State of the Art
Shoulder crane: a concept of suspension, stability,
1
Department of Orthopaedic
Surgery and Trauma, Flinders
University, Adelaide, South
Australia, Australia
2
Shoulder & Elbow Surgery,
Brighton & Sussex University
Hospitals, Brighton, England
3
Department of Orthopaedic
Surgery, Tohoku University
School of Medicine, Sendai,
Japan
4 ►► The suspensory cascade extends from
Department of Orthopedic
Surgery, Hospital for Special
Surgery, Rome, Italy
5
Shoulder & Elbow Service,
Funabashi Orthopaedic Sports
Medicine Center, Funabashi,
Japan
6
Department of Orthopaedic
Surgery, University of Sydney,
Sydney, New South Wales,
Australia
7 labrum and glenohumeral ligaments.
Department of Orthopaedic
Surgery and Trauma, Royal
Adelaide Hospital, Adelaide,
South Australia, Australia
Correspondence to
Prof Gregory Ian Bain,
Department of Orthopaedic
Surgery and Trauma, Flinders
University, South Australia
5006, Australia;
​admin@​gregbain.​com.​au
Received 11 December 2017
Revised 5 February 2019
Accepted 12 February 2019
© International Society of
Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine
2019. No commercial re-use.
See rights and permissions.
Published by BMJ.
To cite: Bain GI, Phadnis J,
Itoi E, et al. JISAKOS Epub
ahead of print: [please
include Day Month
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control and motion
Gregory Ian Bain,  1 Joideep Phadnis,2 Eiji Itoi,3 Giovanni Di Giacomo,4
Hiroyuki Sugaya,5 David H Sonnabend,6 James McLean7
Abstract
What are the new findings
Framework and suspensory cascade  This novel
model uses the structure and workings of the industrial
►► The shoulder crane consists of the primary
crane as a simile to explain the function of the human
parts: the base, axial tower, clavicular boom,
shoulder. As a crane consists of a base, axial tower, boom
suspensory cascade, pulley, and motor.
and suspensory cascade that move and position loads
►► The core stabilises the tower, the periscapular
in space, the base consists of the pelvic platform, with
muscles stabilise the scapular and the rotator
outriggers (legs) that provide stability in human body.
cuff stabilises the glenohumeral joint.
The axial tower consists of an articulated spinal column
and thoracic platform, which are stabilised by the core
the skull to the trapezius muscle, clavicle,
muscles. The clavicular boom articulates with the anterior
coracoclavicular ligaments (CCLs), coracoid,
thoracic platform and is elevated by the trapezius from
coracohumeral ligament (CHL) and finally
the posterior tower. The ’suspensory cascade’ extends
humeral head. The coracoid is a pulley that
from the skull and cervical spine to the trapezius and
swivels below the clavicle to allow the rotator
on to the clavicle, coracoclavicular ligaments, coracoid
cuff to be realigned.
process, coracohumeral ligament and humeral head.
►► The CHL is a sensory organ that interfaces with
Motion  The rotator cuff muscles take origin from
the rotator cuff and interval, biceps tendon,
the scapula and coalesce with each other to form a
multilayered rotator cuff tendon and cable, which cups to
►► The dynamic biceps tendon inserts into the
closely contain the humeral head. The four muscles insert
mobile superior labrum, which is confluent with
into the common tendon and together share the load
the static superior and middle glenohumeral
to stabilise and mobilise the arm in space. The coracoid
ligamentous restraints that wrap around
is a pulley that allows the scapula to swivel on the
humeral head at the extremes of rotation.
coracoclavicular ligaments to enable adjustment of the
►► The shoulder crane is a biomechanical model,
angle of force transmission delivered by the rotator cuff
which explains shoulder suspension, stability,
to the humeral head.
control and motion.
