PART 1
MECHANICS OF MOVEMENT AND EVALUATION
C H A P T E R
2 Robert A. Donatelli
Functional Anatomy and Mechanics
One of the most common peripheral joints to be treated in a
physical therapy clinic is the shoulder joint. The physical
therapist must have an in-depth understanding of the anat-
omy and mechanics of this joint to evaluate and design a
treatment program most effectively for the patient with
shoulder dysfunction. This chapter describes the pertinent
functional anatomy of the shoulder complex and relates this
anatomy to functional movements, stability, muscle activity,
and clinical application.
The shoulder joint is better called the shoulder complex,
because a series of articulations are necessary to position the
humerus in space (Fig. 2-1). Most authors, when describing
the shoulder joint, discuss the acromioclavicular (AC) joint,
the sternoclavicular joint (SC), the scapulothoracic articula-
tion, and the glenohumeral joint.1-4 Dempster5 related all
these areas by using a concept of links. The integrated and
harmonious roles of all the links are necessary for full normal
mobility.5
The glenohumeral joint sacrifices stability for mobility. This
joint is characterized by its large range of motion. The shoulder
is capable of moving in more than 16,000 positions, which can
be differentiated by 1 in a normal person.6 The mobility of
the shoulder relies on the congruent articulating surfaces and
the surrounding soft tissue envelope for static and dynamic sta-
bility. The position of the humerus and scapula must change
throughout each movement to maintain stability.6
OSTEOKINEMATIC AND ARTHROKINEMATIC
MOVEMENT
Analysis of shoulder movement emphasizes the synchronized
movement of four joints: the glenohumeral, scapulothoracic,
SC, and AC joints.2,4,7,8 As the humerus moves into elevation,
movement must occur at all four joints. Elevation of the arm
can be observed in three planes: the frontal plane (abduction),
the sagittal plane (flexion), and the plane of the scapula (POS;
scaption).8,9 Movement of the long bones of the arm into ele-
vation is referred to as osteokinematics. The term arthrokine-
matics describes the intricate movement of joint surfaces:
rolling, spinning, and sliding.10
Osteokinematic Movement
Scaption-Abduction: Plane of the Scapula
Abduction of the shoulder in the frontal or coronal plane has
been extensively researched.4,8,11-17 Poppen and Walker15 and
Johnston8 suggested that the true plane of movement in the
shoulder joint occurs in the POS. The term plane of the scapula
is defined as elevation of the shoulder in a range between 30
and 45 anterior to the frontal plane (Figs. 2-2 and 2-3).15
Kondo et al18 devised a method for taking radiographs to
define scaption during elevation. The medial tilting angle
was used to describe scaption. The medial tilting angle refers
to the tilting of the scapula toward the sagittal plane. As
the medial tilting angle increases, movement of the scapula
around the thoracic cage occurs. Kondo et al18 demonstrated
that the medial tilting angle was constant at 40 anterior to
the frontal plane throughout a range of 150 of elevation.
Several authors believe that the POS is clinically significant
because the length-tension relationship of the shoulder abduc-
tors and rotators is optimum in this plane of elevation.8,15
Research has demonstrated that the length of the muscle deter-
mines the amount of stretch applied to the individual sarco-
meres, thus enabling them to exert maximum tension.19 The
length-tension curves obtained from normal muscles show that
maximum tension develops when the muscle length is approx-
imately 90% of its maximum length.19 Conversely, when the
muscle is fully shortened, the tension developed is mini-
mal.20,21 Therefore, the optimal lengthened position of the
muscle tendon facilitates optimal muscle contraction.22
10 Physical Therapy of the Shoulder

3
5
2 6

Figure 2-1 The components of the shoulder joint complex: 1,

glenohumeral joint; 2, subdeltoid joint; 3, acromioclavicular joint; 4,
scapulothoracic joint; 5, sternoclavicular joint; 6, first costosternal joint;
7, first costovertebral joint.

Several studies have compared the torque production of

different shoulder muscle groups when tested in scaption ver-
sus other body planes.23-27 Soderberg and Blaschak23 and
Hellwig and Perrin24 demonstrated no significant differences
in the peak torque of the glenohumeral rotators between scap-
tion and other body planes. These studies used 45 and 40
anterior to the frontal plane, respectively, for the scaption test
position. Greenfield et al25 reported greater torque in the
external rotators when tested in scaption versus the coronal
plane. Furthermore, Tata et al26 reported higher ratios of
abduction to adduction and external to internal torque when
tested in the scapular plane at 30 and 35 anterior to the
frontal plane, respectively. Whitcomb et al27 found no signif-
icant difference in torque produced by the shoulder abductors
in the coronal and scapular planes when a scaption position
35 anterior to the frontal plane was used.
The studies cited indicate that the external rotators are the
only muscle group that demonstrate a significant increase in
Figure 2-2 Elevation in the plane of the scapula.
torque in the scaption plane 30 anterior to the frontal plane.
The pectoralis major and the latissimus muscle groups are not
attached to the scapula. Therefore, it would seem reasonable
that when the torque output of the internal rotators is com-
pared, the change in position of the scapula should not influ-
ence the optimal length-tension relationship. The internal
rotators exhibit no change in torque when they are tested in
different planes of movement.
In addition to optimal muscle length-tension relationship in
the POS, the capsular fibers of the glenohumeral joint are
relaxed.8 Because the capsule is untwisted in the POS, mobiliza-
tion and stretching in this plane may be tolerated better than in
other planes, where the capsule is starting in a twisted position.

Plane of the scapula

Abduction

Figure 2-3 Abduction in the plane of the scapula.


