movement
Flexion
(150° – 170°)
[3]
Muscles
Anterior fibers of deltoid Clavicle
Origin
Clavicular part of pectoralis major
Long head of biceps brachii
Short head of biceps brachii
Coracobrachialis
Clavicle
Supraglenoid tubercle of scapula
Coracoid process of scapula
Coracoid process
Insertion
Middle of lateral surface of shaft of humerus
Lateral lip of bicipital groove of humerus
Tuberosity of radius, Deep fascia of forearm
Medial aspect of shaft of humerus
7

Glenohumeral joint
Extension
(40°)
Abduction
(160°
Adduction
(30°
–
–
180°)
40°)
Lateral rotation
(in abduction:
95°; in adduction: 70°)
Medial rotation
(in abduction:
40° – 50°; in adduction: 70°)
Posterior fibers of deltoid
Latissimus dorsi
Teres major
Middle fibers of deltoid
Supraspinatus
Sternal part of pectoralis major
Latissimus dorsi
Teres major
Teres minor
Infraspinatus
Teres minor
Upper two thirds of lateral border of scapula
Infraspinous fossa of scapula
Upper two thirds of lateral border of scapula
Posterior fibers of deltoid Spine of scapula
Subscapularis
Latissimus dorsi
Teres major
Anterior fibers of deltoid
Spine of scapula
Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae, lower 3 – 4 ribs, inferior angle of scapula
Lateral border of scapula
Acromion process of scapula
Supraspinous fossa of scapula
Sternum, upper six costal cartilages
Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae, lower 3-4 ribs, inferior angle of scapula
Lower third of lateral border of scapula
Subscapular fossa
Iliac crest, lumbar fascia, spines of lower 3-4 ribs, inferior angle of scapula
Lower third of lateral border of scapula
Clavicle
Middle of lateral surface of shaft of humerus
Floor of bicipital groove of humerus
Medial lip of bicipital groove of humerus
Middle of lateral surface of shaft of humerus
Greater tuberosity of humerus
Lateral lip of bicipital groove of humerus
Floor of bicipital groove of humerus
Medial lip of bicipital groove of humerus
Greater tuberosity of humerus
Greater tuberosity of humerus
Greater tuberosity of humerus
Middle of lateral surface of shaft of humerus
Lesser tuberosity of humerus
Floor of bicipital groove of humerus
Medial lip of bicipital groove of humerus
Middle of lateral surface of shaft of humerus
8
The glenohumeral joint has a loose capsule that is lax inferiorly and therefore is at risk of dislocation inferiorly. The long head of the biceps brachii muscle travels inside the capsule to attach to the supraglenoid tubercle of the scapula.
Because the tendon is inside the capsule, it requires a synovial tendon sheath to minimize friction.
A number of bursae in the capsule aid mobility. Namely, they are the subdeltoid bursa (between the joint capsule and deltoid muscle), subcoracoid bursa (between joint capsule and coracoid process of scapula), coracobrachial bursa
(between subscapularis muscle and tendon of coracobrachialis muscle), subacromial bursa (between joint capsule and acromion of scapula) and the subscapular bursa (between joint capsule and tendon of subscapularis muscle, also known as subtendinous bursa of subscapularis muscle). The bursa are formed by the synovial membrane of the joint capsule. An inferior pouching of the joint capsule between teres minor and subscapularis is known as the axillary recess.
The shoulder joint is a muscle dependent joint as it lacks strong ligaments.
[ citation needed ]

Glenohumeral joint
• Superior, middle and inferior glenohumeral ligaments
•• Coracohumeral ligament
•• Transverse humeral ligament
•• suprascapular nerve
•• axillary nerve
•• lateral pectoral nerve
The glenohumeral joint is supplied with blood by branches of the anterior and posterior circumflex humeral and suprascapular arteries.
The capsule can become inflamed and stiff, with abnormal bands of tissue (adhesions) growing between the joint surfaces, causing pain and restricting movement of the shoulder, a condition known as frozen shoulder or adhesive capsulitis.
9
Cross-section of shoulder joint cavity
Diagram of the human shoulder joint
The left shoulder and acromioclavicular joints, and the proper ligaments of the scapula.
coracohumeral ligament of
Glenohumeral joint articular capsule of glenohumeral joint glenohumeral ligaments of glenohumeral joint cartilage of glenohumeral joint synovial membrane of glenohumeral joint