Stability and control  The inferior glenoid and labrum
are a fixed organ of compression, which coalesces with
the hammock formed by the static inferior glenohumeral
ligaments. The rotator cuff and deltoid compress the Preface
humeral head onto this static structure.  The biceps
tendon passes adjacent to the condensations of the In 2015, the members of the Shoulder and Upper
coracohumeral ligament to insert into the mobile Limb Committee of ISAKOS published a text book
superior labrum and glenoid. Contraction of the biceps titled ‘Normal and Pathological Anatomy of the
pulls the mobile superior labrum onto the humeral head Shoulder’. The editors were Gregory Bain, Eiji Itoi,
and tightens the glenohumeral ligaments that wrap Giovanni Di Giacomo and Hiro Sugaya.31 This book
around the humeral head at the extremes of motion. is a comprehensive state-of-the-art text on clinical
The coracohumeral ligament is a sensory organ that anatomy of the shoulder and how it is affected by
interfaces with these structures and is well positioned to dysplasia, trauma, disease and degeneration. The
work as a servomechanism to redirect the rotator cuff in concluding chapter titled ‘The Functional Shoulder’,
providing stability, control and motion. brings together the many concepts presented by
Level of evidence  Level V. the authors throughout the book and presents a
new model of normal shoulder anatomy.32
This article is based on the chapter ‘The Functional
Shoulder’ and includes many of the concepts and
Introduction images from this original chapter.32 The original
Shoulder evolution has been driven by the devel-
publication has been modified for publication with the
opment of the orthograde posture with anatomic support of the editorial board of JISAKOS, on the basis
changes to accommodate the demands of a mobile, that it offers an important academic and educational
non-weight-bearing joint to create a brachiating, contribution to the readers and the literature.
prehensile limb. There is an interplay of struc-
tural osseous anatomy, static capsuloligamentous
restraints and dynamic musculotendinous units.1 Damage to one or more components will disrupt
Static and dynamic stabilisers enable greater motion the balance between mobility and stability and place
in the shoulder than in any other joint in the body. the shoulder at risk of injury.2–4
Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187. Copyright © 2019 ISAKOS 1
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Figure 1  The shoulder crane. The crane is constructed on top of the pelvic base and leg outriggers, which provide for stability and mobility. The articulated
spinal tower and thoracic platform are stabilised by the core and periscapular muscles, respectively. The clavicular boom articulates with the anterior
platform, at the sternoclavicular joint, and is elevated by the trapezius from the posterior tower. The scapula is suspended and swivels on the coracoclavicular
ligaments, positioned by the powerful periscapular muscles, and traverses the ‘scapular track’. These factors are all designed to enable the rotator cuff to
mobilise the shoulder while it keeps the glenoid aligned and stabilised with the humeral head throughout motion and loading (Copyright Dr Gregory Bain32).

Knowledge of fundamentals of shoulder anatomy is integral to
understanding pathomechanics and underpins treatment plans.
Goss described the superior shoulder suspensory complex, which
illustrates why acromioclavicular (AC) joint disruption unlinks
the upper extremity from the axial skeleton.5 Digiovine et al
defined the phases of pitching and how the chain of muscles
function with precision and synchrony.6 However, it is chal-
lenging to conceptualise how the axial skeleton suspends the
upper limb and maintains glenohumeral stability and function
while enabling the hand to be placed in space. This manuscript
aims to provide an overview of recent advances in the under-
standing of shoulder anatomy and present the ‘shoulder crane’
concept.
Overview of the ‘shoulder crane’
The mechanical workings of the shoulder girdle are analo-
gous to a structural crane (figure 1). We propose the ‘shoulder
crane’ model, which has a framework consisting of its primary
part:
2 Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
The base: pelvic platform with outriggers (legs), which provide
stability and mobility.
Axial tower: articulated spinal column and thoracic platform,
stabilised by the core muscles.
Clavicular boom: articulates with the anterior thoracic plat-
form and is elevated by the trapezius from the posterior tower.
Suspensory cascade: extends from the skull and cervical spine
to the trapezius, clavicle, coracoclavicular ligaments, coracoid
process and coracohumeral ligament (CHL) to the humeral
head.
Pulley: the scapula swivels on the coracoclavicular ligaments,
allowing the scapula to change the direction of the glenoid face
and the rotator cuff alignment to optimise shoulder function.
Motor: the rotator cuff tendons and capsule coalesce to form
a multilayered structure, which stabilises the glenohumeral joint
and powers the humeral head position.
Servomechanism as a balancing sensor: the CHL is a sensory
organ positioned to assess soft tissue tension and provide feed-
back to the rotator cuff.
