Anatomy, Shoulder and Upper Limb, Shoulder Muscles

Cassidy McCausland; Ethan Sawyer; Benjamin J. Eovaldi; Matthew Varacallo.

Author Information

Authors

Cassidy McCausland1; Ethan Sawyer2; Benjamin J. Eovaldi; Matthew Varacallo3.

Affiliations

1 Saint James School of Medicine

2 Creighton University

3 Department of Orthopaedic Surgery, University of Kentucky School of Medicine

Last Update: June 26, 2019.

Go to:

Introduction

The shoulder joint, also known as the glenohumeral joint, is a ball and socket joint with the most
extensive range of motion in the human body. The muscles of the shoulder have a wide range of
functions, including abduction, adduction, flexion, extension, internal and external rotation. [1] The
central bony structure of the shoulder is the scapula, where all of the muscles interact. At the lateral
aspect of the scapula is the articular surface of the glenohumeral joint, the glenoid cavity. The glenoid
cavity is peripherally surrounded and reinforced by the glenoid labrum, shoulder joint capsule,
supporting ligaments, and the myotendinous attachments of the rotator cuff muscles. The muscles of
the shoulder play a critical role in providing stability to the shoulder joint. The primary muscle group
that supports the shoulder joint is the rotator cuff muscles. The four rotator cuff muscles include the
supraspinatus, infraspinatus, teres minor, and subscapularis. [2][1][2]

Go to:

Structure and Function

The upper extremity is attached to the axial skeleton by way of the sternoclavicular joint. The three
joints of the pectoral girdle are the sternoclavicular joint, coracoclavicular joint, and the
acromioclavicular joint. The bones of the pectoral girdle are the clavicle, scapula, and humerus. The
clavicle is positioned immediately superior to the first rib. The distal aspect of the clavicle articulates
with the acromial process and coracoid process of the scapula, forming the acromioclavicular joint and
coracoclavicular joints, respectively. The most important structural ligaments of the shoulder joint are
the glenohumeral ligaments and the coracoacromial ligament.[3]

The scapula is a flat bone with multiple muscular attachments. The glenoid fossa serves the articulating
function with the humeral head at the lateral angle of the scapula. The glenohumeral joint is the point
of articulation between the humerus and the scapula and thoracic cavity, with the latter occurring
through the scapulothoracic articulation. The scapula connects to the clavicle via the coracoclavicular
joint and the acromioclavicular joint.

The coracoclavicular joint is strengthened by the coracoclavicular ligament that unites the undersurface
of the clavicle to the coracoid process of the scapula. The acromioclavicular joint is at the lateral aspect
of the clavicle and does not provide much structural support to the shoulder joint. The coracoid
process, the acromion process, and coracoacromial ligament provide peripheral reinforcement for the
shoulder joint along with the muscles of the shoulder. The shoulder muscles and peripheral structures
of the shoulder function to increase the structural integrity of the shoulder joint.[4]

Go to:

Embryology

Embryologic development of the limbs begins at the end of the fourth week of fetal development. By
the sixth week, the fetus develops hand plates and footplates. During limb development, the shape of
the limb is formed by mesenchymal cells condensing and differentiating into chondrocytes which will
ultimately differentiate into the bones and cartilage of the upper and lower extremity. The upper and
lower extremities undergo very similar embryological development patterns. Limb musculature is first
seen around the seventh week. The mesenchyme migrates from the dorsolateral cells of somites out to
the limb and is differentiated into muscle cells. The shoulder muscles develop earlier than the distal
muscles of the upper extremity.[5]

Go to:

Blood Supply and Lymphatics

The arterial supply to the upper extremity originates from the subclavian artery. These vessels exist on
both sides of the body to provide upper extremity blood supply. Both arteries receive their blood supply
from the arch of the aorta. On both sides of the body, the subclavian artery branches include the
vertebral artery, internal thoracic artery, thyrocervical trunk, and dorsal scapular artery.