Glenohumeral joint articular capsule of glenohumeral joint
[1] http:/ / education.
yahoo.
com/ reference/ gray/ subjects/ subject?id=82#p315
[2] http:/ / www.
nlm.
nih.
gov/ cgi/ mesh/ 2011/ MB_cgi?mode=& term=Glenohumeral+ Joint
• Overview at brown.edu (http:/ / biomed.
brown.
edu/ Courses/ BI108/ BI108_2004_Groups/ Group01/ bioghj.
htm)
• Overview at ouhsc.edu (http:/ / moon.
ouhsc.
edu/ dthompso/ namics/ gh.
htm)
• SUNY Figs 10:03-12 (http:/ / ect.
downstate.
edu/ courseware/ haonline/ figs/ l10/ 100312.
htm)
• Diagram at yess.uk.com (http:/ / www.
yess.
uk.
com/ patient_information/ anatomy/ )
10

Rotator cuff
Muscles on the dorsum of the scapula, and the Triceps brachii.
11
The scapular and circumflex arteries.
In anatomy, the rotator cuff (sometimes incorrectly called a "rotator cup", "rotor cuff", or rotary cup [1] ) is a group
of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff are over half of
the seven scapulohumeral muscles.
The rotator cuff muscles are important in shoulder movements and in maintaining glenohumeral joint (shoulder
joint) stability.
[] These muscles arise from the scapula and connect to the head of the humerus, forming a cuff at the shoulder joint. They hold the head of the humerus in the small and shallow glenoid fossa of the scapula. The glenohumeral joint has been analogously described as a golf ball (head of the humerus) sitting on a golf tee (glenoid fossa).
[2]
During abduction of the arm, moving it outward and away from the trunk, the rotator cuff compresses the glenohumeral joint, a term known as concavity compression, in order to allow the large deltoid muscle to further elevate the arm. In other words, without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. The anterior and posterior directions of the glenoid fossa are more susceptible to shear force perturbations as the glenoid fossa is not as deep relative to the superior and inferior directions. The rotator cuff's contributions to concavity compression and stability vary according to their stiffness and the direction of the force they apply upon the joint.

Rotator cuff
Muscle
Supraspinatus muscle
Infraspinatus muscle
Teres minor muscle
Subscapularis muscle
Origin on scapula supraspinous fossa infraspinous fossa middle half of lateral border subscapular fossa
Attachment on humerus superior and middle facet of the greater tuberosity
Function abducts the arm posterior facet of the greater tuberosity externally rotates the arm inferior facet of the greater tuberosity externally rotates the arm lesser tuberosity (60%) or humeral neck (40%) internally rotates the humerus
Innervation
Suprascapular nerve (C5)
Suprascapular nerve (C5-C6)
Axillary nerve (C5)
Upper and Lower subscapular nerve (C5-C6)
The supraspinatus muscle fans out in a horizontal band to insert on the superior and middle facets of the greater tubercle. The greater tubercle projects as the most lateral structure of the humeral head. Medial to this, in turn, is the lesser tuberosity of the humeral head. The subscapularis muscle origin is divided from the remainder of the rotator cuff origins as it is deep to the scapula.
The tendons at the ends of the rotator cuff muscles can become torn, leading to pain and restricted movement of the arm. A torn rotator cuff can occur following a trauma to the shoulder or it can occur through the "wear and tear" on tendons, most commonly the supraspinatus tendon found under the acromion.
Rotator cuff injuries are commonly associated with motions that require repeated overhead motions or forceful pulling motions. Such injuries are frequently sustained by athletes whose actions include making repetitive throws, athletes such as cheerleaders, baseball pitchers, softball pitchers, American football players (especially quarterbacks), weightlifters, especially powerlifters due to extreme weights used in the bench press, rugby players, volleyball players (due to their swinging motions) [ citation needed ] , water polo players, rodeo team ropers, shot put throwers (due to using poor technique)
[ citation needed ]
, swimmers, boxers, kayakers, western martial artists, fast bowlers in cricket, tennis players (due to their service motion) [ citation needed ] and tenpin bowlers due to the repetitive swinging motion of the arm with the weight of a bowling ball.
This type of injury also commonly affects orchestra conductors, choral conductors, and drummers (due, again, to swinging motions).
A systematic review of relevant research found that the accuracy of the physical examination is low.
[]
The
Hawkins-Kennedy test [3][] has a sensitivity of approximately 80% to 90% for detecting impingement. The infraspinatus and supraspinatus
[4] tests have a specificity of 80% to 90%.
[]
Reduce pain and swelling
As with all muscle injuries, R.I.C.E. is an initial response to injury recommended by health providers:
• R est means ceasing movement of the affected area.
• I cing uses ice to reduce inflammation.
• C ompression limits the swelling.
12