Poppen and Walker14 demonstrated that an increase in joint
congruity occurs in scaption that allows for greater joint sta-
bility. Therefore, for reasons of glenohumeral stability, mini-
mal scapular torsion, avoidance of impingement, and balance
of muscle action, scaption may be the plane in which shoulder
trauma is minimal and may thus be the most advantageous
plane for mobilization, stretching, testing, and strengthening
of the glenohumeral rotators.
Flexion
The movement of flexion has been investigated less thor-
oughly. Flexion is movement in the sagittal plane. Full flexion
from 162 to 180 is possible only with synchronous motion
in the glenohumeral, AC, SC, and scapulothoracic joints.14
The movement is similar to that of abduction.
Arthrokinematic Movement
The motion occurring at joint surfaces is arthrokinematic
motion, the three types of which are rolling, gliding, and rota-
tion (Fig. 2-4). Rolling occurs when various points on a
moving surface contact various points on a stationary surface.
Gliding occurs when one point on a moving surface contacts
multiple points on a stationary surface. During rolling or
gliding, a significant change occurs in the contact area
between the two joint surfaces. The third type of arthrokine-
matic movement, rotation, occurs when one or more points on
a moving surface contact one point on a stationary surface.
Displacement between the two joint surfaces in rotation is
minimal.
All three arthrokinematic movements can occur at the gle-
nohumeral joint, but not in equal proportions. These motions
are necessary for the large humeral head to take advantage of
the small glenoid articulating surface.16 Saha16 investigated
Rolling
Glenohumeral Jt.
Gliding
Figure 2-4 Arthrokinematic motion occurring at the glenohumeral joint: rolling, rotation, and gliding.
Chapter 2 Functional Anatomy and Mechanics 11
the contact area between the head of the humerus and the gle-
noid with abduction in the POS and found that the contact
area on the head of the humerus shifted upward and forward,
whereas the contact area on the glenoid remained relatively
constant, a finding indicating a rotation movement. Poppen
and Walker15 measured the instant centers of rotation for
the same movement. These investigators found in the first
30 , and often between 30 and 60 , that the head of the
humerus moved superiorly in the glenoid by 3 mm, a finding
indicating rolling or gliding. At more than 60 , movement of
the humerus was minimal, a sign of almost pure rotation.15
Effective arthrokinematic movements are achieved by com-
plex interaction between the various articular and soft tissue
restraints in addition to the dynamic action of the rotator cuff
muscles. For example, the rotator cuff muscles center the
humeral head in the congruent glenoid fossa during the mid-
range of motion when the capsuloligamentous structures are
lax.28 Dysfunction of this complex mechanism occurs with
tightening of the capsule anteriorly, a situation that results
in anterior restriction and causes an associated posterior shift
in contact of the humerus on the glenoid. The posterior
migration of the humeral head center and glenohumeral con-
tact are pronounced in shoulder joints with poor congru-
ence.28 To re-establish harmonious movement within the
shoulder complex, the therapist must rehabilitate the connec-
tive tissue by restoring its extensibility and the normal bal-
ance of muscles.
ROTATIONS OF THE HUMERUS
Rotations of the humerus are important for elevation. Con-
comitant external rotation of the humerus is necessary for
abduction in the coronal plane.4,8,10,14,17 Some investigators
have postulated that this motion is necessary for the greater
Rotation
12 Physical Therapy of the Shoulder
tuberosity to clear the acromion and the coracoacromial liga-
ment.1,2,17 Saha16 reported sufficient room between the
greater tuberosity and the acromion to prevent bone impinge-
ment. External rotation also remains necessary for full coronal
abduction even after surgical removal of the acromion and the
coracoacromial ligament. Saha16 reasoned that external rota-
tion is necessary to prevent the humeral head from impinging
on the glenoid rim.
Using cadaveric glenohumeral joints, Rajendran29 demon-
strated that automatic external rotation of the humerus is an
essential component of active and passive elevation of the
arm through abduction. Even in the absence of extra-articular
influences, such as the coracoacromial arch and glenohumeral
muscles, external rotation of the humerus was spontaneous.
An et al30 used a magnetic tracking system to monitor the
three-dimensional orientation of the humerus with respect
to the scapula. Appropriate coordinate transformations were
then performed for the calculation of glenohumeral joint
rotation. Maximum elevation in all planes anterior to the
scapular plane required external axial rotation of the humerus.
Browne et al,31 using three-dimensional magnetic field track-
ing, demonstrated that elevation in any plane anterior to the
scapula required external humeral rotation. Furthermore,
maximum elevation was associated with approximately 35
of external humeral rotation. Conversely, internal rotation
was necessary for increased elevation posterior to the POS.
Otis et al32 demonstrated that external rotation of the
humerus allows the insertion of the subscapularis tendon to
move laterally, with a resulting increase in the distance from
the axis of elevation in the scapular plane. An increase in the
moment arm enhances the ability of the superior fibers of the
subscapularis to participate in scaption. Conversely, internal
rotation of the humerus increases the moment arm of the supe-
rior fibers of the infraspinatus and increases the ability of the
muscle to participate in scaption. Flatow et al33 reported that
acromial undersurface and rotator cuff tendons are in closest
proximity between 60 and 120 of elevation.
Conditions limiting external rotation or elevation may
increase rotator cuff compression. Rajendran and Kwek34
described how the course of the long head of the biceps
(LHB) would influence external rotation of the humerus,
which, in turn, prevents tendon impingement between the
greater tuberosity and the glenoid labrum and allows gleno-
humeral elevation to move to completion. Brems35 reported
that external rotation is possibly the most important func-
tional motion that the shoulder complex allows. Loss of exter-
nal rotation can result in significant functional disability.
Walker36 described external rotation of the humerus as neces-
sary for the greater tuberosity to clear the glenoid, thus
providing more articular cartilage motion to produce eleva-
tion of the arm. Abboud and Soslowsky37 reported that loss
of rotational range of motion is deleterious because of its
effect on activities of daily living and sports and its likely
relation to the development of osteoarthritis.
External rotation is an important component for active
abduction in POS elevation. In a pilot study, Donatelli38
demonstrated a direct correlation between passive external
rotation, measured in the adducted position, and active
abduction in the POS.
When treating patients with limited active elevation, the
practitioner should avoid pushing the joint into painful eleva-
tion activities. Restoring passive external rotation in the
adducted position is a safe and effective way of restoring
extensibility to the capsule and enhancing active abduction
in the POS.
STATIC STABILIZERS OF THE
GLENOHUMERAL JOINT
The stability of the glenohumeral joint depends on the integ-
rity of soft tissue and bony structures such as the labrum,
glenohumeral ligaments, capsular ligaments, and bony gle-
noid.39 The glenohumeral joint contributes the greatest
amount of motion to the shoulder because of its ball and
socket configuration. Saha40 confirmed the ball and socket
joint of the glenohumeral articulation in 70% of his subjects.
In the remaining 30%, the radius of curvature of the humeral
head was greater than the radius of curvature of the glenoid.
Thus, the joint was not a true enarthrosis.16 Saha16 further
described the joint surfaces, especially on the head of the
humerus, to be very irregular and to demonstrate a great
amount of individual variation.
The head of the humerus is a hemispherical convex articu-
lar surface that faces superiorly, medially, and posteriorly. This
articular surface is inclined 130 to 150 to the shaft of the
humerus and is retroverted 20 to 30 .3 The retroversion
and the posterior tilt of the head of the humerus and the gle-
noid cultivate joint stability (Fig. 2-5). This retroversion of
the head of the humerus corresponds to the forward inclina-
tion of the scapula, so that free pendulum movements of the
arm do not occur in a straight sagittal plane but at an angle
of 30 across the body.41 Retroversion of the humeral head
corresponds to the natural arm swing evident in ambulation.
The head of the humerus is large in relation to the glenoid
fossa. Therefore, only one third of the humeral head can contact
the glenoid fossa at a given time.1,41 The glenoid fossa is a shal-
low structure deepened by the glenoid labrum. The labrum is
wedge shaped when the glenohumeral joint is in a resting posi-
tion and changes shape with various movements.42 The glenoid
and the labrum combine to form a socket with a depth up to
9 mm in the superior-inferior direction and 5 mm in the ante-
rior-posterior direction.43 The functional significance of the
labrum is questionable. Most authors agree that the labrum is
a weak supporting structure.42,44 The function of the labrum
has also been described as a “chock block” preventing humeral
head translation.45 Moseley and Overgaard42 considered the
labrum a redundant fold of the capsule composed of dense
fibrous connective tissue but generally devoid of cartilage
except in a small zone near its osseous attachment.
The glenohumeral joint was described by Matsen et al46 as
a suction cup because of the seal of the labrum and glenoid to
the humeral head. This phenomenon is caused by the
graduated flexibility of the glenoid surface, which permits