The subclavian artery becomes the axillary artery once it reaches the lateral border of the first rib.
There are three parts to the axillary artery, with each portion having arterial branches to supply the
muscles of the shoulder. Multiple arteries branch from the axillary artery including the superior thoracic
artery, thoracoacromial artery, circumflex humeral artery, and the lateral thoracic artery. The
subscapular artery is a division of the third part of the axillary artery. The subscapular artery gives off
the circumflex scapular artery and the thoracodorsal artery. In general, the muscles of the shoulder
receive vascular supply by named arteries associated with the muscles that they supply.[6]

Efferent lymphatic vessels arise from the distal upper extremity and pass through the shoulder.
Additionally, axillary lymph nodes contribute to efferent lymphatic vessels in the region of the shoulder
and pass proximally through the shoulder. Deep lymphatic vessels accompany superficial lymphatic
vessels. The deep lymphatic vessels drain lymph from the joint capsule, tendons, and nerves. The
lymphatics of the shoulder and axillary region are drained by the subclavian lymphatic trunk. On the
right, the subclavian trunk drains into the right lymphatic duct. On the left, the subclavian trunk drains
into the thoracic duct.[7]

Go to:

Nerves

The upper and lower branches of the subscapular nerve innervate the subscapularis muscle. The
suprascapular nerve innervates the supraspinatus and infraspinatus muscles. The posterior branch of
the axillary nerve supplies the teres minor. The axillary nerve also innervates the deltoid muscle. The
nerve supply to the trapezius is by the spinal accessory nerve/11th cranial nerve with some direct
branches from cervical plexus. Innervation to levator scapula is by C3-C5. The nerve supply to the
rhomboids is the dorsal scapular nerve. The nerve supply to serratus anterior is the long thoracic nerve.
The pectoralis major muscle receives its nerve supply via the medial and lateral pectoral nerves.[8]

Go to:

Muscles

The primary muscle group that supports the shoulder joint is the rotator cuff muscles. The four rotator
cuff muscles are supraspinatus, infraspinatus, teres minor, and subscapularis. Together the rotator cuff
muscles form a musculotendinous cuff as they insert on the proximal humerus.

The rotator cuff muscles attach to the proximal humerus anteriorly at the greater tuberosity. The
rotator cuff muscles provide considerable structural support to the glenohumeral joint and keep the
humeral head in a firm position by articulating with the scapula within the glenoid cavity. The muscles
of the chest also provide structural support to the shoulder joint.[8]
The origin of supraspinatus is from the supraspinatus fossa above the spine of the scapula crossing the
shoulder joint, passing under the coracoacromial arch, and above the glenohumeral joint where it
inserts at the greater tubercle of the humerus. The supraspinatus muscle functions by abduction of the
humerus up to 30 degrees, as well as to stabilize the glenohumeral joint.[8]

The infraspinatus muscle originates from the infraspinatus fossa below the spine of the scapula and
inserts on the greater tubercle of the proximal humerus below the supraspinatus tendon. The
infraspinatus muscle functions by externally rotating the humerus.

The teres minor muscle is positioned immediately inferior to infraspinatus originating at the inferior
aspect of the dorsal scapula at the lateral border of the scapula. The teres minor inserts on the greater
tubercle of the humerus below the infraspinatus. The Teres minor acts to externally rotate the humerus
and assists with abduction of the humerus.

The subscapularis originates from the subscapular fossa of the scapula and inserts on the lesser tubercle
of the humerus as well as a portion of the anterior capsule of the shoulder joint. A large bursa separates
the muscle from the neck of the scapula. The subscapularis functions by internally rotating and
abducting the humerus.

The rhomboid minor originates from the nuchal ligament and spinous processes of C7-T1. The rhomboid
major originates from the spinous processes of T2-T5. The rhomboid muscles insert on the medial
border of the scapula and work in combination with the levator scapulae muscles to elevate the medial
border of the scapula. The only muscle which acts to depress the shoulder is the lower trapezius, which
is assisted by gravity in the upright position.[8]

The trapezius is a large triangular-shaped muscle that overlies the shoulder posteriorly. The trapezius
originates from the superior aspect of the nuchal line in the occipital, cervical, and upper thoracic region
and inserts at the lateral aspect of the clavicle, the acromion, and spine of the scapula. The function of
the trapezius muscle is both elevation and depression of the shoulder depending on whether the upper
or lower muscle fibers are activated. When the entire trapezius muscle contracts the fibers are
geometrically opposed, and the forces are balanced resulting in no movement of the shoulder.

