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Shoulder Anatomy & Biomechanics (Halder) PDF
Shoulder Anatomy & Biomechanics (Halder) PDF
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This article is supported in part by the Max Biedermann Institut, Berlin, Germany (AH).
From the Orthopedic Biomechanics Laboratory, Mayo Clinic Rochester, The Mayo Foundation, Rochester, Minnesota
(AH,KNA); the Department of Orthopedic Surgery, Asklepios Klinik, Berlin, Germany (AH);
and the Department of
Orthopedic Surgery, Akita University School of Medicine, Akita, Japan (EI)
Figure 1. The two-dimensional orientation of glenoid with respect to the medial border and the plane of
the scapula. (By permission of the Mayo Foundation.)
increase congruity, generating a suction effect the frontal plane. A thickening of middle layer
and enhancing stability of the glenohumeral reinforces the axillary pouch. Contrary to the
joint. anterior joint capsule, the posterior is quite
thin.7O
Glenohumeral Joint Capsule
Glenohumeral Ligaments
The capsule of the glenohumeral joint has a
large volume of normally about 10 to 15 mL The coracohumeral ligament (Fig. 2) origi-
and twice the surface area of the humeral nates from the base and lateral border of the
headyoOn the inside, it is covered with syn- coracoid process and runs transversely to the
ovium; on the outside, rotator cuff tendons greater tuberosity. Its anterior border is dis-
protect the capsule on all but the inferior as- tinct medially and merges laterally whereas its
pect. The tendons of the subscapularis and su- posterior border is i n d i ~ t i n c tIt. ~is~a primary
praspinatus are even fused with the capsule restraint to the long head of the biceps ten-
close to their insertion. The capsule begins at don.s4,%
the border of the labrum, is attached to its The transverse humeral ligament is the roof
outer surface, and is anchored onto the bone of the proximal end of the bicipital groove and
of the glenoid neck. It extends superiorly to the acts as the retinaculum for the long head of the
coracoid process and in varying length along biceps tendon. It is made of transverse fibers
the biceps tendon into the intertubercular of the capsule.
groove. It inserts into the anatomic neck close Although constant in presence, the superior
to the cartilage of the humeral head and with glenohumeral ligament is variable in size and
some distance inferiorly to form the axillary origin. It arises from the anterior labrum,
recess. Apart from the outlet for the biceps ten- sometimes as far superior as the long head of
don, the capsule has a gap for the subscapular the biceps tendon and sometimes as far infe-
recess anteriorly. rior as the middle glenohumeral ligament or
Histologically the capsule is composed of in between.
three layers: an outer and an inner layer with The middle glenohumeral ligament shows
fibers running in the frontal plane from the the largest variation in diameter. It can be as
glenoid to humerus and a middle layer with thin as the capsule or as thick as the subscap-
fibers running in the sagittal plane. The gle- ularis tendon. It originates from the anterior
nohumeral ligaments reinforce the joint cap- labrum or glenoid neck to insert into the lesser
sule. They are an abrupt thickening of the in- tuberosity underneath the subscapularis ten-
ner layer with organized collagen bundles in don with which it is mingled.lo1
ANATOMY AND BIOMECHANICS OF THE SHOULDER 161
The inferior glenohumeral ligament is The humeral head (Fig. 3) is inclined about
thicker than the rest of the capsule, although 130" relative to the shaft with 30" of retrotor-
variable in size and attachment site. Its struc- sion relative to the condyles of the elb0w.2~ The
ture resembles a hammock consisting of a articular surface of the humeral head forms aI-
prominent anterior band,Io1a posterior band, most a true The margin is tilted 45"
and the axillary pouch in between. Looking at relative to the humeral shaft. In contrast to the
the glenoid being divided like a clock, the an- glenoid, the central portion of its hyaline car-
terior band originates from the glenoid or la- tilage is the thickest.