A the dynamic stability of the glenohumeral joint. Joint forces
B tion the shearing force is the greatest. The line of pull of
Figure 2-5 A, Humerus with marker through the head-neck and a
second marker through the epicondyles. B, Retroversion of the
humerus as seen from above.
the glenoid to conform and seal to the humeral head. Com-
pression of the head into the socket expels the synovial
fluid to create suction that resists distraction. Negative intra-
articular joint pressure is produced by the limited joint vol-
ume.47 Matsen et al46 illustrated the importance of an intact
glenoid labrum in establishing concavity compression stabiliza-
tion. The compressive load is provided by dynamic muscle con-
traction. In addition, Matsen et al46 discussed the importance
of the central position of the humerus on the glenoid, to opti-
mize the mechanical advantage of the rotator cuff muscles.
The glenoid fossa faces laterally. Freedman and Munro48
found that the glenoid faced downward in 80.8% of the
shoulders they studied radiographically. Saha40 found a 7.4
retrotilt of the glenoid in 73.5% of normal subjects. The retro-
tilt is a stabilizing factor in the glenohumeral joint. Both the
humeral and glenoid articular surfaces are lined with articular
cartilage. The cartilage is the thickest at the periphery on the
glenoid fossa and at the center of the humeral head.16
Central Position of the Humerus on the
Glenoid
Because the shoulder is not inherently stable, the orientation
and location of the joint reaction force with respect to the gle-
noid surface are important considerations in joint stability
Chapter 2 Functional Anatomy and Mechanics 13
and function. The central location of the humeral head is
maintained by a balance of muscle forces and connective tissue
extensibility. Off-center joint force has more potential for sub-
luxation and dislocation.49
If the head of the humerus is not in a central position, it
will reduce the compressive forces of the rotator cuff muscles,
thereby decreasing dynamic stability by altering the length
tension of the rotator cuff muscles. A reduction in rotator cuff
strength promotes destabilizing forces and poor joint
arthrokinematics.
Clinical Evaluation of Humeral Head Central
Position
• Evaluation of scapula posture
• Assessment of glenohumeral capsular extensibility by tests
of external and internal rotation in various positions
• Assessment of strength of the rotator cuff muscles
• Assessment of strength of the scapula rotators
A centrally located humeral head on the glenoid enhances
associated with the rotator cuff muscles are stabilizing to
the glenohumeral joint, whereas the forces produced by the
deltoid muscles deviate from the surface of the glenoid joint
during elevation of the arm. At 60 of glenohumeral abduc-
the deltoid is oriented superiorly and parallel to the glenoid
surface; this can be described as a shearing force. This parallel
and superior action of the deltoid muscle may therefore result
in a more off-center joint reaction force at the glenoid surface.
This off-centered joint force could be the cause of several
mechanic dysfunctions of the shoulder, including impinge-
ment and rotator cuff tears. Ideally, the best strategy for a
glenohumeral elevation would be the combination of a strong
deltoid muscle and the rotator cuff muscles to stabilize the
joint by directing the joint force toward the a stable compres-
sive force that is the center of the joint surface.
Anatomy of the Glenohumeral Ligaments
The coracohumeral ligament is the strongest supporting liga-
ment of the glenohumeral joint. Fibers of the capsule and cor-
acohumeral ligament blend together and insert into the
borders of the supraspinatus and subscapularis.50 Portions of
the coracohumeral ligament form a tunnel for the biceps ten-
don on the anterior side of the joint. The rotator cuff interval,
the region of the capsule between the anterior border of the
supraspinatus and the superior border of the subscapularis
muscle, is reinforced by the coracohumeral ligament.45 The
superior glenohumeral ligament and the coracohumeral liga-
ment limit external rotation and abduction of the humerus
and are important stabilizers in the inferior direction from
0 to 50 of abduction.45,51
The superior glenohumeral ligament forms an anterior
cover around the LHB tendon and is also part of the rotator
cuff interval.45 The coracohumeral ligament blends with the
superior glenohumeral ligament. The anatomy of the middle
14 Physical Therapy of the Shoulder
glenohumeral ligament is similar to that of the superior gle-
nohumeral ligament. The middle glenohumeral ligament
blends with portions of the subscapularis tendon medial to
its insertion on the lesser tuberosity. The middle glenohum-
eral ligament has been shown to become taut at 45 of abduc-
tion, and at 10 of extension and external rotation, and it
provides anterior stability between 45 and 60 of abduction.
The inferior glenohumeral ligament complex is a
hammock-like structure with attachments on the anterior and
posterior sides of the glenoid. The anterior band of the inferior
glenohumeral ligament is attached to the anterior labrum. At
the neutral position (0 of abduction and 30 of horizontal
extension), the anterior band of the inferior glenohumeral liga-
ment becomes the primary stabilizer. The inferior glenohum-
eral ligament complex was found to be the most important
stabilizer against anterior-inferior shoulder dislocation.45,52
The capsule and ligaments reinforce the glenohumeral joint.
The capsule attaches around the glenoid rim and forms a sleeve
around the head of the humerus, by attaching on the anatomic
neck. A functional interplay or interdependence exists between
the anterior and posterior and superior and inferior capsuloliga-
mentous system. This concept is referred to as the circle theory, a
term implying that excessive translation in one direction may
damage the capsule on the same and opposite sides of the
joint.37 The capsule is a lax structure. The head of the humerus
can be distracted one-half inch when the shoulder is in a
relaxed position.51 The anterior capsule is reinforced by the gle-
nohumeral ligaments noted earlier. The support these liga-
ments lend to the capsule is insignificant.53
Turkel et al54 described the inferior glenohumeral ligament
as the thickest and most consistent structure. The inferior
A B
Figure 2-6 External rotation of the humerus. A, In the adducted position. The most stabilizing structure to this movement is the subscapularis muscle.
B, At 45 of abduction. The most stabilizing structures for this movement are the middle and inferior ligaments and the subscapularis muscle. C, At 90 of
abduction. The most stabilizing structure for this movement is the inferior ligament.
glenohumeral ligament attaches to the glenoid labrum. Turkel
et al54 determined the relative contribution to anterior stability
by testing external rotation in different positions. The subscapu-
laris resisted passive external rotation in the adducted position
more than any other anterior structure (Fig. 2-6A). In patients
with internal rotation contracture and pain after anterior repair
for recurrent dislocation of the shoulder, surgical release of the
subscapularis increased the external rotation range of motion
an average of 27 .55 Turkel et al54 demonstrated that, at 45 of
abduction, external rotation was resisted by the subscapularis,
middle glenohumeral ligament, and superior fibers of the infe-
rior ligament (Fig. 2-6B). At 90 of abduction, the inferior gle-
nohumeral ligament (Fig. 2-6C) restricted external rotation.
Itoi et al56 concluded that the LHB and short head of the
biceps (SHB) have similar functions as anterior stabilizers of
the glenohumeral joint with the arm in abduction and external
rotation. Furthermore, the role of the LHB and SHB increased
with shoulder instability. Warner et al57 studied the capsuloliga-
mentous restraints to superior and inferior translation of the gle-
nohumeral joint. The primary restraint to inferior translation of
the adducted shoulder was the superior glenohumeral ligament.
Abduction to 45 and 90 demonstrated the anterior and poste-
rior portions, respectively, of the glenohumeral ligament to be
the main static stabilizers resisting inferior translation.
Guanche et al58 studied the synergistic action of the cap-
sule and the shoulder muscles. A reflex arch was identified
from mechanoreceptors within the glenohumeral capsule to
muscles crossing the joint. Stimulation of the anterior and
inferior axillary articular nerves elicited electromyographic
(EMG) activity in the biceps, subscapularis, supraspinatus,
and infraspinatus muscles. Stimulation of the posterior
C

