The Cam Effect of the Proximal Humerus: Its Role in the

Production of Relative Capsular Redundancy of the Shoulder

Stephen S. Burkhart, M.D., and Ian K. Y. Lo, M.D.

Purpose: The purpose of this study was to investigate quantitatively the cam effect of the proximal
humerus (whereby the anteroinferior capsule of the shoulder is tensioned in abduction– external rotation
by virtue of asymmetric rotation of the eccentrically positioned humeral head), as well the extent to which
a reduction in the cam effect would cause a relative capsular redundancy, in the cadaveric shoulder.
Methods: Five fresh-frozen cadaveric shoulders were tested. K-wires were used to sequentially position
the shoulder in 3 different positions: neutral anatomic position, with contact at the glenoid bare spot;
90°-90° neutral shift position, with contact at the glenoid bare spot; and 90°-90° posterosuperior shift
position, with contact 4.3 mm posterosuperior to the glenoid bare spot. The topographic anterior band
distance (TABD) was measured with the shoulder in each of the 3 positions. The relative redundancy that
occurred by shifting the glenohumeral contact point was determined by subtracting the TABD in the
90°-90° posterosuperior shift position from the TABD in the 90°-90° neutral shift position. Results: The
results of repeated-measures analysis of variance showed significant differences among the mean TABD
values for the 3 positions (P ⬍ .010). There was a significant increase in TABD when the shoulder was
brought from the neutral anatomic position to the 90°-90° neutral shift position (P ⬍ .020), confirming the
cam effect of the proximal humerus in the 90°-90° position. Furthermore, the TABD decreased signifi-
cantly when the 90°-90° neutral shift position changed to the 90°-90° posterosuperior shift position (P ⬍
.005), indicating a significant reduction in the cam effect with a concomitant relative redundancy in the
anteroinferior capsuloligamentous complex. Conclusions: The proximal humerus produces a significant
cam effect on the anteroinferior capsule when the shoulder is brought into a position of 90° abduction and
90° external rotation. A reduction in the cam effect as a result of a posterosuperior shift of the
glenohumeral contact point with the shoulder in the 90°-90° position results in a relative redundancy of
the anteroinferior capsuloligamentous complex. This relative capsular redundancy, coupled with the
pseudolaxity that occurs with SLAP lesions, can produce a degree of apparent anterior laxity that is
independent of any true translational anterior instability. Clinical Relevance: The relative redundancy in
the anteroinferior shoulder capsule caused by a decrease in the cam effect of the proximal humerus may
have clinical implications in the pathophysiology of the disabled throwing shoulder. This relative
redundancy is a secondary pseudolaxity, with the primary pathology being a tight posteroinferior
capsule. Appropriate treatment (stretching of the posteroinferior capsule) of the primary pathology is
a more appropriate initial treatment than instability surgery. Key Words: Cam effect—Shoulder
ligaments—Throwing injuries.

F or years, microinstability has been postulated as

From The San Antonio Orthopaedic Group (S.S.B.), San Anto-
nio, Texas, U.S.A., and Department of Surgery, University of
Calgary (I.K.Y.L.), Calgary, Alberta, Canada.
S.S.B. and I.K.Y.L. are both consultants for and receive royalties
from Arthrex, Naples, Florida.
Address correspondence and reprint requests to Stephen S.
Burkhart, M.D., The San Antonio Orthopaedic Group, 150 E
Sonterra Blvd, Suite 300, San Antonio, TX 78258, U.S.A. E-mail:
ssburkhart@msn.com
© 2007 by the Arthroscopy Association of North America
0749-8063/07/2303-4500$32.00/0
doi:10.1016/j.arthro.2006.11.018
the major cause of the disabled throwing shoul-
der.1,2 Despite inadequacies in both the definition and
the diagnosis of microinstability, Jobe and col-
leagues2-4 initially proposed and popularized open
capsulolabral reconstruction as a means of reducing
microinstability in the overhead athlete. More re-
cently, some surgeons have used capsular volume
reduction by arthroscopic means in an attempt to
control microinstability.
The concept of microinstability as a pathologic
mechanism in throwers has been called into question