bmm from the 2- to 4-o'clock position and the The anterior border of the articular surface
posterior band from the 7- to 9-o'clock posi- is the lesser tuberosity, and its lateral border is
tion. It inserts into the anatomic neck of the the greater tuberosity with the intertubercular
humerus inferior to the cartilage in a U- or V- groove in between. Together with the medial
shaped f a ~ h i o n . ~ ~ , ~ surface of the surgical neck, they are sites for
a ring of tendinous and ligamentous attach-
Humeral Head ments around the articular surface. This ring
functions to stabilize the joint by centralizing
The articular surface has an ovoid shape9 the humeral head while tightening around the
facing medially, superiorly and posteriorly. prominent articular surface.4o
162 HALDER et a1
The intertubercular groove lies 30" media170 to the intramuscular tendon, whereas 30%at-
or 9 mm anterior to the central axis of the ar- tach directly to the extramuscular t e n d ~ ~ ~ . ~
ticular surface.'O0 It is bordered by the lesser This muscle is categorized as a circumpennate
tuberosity anteriorly and by the greater tuber- muscle.58 The superficial tendon fibers run
osity posteriorly. The transverse ligament longitudinally whereas the deep ones run
bridges the intertubercular groove proximally obliquely40 to mingle with adjacent muscles
to act as a retinaculum for the long head of the and create a tendinous ring. The supraspinatus
biceps tendon. Distally the subscapularis ten- is part of the force couple to stabilize the gle-
don inserting onto the lesser tuberosity forms nohumeral joint by compression and initial-
the floor of the sheath. The supraspinatus izes elevati0n.2~ Elevation in case of supraspi-
tendon inserting onto the greater tuberosity natus paralysis requires more deltoid force,
forms its roof. The depth of the intertubercular but the other rotator cuff muscles are still able
groove seems to play a role in the pathogenesis to stabilize the humeral head sufficiently for
of long head of the biceps tendinitis by more full range of motion.s2 The suprascapular
or less exposing the tendon to an impingement nerve (C4-6) supplies innervation.
process.67 Infraspinatus. The infraspinatus muscle
There are three facets on the greater tuber- takes fleshy origin in the infraspinatus fossa
osity: the superior, the middle, and the infe- and scapular spine to insert with a flat tendon
r i 0 r . 5 The
~ ~ ~supraspinatus
~ muscle inserts onto onto the middle facet of the greater tuberosity.
the superior facet and the superior half of the It is a circumpennate muscle with an intra-
middle fa~et.5~ Anterior fibers of the supra- muscular tendon located in the center of the
spinatus tendon mingle with the subscapularis muscle belly. The infraspinatus muscle stabi-
tendon fibers. Posteriorly the infraspinatus lizes the glenohumeral joint by resisting pos-
tendon attaches to the middle facet, covering t e r i ~ and
r ~ ~superior translation and generates
the posterior border of the supraspinatus ten- 60% of the overall external rotation force.I2The
don. The teres minor tendon inserts onto the suprascapular nerve (C4-6) supplies innerva-
inferior facet.57 tion.
Teres Minor. Origin of the teres minor mus-
cle is the lateral border of the scapula and the
Scapulohumeral Muscles
infraspinatus fascia, and its fleshy insertion is
Supraspinatus. The supraspinatus muscle located inferior to the infraspinatusmuscle on
takes fleshy origin in the supraspinatus fossa the inferior facet of the greater tuberosity.
to have a tendinous insertion onto the greater Similar to the infraspinatus, this is a circum-
tuberosity. The muscle belly has a fusiform pennate muscle with a single intramuscular
shape with a thick tendinous core, the intra- tendon located in the center of the muscle
muscular tendon, located in the anterior third. belly. The teres minor muscle acts as stabilizer
Approximately 70%of the muscle fibers attach of the glenohumeral joint by resisting poste-
ANATOMY AND BIOMECHANICS OF THE SHOULDER 163
rior and superior translation and generates sheathed by the synovial membrane, it runs
45% of the total external rotation force.I2The intra-articularly on top of the humeral head to
posterior branch of the axillary nerve (C5-6) exit the joint capsule through the intertuber-
supplies innervation. cular groove. The short head of the biceps orig-
Subscapularis. The subscapularis muscle inates from the coracoid process. Both heads
takes fleshy origin in the subscapularis fossa have a common insertion onto the tuberosity
and inserts onto the lesser tuberosity. Its ten- of the radius laterally and onto the ulnar fascia
dinous bands are interspersed evenly in the of the forearm medially.40Although it acts as
medial portion of the muscle to condense lat- a stabilizer of the humeral head,33,37,82 its main
erally into a flat tendon in the superior two function is to effect elbow flexion and forearm
thirds, whereas the inferior third remains mus- supination. The biceps muscle is innervated by
~ u l a r This
. ~ ~ muscle with multiple intramus- the musculocutaneous nerve (C5-6).
