PHT1010 FUNCTIONAL ANATOMY FOR PHYSIOTHERAPY
Lecture 2
Shoulder Girdle & Scapula:
Structures and Functions, Muscles, Nerves and Blood Vessels
Contents of this tutorial are intended for use by BSc (Hons) students of TWC only
Dr Anthony Kwok
Associate Professor/Deputy Programme Leader (Physiotherapy)
School of Medical and Health Sciences
1
Scapula: Sh. blade/Wing bone/ Blade bone
• Connects the humerus (upper arm bone) with the clavicle (collar bone), forms the
back of the shoulder girdle.
• A wide, flat bone lying on the thoracic wall. The head, processes, and the thickened
parts of the bone contain cancellous tissue; the rest consists of a thin layer of
compact tissue.
• Provides an attachment for three groups of muscles: intrinsic, extrinsic, and
stabilising and rotating muscles.
• The intrinsic muscles of the scapula include the muscles of the rotator cuff:
subscapularis, teres minor, supraspinatus, and infraspinatus. These muscles attach to
the surface of the scapula and are responsible for the internal and external rotation
of the shoulder joint, along with humeral abduction.
• The extrinsic muscles: biceps, triceps, and deltoid muscles and attach to the coracoid
process and supraglenoid tubercle of the scapula, infraglenoid tubercle of the
scapula, and spine of the scapula, for several actions of the glenohumeral joint.
• The third group for stabilization and rotation of the scapula: trapezius, serratus
anterior, levator scapulae, and rhomboid muscles. These attach to the medial,
superior, and inferior borders of the scapula.
Scapula:
• The scapula has 2 surfaces, 3 borders, 3 angles, and 3 processes.
• Subscapular fossa (the costal/ventral surface) to which the subscapularis
muscle attaches.
• Supraspinous fossa is concave, smooth, and broader at its vertebral than at
its humeral end; its medial two-thirds give origin to the Supraspinatus.
• Infraspinous fossa is much larger than the preceding; toward its vertebral
margin a shallow concavity is seen at its upper part; its center presents a
prominent convexity, while near the axillary border is a deep groove which
runs from the upper toward the lower part. The medial two-thirds of the
fossa give origin to the Infraspinatus; the lateral third is covered by this
muscle.
• 3 borders: Superior, medial and lateral borders
• Acromion
Scapula •
•
Coracoid process
Glenoid cavity
• Supraglenoid tubercle
• Infraglenoid tubercle
• Spine
• Infraspinous fossa
• Borders: Superior, medial and lateral
• Inferior angle
1. Need to know the location of the
bony features, muscle
attachment, what nerve or artery
passing through or around so that
when the bone got fractures or
after surgery near the parts, what
might be the consequence.
2. Know the joint articulation and
understand why dislocation of
should could be frequent in some
people.
3. Need to know how to palpate.
Joints at Shoulder Girdle
• Shoulder girdle (Scapulothoracic): Scapula moves on the rib cage
• Joint motion occurs at the Sternoclavicular (SC) Jt. and to a lesser amount
at the acromioclavicular (AC) jt.
Scapulothoracic Jt: not a true synovial joints (does not have regular synovial
features).
Movement depends on SC and AC joints
which allows the scapula to move:
• 25 degree abduction-adduction
• 60 degree upward-downward rotation
• 55 degree elevation-depression
• Supported dynamically by its muscles.
• No ligamentous support.
SC Jt: (Multiaxial) arthrodial classification
• Movt: anteriorly 15 degree with
protraction, posteriorly 15 degree
with retraction, superiorly 45
degree with elevation, inferiorly 5
degree with depression
• Ligamentous support: anteriorly by
the anterior SC ligament, posteriorly
by the posterior SC ligament.
• Costoclavicular and interclavicular
ligaments provide stability against
superior displacement.
AC Jt.
• arthrodial classification
• 20 to 30 degree total gliding and
rotational motion accompanying other
shoulder girdle and shoulder joint
motions.
Supported by
• Coracoclavicular ligaments
• Supperior acromioclavicular ligament
• Inferior acroclavicular ligament
• Often injured
Movements of Scapula
• The scapula demonstrated a
consistent pattern of downward
rotation initially from rest to 30°
of humeral elevation, followed by
an upward rotation after 30°of
humeral elevation to the highest
level (120°).