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Figure 2  Shoulder gantry. The periscapular muscles mobilises the scapula, while the rotator cuff mobilises and stabilises the humeral head (copyright
Dr Gregory Bain).32 Overhanging the glenohumeral joint is the shoulder gantry (left), which is composed of the clavicle, coracoacromial ligament (CAL),
acromion and scapular spine. The trapezius muscle (posterior) elevates the gantry, hinging on the sternoclavicular joint (anterior-medial). The AC joint
fibrocartilaginous disc buffers the compressive forces, while the coracoclavicular ligaments resist the tensile forces. The shoulder triangle has three sides
(right): medial base: thoracic platform; anterior: clavicular boom; posterior: scapular body/periscapular muscles, which control the scapula. There are three
angles: anterior hinge: sternoclavicular joint; posterior: axial skeleton; lateral: coracoclavicular ligaments, on which the scapula is suspended and swivels. The
clavicle and shoulder triangle lateralise the glenohumeral joint. Lateral to the lateral angle of the triangle is the glenoid, then the centre of rotation of the
humeral head and finally the rotator cuff insertions. The rotator cuff, scapula and humeral head are a functional unit, with the rotator cuff providing stability
and motion.

These mechanisms elevated and rotated the arm, to place the
hand in space, and perform functional activities.
The spinal tower
The base consists of outriggers (legs) that provide leverage for
the entire construct. The pelvis base is a platform for the axial
tower.
The axial tower consists of an articulated spinal column on
which is constructed the thoracic platform. Man-made cranes
have a straight steel tower, which are strong but rigid. The
human spinal tower has multiple vertebral segments in a sinu-
soidal shape of the lumbar, thoracic and cervical spine. This
confers greater flexibility but requires a complex array of core
muscles to maintain control and stability.
The sternoclavicular joint is strategically positioned at the
anterior aspect of the elevated platform. The clavicle is the boom
(or jib) of the crane, which elevates and lateralises the point of
suspension. The main ligament attachment sites are inset from
each end of the bone, with the shock absorber (articular disc) at
each end of the clavicle.
The coracoacromial arch is a gantry composed of the lateral
clavicle, coracoacromial ligament, acromion and scapular spine
(figure 2) (Dr Peter Hales from Perth, Australia coined the term).
A ‘gantry’ is a bridge-like framework or supportive structure
(modified from www.​collinsdictionary.​com). The ‘coracoacro-
mial gantry’ is unique to bipedal animals, most notably the
brachiating animals, and is one of the evolutionary modifications
that have allowed the arm to be elevated from the body. The
gantry creates a ‘pseudo articulation’ between the coracoacro-
mial arch and the rotator cuff. The gantry has various parts, each
with its own function.
Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
The pillars of the gantry are the coracoid process and the spine
of the scapula, which provide cantilever support for the cora-
coacromial arch. The trapezius muscle inserts into its superior
surface, so that it can elevate the entire gantry and with it the
arm, providing an important contribution to abduction strength.
The acromion projects laterally over the humeral head,
increasing the moment arm of the deltoid, and the coracoacro-
mial ligament transfers tension from the acromion to the cora-
coid process. The deltoid is a strong multipennate muscle that
attaches to the lateral acromion and works with the trapezius
and supraspinatus to abduct the shoulder.
The inferior surface of the coracoacromial arch consists of
the thin and somewhat flexible osseous acromion and the cora-
coacromial ligament. During abduction, the deltoid contracts to
narrow the subacromial space, and the flexible arch then moulds
itself to become a ‘soft pivot’ for the rotator cuff. The evolu-
tion of the coracoacromial ligament has allowed the acromion
to better absorb the forces of the deltoid, and therefore enabled
the deltoid/acromial complex to be a more effective shoulder
abductor.
Cascade of suspension
The clavicular boom is elevated by the trapezius muscle (‘boom
guy line’), which originates from the cranium and the cervical
spine. The apex of suspension is above the thoracic platform, at
the top of the spinal tower. From the apex of the tower (cranium)
to the humerus, there is a cascade of osseous and intervening
suspensory structures. For each articulation, there is a set of
‘boom guy line’ muscles, which provide dynamic control of the
articulation. The coracoid is suspended from the lateral aspect
of the clavicular boom by the coracoclavicular ligaments, and in
3
 State of the Art
turn, the coracohumeral and glenohumeral ligaments suspend
the humerus from the coracoid.