cular tendons is a multicircumpennate muscle. Triceps. The long head of the triceps origi-
The subscapularis sends fibers of its tendinous nates from the infraglenoid tubercle and the
insertion across the intertubercular groove to inferior labrum to insert in common with both
form the floor of the bicipital sheath. As the other heads onto the olecranon. The long head
only component of the anterior rotator cuff, it participates in extension and adduction of the
stabilizes actively the glenohumeral joint by glenohumeral joint, whereas the main function
resisting anterior and inferior t r a n ~ l a t i o n ~ ' , ~of~ the whole muscle is extension of the elbow
and acts as a strong internal rotator. It is con- joint. The radial nerve (C6-8) supplies inner-
sidered to be a passive stabilizer,*,"" too, be- vation.
cause of the dense collagen structure of its ten- Coracobrachialis. The coracobrachialis mus-
don and its fusion with the middle and inferior cle originates in common with the short head
glenohumeral ligament. Two branches of the of the biceps on the coracoid process to insert
subscapular nerve (C5-8) for the superior and onto the anteromedial surface of the central
inferior portion of the muscle supply inner- humerus. It participates in flexion and adduc-
vation. tion of the glenohumeral joint.
Deltoid. The deltoid muscle is composed of The musculocutaneous nerve enters the cor-
the clavicular part originating from the lateral acobrachialis muscle between 2 and more than
clavicle, the acromial part from the acromion, 5 cm inferior to the tip of the coracoid process89
and the spinal part from the scapular spine. to innervate it.
Their common insertion is the deltoid tubercle
on the humerus. The deltoid is the most im-
portant abductor of the glenohumeral joint. Biomechanics
Although the acromial portion is the strongest
one and starts the movement, the clavicular Motion
and spinal portions participate at higher de-
grees of abduction. Conversely, in low degrees The humeral head and the glenoid articular
of abduction, the medial fibers of the anterior surface show a high degree of ~onformity.~~
and posterior portions can take part in adduc- The humeral head is believed to be more con-
tion of the arm." Additionally the anterior vex in the anterior-posterior direction than in
portion affects flexion and the posterior por- the superior-inferior Soslowsky
tion extension. Paralysis of the deltoid results et aP7measured the sphericity of the humeral
mainly in 50%loss of abduction ~trength.'~ The head using stereophotogrammetry, however,
axillary nerve (C4-5) innervates the deltoid. and concluded that the articular surface of the
Teres Major. The teres major originates from humeral head could be approximated by a
the posterior surface of the inferior angle of the sphere with small deviations of less than 1%
scapula to take a tendinous insertion on the of the radius. According to Boileau and
medial margin of the intertubercular groove. Walch? the difference between the two diam-
On its way to the humerus, it takes a 180" spi- eters of the humeral head is less than 1 mm in
ral course with the posterior fibers inserting 88.2% of the tested specimens. The motion of
anteriorly? Its functions are internal rotation, the glenohumeral joint is basically ball-and-
adduction, and extension of the humerus. The socket in nature.