axillary articular nerve elicited EMG activity in the acromio-
deltoid muscle.
Between the supporting ligaments and muscles lie synovial
bursae or recesses. Anteriorly, three distinct recesses are pres-
ent.59 The superior recess is the subscapular bursa, which nor-
mally communicates with the shoulder joint. The inferior
recess is referred to as the axillary pouch, and the middle
synovial recess lies posterior to the subscapularis tendon.
Arthrograms of frozen shoulders in relatively early stages,
before glenohumeral abduction is completely restricted, show
obliteration of the anterior glenoid bursa.60
DYNAMIC STABILIZERS OF THE
GLENOHUMERAL JOINT
The major muscles that act on the glenohumeral and scapu-
lothoracic joints may be grouped into the scapulohumeral,
axiohumeral, and axioscapular muscles. The muscles of the
scapulohumeral group, which include the rotator cuff mus-
cles, originate on the scapula and insert on the humerus.
The rotator cuff muscles insert on the tuberosities and along
the upper two thirds of the humeral anatomic neck.10 The
contribution of the shoulder musculature to joint stability
may be caused by the following mechanisms: muscle bulk act-
ing as a passive muscle tension, contraction of the rotator cuff
muscles primarily causing compression of the articular sur-
faces, joint motion that secondarily tightens the ligamentous
constraints, barrier or restraint effects of the contracted mus-
cle, and redirection of the joint force to the center of the gle-
noid surface by coordination of muscle forces.37
The infraspinatus and teres minor control external rotation
of the humerus and reduce anterior-inferior capsuloligamen-
tous strain. The subscapularis muscle is the strongest stabi-
lizer of the rotator cuff muscles. It has the largest amount of
muscle mass of the four rotator cuff muscles.4 Combined con-
traction of the subscapularis and the infraspinatus forms a
force couple, providing stability throughout the midrange of
elevation, which is from 60 to 150 of abduction.52
Researchers showed that during late cocking by baseball
pitchers, the glenohumeral joint reaches extreme external
rotation. The subscapularis is the strongest activity stabilizer,
followed by the infraspinatus and teres minor. The supraspi-
natus has the least stabilizing activity.37 In addition, the sub-
scapularis of a professional baseball pitcher is more active in
the propulsive phase than any other internal rotator.37
Travell and Simons60 believed that a trigger point within
the subscapularis may spur the other shoulder girdle muscula-
ture into developing secondary and satellite trigger points.
These points would lead to major restrictions in glenohumeral
joint motion and cause adhesive capsulitis.
The rotator cuff muscles have been described as steering
mechanisms for the head of the humerus on the glenoid.16
The subscapularis, latissimus dorsi, teres major, and teres
minor act as humeral depressors.16,61 The arthrokinematics
(rolling, spinning, and sliding) of the glenohumeral joint
result from the action of the steering mechanisms and the
Chapter 2 Functional Anatomy and Mechanics 15
depressors of the humeral head. Translation of the humeral
head is of clinical interest in most shoulder disorders. At the
glenohumeral joint, the amount and direction of translation
define the type of instability. Wuelker et al62 demonstrated
that translation of the humeral head during elevation of the
glenohumeral joint between 20 and 90 averaged 9 mm
superiorly and 4.4 mm anteriorly. Translation of the humeral
head during active elevation may be diminished by the coor-
dinated activity of the rotator cuff muscles. This active con-
trol of translation forces provides dynamic stability to the
glenohumeral joint. Perry63 described 17 muscle groups that
provide dynamic interactive stabilization of the composite
movement of the thoracoscapular humeral articulation.
The deltoid muscle makes up 41% of the scapulohumeral
muscle mass.4 This muscle, in addition to its proximal attach-
ment on the acromion process and the spine of the scapula,
also stems from the clavicle. The distal insertion is on the
shaft of the humerus at the deltoid tubercle. The mechanical
advantage of the deltoid is enhanced by the distal insertion
and the evolution of a larger acromion process.4 The deltoid
is a multipennate and fatigue-resistant muscle. These charac-
teristics may explain the rare involvement of this muscle in
pathologic shoulder conditions.64 The deltoid and the clavic-
ular head of the pectoralis major muscles have been described
as prime movers of the glenohumeral joint because of their
large mechanical advantage.4 Michiels and Bodem65 demon-
strated that deltoid muscle action is not restricted to the gen-
eration of abduction in the shoulder joint.
The deltoid provides dynamic stability with the arm in the
scapular plane and decreases stability with the arm in the cor-
onal plane. The middle and posterior heads of the deltoid pro-
vide more stability by generating more compressive forces and
lower shearing forces than the anterior head. Therefore, the
middle and posterior heads of the deltoid should strengthen
vigorously in anterior shoulder instability.66
Itoi et al56 reported that the biceps muscle group becomes
more important than the rotator cuff muscles as stability from