The deltoid muscle overlies the shoulder superficially and functions to abduct the humerus. The deltoid
muscle has three origins; the body of the clavicle, the spine of the scapula, and the acromion. The
deltoid muscle has its insertion on the deltoid tuberosity of the humerus. The function of the deltoid
muscle is variable depending on which muscle fibers are activated. The anterior deltoid flexes and
medially rotations the humerus, the middle deltoid abducts the humerus, and the posterior deltoid
performs the actions of extension and external rotatation of the humerus.[9]
The short head of the biceps brachii originates from the coracoid process, and the long head originates
from the supraglenoid tubercle, passing through the intertubercular groove of the proximal humerus.
The biceps brachii is not a shoulder muscle but the tendon of its long head originates on the superior lip
of the glenoid labrum.

Go to:

Physiologic Variants

The infraspinatus muscle tendon is sometimes separated from the capsule of the shoulder joint by a
bursa. An accessory muscle of the biceps brachii may be confused with a split tear along the biceps
tendon. There is some variability of the location that the rotator cuff muscles insert on the proximal
humerus.[10]

Go to:

Surgical Considerations

Rotator cuff injuries and tendon degeneration are a result of multifactorial processes and pathological
changes, both of which affect the quality of tendons.[11] A pathology affecting the rotator cuff muscles
is common and their surgical intervention is routinely performed in patients who have failed
conservative treatment for a variety of pathologies which include full and partial thickness rotator cuff
tears and subacromial impingement syndrome. Subacromial decompression with rotator cuff
debridement and acromioplasties are performed in cases of subacromial impingement and provide
increased clearance for the supraspinatus tendon.[12]

Arthroscopic procedures can be used to access the shoulder joint and repair the rotator cuff muscles.
There are several port sites that are used to access the joint and they are made in relation to bony
landmarks and pass between or through the muscles of the shoulder. Posterior access is attained by
making a port site that allows access to the joint by passing between the infraspinatus muscle and the
teres minor muscle or directly through the infraspinatus muscle. Anterior access is obtained by passing a
portal through the pectoralis major and the deltoid muscle. Lateral access is obtained by placing a portal
directly through the deltoid muscle.

Surgical repair of individuals with partial thickness rotator cuff tears refractory to conservative
management as well as full-thickness cuff tears is typically done arthroscopically. The torn tendon(s) are
repaired by anchoring them back to the humerus, their original insertion site.
Tendinopathies of the long head of the biceps tendon commonly co-occurs with rotator cuff pathologies
and often contributes to shoulder pain. As the tendon attaches to the superior lip of the glenoid labrum,
it is encountered during arthroscopic shoulder operations and is often included as a component of the
operation. Biceps tendon tenotomy, or tendon release, is a commonly used technique used to relieve
pain caused by biceps tendinopathies. Tenodesis of the biceps tendon, or release and re-anchoring, is
another technique used. There is some debate about which technique is superior.[13]

The functionality of the shoulder muscles is important when considering total shoulder replacement
options. For example, reverse total shoulder arthroplasties are frequently used in individuals with poor
rotator cuff function, but successful operation necessitates a functional deltoid muscle to allow for
shoulder abduction.[14]

Go to:

Clinical Significance

Rotator Cuff Injury

Rotator cuff tears are either partial thickness or full-thickness tears. Partial thickness tears most
commonly occur at the articular or bursal side of the rotator cuff tendons. Full-thickness tears often
involve some degree of tendon retraction. The patient's age, baseline shoulder function, tear size,
chronicity, and degree of tendon retraction are several critical elements to be considered when deciding
how to manage each patient most appropriately.[15][12]

The supraspinatus tendon is the tendon most commonly injured of the rotator cuff muscles, followed by
infraspinatus, subscapularis, and teres minor. The teres minor tendon is only rarely involved in rotator
cuff injuries. The subscapularis tendon tear can be associated with a biceps tendon dislocation from the
bicipital tendon groove moving into the subscapularis tendon medially. Confirmation of intra-articular
tendon tears is by the absence of the biceps tendon in the empty bicipital groove.[10]

Labral injuries and Dislocations

Multiple types of shoulder labral injuries can occur in different patient populations. One particularly
common injury subgroup includes young athletes afflicted with a traumatic shoulder dislocation. In the
setting of glenohumeral instability, clinicians should recognize the importance of not only a recurrent
dislocation, but the risk of increased bone loss and soft tissue compromise which may ultimately affect
the outcome following surgical repair.
Glenohumeral instability, especially in the setting of trauma, is most commonly seen anteriorly.
Posterior shoulder instability can be seen in weightlifters or football linemen. Rare dislocation patterns
include the superior and inferior glenohumeral dislocation (luxatio erecta).

