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The Shoulder Book
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Contents
Articles
Shoulder
1
Glenohumeral joint
7
Rotator cuff
11
References
Article Sources and Contributors
21
Image Sources, Licenses and Contributors
22
Article Licenses
License
23
Shoulder
1
Shoulder
Shoulder
Diagram of the human shoulder joint
Capsule of shoulder-joint (distended). Anterior aspect.
Latin
articulatio humeri
Gray's
subject #81 313
MeSH
Shoulder
[1]
[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.
Shoulder
Human anatomy
Joints
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
Anatomical studies of the shoulder by Leonardo da
triangular and rounded and the manubrium is convex; the two
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
3
Movements
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
Description
Muscles
Scapular retraction
[]
(aka scapular
adduction)
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."
rhomboideus major, minor, and trapezius
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.
serratus anterior (prime mover), pectoralis minor and
major
Scapular elevation
[] The scapula is raised in a shrugging motion.
Scapular depression
[]
Arm abduction
Arm adduction
Arm flexion
pectoralis minor, lower fibers of the trapezius,
subclavius, latissimus dorsi
[]
Arm abduction occurs when the arms are held at the sides, parallel to True abduction: supraspinatus (first 15 degrees),
the length of the torso, and are then raised in the plane of the torso.
deltoid; Upward rotation: trapezius, serratus anterior
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.
[]
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).
pectoralis major, coracobrachialis, biceps brachii,
anterior fibers of deltoid.
The humerus is rotated out of the plane of the torso so that it points
backwards (posteriorly)
latissimus dorsi and teres major, long head of triceps,
posterior fibers of the deltoid
[]
Arm extension
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.
levator scapulae, the upper fibers of the trapezius
[]
Medial rotation of
[]
the arm
Medial rotation of the arm is most easily observed when the elbow is subscapularis, latissimus dorsi, teres major,
held at a 90-degree angle and the fingers are extended so they are
pectoralis major, anterior fibers of deltoid
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.
Lateral rotation of
[]
the arm
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
Shoulder
4
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.
Muscles
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
Attachment
Function
serratus anterior
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.
It fixes the scapula into the thoracic wall and aids in rotation
and abduction of the shoulders.
subclavius
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
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.
This muscle aids in respiration, medially rotates the scapula,
protracts the scapula, and also draws the scapula inferiorly.
sternocleidomastoid
Attaches to the sternum (sterno-), the clavicle (cleido-),
and the mastoid process of the temporal bone of the
skull.
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.
levator scapulae
Arises from the transverse processes of the first four
cervical vertebrae and inserts into the medial border of
the scapula.
It is capable of rotating the scapula downward and elevating
the scapula.
rhomboid major and
rhomboid minor (work
together)
They arise from the spinous processes of the thoracic
They are responsible for downward rotation of the scapula
vertebrae T1 to T5 as well as from the spinous processes with the levator scapulae, as well as adduction of the scapula.
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.
trapezius
Arises from the occipital bone, the ligamentum nuchae, Different portions of the fibers perform different actions on the
the spinous process of the seventh cervical, and the
scapula: depression, upward rotation, elevation, and
spinous processes of all the thoracic vertebrae, and from adductions.
the corresponding portion of the supraspinal ligament. It
inserts on the lateral clavicle, the acromion process, and
into the spine of the scapula.
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).
Shoulder
deltoid, posterior fibers
5
Arises from the lower lip of the posterior border of the
The posterior fibres are strongly involved in transverse
spine of the scapula, as far back as the triangular surface extension particularly since the latissimus dorsi muscle is very
at its medial end.
weak in strict transverse extension. The posterior deltoid is
also the primary shoulder hyperextensor.
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.
Medical problems
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
Evolutionary variation
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
6
Additional images
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) References
[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
[7] Scientific Keys Volume I, The Key Muscles of Hatha Yoga, Ray Long MD FRCSC, Third Edition, pg. 174
http:/
/
www.
prlog.