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 3 (March), 2007: pp 241-246 241
242 S. S. BURKHART AND I. K. Y. LO

because of the fact that disabled throwing shoulders
have displayed minimal, if any, arthroscopic findings
of translational instability.5 As such, microinstability
was the only type of instability that did not have
clear-cut arthroscopic findings.
In mechanical systems a cam is a solid component
that rotates about an eccentric axis,6 producing recip-
rocating forces and motions resulting from the space-
occupying effect of the most prominent part of its
profile. The senior author (S.S.B.) has postulated that
the humeral head produces a cam effect when the
shoulder is in a position of abduction and external
rotation, as well as that this cam effect is reduced by
a posterosuperior shift in the glenohumeral contact
point, as occurs in throwers with tight posteroinferior
capsules5 (Fig 1). In abduction and external rotation
the anteroinferior capsule drapes tightly across the
humeral head and proximal humeral calcar. The cap-
sule is tensioned by virtue of the space-occupying
effect of the eccentrically positioned humeral head
(Fig 1B). With a posterosuperior shift of the glenohu-
meral contact point, as occurs in throwers with a tight
posteroinferior capsule,4,6,7 the space-occupying effect
of the proximal humerus on the anteroinferior capsule
is reduced (reduction of cam effect). This creates
a relative redundancy in the anteroinferior capsule
(Fig 1C). The purpose of this study was to investigate
the cam effect and the ability of a reduction in the cam
effect to create a relative capsular redundancy in the
cadaveric shoulder. Our hypothesis was that a postero-
superior shift of the glenohumeral contact point would
cause a relative redundancy in the anteroinferior cap-
sule as a result of a reduction in the space-occupying
cam effect of the proximal humerus.
METHODS
In this study 5 normal shoulders from 5 different
fresh-frozen cadavers were examined. The shoulders
came from 3 men and 2 women, with a mean age of
53.7 ⫾ 4.2 years (range, 44 to 65 years). The shoul-
ders were dissected free of all soft tissue except for the
inferior glenohumeral ligament complex, composed of
the anterior and posterior bands, as well as the capsu-
lar hammock between the 2 bands (Fig 2). The cam
effect could be observed in each specimen as the
shoulder was brought into a position of abduction and
external rotation.
A 2-mm K-wire was used to drill two holes in the
glenoid face: one in the center of the bare spot and the
other 4.3 mm posterosuperior to the first hole. This
4.3-mm posterosuperior shift represented the shift in
the glenohumeral contact point that has been shown
experimentally to occur when the posteroinferior cap-