The scapula swivels below the coracoclavicular ligaments,
while the acromioclavicular joint (ACJ) capsule restrains anterior
and posterior translation of the scapula. They form part of the
superior suspensory ring of the shoulder, and disruption of this
ring produces acromioclavicular joint instability.7 It is interesting
to note that the conoid and trapezoid ligaments are in continuity
and, when seen from the anterior aspect, appear like an open
book.8 The conoid passes over the medial prominence of the
coracoid process and wrapping around the prominent tubercle
at the posterior angle of the clavicle to be the primary suspen-
sory restraint. In addition, with clavicle rotation, the ligament
shortens and lengthens by wrapping around the clavicle, analo-
gous to the distal biceps tendon wrapping around the proximal
radius. The trapezoid wraps around the medial side of the cora-
coid process and passes laterally to the inferior surface of the
clavicle to be the primary restraint against medialisation of the
scapula. The primary restraint to anteroposterior translation is
the acromioclavicular joint capsule, especially the superior and
posterior aspects. These three structures each provides a primary
restraint in one direction.8
A pulley is a wheel that supports movement and changes force
direction along its circumference. The scapula is a pulley stra-
tegically positioned in the middle of the ‘suspensory cascade’
between the clavicle and humerus. The scapula changes direc-
tion by swivelling on the coracoclavicular ligaments, allowing
the scapula to change the direction of the glenoid face and the
rotator cuff alignment to optimise shoulder function.
The scapular body is a large, thin, triangular bone, which
overlies the thoracic platform. Its extensive surface area serves
as an attachment for the many muscles of the shoulder girdle.
The multiple, powerful periscapular muscles span from the
spinal column and the thoracic cage. These muscles control
scapular rotation and translation across the thoracic cage. The
scapula is almost a sesamoid bone positioned between the peri-
scapular muscles that control the scapula and the rotator cuff
that controls the humeral head. These two major muscle groups
work together to position the humerus in space. The scapula
traverses the thoracic cage along the ‘scapular track’. The rotator
cuff muscles control the humeral head across the ‘glenoid track’.9
The scapula is stabilised and mobilised by an important func-
tional triangle (figure 2). The sides and angles of the triangle
consist of:
Medial side: the fixed thoracic platform.
Anterior angle: the sternoclavicular joint.
Anterior side: the clavicular boom that lateralises and elevates
the scapular pulley.
Lateral angle: the coracoclavicular ligaments that suspend and
swivel the scapula.
Posterior side: the scapula and its periscapular muscles, which
power and dynamically stabilise the scapula.
Posterior angle: the periscapular muscles that attach to the
articulating tower.
Note: the three sides and corners of all have different func-
tions. The position of the scapula is defined by the:
1. Angle of elevation of the sternoclavicular joint.
2. Length of the clavicular boom.
3. Tension in the periscapular muscles.
The scapular pulley is mobilised on the fixed thoracic cage
(‘scapular track’), directed by the static anterior restraints,
as determined by the periscapular muscles. The function of
this triangle is to stabilise and mobilise the scapular pulley, so
that it can align the rotator cuff to stabilise and mobilise the
4 Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
glenohumeral joint. The scapula is oriented so that the glenoid
faces anterolaterally, defining the functional plane of the
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shoulder.
The CHL passes from the base of the coracoid process through
the rotator cuff interval, deep to the biceps tendon, into the supe-
rior glenohumeral ligament (SGHL) and cable, enveloping and
inserting into the supraspinatus and subscapularis tendons, just
before their insertion into the greater and lesser tuberosities.3 4 10
The CHL at first glance appears to be a significant ligamentous
structure that acts like a ‘string on a ball’, to suspend the humeral
head in the glenohumeral joint (figure 3A,B). However, its
histology is similar to that of capsular tissue but with numerous
sensory nerves (figure 3C). As a sensory organ, it is perfectly
positioned to interpret the interplay of these important dynamic
and mobile stabilising structures (figure 3D). In retracted rotator
cuff tears, the CHL will need to be released to enable the cuff
to be mobilised. Contracture of the CHL will restrict external
rotation, as seen in frozen shoulder.11
Glenohumeral joint
The glenohumeral joint is the primary articulation of the
shoulder girdle.