Rotator cuff
• E levation involves placing the area higher to reduce inflammation and swelling.
Cold compression therapy shoulder wraps facilitate the icing and compression of an otherwise difficult body area to ice and compress.
Depending on severity of symptoms, further imaging with radiograph, or MRI may be warranted to see if surgery or an underlying bone injury exists.
Posture and sleeping positions
Postures and sleeping positions may be modified to provide relief. But as your shoulder begins to heal, sleeping positions may vary considerably.
[]
Strengthening
The rotator cuff can be strengthened to rehabilitate shoulder injuries, and prevent future ones. There are different exercises to target the individual rotator cuff muscles.
End Description
The most effective is the side-lying external rotation, which activates the supraspinatus, subscapularis, infraspinatus and teres minor.
Lie on a bench sideways, with the affected arm next to the side and flexed about 90 degrees at the elbow. Rotate the upper arm outward, keeping the elbow flexed and the arm close to the body, until the lower arm is perpendicular to the ceiling (see picture).
For added resistance, use a dumbbell. Pace at two seconds out and four seconds back.
This is an excellent all-around shoulder exercise.
Beginning
The propped external rotator targets the infraspinatus and teres minor.
Sit perpendicular to the dumbell with arm flexed at 90 degrees at the elbow, and the forearm resting parallel on the dumbell. Raise the dumbbell up until the forearm points up. Slowly lower the dumbbell and repeat, exercising both arms.
The posterior deltoid also aids in external rotation. Like the posterior deltoid, both the infraspinatus and teres minor also contribute to transverse extension of the shoulder, such as during a bent over row to the chest. They can be trained in this way besides isolating the external rotation action.
The lateral raise with internal rotation (LRIR) primarily targets the supraspinatus.
Grasping a dumbbell in each hand, internally rotate the arms so that the thumbs point towards the floor when extended (as if emptying a drink into a bin). Raise the arms sideways, keeping the thumbs pointing downwards, until the dumbbells are just below the shoulders.
This exercise is sometimes called a lateral raise.
Strengthening the rotator cuff allows for increased loads in a variety of exercises. When weightlifters are unable to increase the weight they can lift on a pushing exercise (such as the bench press or military press) for an extended period of time, strengthening the rotator cuff can often allow them to begin making gains again. It also prevents future injuries to the glenohumeral joint, balancing the often-dominant internal rotators with stronger external rotators. Finally, exercising the rotator cuff can lead to improved posture, as without exercise to the external rotator, the internal rotators can see a shortening, leading to tightness. This often manifests itself as rounded shoulders.
Non-Operative Treatment
Non-operative treatment is often the first line of treatment for rotator cuff injuries. If the tendons are strained or torn less than 50%, they respond well to an aggressive non-operative approach. Non-operative measures can include physical therapy, oral or injected medications, biologic augmentation such as PRP, ultrasound therapy, dry needling, and other modalities. It will often take 3 months to recover with non-operative measures.
13