It is important to note that in the setting of multidirectional instability (MDI), especially in the case of
bilateral ligamentous laxity or in a patient with a personal or family history of a connective tissue
disorder, the probability of recurrent instability is relatively common. The mainstay treatment for these
injuries centers on physical therapy and shoulder strengthening programs.

Para-labral cysts are most often seen in association with glenoid labral tears. Para-labral cyst formation
can cause subsequent nerve compression and denervation of shoulder muscles. The suprascapular
nerve is susceptible to compression from a para-labral cyst due to its location as it passes through the
suprascapular and spinoglenoid notches adjacent to the anterior-inferior labrum. The subscapular nerve
is also susceptible to compression from a para-labral cyst in the subscapular recess. Isolated atrophy of
the teres minor implies injury to the axillary nerve.[16]

Adhesive capsulitis

The cause of frozen shoulder is the deposition of hydroxyapatite crystals into the muscle tendon. The
shoulder is the most common site of hydroxyapatite calcification in the human body. The supraspinatus
tendon is the most common site of hydroxyapatite crystal deposition. Frozen shoulder is associated
with diabetes mellitus but may also be associated with coronary artery disease, cerebral vascular
disease, rheumatoid arthritis, and thyroid disease.[17]

Subacromial bursitis

Subacromial bursitis, specifically the acute phase, results in painful overhead movement. This is due to
friction between the acromion and deltoid superiorly, and the humeral head and supraspinatus
inferiorly. Chronic bursitis leads to chronic pain because there is inflammation within the bursa. This
inflammatory process can lead to weakness and rupture of the nearby ligaments and tendons. When
confronted with cases of chronic bursitis it is also important to consider tendinitis since it can present
simultaneously with bursitis.

Subacromial bursitis can be caused by repeated steroid injections as they increase the risk of infection
within the shoulder and can also lead to damage to the rotator cuff muscles. Treatment most commonly
consists of avoiding activities that include repetitive overhead movements, taking oral NSAIDs and rest.
[18]
Go to:

Other Issues

An important imaging consideration in patients with previous orthopedic surgical repair of the shoulder
and proximal humerus is metallic MRI artifacts. Performing MRIs at lower magnetic fields can decrease
artifacts from implanted metal hardware.[19]

Go to:

Questions

To access free multiple choice questions on this topic, click here.

Muscles and Fascia of the Shoulder, Supraspinatus, Scapula, Humerus, Deltoid, Infraspinatus, Teres
minor and major, Latissimus Dorsi, Triceps brachii,

Figure

Muscles and Fascia of the Shoulder, Supraspinatus, Scapula, Humerus, Deltoid, Infraspinatus, Teres
minor and major, Latissimus Dorsi, Triceps brachii,. Contributed by Gray's Anatomy Plates

Go to:

References

1.

Bakhsh W, Nicandri G. Anatomy and Physical Examination of the Shoulder. Sports Med Arthrosc Rev.
2018 Sep;26(3):e10-e22. [PubMed]

2.

Cowan PT, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 6, 2018.
Anatomy, Back, Scapula. [PubMed]

3.

Card RK, Lowe JB. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 16, 2019.
Anatomy, Shoulder and Upper Limb, Elbow Joint. [PubMed]

4.

Holt RG, Helms CA, Steinbach L, Neumann C, Munk PL, Genant HK. Magnetic resonance imaging of the
shoulder: rationale and current applications. Skeletal Radiol. 1990;19(1):5-14. [PubMed]

5.
Warmbrunn MV, de Bakker BS, Hagoort J, Alefs-de Bakker PB, Oostra RJ. Hitherto unknown detailed
muscle anatomy in an 8-week-old embryo. J. Anat. 2018 Aug;233(2):243-254. [PMC free article]
[PubMed]

6.

de la Garza O, Lierse W, Steiner D. Anatomical study of the blood supply in the human shoulder region.
Acta Anat (Basel). 1992;145(4):412-5. [PubMed]

7.