The glenoid projects from the lateral scapula and forms the
major articulation of the shoulder girdle. The glenoid is posi-
tioned perpendicular to the body of the scapula, which is intrin-
sically stable, especially with the support of the rotator cuff. A
retroverted glenoid is known to be detrimental, associated with
posterior glenohumeral instability, abnormal kinematics and
osteoarthritis.
The capsule–labral complex is of primary importance in
shoulder stability.12 The inferior labrum (5–9 o’clock) has a
rounded convex surface, which increases the glenoid depth up
to 50% and provides a bumper effect.13–15 It has a stable inter-
face with the articular cartilage and sits on a rigid bony founda-
tion. The inferior labrum and the inferior glenohumeral joint
(figure 4A,B) together form a ‘fixed organ of compression’.13
In contrast, the superior labrum has a loose, mobile inter-
face with no bony foundation and attaches off the rim, away
from the glenoid articular margin. It is concave in cross-sec-
tion, meniscal in nature and follows the contour of the glenoid
surface.13 The superior labrum is a ‘mobile organ of tension’.
The superior labrum is continuous with the SGHL and middle
glenohumeral ligament (MGHL) and the CHL. These structures
together wrap around the humeral head and are static restraints,
which enhance joint stability throughout motion, especially
rotation.13–16 As the long head of the biceps tendon inserts into
the mobile superior labrum, it transmits a dynamic compo-
nent to the static glenohumeral restraints. Biceps is known to
be a head depressor, but it also tensions the mobile superior
labrum onto the humeral head, and thereby tightens the static
glenohumeral ligaments, throughout humeral rotation. In the
athlete, this tension band effect, in conjunction with the sensory
feedback of the CHL, is likely to be important in optimising
performance.
When fixing the torn labrum, it is important to perform an
anatomical repair. The inferior labrum should be repaired onto
the glenoid face and the superior labrum well off the face. If the
inferior labrum is fixed off the face, the shoulder will remain
unstable. If the normally mobile anterior superior labrum is
fixed to the glenoid face or anterior rim, it will create a painful
stiff shoulder.
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Figure 3  The coracohumeral ligament (CHL). (A) The CHL is a significant structure with a wide coracoid attachment. Laterally it attaches to the
subscapularis and supraspinatus and contributes to the rotator cuff cable and biceps pulleys. The two components of the CHL are a four-bar linkage, which
restricts the extremes of the motion of the humeral head throughout circumduction (permission from Di Giacomo et al, Atlas of functional shoulder anatomy.
Milan: Springer-Verlag; 2008.33 (B) The CHL suspends the humeral head. Mechanically, the CHL appears to tethers the humeral head, like a ‘ball on a
string’ (copyright Dr Gregory Bain32). (C Sensory nerves within the CHL, identified with protein gene product(PGP) 9.5 sensory neuronal marker. (D) CHL
attachments. The CHL envelops the subscapularis and supraspinatus tendons, spans the rotator cuff interval and is closely related to the biceps tendon. The
cable links the various components of the rotator cuff. (Permission sort from Di Giacomo et al, Atlas of functional shoulder anatomy. Milan: Springer-Verlag;
2008.33

Shoulder spaces acromioclavicular joint instability), muscular (ie, fatigue) and

The ‘shoulder crane and gantry construct’ has various working
parts, which require spaces or ‘pseudo-articulations’ between
them to allow the functional units to work effectively.
The subacromial space is the potential space between the
acromion and rotator cuff. With shoulder abduction from 0°
to 90°, the supraspinatus mobilises the glenohumeral joint,
and the tendon traverses the subacromial space. From 135° to
180°, abduction is predominantly scapulothoracic motion, with
minimal translation of the rotator cuff, which is positioned on
the under-surface of the coracoacromial arch.