• Scapular upward rotation is
greater in the scapular plane than
in the sagittal plane.
• Overhead rehabilitation exercises
should be performed in the
scapular plane, especially in
subjects with rotator cuff
tendinopathy.
(Borsa,P.,Timmons, K, Sauers,E. 2003)
Important Movements of
Scapula
Shoulder Girdle
1. Clavicle: Sternal end, acromion end of clavicle
2. Scapula: Superior border, suprascapular notch,
medial border, lateral border, Body of scapula,
subscapula fossa, inferior angle
Upper Limb
3. Humerus: Anatomical neck, Surgical neck,
Greater tubercle, Lesser tubercle, Deltoid
tuberosity, shaft of humerus, medial and later
supracondylar ridges, Radial fossa, coronoid fossa,
medial epicondyle, later epicondyle, Capitulum,
Trochlea
4. Radius: Head of radius, Neck of radius,
Tuberosity of radius, shaft of radius, styloid
process of radius
5. Ulna: shaft of ulna, tuberosity of ulna,
6. Carpal bones (2 rows, total 8 carpal bones):
Scaphoid, lunate, Triquetrum, pisiform
Trapezium, Trapezoid, Capitate, Hamate (hook of
hamate)
7. Metacarpal bones (5)
8. Phalanges (14): proximal, middle, distal
Shoulder Girdle (posterior)
Scapula:
• Spine of scapula
• Acromion
• Superior border
• Supraspinatus fossa
• Head & Neck of scapula
• Inferior angle
Upper Limb (Posterior)
Humerus
• Greater tubercle
• Head of Humerus
• Surgical neck of Humerus
• Deltoid tuberosity
• Radial Groove
• Medial and lateral supracondular ridges
• Medial and Lateral condyles
• Olecranon
Ulna: posterior border, styloid process
Radius: Posterior oblique line, styloid process, Dorsal radial tubercle
Carpal bones
Metacarpal bones
Phalanges
Nerve Supply (anterior)
From the cervical nerve roots: C1-8T1
• Phrenic n. , C3,4,5, diaphragm
• Long Thoracic n., C5,6,7,(8), Serratus Anterior
• [Link] Subclavius, C5,6, Subclavius
• Thoracodorsal n., C(5),6,7,8, Latissimus Dorsi
• Lat. Pectoral n., C5,6,7, Pectoralis Major
(Upper & Lower fibres)
• Med. Pectoral n, C(6),7,8, Pectoralis Maj
(Lower), Pectoralis Minor
• Musculocutaneous n., C(4),5,6,7,
Coracobrachialis, Biceps, Brachialis
• Median n., C5,6,7,8T1, Pronator Teres, Flex
Carpi Radialis, Palmaris Longus, Flex Digit
Superficialis, Flex Digit Prof I & II, Flex Pollicis
Longus, Pronator Quadratus, Abd Pollicis
Brevis, Oppons Pollicis, Flex. Poll Brev
(superficial H), Lumbricales I & II
• Note the nerve supply to muscles
Nerve supply (posterior)
• Suprascapular n., C4,5,6, Supraspinatus,
Infraspinatus
• Dorsal Scapular n., C4,5, Levator Scapulae,
Rhomboids Maj & Min.
• Upper and lower subscapular n, C5,6,7,
Subscapularis
• Lower subscapular n, C5,6,(7), Teres Major
• Axiliary n, C5,6, Teres Minor, Deltoid
• Radial n, C5,6,7,8,T1, Triceps, Anconeus,
Brachialis (small part), Brachioradialis,
ECRL, ECRB, Supinator, Ext Digitorum, Ext
Digi Minimi, Ext Carpri Unlaris, EPL, EPB,
AbdPL, Ext Indicis
• Superficial branch of radial n (sensory)
• Deep branch of radial n.
• Note the nerve supply to muscles
Nerve Supply
• Ulnar N, C7,8T1,
Flexor Carpi Ulnaris,
Flexor Digitorum Profundus III & IV,
Palmaris Brevias,
Abductor Digiti Minimi,
Opponens Digiti Minimi,
Flexor Digiti Minimi,
Palmar Interossei,
Dorsal Interossei,
Lumbricales III & IV,
Adductor Pollicis,
Flexor Pollicis Brevis (deep Head).