Cuadrado GA, de Andrade MFC, Akamatsu FE, Jacomo AL. Lymph drainage of the upper limb and
mammary region to the axilla: anatomical study in stillborns. Breast Cancer Res. Treat. 2018
Jun;169(2):251-256. [PubMed]

8.

Okwumabua E, Thompson JH. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 27,
2018. Anatomy, Shoulder and Upper Limb, Nerves. [PubMed]

9.

Precerutti M, Garioni E, Madonia L, Draghi F. US anatomy of the shoulder: Pictorial essay. J Ultrasound.
2010 Dec;13(4):179-87. [PMC free article] [PubMed]

10.

Cook TS, Stein JM, Simonson S, Kim W. Normal and variant anatomy of the shoulder on MRI. Magn
Reson Imaging Clin N Am. 2011 Aug;19(3):581-94. [PubMed]

11.

Plachel F, Moroder P, Gehwolf R, Tempfer H, Wagner A, Auffarth A, Matis N, Pauly S, Tauber M,

Traweger A. Risk Factors for Rotator Cuff Disease: An Experimental Study on Intact Human Subscapularis
Tendons. J. Orthop. Res. 2020 Jan;38(1):182-191. [PubMed]

12.

Varacallo M, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 13, 2019.
Rotator Cuff Syndrome. [PubMed]

13.

Friedman JL, FitzPatrick JL, Rylander LS, Bennett C, Vidal AF, McCarty EC. Biceps Tenotomy Versus
Tenodesis in Active Patients Younger Than 55 Years: Is There a Difference in Strength and Outcomes?
Orthop J Sports Med. 2015 Feb;3(2):2325967115570848. [PMC free article] [PubMed]

14.

Familiari F, Rojas J, Nedim Doral M, Huri G, McFarland EG. Reverse total shoulder arthroplasty. EFORT
Open Rev. 2018 Feb;3(2):58-69. [PMC free article] [PubMed]

15.
Varacallo M, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 4, 2019.
Rotator Cuff Tendonitis. [PubMed]

16.

Carroll KW, Helms CA, Otte MT, Moellken SM, Fritz R. Enlarged spinoglenoid notch veins causing
suprascapular nerve compression. Skeletal Radiol. 2003 Feb;32(2):72-7. [PubMed]

17.

Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Park JS, Ryu KN. Systematic review and meta-analysis of magnetic
resonance imaging features for diagnosis of adhesive capsulitis of the shoulder. Eur Radiol. 2019
Feb;29(2):566-577. [PubMed]

18.

Faruqi T, Rizvi TJ. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 4, 2019.
Subacromial Bursitis. [PubMed]

19.

Fahlenkamp UL, Gerhardt C, Hermann KG. [Magnetic resonance imaging findings after shoulder surgery:
What the radiologist needs to know]. Radiologe. 2017 Nov;57(11):915-922. [PubMed]

Copyright © 2019, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution,
and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are
indicated.

Bookshelf ID: NBK534836PMID: 30521257

Share on FacebookShare on TwitterShare on Google+

Views

PubReader

Print View

Cite this Page

In this Page

Introduction

Structure and Function

Embryology
Blood Supply and Lymphatics

Nerves

Muscles

Physiologic Variants

Surgical Considerations

Clinical Significance

Other Issues

Questions

References

Related information

PMC

PubMed

Similar articles in PubMed

Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of
motion. A study in cadavera.

[J Bone Joint Surg Am. 2000]

Contributions of the individual muscles of the shoulder to glenohumeral joint stability during abduction.

[J Biomech Eng. 2008]

Review Anatomy, Rotator Cuff

[StatPearls. 2019]

Review Shoulder muscle activity and function in common shoulder rehabilitation exercises.

[Sports Med. 2009]

Review Anatomy, Shoulder and Upper Limb, Arm Supraspinatus Muscle

[StatPearls. 2019]

Gene Expression Omnibus

Genome Data Viewer

Human Genome

Mouse Genome

https://www.ncbi.nlm.nih.gov/books/NBK534836/