the capsuloligamentous structure decreases. The anterior dis-
placement of the humeral head under a 1.5-kg force was signif-
icantly decreased by both LHB and SHB loading in all capsular
conditions when the arm was in 60 or 90 of external rotation
and abduction. Abboud and Soslowsky37 demonstrated that the
LHB in the shoulder neutral position is anterior to the joint.
Internal rotation of the humerus positions the tendon of the
biceps further anterior to the joint, and external rotation posi-
tions the biceps tendon posterior to the joint. The forces gener-
ated by the LHB help to stabilize the glenohumeral joint and
assist in restricting the translations of the humeral head. The
restrictions in translation of the humeral head result from inter-
nal and external rotation of the humerus that allow the forces
generated by the tendon to change to compressive with a pos-
terior-directed force and compressive with an anterior-directed
force, respectively (Fig. 2-7).
The deltoid and the rotator cuff muscles produce shearing
and compressive forces in the glenohumeral joint. These forces
vary as the alignment of the muscles changes.67 The compres-
sive forces produced by those muscles acting parallel to the
16 Physical Therapy of the Shoulder
ER
N
IR
A toid during flexion and abduction demonstrated a potential
B C
Figure 2-7 Forces produced by the long head of the biceps tendon in
conjunction with internal rotation (IR) and external rotation (ER) of the
humerus. A, Tendon position neutral and anterior to joint, ER posterior
to joint, IR anterior to joint. B, Forces are compressive and posterior
with IR. C, Forces are compressive and anterior with ER. (Modified
from Pagnani MJ, Xiang-Hua D, Warren RF, et al: Role of the long head
of the biceps brachii in glenohumeral stability: a biomechanical study in
cadavers, J Shoulder Elbow Surg 5:225–262, 1996.)
glenoid fossa stabilize the humeral head. Muscles acting more
perpendicular to the glenoid produce a translational shear.
A larger superior shear produces impingement, whereas a
larger compressive force centers the humeral head in the
glenoid and reduces impingement of the rotator cuff under
the acromion.67 The central position of the humeral head on
the glenoid helps to stabilize the glenohumeral joint.
Payne et al67 simulated rotator cuff, deltoid, and biceps mus-
cle forces on 10 human cadaver shoulders using transducers
within the acromial arch. The muscle forces that reduced acro-
mial pressure included the biceps, which decreased acromial
pressure by 10% in all the shoulders and 34% in 6 of the
shoulders. Rotator cuff muscle force, without simulating supra-
spinatus, was very effective in reducing the acromial pressure.
With simulation of the subscapularis, infraspinatus, and teres
minor, these investigators noted a 52% decrease in the ante-
rior-lateral acromion pressure in neutral shoulders with type
III acromion. Without the rotator cuff force, the amount of
deltoid force required to abduct the arm increased by 17%.
According to the study by Payne et al,67 the action of the deltoid
muscle increased the pressures under the acromion by 1240%.
One study described the lines of action of 18 major muscles
spanning the shoulder joint during abduction and flexion and
their potential contributions to glenohumeral joint stability.68
The superior pectoralis major and inferior latissimus dorsi were
the chief scapular plane destabilizers, with a demonstrated abil-
ity to provide superior and inferior shear to the glenohumeral
joint, respectively. Evaluation of the middle and anterior del-
contribution to superior shear, by opposing the combined
destabilizing inferior shear potential of the latissimus dorsi
and inferior subscapularis. The rotator cuff muscles were more
aligned to stabilize the glenohumeral joint in the transverse
plane than in the scapular plane. Overall, the anterior supraspi-
natus was most favorably oriented to apply glenohumeral joint
compression. The study identified the posterior deltoid and
subscapularis as potential stabilizers because they had posteri-
orly directed muscle lines of action, whereas the teres minor
and infraspinatus had anteriorly directed lines of action.
The foregoing study helps the clinician identify the
dynamic action of muscles surrounding the shoulder. A coor-
dinated activation of the destabilizers and stabilizer muscles
results in movement patterns that are not destructive to the
shoulder. However, muscle imbalances around the shoulder
may be the underlying cause of abnormal movement patterns
and the resultant pathologic process. Knowledge of the stabi-
lizing potential of shoulder musculature may assist clinicians
in identifying muscle-related instabilities and may aid in
the development of rehabilitation programs to improve joint
stability and prevention programs.
STERNOCLAVICULAR JOINT
The SC joint is the only articulation that binds the shoulder
girdle to the axial skeleton (Fig. 2-8). This is a sellar joint,
with the sternal articulating surface greater than the clavicular
surface, thus providing stability to the joint.10 The joint is
also stabilized by its articular disk, joint capsule, ligaments,
and reinforcing muscles.5,69 The disk binds the joint together
Figure 2-8 The upper and lower attachments of the meniscus and the
upper and lower ligaments of the sternoclavicular joint.