The size and shape of the acromion are important factors in
the development of rotator cuff tears.17 18 The ageing coracoacro-
mial ligament loses its resilience, becomes stiffer and places
greater force on the rotator cuff, predisposing it to impingement,
degeneration and tearing.
The scapulothoracic space is a potential space. The multiple
periscapular muscles coordinate how the scapular moves across
the chest wall along the ‘scapular track’. Winging is dysfunc-
tional scapular motion, where the scapula posture results in
prominence of the medial scapula border. The four basic causes
of winging are osseous (ie, clavicle fractures), articular (ie,
Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
neurological (ie, long thoracic nerve palsy).
Mobilisation of the shoulder crane
The ‘core’ muscles are counterbalance stabilisers for the plat-
form and articulated tower (figure 1). This model highlights
the importance of the lower limb and truncal core muscles
and why they are critical to good shoulder function and
rehabilitation.
The trapezius is a major muscle with an extensive origin
(occiput to lumbar vertebrae) and an extensive insertion into the
shoulder ‘gantry’ (lateral clavicle, acromion and scapular spine),
which enables it to spin the scapula like a wing nut. The supe-
rior part elevates the gantry, middle part retracts the scapula and
inferior part rotates the scapula.
The powerful deltoid has unipennate anterior and posterior
portions and a multipenate lateral portion (figure 5).19 20 Each
portion will act in a different way depending on the position of
the arm.21
Each rotator cuff muscle takes origin from the wide scapular
body and coalesce into a common tendon cuff, which inserts into
5
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Figure 4  Inferior and superior and labrum composite histology image of the glenoid labrum at 5 and 12 o’clock. (A) The inferior labrum is a fixed organ
of compression. The convex bumper of the inferior labrum is mounted onto of the osseous glenoid. There is no defect between the glenoid, labrum and
articular surface. (B) Superior labrum is a mobile organ of tension, attached off the glenoid face, with a synovial fined cleft between the labrum and the
glenoid. It is a mobile organ of tension. The superior labrum is continuous with the static restraints (SGHL and MGHL), which become taut at the extremes
of rotation. Biceps contraction pulls the mobile superior labrum onto the humeral head to increase containment and secondarily tightens the associated
static restraints (SGHL and MGHL). The coracohumeral ligament (CHL) is closely associated with the biceps, SGHL and rotator cuff attachments to provide
sensory feedback. (Copyright Dr Gregory Bain32). (C) The CHL drapes the rotator cuff, biceps tendon, superior labrum, SGHL and MGHL. This sensory organ is
perfectly positioned to receive the feedback on the tension in the rotator cuff and the ligament, the position of the humeral head and if it is subluxating. This
servomechanism can fine tune rotator cuff function for function and elite performance. MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral
ligament.

the rotator cable and the tuberosities of the proximal humerus
(figure 6).22
Each rotator cuff muscle has a different intramuscular tendi-
nous configuration.
Supraspinatus: bipennate muscle with single tendon.
Subscapularis: multipennate with thick upper tendon.
Infraspinatus: multipennate with oblique and transverse
heads.23
The rotator cuff is a network of interlacing tendons and
ligamentous structures including CHL, glenohumeral liga-
ments and the ‘rotator cuff cable’ (semicircular ligament of
the humerus).24 25 At arthroscopy, the ‘cable’ is visualised as a
6 Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
1 cm wide ligamentous ‘suspension bridge’, spanning and rein-
forcing the deep surface of the cuff from subscapularis to teres
minor.25–27 The ‘cable’ closely contains the head for stability
and allows the individual cuff muscles to create different effects
depending on the position of the humerus.28
Muscle synchronisation and coordination is important for
shoulder function. This includes the lower limb, core, periscap-
ular and rotator cuff muscles. EMG studies have demonstrated
that with shoulder abduction, the supraspinatus activates first.
However, prior to arm movement, the scapula is stabilised
by the trapezius and deltoid.29 With abduction beyond 135°,
the inferior trapezius rotates the scapula, boosting abduction,

Figure 5  The deltoid muscle can be divided into seven segments. The
anterior segments (A1, A2 and A3) converge and attach to the anterior
insertion. The middle segment (M1) attaches to the middle insertion. The
posterior segments (P1, P2 and P3) converge and attach to the posterior
insertion (used with permission from Yoshimasa21; modified from Rispoli et
al20).