Rotator cuff
Surgery
Even for full thickness rotator cuff tears, conservative care (i.e., non-surgical treatment) outcomes are usually reasonably good.
[5] However, many patients still suffer disability and pain despite non-surgical therapies. For massive tears of the rotator cuff, surgery has shown durable outcomes on 10 year follow-up.
[6] However, the same study demonstrated ongoing and progressive fatty atrophy and repeat tears of the rotator cuff. Shen has shown that
MRI evidence of fatty atrophy in the rotator cuff prior to surgery is predicative of a poor surgical outcome.
[7] If the rotator cuff is completely torn, surgery is usually required to reattach the tendon to the bone.
[8]
Surgery for the Rotator Cuff
Surgery for the rotator cuff can be for complete tears, or partial tears/strains that fail to get better. If a torn rotator cuff goes untreated for too long, it may become un-repairable and so shoulder pain should not be ignored. Surgery often consists of removing damaged tissue and repairing the good tissue back to the bone. Bone spurs and inflammation (bursitis) is also removed to try to prevent re-tears. all arthroscopic rotator cuff repairs can fix most tears through 4-5 small incisions. On occasion a patch needs to be placed on the rotator cuff tendons which requires a larger incision. Many times, the biceps tendon is damaged with rotator cuff tears and may also require biceps tenodesis surgery at the same time.
Rehab
The rehab for rotator cuff surgery falls into three basic categories; some damage to the tendons with surgery consisting of debridement, removing spurs and cleaning out inflammation, tears requiring repair with excellent quality tendon tissue, and tears requiring repair with poor quality tendon tissue. The first category, rehab consists of early active and passive range of motion exercises focused on maintaining range of motion for 4 weeks and then strengthening and return to sports from weeks 4-8. Repaired tendons with excellent quality will begin full passive motion early, start active motion from weeks 4-8, strengthening from 8-12 and return to sports after 3 – 4 months.
Repairs with poor tissue quality will have no motion early on, start passive motion after 2 – 4 weeks, active at 6 – 8 weeks, strengthening at 4 months and return to sports at 6 months. Your doctor will guide you through the rehabilitation process.
There are several ways to depict the structures of the shoulder, which consist of muscles, tendons, bones, cartilage and soft tissue. When deciding which medical imaging technique should be used, there are a couple of factors that need to be taken into account. Firstly, one has to consider the suspected clinical diagnosis. Together with the knowledge of the advantages and limitations of the various medical imaging techniques ( i.e. conventional radiography, ultrasound, computer tomography and magnetic resonance), one has to make an informed decision which technique would best suit the specific situation.
Hodler et al. recommend to start scanning with conventional x-rays taken from at least two planes, since this method gives a wide first impression and even has the chance of exposing any frequent shoulder pathologies, i.e.
decompensated rotator cuff tears, tendinitis calcarea, dislocations, fractures, usures and/or osteophytes. Furthermore, x-rays are required for the planning of an optimal CT or MR image.
[9]
Conventional x-rays and ultrasonography are the primary tools used to confirm a diagnosis of injuries sustained to the rotator cuff. For extended clinical questions, imaging through Magnetic Resonance with or without intraarticular contrast agent is indicated.
The conventional invasive arthrography is now-a-days being replaced by the non-invasive MRI and US and is used as an imaging reserve for patients who are contraindicated for MRI, for example pacemaker-carriers with an unclear and unsure ultrasonography.
[10]
14

Rotator cuff
a.-p.-projection 40° posterior oblique after Grashey
The scapula should be positioned parallel to the x-ray film. The body has to be rotated about 30 to 45 degrees towards the shoulder to be imaged, and the standing or sitting patient lets the arm hang.
This method allows the diagnostician to judge: [10]
•• The joint gap and the vertical alignment towards the socket.
The humerus head should be aligned in the neutral position and external rotation in a way towards the socket, that a fictive continuous line can be seen. This line is called Bandi line, otherwise known as the
Ménard-Shenton line. A discontinuous line alludes to a cranial decentralization of the humerus head.
[11]
CR. shoulder x-ray, a.p.
Transaxillary projection
The arm should be abduced 80 to 100 degrees at a precise defined scapular or frontal plane.
This method allows the diagnostician to judge:
[10]
•• The horizontal alignment of the humerus head in respect to the socket, and the lateral clavicle in respect to the acromion.
•• Lesions of the anterior and posterior socket border or of the tuberculum minus.
•• The eventual non-closure of the acromial apophysis.
•• The coraco-humeral interval
Transaxillary conventional radiography
15