subscapular nerve (C5-7) supplies innerva- During active and passive arm elevation, the
tion. superior-inferior translation of the humeral
Biceps. The long head of the biceps muscle head is only 0.3 to 0.35 mm in normal shoul-
has its origin at the supraglenoid tubercle. En- ders."fu Anterior-posterior translation is sub-
164 HALDERetal
sive anterior stabilizer among the rotator cuff the rotator cuff muscles are loaded simulta-
muscles.*6Blasier et a17demonstrated in a dis- neously, the humeral head is stabilized in the
placement control study, however, that the superior-inferior directiong5as well as in the
subscapularis, supraspinatus, and infraspina- anterior-posterior direction (Fig. 9).Io7
tus and teres minor equally contributed to an- Biceps. Clinical data suggest that the biceps
terior stability of the abducted shoulder with functions as stabilizer of the shoulder. In pa-
the arm in neutral and in external rotation. tients with rupture of the long head of the bi-
With the arm in 90" of flexion, the subscapu- ceps tendon, the humeral head translates su-
laris is the primary posterior stabilizer? periorly during arm abduction.'02In anteriorly
The rotator cuff muscles usually function to- unstable shoulders, electromyographic activ-
gether. Inman et aI3' introduced a concept of a ity of the biceps during throwing motion is in-
force couple in the frontal plane consisting of Studies using cadaveric shoulders
the deltoid and supraspinatus muscles as ele- have clarified the stabilizing function of the
vators and inferior portions of the rotator cuff biceps in the superi0r,4~,~ inferi~r?~ ante-
,~~
muscles as depressors. Sahag2described the rior;3,37J9,91 and posterior direction^.^,^^ Stabi-
force couple in the horizontal plane compris- lization by the long head of the biceps depends
ing the subscapularis anteriorly and infraspi- on the integrity of the superior labrum. After
natus and teres minor muscles posteriorly. If creating a superior labral lesion, the stabilizing
ANATOMY AND BIOMECHANICSOF THE SHOULDER 167
Effective Glenoid
Effective Glenoid
Depth
A I
Glenoid Center Line
81
20 10 0 10 20
B Translation (mm)
Figure 7. The glenoid fossa has a concavity, which centers the
humeral head on the glenoid (A). The glenoid fossa is deeper and,
thus, the humeral head is more stable in the superior-inferiordirec-
tion than in the anterior-posterior direction (6).
(ModifiedfromMat-
sen FA 111, Lippitt SB, Sidles JA, et al: Practical Evaluation and
Management of the Shoulder. Philadelphia, WB Saunders, 1994.)
function of the biceps becomes less efficient as and 6.3 kg/cm2 with the elbow extended30to
a result of the lax labrum and the elongated 9.2 kg/cm2.61
tendon.78 Moment Ann. The effectiveness of a muscle
as a mover depends on the orientation of the
Force muscle relative to the center of rotation. The
Physiologic Cross-Sectional Area. Maximal distance from the center of rotation to the line
muscle force is proportional to the physiologic of force is defined the moment arm, which can
cross-sectional area of the muscle, which is ob- be calculated by the geometricmethod, tendon
tained by dividing muscle volume by muscle excursion-joint rotation method, or direct load
fiber length. The absolute maximal force of the measurement.'
muscle is calculated by multiplying the phys- Kuechle et a147used an electropotentiometer
iologic cross-sectional area by a conversion to measure the moment arms of the rotator
factor depending on muscle pretension, which cuff muscles during abduction and adduction.
varies from 4.7 kg/cm2 with the elbow flexed According to their study, the supraspinatus is
168 HALDER et a1
B
Figure 8. A and B, In adduction, the superior capsuloligamentous structures become
tight because of the slope of the glenoid fossa, which prevents inferior translation of
the humeral head. (From Basmajian JV, Banzat FJ: Factors preventing downward
dislocation of the adducted shoulder joint. J Bone Joint Surg 41A:1182,1959; with
permission.)
Figure 9. The force couple in the frontal plane consists of the deltoid and supraspinatus muscles as
elevators and inferior portions of the rotator-cuff muscles as depressors (A). The force couple in the
horizontal plane comprises the subscapularisanteriorly and infraspinatusand teres minor muscles pos-
teriorly (€3). If the rotator-cuff muscles are loaded simultaneously, the humeral head is stabilizedin the
superior-inferior direction as well as in the anterior-posterior direction. (Modified from Matsen FA 111,
Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, WB
Saunders, 1994.)
