Journal of Sport Rehabilitation, 2018, 27, 334-339

https://doi.org/10.1123/jsr.2016-0217
© 2018 Human Kinetics, Inc. ORIGINAL RESEARCH REPORT

Infraspinatus Isolation During External Rotation Exercise

at Varying Degrees of Abduction
Gareth Ryan, Heather Johnston, and Janice Moreside

Context: External rotation (ER) strengthening exercises are a common component of shoulder injury prevention and
rehabilitation programs. They are primarily intended to target the infraspinatus muscle, based on its role in glenohumeral
stabilization and inferior humeral glide. ER also recruits the posterior deltoid, which can be undesirable due to its role in
subacromial space narrowing. Objective: To determine the angle of humeral abduction that maximizes the infraspinatus to
posterior deltoid activation ratio (INFRA/PD) during ER. Design: Within-subjects repeated-measures controlled lab trial.
Participants: A total of 10 healthy participants (5 males, 5 females) aged 21 (0.67) years participated in the study. Intervention:
7 consecutive repetitions of ER at 7 different abduction angles ranging from 0° to 90°, with resistance normalized to 3% body
mass. Main Outcome Measures: Surface electromyography was performed on the infraspinatus, middle deltoid, and posterior
deltoid. Surface electromyography data were processed to determine absolute muscle activation as well as INFRA/PD at each
abduction angle. Group means were compared between abduction angles using 1-way analysis of variance. Results: Abduction
significantly reduced overall infraspinatus activity but increased posterior deltoid activity (P < .01). Average and peak INFRA/
PD decreased as the angle of abduction increased (P < .001 and P < .01, respectively). Conclusion: Our findings suggest that ER
should be performed in 0° of abduction to maximize infraspinatus isolation. Slight abduction, such as placing a towel under the
humerus, as recommended by some clinicians, may improve patient comfort, but did not increase infraspinatus isolation in this
study.

Keywords: rotator cuff, shoulder, rehabilitation

Up to 67% of individuals will experience some form of
shoulder injury in their lifetime.1 External rotation (ER) is one
of the most commonly prescribed shoulder strengthening exercises
for injury rehabilitation and prevention.2,3 Although primarily
intended to target the infraspinatus, the posterior deltoid is also
recruited significantly.4 Infraspinatus muscle fibers run supero-
laterally from the inferior scapula to the greater tubercle of the
humerus and translate the head of the humerus inferiorly upon
contraction. In some patients, this can help prevent subacromial
impingement by increasing the space between the rotator cuff and
the acromion/coracoacromial ligament.2,5–8 Conversely, posterior
deltoid fibers run inferolaterally from the spine of the scapula to the
deltoid tubercle, resulting in superior humeral glide and subacro-
mial space narrowing upon contraction. In addition, when the
glenohumeral joint is not stabilized properly, posterior deltoid
activation can place significant shear stress on the anterior
capsule.7 Several authors have suggested minimizing posterior
and middle deltoid activation during ER to reduce subacromial
space narrowing.6,9–11
Although there has been considerable research analyzing
different ER positions,2,11–21 no studies have examined the effect
of frontal plane humeral abduction on infraspinatus and posterior
deltoid recruitment across a range of angles. Many clinicians
anecdotally suggest placing a rolled towel in the axillary region
when performing ER for a variety of reasons, including increased
rotator cuff perfusion and infraspinatus isolation5,8,11; however,
The authors are with the Department of Kinesiology, School of Health and Human
Performance, Dalhousie University, Halifax, Nova Scotia, Canada. Moreside is also
with the School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada.
Moreside (jmoreside@dal.ca) is corresponding author.
334
there is little evidence supporting increased infraspinatus isolation.
In a clinical commentary, Kolber et al4 advocated for this tech-
nique, however, no experimental evidence was provided. Sakita
et al11 were the first to examine the effects of a rolled towel on
infraspinatus activation. They found that in a side-lying position, a
rolled towel decreased middle deltoid activity yet increased poste-
rior deltoid activity, whereas when standing, a rolled towel
increased posterior deltoid activity with no effect on the middle
deltoid. No significant differences in infraspinatus activation were
observed between conditions. In this study, participants were
instructed to actively adduct against the towel. Given that the
posterior deltoid can have an adductor moment in a neutral
position,22 this could have accounted for the increased posterior
deltoid activity.
To date, no published study has inclusively examined infra-
spinatus and deltoid activation during ER performed in incremental
abduction from 0° to 90°. The purpose of this study was to
determine the angle of abduction that resulted in the greatest
infraspinatus isolation during standing ER. Standing ER was
chosen because it is one of the most common exercise positions
used in rehabilitation settings.4 We hypothesized that maximum
infraspinatus isolation would occur at 15° to 30° of abduction,
as measured by the infraspinatus to posterior deltoid (INFRA/
PD) ratio.
Methods
Participants
A total of 5 male and 5 female volunteers participated (age = 21.3
[0.7] y, height = 175.0 [7.4] cm, and mass = 71.1 [10.7] kg).
To partake in the study, individuals had to be ≥18 years of age and