Rotator cuff
Transaxillary projection. Schematic drawing.
After "Orthopedic radiology: a practical approach; Adam Greenspan; ISBN
0-7817-1589-X, 9780781715898"
Y-projection
The lateral contour of the shoulder should be positioned in front of the film in a way that the longitudinal axis of the scapula continues parallel to the path of the rays.
This method allows the diagnostician to judge:
[10]
•• The horizontal centralization of the humerus head and socket.
•• The osseous margins of the coraco-acromial arch and hence the supraspinatus outlet canal.
•• The shape of the acromion
This Y-projection can be traced back to Wijnblath ’ s 1933 published cavitas-en-face projection.
[12]
It must be pointed out that this projection has a low tolerance for errors and accordingly needs proper execution.
[10]
There are several solid advantages of ultrasound. It is relatively cheap, does not emit any radiation, is accessible, is capable of visualizing tissue function in real time and allows to the performing of provocative maneuvers in order to replicate the patient ’ s pain. Those apparent benefits have helped ultrasound become a common initial choice for
Y-projection conventional radiography assessing tendons and soft tissues. Limitations include, for example, the high degree of operator dependence and the inability to define pathologies in bones. One also has to have an extensive anatomical knowledge of the examined region and keep an open mind to normal variations and artifacts created during the scan.
[13]
Although musculo-skeletal ultrasound training, like medical training in general, is a lifelong process, Kissin et al.
suggest that rheumatologists who taught themselves how to manipulate ultrasound can use it just as well as international musculo-skeletal ultrasound experts to diagnose common rheumatic conditions.
[14]
After the introduction of high-frequency transducers in the mid-eighties, ultrasound has become a conventional tool for taking accurate and precise images of the shoulder to support diagnosis.
[15][16][17][18][19]
Adequate for the examination are high-resolution, high-frequency transducers with a transmission frequency of 5,
7.5 and 10 MHz. To improve the focus on structures close to the skin an additional „ water start-up length “ is advisable. During the examination the patient is asked to be seated, the affected arm is then adducted and the elbow
16

Rotator cuff is bent to 90 degrees. Slow and cautious passive lateral and/or medial rotations have the effect of being able to visualize different sections of the shoulder. In order to also demonstrate those parts which are hidden under the acromion in the neutral position, a maximum medial rotation with hyperextension behind the back is required.
[20]
To avoid the different tendon echogenicities caused by different instrument settings, Middleton compared the tendon ’ s echogenicity with that of the deltoid muscle, which is still lege artis.
[21][22]
Usually the echogenicity compared to the deltoid muscle is homogeneous intensified without dorsal echo extinction.
Variability with reduced or intensified [23] echo has also been found in healthy tendons. Bilateral comparison is very helpful when distinguishing and setting boundaries between physiological variants and a possible pathological finding. Degenerative changes at the rotator cuff often are found on both sides of the body. Consequently unilateral differences rather point to a pathological source and bilateral changes rather to a physiological variation.
[24]
In addition, a dynamic examination can help to differentiate between an ultrasound artifact and a real pathology.
[25]
To accurately evaluate the echogenicity of an ultrasound, one has to take into account the physical laws of reflection, absorption and dispersion. It is at all times important to acknowledge that the structures in the joint of the shoulder are not aligned in the transversal, coronal or sagittal plane, and that therefore during imaging of the shoulder the transducer head has to be hold perpendicularly or parallel to the structures of interest. Otherwise the appearing echogenicity may not be evaluated.
[26]
Orientation-aid for the longitudinal plane:
As an aid to orientation, it is advisable to begin the examination with the delineation of the acromion, as it is easy to palpate and it has an identifiable echo extinction. To adjust the longitudinal plane image the way it is known in the x-rays and the physical examination, the acromion has to be visible at the image border.
[26]
Orientation-aid for the transversal plane:
Again it is advantageous to start above the acromion and then move the transducer to the humerus. The acromion echo extinction disappears and the wheel-like figure with almost concentric projection of the deltoid muscle, supraspinatus muscle tendon and humeral head-outline turns up as soon as the transducer is directed perpendicularly and parallel to the acromion edge. Using the anterior transversal plane one can depict the intraarticular part of the long head of the biceps brachii muscle. Additionally one can use the posterior transversal plane to depict the intersection of the infraspinatus muscle tendon and the posterior edge of the fossa.
[26] usual longitudinal front vision usual longitudinal back vision supraspinatus tendon acromion of the left shoulder in the left half of the image and vice versa. (In order to explore the entire tendon the examiner must move the transducer from ventral to dorsal perpendicular at the acromion axis. Either through a maximal medial rotation or an according position of the transducer it is possible to see the supra- infraspinatus tendon intersection.) infraspinatus tendon scapula spine of the right shoulder in the left half of the image and vice versa.
usual transversal side vision ventral right shoulder in the right half of the image and vice versa.
17
Longitudinal ultra sonography of the supraspinatus tendon
Transversal ultra sonography of the supraspinatus tendon