and divides the joint into two cavities. The capsule surrounds
the joint and is thickest on the anterior and posterior aspects.
The section of the capsule from the disk to the clavicle is more
lax and allows more mobility than among the disk, sternum,
and first rib.10 The interclavicular ligament anteriorly and
inferiorly reinforces the capsule. The costoclavicular ligament
connects the clavicle to the first rib.10 The SC joint gains
increased stability from muscles, especially the sternocleido-
mastoid, sternohyoid, and sternothyroid.69
ACROMIOCLAVICULAR JOINT
At the other end of the clavicle is the AC joint. This articula-
tion is characterized by variability in size and shape of the cla-
vicular facets and the presence of an intra-articular
meniscus.66 The AC joint capsule is more lax than the SC
joint, and thus a greater degree of movement occurs at the
AC joint that contributes to the increased incidence of dislo-
cations.69 The AC joint has three major supporting ligaments.
The conoid and trapezoid ligaments are collectively called the
coracoclavicular ligament and the AC ligament. It is through the
conoid and trapezoid ligaments that scapula motion is trans-
lated to the clavicle.5
Rotation of the clavicle is the major movement at the AC
joint. Steindler70 described AC joint rotation occurring
around three axes. Longitudinal axial rotation, vertical axis
for protraction and retraction, and horizontal axis for elevation
and depression are all controlled and facilitated by the conoid,
trapezoid, and AC ligaments (Fig. 2-9).
Scapulothoracic Joint
The scapulothoracic joint is not an anatomic joint, but it is an
important physiologic joint that adds considerably to motion
of the shoulder girdle. The scapula is concave, articulating
B function and joint kinematics allow normal, pain-free motion.
C ment of shoulder dysfunction.
A ing surface.16 Saha74 and Sharkey and Marder75 investigated
Figure 2-9 Axes of motion of the clavicle. A, Longitudinal axis of
rotation. B, Vertical axis for protraction and retraction. C, Horizontal axis
for elevation and depression. The sternal end of the scapula is on the
left. (From Schenkman M, Rugo de Cartaya V: Kinesiology of the
shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with
permission of the Orthopaedic and Sports Physical Therapy Sections of
the American Physical Therapy Association).
Chapter 2 Functional Anatomy and Mechanics 17
with a convex girdle.1,63 The scapula is without bony or liga-
mentous connections to the thorax, except for its attachments
at the AC joint and coracoacromial ligament. The scapula is
primarily stabilized by muscles. The importance of the scap-
ula rotators has been established as an essential ingredient of
glenohumeral mobility and stability (Fig. 2-10). The stable
base and therefore the mobility of the glenohumeral joint
largely depend on the relationship of the scapula and the
humerus. The scapula and humerus must accommodate to
ever-changing positions during shoulder movement to main-
tain stability.6 Figure 2-11 demonstrates the force couple of
the scapula rotators.
Scapulothoracic kinematics involve combined SC and AC
joint motions.71,72 Three-dimensional motion occurs at both
the SC and AC joints during arm elevation in healthy sub-
jects.71,72 The clavicle demonstrates a pattern of slight eleva-
tion and increasing retraction as arm elevation progresses
overhead.72
Teece et al71 described that the scapula is simultaneously
upwardly rotating, internally rotating, and posteriorly tilting
relative to the clavicle at the AC joint (Fig. 2-12). In addi-
tion, scapulothoracic “translations” of elevation and depres-
sion and abduction and adduction were observed by the
Teece et al.71 These scapula movements actually derive from
clavicular motions at the SC joint. Scapulothoracic elevation
is a result of SC elevation, and abduction and adduction result
from SC protraction and retraction.72,73
FUNCTIONAL BIOMECHANICS
As previously noted, shoulder elevation is defined as the move-
ment of the humerus away from the side. It can occur in a
seemingly infinite number of body planes.47
Shoulder elevation can be divided into three phases. The
initial phase of elevation is 0 to 60 . The middle or “critical”
phase is 60 to 140 . The final phase of elevation is 140 to
180 . Specific to each phase of movement, precise muscle
Analysis of the precise components critical for each phase of
shoulder elevation determines the success of clinical manage-
Initial Phase of Elevation: 0 to 60
All three arthrokinematic movements occur at the glenohum-
eral joint, but they do not occur in equal proportions. These
movements—roll, spin, and glide—are necessary for the large
humeral head to take advantage of the small glenoid articulat-
the contact area between the head of the humerus and the gle-
noid with elevation in abduction and in scaption. The studies
found that the contact area on the head of the humerus was
centered at 30 and was superiorly shifted 1.5 mm by 120 .
Poppen and Walker14 also studied the instant centers of rota-
tion for abduction. These investigators reported that in the
first 30 and often between 30 and 60 of abduction, the
18 Physical Therapy of the Shoulder