12015359-acromioclavicular-arthritis-by-dr-les-bailey-phddoacopmapta-int-part-dr-les-bailey.html
org/
• 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)
Glenohumeral joint
7
Glenohumeral joint
Glenohumeral joint
The right shoulder and Glenohumeral joint
Latin
Articulatio humeri
Gray's
subject #82 315
MeSH
Glenohumeral+Joint
[1]
[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.
Movements
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.
Movements of the shoulder joint.[3]
Movement
Flexion
(150°–170°)
Muscles
Origin
Insertion
Anterior fibers of deltoid
Clavicle
Middle of lateral surface of
shaft of humerus
Clavicular part of
pectoralis major
Clavicle
Lateral lip of bicipital groove
of humerus
Long head of biceps
brachii
Supraglenoid tubercle of scapula
Tuberosity of radius, Deep
fascia of forearm
Short head of biceps
brachii
Coracoid process of scapula
Coracobrachialis
Coracoid process
Medial aspect of shaft of
humerus
Glenohumeral joint
Extension
(40°)
8
Posterior fibers of deltoid
Spine of scapula
Middle of lateral surface of
shaft of humerus
Latissimus dorsi
Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae,
lower 3–4 ribs, inferior angle of scapula
Floor of bicipital groove of
humerus
Teres major
Lateral border of scapula
Medial lip of bicipital groove
of humerus
Middle fibers of deltoid
Acromion process of scapula
Middle of lateral surface of
shaft of humerus
Supraspinatus
Supraspinous fossa of scapula
Greater tuberosity of humerus
Sternal part of pectoralis
major
Sternum, upper six costal cartilages
Lateral lip of bicipital groove
of humerus
Latissimus dorsi
Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae,
lower 3-4 ribs, inferior angle of scapula
Floor of bicipital groove of
humerus
Teres major
Lower third of lateral border of scapula
Medial lip of bicipital groove
of humerus
Teres minor
Upper two thirds of lateral border of scapula
Greater tuberosity of humerus
Lateral rotation Infraspinatus
(in abduction:
Teres minor
95°;
in adduction: 70°) Posterior fibers of deltoid
Infraspinous fossa of scapula
Greater tuberosity of humerus
Upper two thirds of lateral border of scapula
Greater tuberosity of humerus
Spine of scapula
Middle of lateral surface of
shaft of humerus
Medial rotation Subscapularis
(in abduction:
Latissimus dorsi
40°–50°;
in adduction: 70°)
Teres major
Subscapular fossa
Lesser tuberosity of humerus
Iliac crest, lumbar fascia, spines of lower 3-4 ribs, inferior angle
of scapula
Floor of bicipital groove of
humerus
Lower third of lateral border of scapula
Medial lip of bicipital groove
of humerus
Clavicle
Middle of lateral surface of
shaft of humerus
Abduction
(160°–180°)
Adduction
(30°–40°)
Anterior fibers of deltoid
Capsule
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
9
Ligaments
• Superior, middle and inferior glenohumeral ligaments
• Coracohumeral ligament
• Transverse humeral ligament
Nerve Supply
• suprascapular nerve
• axillary nerve
• lateral pectoral nerve
Blood Supply
The glenohumeral joint is supplied with blood by branches of the anterior and posterior circumflex humeral and
suprascapular arteries.
Pathology
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.
Additional images
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
References
[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
External links
• 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
11
Rotator cuff
Rotator cuff
Muscles on the dorsum of the scapula, and the Triceps brachii.
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.
Function
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
12
Muscles comprising rotator cuff
Muscle
Origin on scapula
Attachment on humerus
Function
Innervation
Supraspinatus
muscle
supraspinous fossa
superior and middle facet of the
greater tuberosity
abducts the arm
Suprascapular nerve (C5)
Infraspinatus
muscle
infraspinous fossa
posterior facet of the greater
tuberosity
externally rotates the
arm
Suprascapular nerve (C5-C6)
Teres minor
muscle
middle half of lateral
border
inferior facet of the greater tuberosity
externally rotates the
arm
Axillary nerve (C5)
Subscapularis
muscle
subscapular fossa
lesser tuberosity (60%) or humeral
neck (40%)
internally rotates the
humerus
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.
Injuries
Rotator cuff tear
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).