in good overall health. Individuals with a history of shoulder injury
or surgery, muscular disease or dystrophy, or neurological disorder,
as well as those with skin lesions/infections on the shoulder region,
were excluded from the study. Participants were recruited by means
of a poster displayed on the university campus. Each participant
signed an informed consent form before any data were collected.
Fulfillment of participation criteria was assessed verbally as well as
through completion of the study questionnaire. The rights and
confidentiality of each participant were protected throughout their
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participation in the study. The research protocol was reviewed and
approved by the Faculty of Health Sciences Research Ethics Board
at Dalhousie University.
Design
This study was a controlled lab trial with 1 independent and 8
dependent variables. The independent variable was the angle of
humeral abduction at which ER was performed (7 levels: 0°, 15°,
30°, 45°, 60°, 75°, and 90°). Dependent variables were average and
peak muscle activation for each of the infraspinatus, middle
deltoid, posterior deltoid, and INFRA/PD.
Procedures
Surface electromyography (SEMG) was performed on the domi-
nant shoulder (eg, right-handed, right shoulder). The skin was
shaved and cleaned with isopropyl alcohol prior to electrode
application. Adhesive bipolar differential Ag-AgCl surface electro-
des (MediTrace 133; Kendall (Covidien), Dublin, Ireland) were
placed on the infraspinatus, posterior deltoid, and middle deltoid
as follows: infraspinatus electrodes 2.5 cm inferior to the midpoint
of the scapular spine, posterior deltoid electrodes 2 cm inferior to
the posterior angle of the acromion, middle deltoid electrodes at
intersection of line from the acromion to the greater tubercle, and
line from the posterior deltoid electrodes’ center to 3.5 cm inferior
to the anterior angle of the acromion6 (Figure 1A). A reference
electrode was placed over the acromion. Electrode poles were
spaced 20 mm apart and oriented parallel to the direction of muscle
action. All electrodes were applied by the primary investigator.
A wired 8-channel amplifier (AMT-8; Bortec Biomedical,
Calgary, AB) was used with Mr. Kick© data acquisition software
(Center for Sensory-Motor Interaction, Aalborg University,
Denmark) for SEMG recording. Amplifier characteristics were
as follows: input impedance of 10 GΩ, common mode rejection
ratio of 115 dB, gain of 1000, and sampling frequency of 2000 Hz.
Signal-to-noise ratio was 57.6 dB. A 16-bit analog-to-digital card
Figure 1 — Posterior (A) and sagittal (B) views of electrode
placements. The cable system can be seen in the right image. As can
be seen in the above figure, supraspinatus surface electromyography data
were collected but were not used in this analysis.
JSR Vol. 27, No. 4, 2018
Infraspinatus Isolation During External Rotation 335