FIGURE 1. (A) In the neutral position, with the arm at the side, the anterior capsule is lax (axial projection, neutral rotation). (B) In a position
of combined abduction and external rotation, the humeral head and proximal humeral calcar create a cam effect that tensions the anterior
capsuloligamentous sleeve (axial projection). (A, anterior; P, posterior; C, glenohumeral contact point.) (C) When the glenohumeral contact
point (C) shifts posterosuperiorly, as occurs in throwers with a tight posteroinferior capsule, there is a reduction in the cam effect of the
proximal humerus, which manifests itself as a relative redundancy of the anterior capsuloligamentous sleeve. (D) Superimposition of normal
glenohumeral relationship (with cam effect [dashed line]) with posterior shift of glenohumeral contact point (C) (reduction of cam effect with
redundant capsule [solid line]).
 CAM EFFECT OF PROXIMAL HUMERUS
FIGURE 2. Anatomic specimen showing inferior capsular “ham-
mock” (asterisk) of inferior glenohumeral ligament. (Note that the
K-wire in the humeral head is used to establish the glenohumeral
contact point in this specimen.)
sule is plicated 1.5 cm to simulate a tight posteroin-
ferior capsule.7,8 With the humerus in the neutral
position (no abduction and no rotation), the humeral
articular contact point was drilled with a 2-mm K-
wire. The humerus was then placed in 90° abduction
(in the plane of the scapula) and 90° external rotation,
and the humeral articular contact point was marked
and then drilled with a 2-mm K-wire.
With the 4 holes established in the bone (2 humeral
and 2 glenoid), we were able to use a short K-wire to
fix the glenohumeral contact point first in the neutral
anatomic position, with contact at the glenoid bare
spot, and then in the 90°-90° position for two condi-
tions: (1) 90°-90° neutral shift position, with contact at
the glenoid bare spot, and (2) 90°-90° posterosuperior
shift, with contact 4.3 mm posterosuperior to the gle-
noid bare spot, in the posterosuperior quadrant of the
glenoid.
A flexible tape was used to measure the topographic
243
distance (i.e., distance along the bone surfaces) be-
tween the humeral and glenoid insertion points of the
anterior band of the inferior glenohumeral ligament
(topographic anterior band distance [TABD]) (Fig 3).
In this way, the topographic surface features of the
bone entered into the measured distance because the
flexible tape had to traverse the cam of the proximal
humerus. Measurement of this topographic distance
precluded the use of a digital caliper, because the
caliper would have only measured the straight-line
distance between 2 points, ignoring the surface fea-
tures. By use of the flexible tape, 3 consecutive mea-
surements were made for the TABD in each position
and a mean TABD was calculated to the nearest tenth
of a centimeter. In every case the repeat measurements
for each position were within 0.1 cm of the original
measurement, confirming the reproducibility of this
method. The measurements were made in each spec-
imen in 3 positions: neutral anatomic position with
neutral contact point (position 1), 90°-90° position
with neutral contact point (position 2), and 90°-90°
position with “shifted” contact point (position 3) (Fig 3).
A mean TABD was calculated for each position in
each cadaveric specimen (Table 1). The anterior band
distance in the 90°-90° posterosuperior shift position
was then subtracted from the anterior band distance in
the 90°-90° neutral shift position, yielding a measure-
ment that represented the relative redundancy that
occurred by shifting the glenohumeral contact point
(Table 2).
Statistical comparisons of TABD values among the
3 positions were evaluated by repeated-measures anal-
ysis of variance (ANOVA). If the F test indicated
significant differences among the positions, then Bon-
ferroni-adjusted paired Student t tests were performed
to identify position differences. In addition, Pearson
correlations were used to check for linear associations
between TABD values for positions 1 and 2 and for
positions 2 and 3. P ⬍ .05 was considered to be
statistically significant.
The cam effect represented by the repeated TABD
measures obtained at the 3 defined positions in cadav-
ers can be considered to be clinically significant if the
population mean change in TABD between any 2
positions is at least 1.5 times the population SD of the
TABD change values. The sample size of 5 cadavers
is sufficient to detect clinically significant position
differences by use of repeated-measures ANOVA
with post hoc Bonferroni-adjusted paired Student t
tests at the .05 level with a power of 83%.
244 S. S. BURKHART AND I. K. Y. LO

FIGURE 3. A flexible tape was used to measure the TABD (solid red lines) between the humeral and glenoid insertion points of the inferior
glenohumeral ligament. The TABD was measured with the shoulder in 3 positions: (A) neutral anatomic position (position 1), (B) 90°-90°
position with neutral contact point (C) (position 2), and (C) 90°-90° position with shifted contact point (C) (position 3).

RESULTS topographic distance between anterior band insertion

Measurements of the topographic distance between
the humeral and glenoid insertions of the anterior band
of the inferior glenohumeral ligament (TABD) were
performed as detailed in the “Methods” section. The
results of repeated-measures ANOVA indicated sig-
nificant differences among the mean TABD values for
the 3 positions (P ⬍ .010).
When the shoulder was brought from the neutral
anatomic position (position 1) to the 90°-90° position
without shift (position 2), we observed the cam effect
of the proximal humerus, whereby its space-occupy-
ing effect tensioned the anterior-inferior capsule to
eliminate the capsular redundancy. This cam effect
was verified objectively by our topographic measure-
ments, which showed a significant increase in the
points from the neutral position (2.76 ⫾ 0.410 cm) to
the 90°-90° position (4.4 ⫾ 0.418 cm) (P ⬍ .020)
(Table 1).
A significant reduction of the cam effect and the
TABD was noted when the 90°-90° neutral shift po-
sition (position 2) was changed to the 90°-90° postero-
superior shift position (position 3) (P ⬍ .005) (Table 1).
Differences in the TABD between the 2 positions in the
same cadaver were taken to represent the relative redun-
dancy that occurred with a posterosuperior shift of the
glenohumeral contact point (mean, 0.56 ⫾ 0.152).
Data were analyzed by repeated-measures ANOVA.
The mean TABD for position 2 was found to be
significantly longer than that for position 1 (P ⬍ .020),
thereby confirming the cam effect of the proximal

