Functional Anatomy of the Shoulder Complex

Elsie Culham, PhD, PT'

Malcolm Peat, PhD2

- Recent research findings are incorporatedin this review of the functional anatomy of the
shoulder complex. The scapulothoracic mechanism is described, including a review of scapular
motion and the structure and function of the sternoclavicularand acromioclavicularjoints. New
inbrmation regadng the resting position of the scapula on the thorax and the effect of aging and
; spinal posture on position has been presented. In the second part of the paper, the anatomy of the
1 glenohumeraljoint is reviewed, with emphasis on the articular, periarticular, and muscular mecha-
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nisms responsible for stability of this articulation. The article concludes with a discussion of the
\ integrated function of the scapulothoracic and glenohumeral articulations in upper extremity
Elsie Culham Malcolm Peat elevation.
Key Words: shoulder, anatomy, function
' Assistant Professor, School of Rehabilitation Therapy, Louise D. Acton Building, Queen's University, Kingston,
Ontario, Canada K7L 3N6
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Professor and Director, School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada

T
h e shoulder complex
consists of the clavicle,
scapula, and humerus;
the glenohumeral and
acromioclavicular
(AC) joints that unite them; and the
sternoclavicular (SC)joint, the only
connection of the complex t o the ax-
Journal of Orthopaedic & Sports Physical Therapy
SCAPULOTHORACIC MECHANISM
T h e scapula has n o bony o r liga-
mentous attachment t o the axial
skeleton other than through the AC
and SC joints (69). It is retained in
third thoracic spinous process, and
the inferior angle is a t the level of
the spinous process of the seventh o r
eighth thoracic vertebra (34.45).
T h e vertebral border lies 5-6 cm
from the midline in the erect stand-

ial skeleton. In addition, a scapulo-
thoracic and a subacromial joint are
often included in anatomical descrip
tions of the shoulder complex. To-
gether, these articulations provide
the shoulder with a range of motion
that exceeds any other joint mecha-
nism. Full mobility is dependent on
coordinated, synchronous motion in
all joints of the shoulder complex.
This wide range of mobility, to-
gether with elbow motion, allows po-
sitioning of the hand anywhere
within the visual work space. While
some occupations and sporting
events require this wide range of
movement, most activities of daily
living can be performed despite loss
of shoulder complex motion, provid-
ing mobility is unimpaired in the cer-
vical spine and distal upper extrem-
ity joints.
place by atmospheric pressure and
axioscapular muscles, including the
trapezius, serratus anterior, rhom-
boid major and minor, and the leva-
tor scapulae (67). T h e concave ante-
rior surface of the scapula is sepa-
rated from the convex external
surface of the thorax by the subscap
ularis and serratus anterior muscles,
which glide over o n e another during
movement.
Resting Position of the Scapula
T h e scapula is a thin, flat trian-
gular bone that lies on the postero-
lateral aspect of the thorax over ribs
two t o seven (34,67). With the arm
dependent, the superior angle of the
scapula lies a t the level of the second
thoracic vertebra, the root of the
scapular spine is at the level of the
ing position (34.67). T h e plane of
the scapula is approximately a t right
angles t o the plane of the glenoid
(50). At rest, it lies obliquely be-
tween the frontal and sagittal planes,
30-45" anterior t o the coronal plane
(6,57,67). In addition, the scapula is
described as having a slight forward
tilt in the sagittal plane (23). Radio-
graphic measurements indicate that,
in the resting position, the glenoid
fossa has a downward inclination in
normal shoulders (27.57) rather than
upward as proposed by Basmajian
and Bazant (4).
It is postulated that the resting
position of the scapula is altered in
subjects with abnormal cervical and
thoracic spine sagittal plane align-
ment, leading to decreased range of
motion of the upper extremity,
shoulder dysfunction, and weakness