with a common mode rejection ratio of 11 dB was used (PCI3
6321; National Instruments, Austin, TX). Electrode placements
were verified using the free-running scope feature of Mr. Kick©
while participants performed movements intended to activate each
muscle. If the SEMG signal was inadequate for any reason,
electrodes were replaced.
Participants performed a warm-up consisting of pendulum,
shoulder flexion, abduction, ER, and internal rotation before
performing maximum voluntary isometric contraction (MVIC)
tests against experimenter-applied resistance. The order of
MVIC tests was randomized between participants to control for
fatigue. Infraspinatus was tested in 0° abduction and 90° elbow
flexion with the participant externally rotating against the experi-
menter.23 The middle deltoid was tested in 90° abduction, elbow
extension, and shoulder internal rotation with the participant
resisting experimenter-applied adduction.24 The posterior deltoid
was tested in the same position as the middle deltoid, but instead the
participant resisted horizontal experimenter-applied adduction.24
Participants performed three 5-second repetitions of MVIC in each
of the 3 positions, with a 30-second rest between repetitions and a
2-minute rest between positions. Participants were instructed to
increase their force output for the first second, maintain maximal
contraction for 3 seconds, and gradually relax during the final
second while the experimenter attempted to break the isometric
hold. The highest activity from the processed data for each muscle
recorded across the 4 positions was used as the MVIC.
After a 5-minute rest, participants performed 7 cyclic concen-
tric/eccentric repetitions of ER at each of the 7 abduction angles,
with the elbow flexed to 90°. The order of abduction angles was
randomized to control for fatigue. ER was performed using a cable
system with resistance normalized to 3% body mass (mean resis-
tance = 2.13 [0.3] kg; Figure 1B). Bitter et al16 showed that
resistances greater than 40% MVIC result in increased posterior
deltoid recruitment and reduced infraspinatus isolation. A resis-
tance of 3% body mass was selected based on pilot trials, which
suggested that this would be low enough to maximize infraspinatus
isolation for the majority of participants. Abduction angle was
maintained using triangular foam braces in 15° (0°–90°) incre-
ments strapped to participants’ torsos (Figure 2) and was verified
using a goniometer. Participants were instructed to rest their
humerus on the brace, removing the effect of gravity, without
actively adducting. The cable height was changed in sync with
the abduction angle to ensure the direction of pull remained
Figure 2 — Participant in 15° (A) and 45° (B) of abduction with foam
braces in place. Braces were positioned to ensure the shoulder was not in
forced elevation.
 336 Ryan, Johnston, and Moreside