Rotator cuff
Orthopedics established early the MRI as the tool of choice for joint- and soft tissue-imaging, because its non-invasiveness, the lack of radiation exposure, multi planar slicing possibilities and the high soft tissue contrast.
[27]
The MR Imaging should provide joint details to the treating orthopedist, to help him diagnose and decide the next appropriate therapeutic step. To examine the shoulder, the patient is lying and the concerned arm is in lateral rotation. For signal detection it is recommended to use a surface-coil. To find pathologies of the rotator cuff in the basic diagnostic investigation, T2-weighted sequences with fat-suppression or STIR sequences have proven value. In general, the examination should occur in the following three main planes: axial, oblique coronal and sagittal.
[28]
Most morphological changes and injuries are sustained to the supraspinatus tendon. Traumatic rotator cuff changes are often located antero-superior, meanwhile degenerative changes more likely are supero-posterior.
[29]
Tendons are predominantly composed of dense collagen fiber bundles. Because of their extreme short T2-relaxation time they appear typically signal-weak, respectively, dark. Degenerative changes, inflammations and also partial and complete tears cause loss of the original tendon structure. Fatty deposits, mucous degeneration and hemorrhages lead to an increased intratendinal T1-image. Edema formations, inflammatory changes and ruptures increase the signals in a T2-weighted image.
[28]
Magic angle artifact
Erickson et al. noticed and described a typical artifact and gave the phenomenon the name „ magic angle “ . The „ magic angle “ describes a changed T2-relaxation time depending on the spatial orientation of the tissue to the main magnetic field. If parts of the tendon are located at the area of the magic angle at 55 degrees to the main magnetic field, their T2-relaxation time gets influenced and the signal heavily intensified. Unluckily these artifacts occupy similar areas where clinical relevant pathologies are found. To avoid a wrong diagnosis it is recommended to exclude this phenomenon in a case of doubt through a heavy T2-weighted sequence or an additional fat-suppression at a proton weighted sequence.
[30]
MRA
While using MRI, true lesions at the rotator interval region between the parts of the supraspinatus and subscapularis are all but impossible to distinguish from normal synovium and capsule.
[31]
In 1999, Weishaupt D. et al. reached through two readers a significant better visibility of pully lesions at the rotator interval and the expected location of the reflection pulley of the long biceps and subscapularis tendon on parasagittal
(reader1/reader2 sensitivity: 86%/100%; specificity: 90%/70%) and axial
(reader1/reader2 sensitivity: 86%/93%; specificity: 90%/80%) MRA images.
[32]
When examining the rotator cuff, the MRA has a couple of advantages compared to the native MRI. Through a fat suppressed T2-weighted spin echo, MRA can reproduce an extreme high fat-water-contrast, which helps to detect water-deposits with better damage diagnosis in structurally changed collagen fiber bundles.
[33] MRI. Magic angle artifact.
18