• Note the nerve supply to muscles
Kendall et al, 2005
Muscle Testing &
Function with
Posture and Pain
(p.27)
3 types of nerves in the body
• Motor nerves control your movements and actions by passing information from your
brain and spinal cord to your muscles.
• Sensory nerves relay information from your skin and muscles back to your spinal cord
and brain. The information is then processed to let you feel pain and other sensations.
• Autonomic nerves control the involuntary or partially voluntary activities of your body,
e.g. heart rate, BP, digestion, and temperature regulation.
Autonomic nerve damage may produce the following symptoms:
• Inability to sense chest pain, such as angina or heart attack
• Too much sweating (known as hyperhidrosis) or too little sweating (known as anhidrosis)
• Lightheadedness
• Dry eyes and mouth
• Constipation
• Bladder dysfunction
• Sexual dysfunction
Nerve damage
Motor nerve:
• Muscle atrophy
• Weakness
• Twitching, also known as fasciculation
• Paralysis
Sensory nerve damage may produce the following symptoms:
• Pain
• Sensitivity
• Numbness
• Tingling or prickling
• Burning
• Problems with positional awareness
Nerve Damage
• Ape hand or Simian Hand : Median Nerve (distal part)
damage
• Hand of benediction/Benediction sign/Preacher's
Hand: Prolonged compression or injury of the
median nerve at the forearm or elbow.
• Drop wrist: Radial Nerve damage
• Claw Hand/Ulnar Claw/ Spinster's Claw: ulnar nerve
damage causing paralysis of the Lumbricals.
• Erb’s Plasy/Erb–Duchenne Palsy: a paralysis of the
arm caused by injury to the upper trunk C5–C6
nerves. These form part of the brachial plexus,
comprising the ventral rami of spinal nerves C5–C8
and thoracic nerve T1. Commonly resulted from
shoulder dystocia during a difficult birth.
• Diabetic Neuropathy (could involve many nerves)
Shoulder Girdle
1. Clavicle: Sternal end, acromion end of clavicle
2. Scapula: Superior border, suprascapular notch,
medial border, lateral border, Body of scapula,
subscapula fossa, inferior angle
Upper Limb
3. Humerus: Anatomical neck, Surgical neck,
Greater tubercle, Lesser tubercle, Deltoid
tuberosity, shaft of humerus, medial and later
supracondylar ridges, Radial fossa, coronoid fossa,
medial epicondyle, later epicondyle, Capitulum,
Trochlea
4. Radius: Head of radius, Neck of radius,
Tuberosity of radius, shaft of radius, styloid
process of radius
5. Ulna: shaft of ulna, tuberosity of ulna,
6. Carpal bones (2 rows, total 8 carpal bones):
Scaphoid, lunate, Triquetrum, pisiform
Trapezium, Trapezoid, Capitate, Hamate (hook of
hamate)
7. Metacarpal bones (5)
8. Phalanges (14): proximal, middle, distal
Shoulder Girdle (posterior)
Scapula:
• Spine of scapula
• Acromion
• Superior border
• Supraspinatus fossa
• Head & Neck of scapula
• Inferior angle
Upper Limb (Posterior)
Humerus
• Greater tubercle
• Head of Humerus
• Surgical neck of Humerus
• Deltoid tuberosity
• Radial Groove
• Medial and lateral supracondular ridges
• Medial and Lateral condyles
• Olecranon
Ulna: posterior border, styloid process
Radius: Posterior oblique line, styloid process, Dorsal radial tubercle
Carpal bones
Metacarpal bones
Phalanges
Muscle attachments
• Subscapularis
• Triceps
• Serratus Anterior
• Biceps
• Pectoris Minor
• Supraspinatus
• Deltoid
• Latissimus Dorsi
• Coracobrachialis
• Brachialis
• Deltoid
• Common Extensor origin
• Common Flexor origin
Muscles attachment on the bony features
• Attachment of muscles to the
bone
• Give rise to origin and insertion
• When muscles contract, it give
action
• Take note of the leverage, range
of motion, lengthen or shortened
positions
• Muscle grading: gravity
eliminated, against gravity or
assisted by gravity
Cross section of
the Shoulder
Girdle showing
the relationship of
different muscles
with bones in the
region.
• Note the
relationship with
Axillary artery,
nerve and lymph
nodes in the
Scapular area.