TABLE 1. TABD (in Centimeters)

Position 1 (Anatomic Position 2 (90°-90° Position 3 (90°-90°
Specimen No. Position With No Shift) Position With No Shift) Position With Shift)

1 2.1 5.0 4.2

2 2.7 4.2 3.6
3 3.2 4.3 3.8
4 2.9 4.6 4.2
5 2.9 3.9 3.4
Mean 2.76. ⫾ 0.410 4.4 ⫾ 0.418 (P ⬍ .020) 3.84 ⫾ 0.358 (P ⬍ .005)
 CAM EFFECT OF PROXIMAL HUMERUS
TABLE 2. Relative Capsular Redundancy From Position
2 to Position 3
Relative Capsular
Specimen No. Redundancy (cm)
1 0.8
2 0.6
3 0.5
4 0.4
5 0.5
Mean 0.56 ⫾ 0.152
humerus in the 90°-90° position. The TABD did not
have a linear correlation between positions 1 and 2
(Pearson r ⫽ ⫺0.685, P ⬎ .20). This indicates that the
magnitude of the cam effect in position 2 was not
linearly related to the TABD in position 1, as might be
expected from random variation in anatomy among
specimens. The TABD was found to be significantly
shorter for the 90°-90° posterosuperior shift position
(position 3) than for the 90°-90° neutral shift position
(position 2) (P ⬍ .005), indicating that a relative
redundancy of the anteroinferior capsule occurs with
posterosuperior shift of the contact point. Such a rel-
ative redundancy occurs because of the decrease in the
cam effect of the proximal humerus that is brought on
by the shift, thereby confirming our hypothesis. Fur-
thermore, there was a linear correlation between the
TABD in positions 2 and 3 (Pearson r ⫽ 0.935, P ⬍
.020), which one would expect because the same
topographic profile of each humerus was present in
positions 2 and 3.
DISCUSSION
The senior author has described a “tethered shoul-
der” model of the disabled throwing shoulder that is
influenced by glenohumeral internal rotation deficit,
the peel-back mechanism, hyper– external rotation,
and the cam effect.5 SLAP lesions can create an an-
teroinferior pseudolaxity, manifested arthroscopically
by a positive drive-through sign, by virtue of the
posterosuperior break in the labral ring.9,10 This
pseudolaxity occurs in the absence of the usual arthro-
scopic signs of instability (e.g., Bankart lesion, ante-
rior labral periosteal sleeve avulsion lesion, Hill-Sachs
lesion, or capsular disruption), and it is eliminated by
repair of the SLAP lesion. Correction of pseudolaxity
is shown by conversion of the drive-through sign from
positive to negative.
This study confirms the cam effect of the proximal
humerus and identifies another potential source of
245
pseudolaxity in the abducted and externally rotated
throwing shoulder, namely reduction of the humeral
cam effect by a posterosuperior shift in the glenohu-
meral contact point. Such a shift in the contact point
has been shown to be caused by a tight posteroinferior
capsule,7,8 which is a common finding in the disabled
throwing shoulder.
A relative redundancy of the anteroinferior capsule
has been shown experimentally to allow increased exter-
nal rotation with the shoulder at 90° of abduction.8 Such
an increase in external rotation is characteristic of the
throwing shoulder,11-14 and this increased external
rotation places the point of glenohumeral internal im-
pingement15,16 at a position that is more posteroinfe-
rior on the glenoid rim5 than normal. This hyper–
external rotation causes increased torsional and shear
forces at the rotator cuff insertions (predisposing to-
ward cuff failure) and is a part of the pathologic
cascade of the disabled throwing shoulder.5 Reduction
of the cam effect is but one more component of the
pathologic cascade that is initiated by a tight postero-
inferior joint capsule.
CONCLUSIONS