Rotator cuff
Diagram of the human shoulder joint
Suprascapular and axillary nerves of right side, seen from behind.
The suprascapular, axillary, and radial nerves.
[1] Tnation article Push-Ups, Face Pulls, and Shrugs ...for Strong and Healthy Shoulders! (http:/ / www.
t-nation.
com/ free_online_article/ sports_body_training_performance_repair/ pushups_face_pulls_and_shrugs) by Bill Hartman and Mike Robertson: The rotator cuff, of course.
(Or for those of you from Indiana, that would be your "rotary cup").
[10] Hedtmann A et al.. Imaging in evaluating rotator cuff tears. Orthopade. 2007 Sep;36(9):796-809. - (http:/ / www.
springerlink.
com/ content/
26l346817932h383/ )
[13] Broadhurst NA. Musculoskeletal ultrasound - used to best advantage. Aust Fam Physician. 2007 Jun;36(6):430-2. - free article(http:/ / www.
racgp.
org.
au/ afp/ 200706/ 200706broadhurst.
pdf)
[14] Kissin et al.. Self-directed learning of basic musculo-skeletal ultrasound among rheumatologists in the United States. Arthritis Care Res
(Hoboken). 2010 Feb;62(2):155-60 - (http:/ / www3.
interscience.
wiley.
com/ journal/ 123236784/ abstract)
[15] Allen GM, Wilson DJ, Eur J Ultrasound. 2001 Oct;14(1):3-9. Review - (http:/ / linkinghub.
elsevier.
com/ retrieve/ pii/
S0929826601001409)
[16] Middleton WD, Edelstein G, et al. Sonographic detection of rotator cuff tears. Ajr American Journal of Roentgenology.
1985a;144(2):349 – 53. free article(http:/ / www.
ajronline.
org/ cgi/ reprint/ 144/ 2/ 349)
[17] Middleton WD, Reinus WR, et al. Ultrasonographic evaluation of the rotator cuff and biceps tendon. Journal of Bone and Joint Surgery
American Volume. 1986;68(3):440 – 50.
[18] Crass JR, Craig EV, et al. Ultrasonography of rotator cuff tears: a review of 500 diagnostic studies. Jcu J Clin Ultrasound.
1988;16(5):313 – 27.
[19] Mack LA, Gannon MK, et al. Sonographic evaluation of the rotator cuff. Accuracy in patients without prior surgery. Clinical Orthopaedics and Related Research. 1988a;234:21 – 7.
3-13-778701-7
[22] Middleton WD. et al.. Pitfalls of rotator cuff sonography. AJR AM J Roentgenol. 1986 Mar;146(3):555-60 @Katthagen BD. et al..
Schultersonographie. Stuttgart. ISBN 3-13-719401-6 - free article(http:/ / www.
ajronline.
org/ cgi/ reprint/ 146/ 3/ 555)
Verfahren. Stuttgart [etc.]. G. Thieme. 1992. ISBN 3-13-780501-5
[27] Trattnig S. et al.. High-field and ultrahigh-field magnetic resonance imaging: new possibilities for imaging joints. Z Rheumatol. 2006
Dec;65(8):681-7 - (http:/ / www.
springerlink.
com/ content/ 54r55191m43327j5/ )
[28] Romaneehsen B. et al.. MR imaging of tendon diseases. Exemplified using the examples of rotator cuff, epicondylitis and achillodynia.
Orthopade. 2005 Jun;34(6):543-9 - (http:/ / www.
springerlink.
com/ content/ r60654q134376711/ )
19

Rotator cuff
[30] Erickson SJ, Cox IH, Hyde JS, Car re ra GF, Strandt JA, Estkowski LD (1991) Effect of tendon orientation on MR imaging signal intensity: a manifestation of the „ magic angle “ phenomenon. Radiology 181:389 – 393
[31] Seeger LL, Lubowitz J, Thomas BJ (1993) Case report 815: Tear of the rotator interval. Skeletal Radiol 22(8): 615 – 617
[32] Weishaupt D, Zanetti M, Tanner A et al. (1999) Lesions of the reflection pulley of the long biceps tendon. MR arthrographic findings. Invest
Radiol 34: 463 – 469 @Hedtmann A. et al.. Imaging in evaluating rotator cuff tears. Orthopade. 2007 Sep;36(9):796-809 - (http:/ / www.
springerlink.
com/ content/ 26l346817932h383/ )
[33] Palmer WE, Brown JH, Rosenthal DI (1993) Rotator cuff: evaluation with fat-suppressed MR arthrography.Radiology 188:683 – 687
20

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