Figure 6  Rotator cuff muscles and their intramuscular tendons. The supraspinatus tendon has a single tendon within a bipennate muscle. The
subscapularis has four tendons that span the insertion. The infraspinatus has an oblique head that is an effective head depressor, and a transverse head that
is an effective external rotator (images courtesy of Dr Afsana Hasan, Adelaide32).
Bain GI, et al. JISAKOS 2019;0:1–8. doi:10.1136/jisakos-2017-000187
State of the Art
while deltoid and supraspinatus stabilise the glenohumeral
joint.
J ISAKOS: first published as 10.1136/jisakos-2017-000187 on 8 April 2019. Downloaded from http://jisakos.bmj.com/ on 12 August 2019 by guest. Protected by copyright.
Composite activities (eg, throwing) involve a series of articula-
tions from ground to hand. This coordinated sequence is a series
of ‘levers on levers’, enabling the amazing velocity of the hand at
the time of ball release.
How does the shoulder crane differ from a man-made crane?
The man-made crane has wide outriggers, straight steel tower,
with a mobile boom and a counter balance weight. It lifts
objects, rotates the boom and lowers the object. The construct
is stiff, rigid and cannot mobilise without deactivating the
crane.
The shoulder crane is mobile, with a flexible ‘S’ shaped artic-
ulated spinal tower stabilised by the core muscles. The clavicular
boom, lifts and orientates the upper limb and hand to grasp and
bring objects to the mouth.
A man-made servomechanism is an electronic device that
operates via negative feedback, where the expected position is
compared with the actual position of the mechanical system as
measured by a transducer at the output. Any difference between
the actual and desired values (an ‘error signal’) is amplified
(and converted) and used to drive the system in the direction
necessary to reduce or eliminate the error. The sensory CHL is
well positioned to be the servomechanism to fine tune rotator
cuff function, which is essential for glenohumeral stability and
optimal performance (figure 4c). It seems no coincidence that
sensory organ disorders include: dysfunctional coordination
of multidirectional instability, rotator interval capsulitis30 and
painful biceps pathology.
7
 State of the Art
The viscoelastic soft tissues are flexible, supple and absorb
forces. As the forces are concentrated to a few areas, it is not
surprising that the athlete with bad technique, which overtrains
to the point of fatigue, gets soft tissue injuries.
Discussion
The ‘shoulder crane’ framework consists of a base, axial skel-
eton, clavicular boom, suspensory cascade, pulley, motor and
arm. It highlights that the lower limbs and core muscles stabilise
the articulated spinal tower, the periscapular muscles stabilise
the scapular and the rotator cuff stabilises the humeral head. The
shoulder crane positions the arm in space and then gracefully
brings it back to the body. Then the elbow adjusts the reach, the
forearm provides rotation and the wrist is a universal joint that
allows the hand to have strength of grasp and precision of pinch
in almost any orientation of motion.
This concept does not replace previous published concepts of
shoulder function5 6 but provides a framework on which they can
be applied. Athletes, trainers, therapists and clinicians may better
understand the normal and pathological shoulder and assist in
design of training programmes to optimise technique and perfor-
mance. These concepts may have an even more important role
in defining the effect of any deviation in technique, training and
fatigue that will have a negative impact on performance and
increase the risk of overuse injuries. It refocuses rehabilitation to
the base, platform, core, periscapular and rotator cuff muscles.
The relationship of the dynamic biceps tendon, mobile supe-
rior labrum/SGHL, cable and the sensory CHL is particularly
fascinating. Future research into sensory feedback and motor
coordination is required to better understand the crane model
and to advance athletic performance, recovery and reduce
overuse injuries.
Contributors  GIB: co-editor in the initial book, development of concepts in
this manuscript, writing, figure preparation, rewritting of manuscript. JP: assisted
with development of concepts, writing of intimal chapter and manuscript, figure
preparation, rewritting of manuscript. EI, HS and GDG: co-editor in the initial book,
support and editing of text. JM: assistance in editing of text. DHS: assistance with
concepts, editing and rewriting.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Commissioned; externally peer reviewed.
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