perpendicular to the humerus. ER repetitions were performed at a

cadence of 2 s/repetition, resulting in a rotational velocity of
approximately 60° to 90° per second, previously shown to elicit
the greatest infraspinatus activation.25 SEMG data were collected
for 10 seconds for each trial starting after the first repetition
and ending after the sixth repetition, capturing 5 repetitions of
data. Participants were given a 2-minute rest between abduction
angles.
SEMG data from the MVIC and ER trials were processed using
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MATLAB® (MathWorks, Natick, MA). Data were detrended to

remove direct current offset, band-pass filtered (5–500 Hz), full-
wave rectified, and low-pass filtered at a 20-millisecond time
constant (fourth-order 3-Hz Butterworth) to create a linear enve-
lope. SEMG data from the ER trials were normalized to MVIC and
displayed as percentages. Peak and average muscle activation at
each abduction angle were determined from the processed data, as
well as peak and average INFRA/PD, which was used as the
measure of infraspinatus isolation. Peak activation was selected
as the highest nonartifact activation from the linear envelope of the 5
repetitions in each position. Average activation was calculated as
the average activation across the linear envelope of the 5 repetitions
in each position.

Statistical Analysis
Statistical analysis was performed using SPSS V.21 (IBM,
Armonk, NY) and Excel V14.6.4 (Microsoft, Redmond, WA).
One-way repeated-measures analysis of variances was used to
identify differences in muscle activity between abduction
angles. The assumptions of analysis of variance were tested in Figure 3 — Average (A) and peak (B) activation of the PD and
SPSS. Data were normally distributed, and Mauchly’s test was INFRA during external rotation throughout the range of frontal plane
used to assess the assumption of sphericity. When sphericity was abduction examined. INFRA indicates infraspinatus; MVIC, maximum
violated, the Greenhouse–Geisser correction was applied to the voluntary isometric contraction; PD, posterior deltoid. *Significantly
different from 0° (P < .05). **Significantly different from 15° (P < .05).
data. Bonferroni-corrected post hoc analyses were performed to ***Significantly different from 45° (P < .05). ****Significantly different
determine the location of significant differences. The significance from 75° (P < .05).
level was set at α = .05.

Results
Muscle Activation
A main effect of abduction was observed for average and peak
infraspinatus (both Ps < .01) and posterior deltoid (P < .01 and
P < .001, respectively), but not middle deltoid (both Ps > .05).
Average infraspinatus activation was lower at 60° and 75° versus
0° (P < .05 and P < .01, respectively) and at 60° versus 15°
(P < .05) (Figure 3A). Peak infraspinatus activity was lower at
60° versus 0° (P < .05; Figure 3B). Average posterior deltoid
activity was higher at 90° versus 0° (P < .05; Figure 3A). Peak
posterior deltoid activation was higher at 60° and 90° versus 0°
(both Ps < .01), at 60° versus 45° (P < .05), and at 90° versus 75°
(P < .05) (Figure 3B). Middle deltoid data were excluded from
Figure 3 for clarity since no significant differences were observed.
Infraspinatus Isolation
A main effect of abduction was observed for average and
peak INFRA/PD (P < .001 and P < .01, respectively). Average
INFRA/PD was lower in 30°, 60°, 75°, and 90° versus 0° (P <
.05, P < .01, P < .05, and P < .01, respectively; Figure 4A). Peak
INFRA/PD was lower in 60° and 90° versus 0° (both Ps < .05;
Figure 4B).
JSR Vol. 27, No. 4, 2018
Discussion
We found that humeral abduction had a significant effect on both
peak and average infraspinatus (Figure 3) and posterior deltoid
(Figure 3) activity during standing ER. Incremental abduction
resulted in a gradual increase in posterior deltoid activity but a
reduction in infraspinatus activity. Neither peak nor average middle
deltoid activation was significantly impacted by abduction.
Our findings contradicted our hypothesis that maximal infra-
spinatus isolation would occur between 15° and 30° abduction.
Although abduction resulted in an overall reduction in peak and
average INFRA/PD, no significant differences were observed in
peak isolation between any of the 15° increments from 0° to 45°
abduction or average isolation between 0° and 15° abduction
(Figure 4B).
Our findings could be explained by changes in muscle moment
arm length that occur with humeral abduction. Nourbakhsh and
Kukulka26 reported a significant inverse relationship between
muscle moment arm length and SEMG activity. In a cadaveric
model, Ackland et al22 demonstrated that the ER moment arm of
posterior deltoid was longest in 5° abduction and gradually short-
ened with abduction, until reaching its lowest value in 120°
abduction. The increase in posterior deltoid activity with abduction
angle could therefore be due to a reduction in mechanical advan-
tage, requiring a higher activation to generate a given force.