FUT
FUT

FSA
FSA

FLT

A B

Figure 2-10 Force couple of muscles acting at scapula. A, Axis of scapular rotation from 0 to 30 . B, Axis of scapular rotation from 30 to 60 . FLT, force
of lower trapezius; FSA, force of serratus anterior; FUT, Force of upper trapezius. (Modified from Schenkman M, Rugo de Cartaya V: Kinesiology of the
shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with permission of the Orthopaedic and Sports Physical Therapy Sections of the American
Physical Therapy Association.)

humerus in the initial phase of elevation.3 Kadaba et al61

Upper reported EMG activity of the upper and lower portions of
trapezius Levator
scapulae the subscapularis muscle recorded by intramuscular wire elec-
trodes. During the initial phase of elevation, EMG activity of
the upper subscapularis was greater at the beginning of the
range, whereas the lower subscapularis increased as the eleva-
Rhomboideus tion reached 90 .54 A significant amount of force is generated
minor at the glenohumeral joint during abduction.4,15 In the early
Middle stages of abduction, the loading vector is beyond the upper
trapezius edge of the glenoid.76
Rhomboideus During the initial stage of elevation, the pull of the deltoid
major muscle produces an upward shear of the humeral head.3 This
shearing peaks at 60 of abduction and is counteracted by the
transverse compressive forces of the rotator cuff muscles.3,15
The primary function of the subscapularis muscle is to depress
Serratus the humeral head, thus counteracting the superior migrating
anterior force of the deltoid.61 At 60 (abduction), the downward
(short rotator) force is maximal at 9.6 times the limb weight
Lower
trapezius or 0.42 times the body weight.2,15 The subscapularis, infra-
spinatus, and latissimus dorsi muscle have small lever arms
that form 90 angles to the glenoid face, thereby producing
compressive forces to the joint.
Figure 2-11 Force couple of the scapula rotators.
Movement of the AC and SC joints permits movement of
the scapula. Shoulder abduction is accompanied by clavicular
elevation. SC elevation is most evident during the initial
head of the humerus moved superiorly in the glenoid by phase of arm elevation. A 4 SC movement occurs for each
3 mm, a finding that indicates the occurrence of rolling or 10 of shoulder abduction.4 The AC joint moves primarily
gliding of the head. The EMG activity of the supraspinatus before 30 and after 135 .4
muscle indicates an early rise in tension that produces a com- The instantaneous center of rotation (ICR) of the scapula
pressive force on the glenohumeral joint surface. during the initial phase of elevation is located at or near the
The deltoid muscle also demonstrates EMG activity in the root of the scapula spine in line with the SC joint.77 The
initial phase of elevation. The subscapularis, infraspinatus, initial phase of arm elevation was referred to by Poppen
and teres minor muscles are important stabilizers of the and Walker15 as the setting phase; scapula rotation occurs
 Chapter 2 Functional Anatomy and Mechanics 19

A B

D E
C

Figure 2-12 It is important to understand the various motions of the scapula relative to the thorax: A, upward and downward rotation; B, protraction and
retraction; C, elevation and depression; D, tilting about a frontal axis; and E, tilting about a vertical axis. (Porterfield, James A. Mechanical Shoulder
Disorders: Perspectives in Functional Anatomy. W.B. Saunders Company, 102003.)

about the lower midportion. The relative contribution from

scapular rotation during the initial phase of elevation is
D
considerably less than from glenohumeral motion. Bagg S
and Forest77 estimated a 3.29:1 ratio of glenohumeral to R
scapulothoracic mobility during the initial phase of elevation. D
The upper trapezius and lower serratus anterior muscles pro-
vide the necessary rotatory force couple to produce upward I SⴙI
scapular rotation during the early phase of arm abduction.78

Middle or Critical Phase of Elevation:

60 to 100
The middle or critical phase of elevation is initiated by exces-
sive force at the glenohumeral joint. As previously noted, the
shearing of the deltoid muscle is maximal at 60 elevation
(Fig. 2-13). Wuelker et al62 simulated muscle forces under
the coracoacromial vault. The forces at the glenohumeral joint
were recorded and applied to the shoulder muscles at a con-
stant ratio approximating physiologic conditions of shoulder
elevation: deltoid, 43%; supraspinatus, 9%; subscapularis,
26%; and infraspinatus/teres minor, 22% (Fig. 2-14). Peak
forces under the coracoacromial vault occurred between 51
and 82 of glenohumeral joint elevation. These force values
may represent the pathomechanics of shoulder impingement.
Figure 2-15 demonstrates the compressive and depressive
forces generated by the muscles that provide a parallel force
to the glenohumeral joint to counteract the shearing of the
deltoid muscle group, which is perpendicular to the gleno-
humeral joint.
Figure 2-13 In the early stages of glenohumeral abduction, the deltoid
reactive force (D) is located outside the glenoid fossa. The transverse
compressive forces of the supraspinatus (S) and infraspinatus (I)
muscles are counteracted by this force. The resultant reactive force (R)
is therefore more favorably placed within the glenoid fossa for joint
stability.
The resultant acting forces, which help to stabilize the
joint, are maximal at 90 of elevation,3 with shear and com-
pressive forces equal.78 As the arm reaches the end of the crit-
ical phase, the resultant and shearing forces of the deltoid are
almost zero.3,15
The balance of shearing and compressive force establishes
dynamic stability of the glenohumeral joint. In the early part
20 Physical Therapy of the Shoulder

110 of abduction and maintains a plateau level of activity.3

Supraspinatus EMG activity peaks at 100 of elevation and
rapidly diminishes thereafter.3 The subscapularis activity
FTD
decreases substantially after 130 of elevation, a finding sup-
porting the concept that anterior ligament stability is critical

FDeltoid
beyond 130 of elevation.3
The head of the humerus demonstrates an excursion of 1 to
2 mm of a superior and inferior glide on the glenoid surface.14
FRR The movement of the humeral head in a superior and inferior
FTR
FRD
direction after 60 of elevation indicates that roll and glide
uff

are occurring in opposite directions, resulting in a spin of

rc
o
tat

the bone. As previously noted, external rotation of the

Ro
F

humerus is critical for elevation (abduction) of the arm.