ANATOMY AND BIOMECHANICS OF THE SHOULDER 169
the most efficient elevator, and the teres minor pectoralis major, latissimus dorsi, and teres
is the most efficient depressor of the rotator major.
cuff muscles throughout the entire range of Muscle Activity. The electromyographic
motion. The infraspinatus changes from being study by Inman et a131showed that the abduc-
an elevator to being a depressor, and the sub- tors were the deltoid, pectoralis major, and su-
scapularis changes from being a depressor to praspinatus, whereas the depressors were the
being an elevator with increasing elevation an- infraspinatus, teres minor, and subscapular-
gle (Fig. 10). is. The abductors and depressors are coupled
Kuechle&also reported the moment arms of and act together during elevation. Electromy-
10 muscles around the shoulder. The results ographic activity of the biceps increased in one
showed that during horizontal flexion and ex- third of the patients with rotator cuff tears.44
tension, the pectoralis major and the anterior Because these patients showed decreased
deltoid were the most efficient horizontal flex- strength in abduction and external rotation, it
ors, whereas the posterior deltoid along with is likely that the biceps functions as a supple-
the posterior rotator cuff muscles were the mentary mover.
most effective horizontal extensors. During ro- Torque. Theoretic torque is calculated by the
tation with the arm at the side, the infraspi- physiologic cross-sectional area, a constant,
natus and the teres minor were the most effi- the percentage of maximal voluntary contrac-
cient external rotators. The subscapularis was tion, and the moment arm. The model pro-
the most efficient internal rotator followed by posed by Hughes and AnBpredicted the high-
the pectoralis major, latissimus dorsi, teres ma- est rotator cuff muscle forces during maximal
jor, and anterior deltoid. During rotation with internal rotation (subscapularis) and external
the arm abducted, the most efficient external rotation exertions (infraspinatus, teres minor,
rotators were the teres minor followed by in- and supraspinatus). The results indicate that
fraspinatus,whereas the most efficient internal abduction exertions may not produce the
rotators were the subscapularis followed by highest loads on the supraspinatus tendon.
ABDUCTION
- - - . SUBSCAPULARIS
-
-..- TERES MINOR
-.-. INFRASPINATUS
- - - SUPRASPINATUS
LATISSIMUS DORSI
- ANTERIOR DELTOID
- - MiDDLE DELTOID
....,......... TERES MAJOR
---- POSTERIOR DELTOID
0 10 20 30 40 50 GO 70 80 90
--- PECTORALIS MAJOFI
ABDUCTION (DEGREES )
Clinically, shoulder torques in various tion. Using this model, the joint reaction force
movements are measured with use of an iso- reached a peak value of 650 N at 60" abduction.
kinetic dynamometer. Ivey et a13sestablished
isokinetic normative torque of the shoulder SCAPULOTHORACIC JOINT
muscles. Internal rotation is higher than exter-
nal rotation torque (3:2), extension is higher Anatomy
than flexion torque (5:4), and adduction is
higher than abduction torque (2: 1). Overall, Scapula
adduction strength is highest, followed by ex-
tension, flexion, abduction, internal rotation, The scapula (see Fig. 1) functions mainly as
and external rotation. a site of muscle attachment. It is a flat, trian-
The overall strength of the shoulder is mea- gular bone that is thicker at its superior and
surable, but the function of each of the shoulder inferior angles and at its lateral border to sup-
muscles cannot be specified by this method. To port the attachment of powerful muscles. The
isolate the function of the supraspinatus, Itoi anterior subscapular fossa is flat and slightly
et a P measured isokinetic strength of the concave, whereas the posterior, slightly con-
shoulders with isolated tears of the supraspi- vex infraspinatus fossa is separated from the
natus tendon. The decreases in torque of 19% supraspinatus fossa by the scapular spine,
to 33% in abduction and 22% to 33% in exter- which is one of four scapular processes.