Nerve Supply (anterior)
From the cervical nerve roots: C1-8T1
• Phrenic n. , C3,4,5, diaphragm
• Long Thoracic n., C5,6,7,(8), Serratus Anterior
• [Link] Subclavius, C5,6, Subclavius
• Thoracodorsal n., C(5),6,7,8, Latissimus Dorsi
• Lat. Pectoral n., C5,6,7, Pectoralis Major (Upper
& Lower fibres)
• Med. Pectoral n, C(6),7,8, Pectoralis Maj
(Lower), Pectoralis Minor
• Musculocutaneous n., C(4),5,6,7,
Coracobrachialis, Biceps, Brachialis
• Median n., C5,6,7,8T1, Pronator Teres, Flex Carpi
Radialis, Palmaris Longus, Flex Digit Superficialis,
Flex Digit Prof I & II, Flex Pollicis Longus,
Pronator Quadratus, Abd Pollicis Brevis, Oppons
Pollicis, Flex. Poll Brev (superficial H),
Lumbricales I & II
• Note the nerve supply to muscles
Nerve supply (posterior)
• Suprascapular n., C4,5,6, Supraspinatus,
Infraspinatus
• Dorsal Scapular n., C4,5, Levator Scapulae,
Rhomboids Maj & Min.
• Upper and lower subscapular n, C5,6,7,
Subscapularis
• Lower subscapular n, C5,6,(7), Teres Major
• Axiliary n, C5,6, Teres Minor, Deltoid
• Radial n, C5,6,7,8,T1, Triceps, Anconeus,
Brachialis (small part), Brachioradialis,
ECRL, ECRB, Supinator, Ext Digitorum, Ext
Digi Minimi, Ext Carpri Unlaris, EPL, EPB,
AbdPL, Ext Indicis
• Superficial branch of radial n (sensory)
• Deep branch of radial n.
• Note the nerve supply to muscles
Nerve Supply
• Ulnar N, C7,8T1,
Flexor Carpi Ulnaris,
Flexor Digitorum Profundus III & IV,
Palmaris Brevias,
Abductor Digiti Minimi,
Opponens Digiti Minimi,
Flexor Digiti Minimi,
Palmar Interossei,
Dorsal Interossei,
Lumbricales III & IV,
Adductor Pollicis,
Flexor Pollicis Brevis (deep Head).
• Note the nerve supply to muscles
• Dermatome of the nerve
supply in the upper limb
• C5, C6, C7, C8, T1
Brachial
Plexus into
the Shoulder
region.
• Note the cervical nerve
roots C5,6,7,8T1 forming
different nerves to
supply different muscles
in the upper limb.
Blood supply to nerves and muscles in the Scapular Region into the Upper Limb
• Note the position of
the Pectoralis Major
and Pectoralis Minor
• Note the position of
the artery and vein
• Note the position of
the nerve
• Nerve: Yellow colour
• Artery: Red Colour
• Vein: blue colour
Blood supply to nerves and muscles in the Scapular Region into the Upper Limb
• Note the different
muscles in the
Scapular Region:
• Nerve: Yellow
colour
• Artery: Red Colour
• Vein: blue colour
Arteries to the Scapular Region
• Suprascapular a.
• Dorsal scapular a.
• Axillary a.
• Subscapular a.
• Circumflex scapular a.
• Thoracodoral a.
• Brachial a.
• Anatomoses with intercostal
arteries
Blood supply to the Upper Limb
• Brachial a.
• Deltoid branch
• Profunda brachii a. (deep a. of
arm)
• Collateral a. (middle and radial
branches)
• Radial recurrent a.
• Superior Ulnar collateral a.
• Inferior ulnar collateral a.
• Ulnar a.
• Ulnar recurrent a.
• Interosseous a.
• Radial a.
Note: the relationship of blood
vessels to nerves and muscles
Blood supply to the
Scapular Region
• Angiogramme/Agiography
(with contrast) showing the
blood supply to the Shoulder
Girdle.
Veins in the
Shoulder
Girdle
Clinical Applications:
What can you tell from the X-rays?
If an X-rays cannot provide you all the information, the doctor may need
to order a CT (give a much better bony and cartilage images) or a MRI
(give a fine soft tissue and nerve images).
Contrast medium may be needed for a better images for differential
diagnosis.
Ultra sound images give general information on the soft tissues and
nerve, but not too accurate.
Ultra-sound Anatomy is a new branch of anatomy for pathology
evaluation and treatment planning and management.
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