The proximal humerus produces a significant cam
effect in the 90°-90° position, and a reduction in the
cam effect as a result of a posterosuperior shift of the
glenohumeral contact point causes a relative redun-
dancy of the anteroinferior capsule. It follows that the
relative capsular redundancy that results from a reduc-
tion in the cam effect, coupled with the pseudolaxity
that occurs with SLAP lesions, can produce a degree
of apparent anterior laxity that is independent of any
true translational anterior instability.
Acknowledgment: The authors thank John Schoolfield,
M.S., for his assistance with the statistical analysis of the
data in this study.
REFERENCES
1. Garth WP, Allman FL, Armstrong WS. Occult anterior sub-
luxation of the shoulder. Am J Sports Med 1987;15:579-585.
2. Jobe FW, Tibone JE, Jobe CM, et al. The shoulder in sports.
In: Rockwood CA Jr, Matsen FA III, eds. The shoulder.
Philadelphia: WB Saunders, 1990;963-967.
3. Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior
capsulolabral reconstruction of the shoulder in athletes in
overhand sports. Am J Sports Med 1991;19:428-434.
4. Glousman RE, Jobe FW. Anterior shoulder instability: Im-
pingement and rotator cuff tear. Anterior and multidirectional
instability. In: Jobe FW, ed. Operative techniques in upper
extremity sports injuries. St. Louis: Mosby, 1996;191-209.
5. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing
246 S. S. BURKHART AND I. K. Y. LO
shoulder: Spectrum of pathology part I: Pathoanatomy and
biomechanics. Arthroscopy 2003;19:404-420.
6. Hall SJ. Movement: Equilibrium. In: Basic biomechanics. St.
Louis: Mosby, 1991;363-365.
7. Koffler KM, Bader D, Eager M, et al. The effect of posterior
capsule tightness on glenohumeral translation in the late cock-
ing phase of pitching: A cadaveric study. Presented at the 21st
Annual Meeting of the Arthroscopy Association of North
America, Washington, DC, April 25, 2002.
8. Grossman MG, Tibone JE, McGarry MH, Schneider DJ, Ven-
eziani S, Lee TQ. A cadaveric model of the throwing shoulder:
A possible etiology of superior labrum anterior-to-posterior
lesions. J Bone Joint Surg Am 2005;87:824-831.
9. Burkhart SS, Morgan CD. The peel-back mechanism: Its role
in producing and extending posterior type II SLAP lesions and
its effect on SLAP repair and rehabilitation. Arthroscopy 1998;
14:637-640.
10. Morgan CD, Burkhart SS, Palmeri M, et al. Type II SLAP
lesions: Three subtypes and their relationships to superior
instability and rotator cuff tears. Arthroscopy 1998;14:553-
565.
11. Brown LP, Niehues SL, Harrah A, Yavorsky P, Hirshman HP.
Upper extremity range of motion and isokinetic strength of the
internal and external shoulder rotators in major league baseball
players. Am J Sports Med 1988;16:577-585.
12. Bigliani LU, Codd TP, Connor PM, Levine WN, Littlefield
MA, Hershon SJ. Shoulder motion and laxity in the profes-
sional baseball player. Am J Sports Med 1997;25:609-
613.
13. Crockett HC, Gross LB, Wilk KE, et al. Osseous adaptation
and range of motion at the glenohumeral joint in professional
baseball pitchers. Am J Sports Med 2002;30:20-26.
14. Wilk KE, Meister K, Andrews JR. Current concepts in the
rehabilitation of the overhead throwing athlete. Am J Sports
Med 2002;30:136-151.
15. Walch G, Boileua J, Noel E. Impingement of the deep surface
of the supraspinatus tendon on the posterior superior glenoid
rim. An anatomic study. J Shoulder Elbow Surg 1992;1:238-
243.
16. Jobe CM. Posterior superior glenoid impingement: Expanded
spectrum. Arthroscopy 1995;11:530-536.