nal rotation appear to represent the contri- Processes
bution of the supraspinatus to the overall
strength of the shoulder. Spine. The scapular spine originates from
Selective nerve blocking is used to examine the medial scapular border with a triangular
single muscle functions, although isolation is thickening and runs superolaterally on the
posterior surface to form the trapezoidal acro-
not complete. Howell et a127measured the re-
mion process. It stiffens the body of the scap-
duction in shoulder torque produced by pa-
ula and suspends the acromion as lever arm
ralysis of the suprascapular nerve and axilIary for the deltoid muscle.
nerve. Each of the suprascapular and axillary Acromion. As the acromion extends antero-
nerve palsies produced a similar 50% reduc- laterally in bipeds to form a sufficient insertion
tion in torque compared with the nonparaly- site for the strong deltoid muscle, it is placed
zed shoulder. As the suprascapular nerve in- on top the rotator cuff tendons. It limits the
nervates the supraspinatus and infraspinatus space mainly for the supraspinatus tendon
and the axillary nerve innervates the deltoid confined inferiorly by the humeral head. For
and teres minor muscles, it is likely that the this reason, the shape of the acromion is be-
supraspinatus-infraspinatus unit and the del- lieved to be decisive in the development of ro-
toid-teres minor unit are equally responsible tator cuff degeneration. Bigliani et a16defined
for producing torque about the shoulder joint. three types of the acromion: flat, curved, and
Resultant Force. Inman et aI3lcalculated the hooked. A curved undersurface of the acro-
joint reaction force of the glenohumeral joint mion as well as an increased inferior tilt seems
with only the deltoid and the rotator cuff mus- to be associated with rotator cuff tears.3An un-
cles taken into account. Poppen and WalkeF fused acromion epiphysis causes functional
calculated the joint reaction force using the deformability and decreased subacromial
same method but took all the muscles active space.65Based on the size of the unfused bone,
at each phase of the motion into account. The Liberson51defined a preacromion, mesoacro-
joint reaction force reached a maximum of 0.89 mion, metaacromion, and basiacromion, of
times body weight at 90" of abduction in the which the meso-metaacromion has the highest
scapular plane, whereas the shear force com- incidence?]
ponent on the glenoid reached a maximum of Coracoid. Anterior to the base of the acro-
0.42 times body weight at 60" of abduction. mion, the coracoid process originates from the
Karlsson and Petersonmintroduced a three- neck of the glenoid. The round process hooks
dimensional biomechanical model of the to point anterolaterally and ends flattened. In
shoulder to analyze static load sharing be- 1% of the population, an abnormal connection,
tween the muscles, bones, and ligaments. The such as a bony bar or an articulation to the
musculoskeletal forces were predicted using clavicle, is described.69The coracoid process is
the optimization technique with the sum of the attachment site of muscles-the pectoralis
squared muscle stresses as an objective func- minor, short head of the biceps, and coraco-
ANATOMY AND BIOMECHANICSOF THE SHOULDER 171
Subclavius. The tendinous origin site of the forward-backward movement. These move-
subclavian muscle is the medial part of first ments do not occur independently.Protraction
rib, and it has a fleshy insertion on the subcla- is the combination of forward movement of
vian groove on the inferior surface of the clav- the scapula away from the vertebral column,
icle. By pulling the clavicle toward the ster- rotation of the scapula around the acromiocla-
num, it stabilizes the sternoclavicular joint. vicular joint (anterior tilt), and internal rota-
The subclavian nerve (C5-6) innervates it. tion.I3 Retraction is the combination of oppo-
site movements. Abduction of the scapula is
advantageous from a biomechanical point of
Biomechanics view: (1)It increases the range of humerothor-
acic motion, (2) it maintains muscle efficiency
Motion by enabling the muscles to work in the optimal
The scapula is positioned on the thorax portion of their length-tension curve, and (3)
about 30" internally rotated in the horizontal it allows the glenoid to be brought underneath
plane, 3" abducted in the frontal plane, and the humerus to share some weight of the arm.