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Figure 4 — Ratio of average (A) and peak (B) INFRA/PD activity
during external rotation, at varying degrees of frontal plane humeral
abduction. INFRA/PD indicates infraspinatus to posterior deltoid.
*Significantly different from 0° (P < .05).
Ackland et al22 also demonstrated that infraspinatus moment arm
lengthens with abduction. They separated infraspinatus into super-
ior and inferior portions, each of which responded differently to
abduction. In this study, infraspinatus electrodes were placed
2.5 cm inferior to the spine of the scapula, thereby recording
activity of the superior portion of infraspinatus. Ackland et al22
reported that the superior infraspinatus moment arm rapidly
increased with abduction angle from 0° to 28° followed by a
plateau. These changes in mechanical advantage early in the
abduction range of motion could account for the initial decrease
in INFRA/PD observed between 0° and 30° abduction. Significant
differences in infraspinatus activation or isolation were not
observed beyond 30°, supporting the findings of Ackland et al22
that a plateau in infraspinatus moment arm length may occur at 28°
abduction.
Our results could also be attributed to the muscle length–
tension relationship. Abduction elongates the infraspinatus,27
which could have resulted in increased force production for a
given activation level, and could account for the reduction in
infraspinatus activation with abduction. Conversely, abduction
shortens the posterior deltoid, which may account for its increased
activity during ER in abduction. The combined effects of changes
in moment arms and muscle fiber length in different positions likely
have a significant impact on force generation and muscle activation
patterns in the shoulder, where there are many possible planes of
motion.
Although not instructed to do so, some participants may
have actively adducted against the foam braces, causing reci-
procal inhibition. Reciprocal inhibition occurs when agonist
muscle activation inhibits the antagonist muscle through a spinal
JSR Vol. 27, No. 4, 2018
Infraspinatus Isolation During External Rotation 337
interneuron, thereby facilitating the agonist’s action. When the
adductor muscles are activated to hold a rolled towel under the
humerus, reciprocal inhibition of the deltoid may occur, it being a
prime mover for abduction. Such a mechanism would result in
greater infraspinatus isolation during ER,4 which would contradict
the findings of this study, since posterior deltoid activity increased
with abduction. Since adductor force and muscle activity were not
measured, it cannot be determined whether reciprocal inhibition
occurred.
Minor subacromial narrowing or impingement, as occurs
with superior humeral glide, may also have affected the activation
ratios.4,8 Smith et al28 found that scapular protraction, which
increases subacromial narrowing, resulted in a significant reduction
in the strength of ER. Although several authors have suggested
that performing ER in abduction may lead to inferior humeral glide
by increased infraspinatus isolation,4,11,16,29 it is possible that the
triangular braces used in this study forced glenohumeral elevation,
causing subacromial narrowing. While efforts were made to
ensure that braces were positioned to maintain a neutral shoulder
position, even minor elevation could have affected the size of
the subacromial space. If rotator cuff impingement occurred
as a result, muscle activation data and ratios may have been
impacted.
Our findings varied slightly from those of Reinold et al,2
who reported no significant differences in infraspinatus activation
between 0°, 15°, and 90° abduction, but significantly elevated
posterior deltoid activity in 90° versus 0° and 15° abduction.
Conversely, we found significant differences in infraspinatus
activation between 0°–60°, 15°–60°, and 15°–75° abduction and
differences in infraspinatus isolation between 0°–30°, 0°–60°,
0°–75° and 0°–90° abduction in addition to the elevated posterior
deltoid activity reported by Reinold et al.2 The discrepancy in
results between the studies could be due to the fact that Reinold
et al2 did not use braces to maintain abduction angle.
Our findings align with those of Sakita et al11 in that minor
humeral abduction did not significantly impact infraspinatus activ-
ity during ER; however, the increased posterior deltoid activity that
they reported with the towel in situ (∼15°–30° abduction) was not
observed in this study until 60° abduction. The increased posterior
deltoid activation observed by Sakita et al11 could be explained by
the fact that participants were instructed to actively adduct their
humerus against the rolled towel. Ackland et al22 demonstrated that
the posterior deltoid has an adduction moment arm from 0° to 30°
abduction, resulting in the posterior deltoid functioning as an
adductor in addition to an external rotator in this position.
Implications
One of the major force couples of the glenohumeral joint is that
which controls superior–inferior translation of the humeral head.
Controlled by the infraspinatus, teres minor, and deltoid, this force
couple keeps the humeral head centered in the glenoid, allowing for
proper shoulder mechanics. In this study, INFRA/PD was used as
an indirect measure of the integrity of this force couple. Although