Rotator cuff impingement
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%.[]
Treatment
Reduce pain and swelling
As with all muscle injuries, R.I.C.E. is an initial response to injury recommended by health providers:
• Rest means ceasing movement of the affected area.
• Icing uses ice to reduce inflammation.
• Compression limits the swelling.
Rotator cuff
13
• Elevation 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.
Description
Beginning
End
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.
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.
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.
Imaging
Shoulder imaging
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
15
Conventional x-rays
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
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]
Ultrasound
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
Y-projection conventional radiography
benefits have helped ultrasound become a common initial choice for
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
17
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
supraspinatus
tendon
usual longitudinal back
vision
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
ventral right shoulder
in the right half of the
image and vice versa.
scapula spine of the right
shoulder in the left half
of the image and vice
versa.
Longitudinal ultra sonography of the
supraspinatus tendon
usual transversal
side vision
Transversal ultra sonography of the
supraspinatus tendon
Rotator cuff
18
MRI
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.
Rotator cuff
19
Additional images
Diagram of the human shoulder
joint
Suprascapular and axillary nerves of right
side, seen from behind.
The
suprascapular,
axillary, and
radial nerves.
References
[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").
[3] (video)
[4] (video)
[9] Hodler J et al.. Gelenkdiagnostik mit bildgebenden Verfahren. Stuttgart [etc.]. G. Thieme. 1992. ISBN 3-13-780501-5
[10] Hedtmann A et al.. Imaging in evaluating rotator cuff tears. Orthopade. 2007 Sep;36(9):796-809. - (http:/ / www. springerlink. com/ content/
26l346817932h383/ )
[11] Bandi W (1981) Die Läsion der Rotatorenmanschette. Helv Chir Acta 48:537-549
[12] Wijnbladh H (1933) Zur Röntgendiagnose von Schulterluxationen. Chirurg 5:702
[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.
[20] Thelen M. et al.. Radiologische Diagnostik der Verletzungen von Knochen und Gelenken. Stuttgart [etc.]. Georg Thieme. 1993. ISBN
3-13-778701-7
[21] Middleton WD. et al.. Ultrasonography of the rotator cuff: technique and normal anatomy. J Ultrasound Med.. 1984 Dec;3(12):549-51
[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)
[23] crass 1984 @Katthagen BD. et al.. Schultersonographie. Stuttgart. ISBN 3-13-719401-6
[24] Middleton WD. et al.. Pitfalls of rotator cuff sonography. AJR AM J Roentgenol. 1986 Mar;146(3):555-60
[25] Hedtmann A. et al.. Atlas und Lehrbuch der Schultersonographie. Stuttgart. 1988@ Hodler J et al.. Gelenkdiagnostik mit bildgebenden
Verfahren. Stuttgart [etc.]. G. Thieme. 1992. ISBN 3-13-780501-5
[26] Katthagen BD. et al.. Schultersonographie. Stuttgart. ISBN 3-13-719401-6
[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/ )
Rotator cuff
[29] Nové-Josserand L, Gerber C, Walch G (1997) Lesions of the antero-superior rotator cuff. Lippincott-Raven, Philadelphia
[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
Article Sources and Contributors
Article Sources and Contributors
Shoulder Source: http://en.wikipedia.org/w/index.php?oldid=564664668 Contributors: A Stop at Willoughby, Achowat, AdiJapan, Akamad, Akanemoto, Al tally, AnakngAraw, Arcadian,
Auntof6, Badgettrg, Barzkar, Basharh, Beth ohara, Bhadani, Borgx, Bryan H Bell, COMPFUNK2, Carlos T. Blackburn, Chsf, Clark89, Clarkcj12, Conquerist, Darren Snoogy, Deathawk, Delldot,