20" tilted anteriorly in the sagittal plane.% If the scapulothoracic joint is fused, gleno-
Laurnann50 measured the three-dimensional humeral extension and external rotation are
motion of the scapula using stereophoto- significantly decreased, whereas internal ro-
grammetry and concluded that the scapula ab- tation remains unchanged.25This situation is
ducted 609 tilted posteriorly 20°, and rotated due to the fact that internal rotation occurs
internally 6" during the first half of elevation, mainly in the glenohumeraljoint. Healthy sub-
then externally rotated 16"during the second jects use about 15" of scapulothoracic internal
half of elevation. As a result, the scapula ex- rotation to perform personal care activities. In
ternally rotated 10". In addition to these three contrast, an average of 51" of scapulothoracic
rotatory motions, there are two translatory internal rotation is used to perform these ac-
movements: superior-inferior movement and tivities after glenohumeral fusion. In contrast
ANATOMY AND BIOMECHANICSOF THE SHOULDER 173
Force
The movers for scapular abduction are the
trapezius and the serratus anterior muscles.
The serratus anterior and pectoralis minor
muscles are the prime movers for protraction,
whereas the middle trapezius and rhomboid
muscles effect retraction.62Inman et a131devel- 0" 60" 120" 180"
oped the concept of a force couple about the
scapula. He noted three force directions: up- Figure 12. The coordinated movements in the glenohu-
ward rotation, medial contraction, and antero- meral and scapulothoracic joint-effecting arm elevationare
known as scapulohumeral rhythm. Angular changes of the
lateral force at the inferior angle. The upper glenohumeraljoint with respect to arm elevation were m e a
trapezius, upper digitations of the serratus an- sured by several investigators. Nobuhara et al, 1977; Pop-
terior, and levator scapulae form the upper pen U. Walker, 1976; lnman et al, 1944; Freedman U.
part of the force couple. The lower trapezius Munro, 1966; Wallace, 1982; Reeves, 1972. (from Berg-
mann G: Biomechanics and pathomechanicsof the shoul-
and lower digitations of the serratus anterior der joint with reference to prosthetic joint replacement: In
form the lower part of the force couple. This Koelbel R, Helbig B, Blauth W (eds): Shoulder Replace-
was confirmed by an electromyographicstudy ment. Berlin, Springer-Verlag, 1987; with permission.)
174 HALDER et a1
Abnormal Scapulothoracic Rhythm 10. Browne AO, Hoffmeyer P, Tanaka S, et al: Glenohu-
meral elevation studied in three dimensions. J Bone
Poppen and Walkef17noticed that the rhythm Joint Surg Br 72:843-845,1990
became abnormal in patients with shoulder 11. Chen SK, Simonian IT,Wickiewicz TL, et al: Radio-
graphic evaluation of glenohumeral kinematics: A
pain, but they did not correlate this with the muscle fatigue model. J Shoulder Elbow Surg 8:49-
clinical diagnosis. Glenohumeral-to-scapulo- 52,1999
thoracic ratio increases in shoulders with 12. Colachis SC,Strohm BR, Brecher VL Effects of axil-
multidirectional instabilityn and decreases in lary nerve block on muscle force in the upper extrem-
shoulders with impingement and rotator cuff ity. Arch Phys Med Rehabil50:645-647,1969
13. Culham E, Peat M: Functional anatomy of the shoul-
tear.I7Paletta et alsospecified that in anteriorly der complex. J Orthop Sports Phys Ther 18:342-350,
unstable shoulders, the ratio increased during 1993
the first half of elevation, then decreased dur- 14. Debski RE, Wong EK, Warner JJP,et al: Interrelation-
ing the second half of elevation. Relatively in- ships of the capsuloligamentous restraints during
creased motion at the glenohumeral joint may translation of the glenohumeral joint. Transactions of
the 42nd Annual Meeting, Orthopedic Research So-
be caused by imbalance of the scapular mov- ciety 21:230,1996
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