joint forces cannot be directly determined from SEMG data, this
ratio provided an estimation of the action of the force couple. Since
INFRA/PD during ER decreased as abduction increased, it can be
inferred that there was an associated imbalance in the force couple,
resulting in deltoid dominance and subsequent superior translation
of the humeral head. Since teres minor also contributes to this force
couple, the measure of INFRA/PD does not completely describe
this force couple.
 338 Ryan, Johnston, and Moreside
Despite the fact that, from a biomechanical perspective, our
findings do not support performing ER in abduction, there may
some benefit of abduction regarding perfusion. Cadaveric stud-
ies27,30 have demonstrated that tension in the supraspinatus de-
creases with minimal abduction, resulting in decreased vascular
compression and increased perfusion. Although this likely would
not have an immediate benefit, there may be a significant effect
over the course of a long-term rehabilitation program.
Clinicians often suggest placing a rolled towel under the
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humerus during ER to increase infraspinatus isolation and rotator
cuff perfusion.4 Our results, and those of Sakita et al,11 suggest that
this technique does not increase infraspinatus isolation, and may in
fact cause a decrease. When considering all effects of abduction
during ER, it appears that there are contrasting advantages and
disadvantages. We found that INFRA/PD was not significantly
reduced until 30° abduction. Since cadaveric studies27,30 have
shown that the reduction in rotator cuff tension can occur in as
little 15° abduction, it may be beneficial to perform ER in slight
(∼15°) abduction, to benefit from increased perfusion, without
significantly reducing infraspinatus isolation.
Limitations
A major limitation of this study was that the sample consisted
solely of healthy university students. This sampling bias limits the
generalizability of our findings to other populations and demo-
graphics, such as those with shoulder injuries or neuromuscular
disorders, who may benefit most from infraspinatus isolation.
SEMG is commonly used in research; however, electrode
cross-talk, noise, and displacement during motion can affect the
quality of the data.31–35 In addition, the small scale of the shoulder
musculature can make it difficult to distinguish activity of the
individual muscles, and can result in signals from overlying
muscles being superimposed into 1 signal. Allen et al31 found
that SEMG can significantly overestimate rotator cuff muscle
activation compared with intramuscular EMG. Although not pos-
sible in this study, intramuscular EMG may have provided more
accurate data and allowed for analysis of the teres minor and
subscapularis, which cannot be examined using SEMG.
Although separate analysis of the concentric and eccentric
portions of each repetition may have provided additional information
from a biomechanical perspective, we elected to analyze the com-
plete repetition, since we believe it is more representative of
exercises performed by patients in clinical and fitness settings. In
addition, we chose not to compare activation between muscles at
each position, as this was not the focus of this study. Our objective
was to determine changes in infraspinatus isolation between abduc-
tion angles, which only required comparisons within muscles.
Since the glenohumeral joint is also supported by passive
structures such as the labrum and glenohumeral ligaments, shoul-
der stability cannot entirely be inferred from muscle activity. Joint
force modeling was not performed in this study, so we cannot infer
the overall stability of the glenohumeral joint during ER at each of
the abduction angles. However, since the shoulder is largely
supported by the musculature, the activation ratios do provide
useful information.
Although ER resistance and cadence were controlled, there
was no attempt to quantify participants’ adductive force against the
abduction braces during ER. While participants were instructed to
rest their humerus on the brace without adducting, it is possible that
some participants did actively adduct, thereby causing reciprocal
inhibition of the deltoid and affecting muscle activation outcomes.
JSR Vol. 27, No. 4, 2018
Conclusion
We found that incremental increases in abduction angle during ER
decreased infraspinatus activity and increased posterior deltoid
activity, resulting in a reduction in infraspinatus isolation. Middle
deltoid activation was not significantly impacted by abduction.
Based on these findings, standing ER exercise should be performed
in 0° abduction when it is desirable to maximize infraspinatus
isolation. Since there was not a significant difference in infraspi-
natus isolation between 0° and 15° abduction, placing a rolled
towel under the humerus, as has been suggested by some clinicians,
may allow for increased patient comfort but does not affect
infraspinatus isolation in standing ER.
Acknowledgments
This study was reviewed and approved by the Dalhousie University
Faculty of Health Sciences review board (REB# 2015-3710). The authors
certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or
materials discussed herein.
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