Shoulder and Elbow Clinic

The shoulder girdle is a sophisticated mechanism that acts as the fulcrum for the upper limb, and its smooth function, strength and stability are vital in order to reliably place the hand in space to undertake everyday tasks.

It is composed of three bones:

• Scapula (shoulder blade)
• Clavicle (collarbone)
• Humerus (arm bone)

The scapula is a large flat bone which has a body (the flat part), a spine (the ridge at the back of the shoulder), an acromion (tip of the shoulder blade) and a coracoid process (a projection from the front of the blade that serves as an attachment point for muscles and ligaments).

These bones are linked by ligaments to form joints, upon which framework the tendons and muscles facilitate movement.

The joints are:

• Sternoclavicular (between the breastbone and the collarbone)
• Scromioclavicular (between the collarbone and the acromion)
• Glenohumeral (the main ball and socket joint)
• Gcapulothoracic (not a joint in the usual sense, but a plane of motion between the shoulder blade and chest wall)

These bones and joints depend on linkages provided by ligaments which are tough fibrous flexible bands.

Some of the important ligaments are:

• Coraco-clavicular (suspending the scapula from the collarbone)
• Acromio-clavicular (connecting the collarbone to the tip of the shoulder blade)
• Coraco-acromial (forms an arch over the ball of the humerus)
• Glenohumeral (three in number - superior, middle and inferior- connecting the ball and socket)
• Joint capsule (a sheet of ligament tissue wrapping around the ball, and thickened in parts to form the glenohumeral ligaments)

The shoulder blade serves as the origin of several important muscles that attach to the humerus.  Tendons are the short bands or cords of tough connective tissue that connect muscles to bones.  The tendons from the muscles arising from the scapula converge on the ball, together forming the 'rotator cuff'.

The main functional components of the rotator cuff are:

• Subscapularis (at the front, rotates the ball inwards)
• Supraspinatus (at the top, elevates the arm)
• Infraspinatus (at the back, rotates the ball outwards)
• Teres minor (rotates the ball outwards when the arm is elevated)

In addition, the biceps muscle has two attachments from the scapula.  One, the ‘short head', arises from the coracoid process outside the joint, while the other, the ‘long head', arises from the top of the socket and travels across the ball, through a groove and into the arm to join together to the main biceps muscle.

Where the tendons pass over or under bony prominences a special membranous sac called a bursa exists to lubricate the motion.  Numerous bursae have been identified around the shoulder of which the subacromial (or subdeltoid) bursa is the largest and the most often implicated in shoulder problems.  When irritated or injured, the bursa may produce fluid and the walls of the sac may thicken and contribute to impingement.

The shoulder is also richly supplied with nerves and blood vessels.  Nerves carry sensory signals from the joint tissues to the brain and also convey motor signals from the brain via the spinal cord to the muscles.  The most important nerves are:

• Axillary (supplying the deltoid muscle)
• Suprascapular (supplying the supraspinatus and infraspinatus)
• Musculocutaneous (supplying the biceps and brachialis muscles)
• Accessory (supplying the trapezius muscle)