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Jim1138, Jncraton, Julesd, Kbh3rd, Keitei, LedgendGamer, LifeStar, LokiClock, LucasVB, M karzarj, MONGO, MW3915, Mac Davis, MacedonianBoy, Marek69, Massimo Macconi, Matsen,
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Nono64, Norden83, Nposs, Nurg, Nwbeeson, Nyttend, Ohnoitsjamie, Orthosurgeon, Oxymoron83, Palnatoke, Patiwat, Patrick, Patxi lurra, Pb30, PhilipBembridge, Piet Delport, Quadell,
RDBrown, RSatUSZ, Rajkiandris, Ranveig, Raven in Orbit, Raygun man, Rebroad, Rivertorch, RockMFR, Romanm, Rpf, Saganaki-, Sardaukar Blackfang, Shobhitha, Snoyes, Symane,
Termininja, The Anome, The Minister of War, The Rationalist, TheWama, Theone00, Thrissel, TimonyCrickets, Tobby72, Tristanb, Unyoyega, V.narsikar, Vchimpanzee, Vclaw, WLU,
Whhalbert, Wi-king, Wireless Keyboard, Yekrats, Yidisheryid, 206 anonymous edits
Glenohumeral joint Source: http://en.wikipedia.org/w/index.php?oldid=570678297 Contributors: -Marcus-, AB, Ajp, Anatomist90, Arcadian, Barzkar, BirgitteSB, BruceBlaus, Daleee, Damian
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KnightLago, LokiClock, Madhero88, Mandarax, Nono64, Nurg, Oliver Münz, Pearle, Petruss, Prsephone1674, RSatUSZ, Raven in Orbit, Robert.Allen, Root4(one), Saltanat ebli, Sandr0,
Savabubble, Shawnc, Shellystander, Stamboltsyan, Str13, Visium, Woohookitty, 23 anonymous edits
Rotator cuff Source: http://en.wikipedia.org/w/index.php?oldid=568890260 Contributors: Abbaroodle, Alansohn, AlbertBickford, Allens, Alwebuser, Amerikenny, Angela26, Anthony
Appleyard, Arcadian, BD2412, Badgettrg, Basicsharingwatuknow!, Beigemush, Boothy443, Bubba73, Calabe1992, Catpochi, Chris Capoccia, Cloudedcrimson, Colin Kimbrell, Collinpark,
CommonsDelinker, Cshay, DanB, Danandlollie, Dangling Conversation, Davidhaha, Dbizz, Deathawk, Dictabeard, Download, Editor randy, Esrever, FXShannon, Fama Clamosa, Fraggle81,
FutureNJGov, GamingFreek101, Gareth Griffith-Jones, Glacian79, Grafen, Grayshi, GregorB, Grey Knight 1ce, Hraefen, Imesj, Infinity95695, J.delanoy, Jack Greenmaven, Jack Schlederer,
JakobSteenberg, Jehochman, Jfdwolff, Jmh649, Jncraton, Julesd, KC Panchal, KGV, Kevin.cohen, Kghusker, KnightRider, LedgendGamer, Lenny Kaufman, Leonard glas, Libbydelux, Loco7,
Magioladitis, Matsen, MatthewS1973, Mawa, Mme Mim, MrOllie, Mzkitteh, Naniwako, Nick123, Nishanthb, Opelio, Osm agha, Outside Media, PaganPliskin, Philippe, Piano non troppo,
Pinethicket, Porco-esphino, Protenpinner, Quintote, RSatUSZ, RaseaC, Raven in Orbit, Rgoodwin13, Rich Farmbrough, Rjwilmsi, Roger Roger, Ryuko2001, SMC, SaintedLegion, Sasuke
Sarutobi, Sballdaway, Scarian, SchreiberBike, ScottDT1, Steve p, StevenLewis, Stismail, Sue Douglasss, Swim360, TaalVerbeteraar, Tamfang, Tanabesan, Tarek, Tbhotch, Tentinator, Texx064,
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Image Sources, Licenses and Contributors
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File:Shoulderjoint.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Shoulderjoint.PNG License: Public Domain Contributors: National Institute Of Arthritis And Musculoskeletal
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File:shoulder_2.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Shoulder_2.jpg License: Public Domain Contributors: Graichen
File:Blausen 0797 ShoulderJoint.png Source: http://en.wikipedia.org/w/index.php?title=File:Blausen_0797_ShoulderJoint.png License: Creative Commons Attribution 3.0 Contributors:
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Image:Shoulderjoint.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Shoulderjoint.PNG License: Public Domain Contributors: National Institute Of Arthritis And
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