Figure 2-14 Force couple of deltoid and rotator cuff muscles. Rotatory
forces, acting on opposite sides of the axis of motion, combine to
produce upward rotation. Translatory forces cancel each other out. FRD,
rotatory force of deltoid; FRR, Rotatory force of rotator cuff; FTD,
translatory force of deltoid; FTR, translatory force of rotator
cuff. (Modified from Schenkman M, Rugo de Cartaya V: Kinesiology of
the shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with
permission of the Orthopaedic and Sports Physical Therapy Sections of
the American Physical Therapy Association.)
Acromion Supraspinatus
Deltoid
Subscapularis
Lat
iss Infraspinatus
imu
sd and Teres minor
ors
i
Biceps
Figure 2-15 Forces provided to the muscles that are parallel to the
glenohumeral joint. These muscles produce compressive and
depressive forces to help stabilize the glenohumeral joint. The deltoid
muscle is perpendicular to the glenohumeral joint.
of the critical phase, dynamic stability must be initiated
before further progression of pain-free movement can occur.
As previously noted, the lower fibers of the subscapularis
muscle showed more activity at 90 of abduction.61 The del-
toid muscle reaches maximum EMG activity at approximately
Bagg and Forrest77 examined 20 subjects and found three
distinctive patterns of scapulohumeral movement. Each pat-
tern had three phases with varying ratios of humeral to scap-
ular movement. The most common pattern had 3.29 of
humeral motion to every degree of scapular motion from
20.8 to 81.8 of scaption. The humeral component decreased
to 0.71 for scaption between 81.8 and 139.1 . Therefore,
the greatest relative amount of scapular rotation occurs between
80 and 140 of arm abduction.77 The ratio of glenohumeral to
scapulothoracic motion has been calculated to be 0.71:1 during
the middle phase of elevation.78 Doody et al,12 along with
Freedman and Munro,48 proposed that the significant role of
the scapular rotators during the critical phase of elevation is
secondary to the relatively long moment arms of the upper tra-
pezius, lower trapezius, and lower serratus anterior muscles.
Therefore, during the middle phase of elevation, the scapular
rotators provide an important contribution to elevation of the
humerus in the POS.
Movement of the AC and SC joints permits movement of
the scapula. The relative contribution of these two joints
changes throughout the range of motion, depending on where
the ICR lies.77 During the middle phase of abduction, the
ICR of the scapula begins to migrate toward the AC joint.
Clavicular elevation about the SC joint, coupled with scapular
rotation about the AC joint, facilitates normal scapula mobil-
ity. Motion can occur at the AC joint, with less movement
occurring at the SC joint because of the clavicular rotation
around its long axis.4 The double-curved clavicle acts like a
crankshaft, to permit elevation and rotation at the AC end.
The rotation of the scapula about the AC joint is initiated
between 60 and 90 of elevation.78 Clavicular elevation is
completed between 120 and 150 of humeral abduction.77
Clavicular elevation at the AC joint permits maximum scapu-
lar rotation. At approximately 150 of elevation, the ICR of
the scapula is in line with the AC joint.77
Final Phase of Elevation: 140 to 180
During the final phase of elevation, the ratio of glenohumeral
to scapulothoracic motion is 3.49:1, a finding indicating rel-
atively more glenohumeral motion.77 The ICR of the scapula
has relocated upward and laterally. The rotatory force arm of
the upper trapezius muscle has reduced in length, and the role
of this muscle is now supportive of the scapula.78 The new

location of the ICR of the scapula allows the middle trapezius
to become a prime mover for downward scapular rotation.78
The lower trapezius and the serratus anterior muscles continue
to increase in activity during the final phase of elevation, and
they act as an upward rotator and oppose the forces of the
upper and middle trapezius.77
As the humerus elevates toward the end of the elevation
range of motion, it must disengage itself from the scapula.
As previously noted, the ratio of glenohumeral to scapulothor-
acic motion is 3.49:1. Good extensibility of the teres major and
the subscapularis muscles is important, to allow the humerus to
disassociate itself from the scapula. Often, with passive humeral
elevation, a bulge of the scapula is noted laterally. The bulge is
usually the inferior angle that is secondary to increased protrac-
tion of the scapula. Lack of elongation of these muscles prevents
the normally dominant movement of the humerus at the end of
the elevation range. Tightness of the subscapularis muscle, teres
major muscle, or both, is often observed.
Furthermore, observation of limited passive humeral eleva-
tion may exhibit elevation of the chest cavity. If muscles con-
necting the humerus and rib cage are not flexible enough,
movement will occur at both ends. The latissimus and pector-
alis major muscles connect the humerus to the rib cage. Lack
of dissociation of the rib cage from the humerus results in
excessive rib cage mobility in passive terminal elevation.
Summary of Shoulder Phases of
Movement
The initial phase of elevation occurs predominantly at the gle-
nohumeral joint. A 3-mm superior glide of the humeral head
has been observed in the initial phase of elevation. The activ-
ity of the deltoid muscle produces this superior shearing at
the glenohumeral joint. The activity of the supraspinatus,
infraspinatus, teres minor, and subscapularis muscles counter-
acts the forces of the deltoid muscle and creates a resultant
force that helps to stabilize the joint and is necessary for full
pain-free movement to continue. The resultant force in the
normal glenohumeral joint is maximal at 90 of elevation.
The early phase of scapula movement is described as the
setting phase, with the majority of movement occurring at
the glenohumeral joint.
The middle phase of elevation is referred to as the critical
phase. At the beginning of the critical phase, maximum shear-
ing forces of the deltoid muscle occur. The ratio of glenohum-
eral to scapulothoracic movement shifts and emphasizes
scapulothoracic movement. The increased scapula movement
is established by the activity of the upper and lower trapezius
and lower anterior serratus muscles. The arthrokinematic
movement of the head of the humerus on the glenoid has been
observed as an inferior and superior glide of 1.5 mm.
During the final phase of elevation, the glenohumeral joint
once again dominates the movement. Good extensibility of
the latissimus, pectoralis major, teres major, teres minor, and
subscapularis muscles is necessary to allow the increased
and unconstrained movement of the humerus away from the
scapula.
Chapter 2 Functional Anatomy and Mechanics 21
SUMMARY
Patients with shoulder dysfunction are routinely treated in the
physical therapy clinic. An understanding of the anatomy and
biomechanics of this joint can help to provide the physical
therapist with a rationale for evaluation and treatment. Most
studies involving shoulder anatomy and biomechanics reveal
a common pattern, along with a wide variation among sub-
jects. The physical therapist should keep this variation in
mind when treating an individual patient.
Treatment may be directed toward restoring mobility,
providing stability, or a combination of the two. The shoulder
is an inherently mobile complex, with various joint surfaces
adding to the freedom of movement. The shallow glenoid,
with its flexible labrum and large humeral head, provides
mobility. At times, this vast mobility occurs at the expense
of stability. The shoulder relies on various stabilizing mechan-
isms, including shapes of joint surfaces, ligaments, and mus-
cles to prevent excessive motion. Almost 20 muscles act on
this joint complex in some manner, and at different times
these muscles can be both prime movers and stabilizers. Har-
monious actions of these muscles are necessary for the full
function of this joint.
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