Volume 18 Number 1 July 1993 JOSPT


or contracture of the axioscapular
n~usculature(l0,13,35,37). How-
ever, with the exception of glenoid
inclination angle, few objective meas-
ures of scapular position have been
reported, and alterations in position
related to age or spinal posture have
not been studied objectively. T h e re-
lationship of shoulder complex posi-
It is postulated that
the resting position of
the scapula is altered
in subjects with
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abnormal cervical and
thoracic spine sagittal
plane alignment.
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
tion to age and spinal posture was
examined in a recent study by the
authors (18). T h e position of the
skeletal conlponents of the shoulder
complex was measured in three
planes using an electroniagnetic de-
vice as subjects stood with their arms
Journal of Orthopaedic & Sports Physical Therapy
relaxed by their sides. Ninety-one
wornen between the ages of 20 and
85 years were studied, 23 of whom
had a diagnosis of osteoporosis.
In the transverse plane, the spine
of the scapula formed an average an-
gle of 30.2" to the coronal plane in
34 healthy women under 40 years of
age (Figure 1). T h e scapula was sig-
nificantly more retracted in healthy
women over 50 years of age. Retrac-
tion of the scapula was accompanied
by retraction of the clavicle and ex-
tension of the humerus in the sagit-
tal plane. I t was postulated that these
changes represent compensatory
n~echanismsto rnairltaili balance as
the trunk assumes a more flexed pos-
ture in older individuals. Increasing
thoracic kyphosis resulted in an in-
crease in scapular protraction angle
and an increase in the angle between
the clavicle and scapula ill the trans-
LITERATURE REVIEW
FIGURE 1. Retraction angle of the clavicle (a),
protraction angle of the scapula ( b l and angle
formed between the scapular spine and clavicle (c)
in the transverse plane, measured using the 3Space
Isotrak. Angles a and b were measured relative to a
coronal axis defined by a line connecting the roots
of the right and left scapular spines. The scapular
spine was represented by a line connecting the root
of the scapular spine and the angle of the acromion.
Mean angles a, b, and c in healthy women under 40
years of age were 18.9, 30.2, and 49.1, respectively
FIGURE 2. Abduction angle of the medial border of
the scapula (a) measured in the plane of the
fn = 34). scapular spine using the 3Space Isotrak. The medial
border of the scapula was represented by a line
verse plane. These changes were
connecting the root of the scapular spine and the
inferior angle. The mean angle, a, measured in
most likely necessary to accommo-
healthy women under the age of 40 was 91.3'
(n = 34).
date the increase in anteroposterior
chest diameter seen in subjects with
an increase in thoracic curvature.
ward tilt of the scapula was also re-
There was no significant increase in
lated to spinal posture; the forward
the linear distance between the ver-
a~igulationincreased as the slope of
tebral column and scapula as ky-
the uppel thoracic spine
phosis increased, and, thus, no evi-
increased
dence supported the concept of lat-
eral translation of the scapula on the
thorax in subjects with kyphosis lead-
ing to elongation and stretch weak-
ness of the rhomboid and middle
trapezius niuscles as suggested by
previous authors (20,35).
In the coronal plane, the lateral
angle formed between the medial
border of the scapula arid the hori-
zontal nieasured 91.3" on average in
women under 40 years of age (Fig-
ure 2). This angle did not change
significantly either with increasing
a g e a r with increasing thoracic cur-
vature. Thus, there was no support
for the concept of downward rota-
tion of the scapula with increasing
kyphosis as proposed by Cailliet ( 1 3).
In the sagittal plane, the forward
tilt of the rnedial border of the scap-
ula averaged 9.0" to the vertical in
women under the age of 40 years
(Figure 3). The forward tilt in-
creased with age, averaging 1 3.2" in FIGURE 3. Angle of forward tilt of the medial border
o i the scapula (a). The mean angle measured in
women over 50 years ot' age without healthy women under the age of40 was 9.0"
a diagnosis of' osteoporosis. T h e for- In = 34).
 LITERAPI'URE REVIEW
Scapular Motion
.l'hree rotatory rnotions and two
translatory nlovenlents of the scapula
are described, although it is recog-
nized that these motions d o not oc-
cur independently of one another.
Rotation of the scapula about a sagit-
tal axis results in upward or down-
ward tilt of the glenoid fossa. l'his
niovenlerit occurs at the AC and SC
joints (69) and has been labeled as
both abductio~i/adduction(22) and
upward/downward rotation (50).
'I'he prime movers for upward rota-
tion, an esseritial co~nponentof total
arni elevation, are the trapezius and
the serratus anterior n~uscles(69).
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T h e remaining two rotatory
niovements occur primarily at the
ACjoint (46). Rotation about a ver-
tical axis through the AC joint re-
sults in scapular winging, which is
posterior nlovernent of the vertebral
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
border of the scapula (46,50). Rota-
tion about a coronal axis results in
scapular tipping or tilting (46).
Elevation and depression of the
scapula are translatory ~ilotionsin
which the scapula moves upward o r
downward on the rib cage. T h e scap-
ula can also translate toward or away
from the vertebral colunin, a niove-
Journal of Orthopaedic & Sports Physical Therapy
nient labeled abduction/adductio~i
by some authors (50). Protraction,
defined as forward nlovenlerlt of the
scapula around the thoracic wall,
combines linear translation away
fro111 the vertebral columti, rotation
of the scapula around the end of the
clavicle (winging), and anterior
niovenient of the lateral end of the
clavicle (69). 'l'he prime movers for
protraction are the serratus anterior
and pectoralis minor ~iiuscles(69).
-1'he middle trapezius and rhomboid
~nusclesare the prime movers for
scapular retraction.
Sternoclavicular Joint
-1'he SC joirlt is a plam svnovial
joint in which the bulbous medial
end of the clavicle articulates with a
shallow sternal socket arid with the
cartilage of the first rib (36,45). Fi-
brocartilage covers both articular
surfxes (69). T h e medial end o f t h e
clavicle is concave anteroposteriorly
and convex cephalocaudally; the ar-
ticular surface of the sternurn is re-
ciprocally curved (69). An articular
disc is attached to the upper nonar-
ticular portion of the medial end of
the clavicle superiorly and to the
sternum arid first rib below, com-
pletely dividing the joint cavity into
two compartments (22,46,53).
l ' h e SC joint is dependent on
the disc, a strong capsule, and three
ligaments for stability. T h e disc
helps prevent the clavicle froni dislo-
cating niedially over the sternurn
when forces are transmitted along
the clavicle to the axial skeleton (-53).
Anterior and posterior sternoclavicu-
lar ligaments reinforce the capsule
and limit anterior-posterior niove-
nient of the medial end of the cla-
vicle (45). T h e costoclavicular liga-
rnent attaches the inferior surfice of
the medial end of the clavicle to the
first rib. It acts as a check to clavicu-
lar elevation and helps limit clavicu-
lar protraction (45). 'l'he interclavi-
cular liganlent unites the nonarticu-
Iar portion of one clavicle to the
other above the manubrium and
functions to h i i t excessive down-
ward moven~entof the riiedial end of
the clavicle (22,45).
Although the articular surfices
of the SC joint are saddle-shaped,
the joint functions as a ball- and-
socket joint and has three degrees of
freedoni (1,4 1.69). Elevation and
depression of the clavicle occur be-
tween the medial end of the clavicle
and the disc (22). Protraction and re-
traction occur betweell the disc and
the sternum (22,46,67). In addition,
the clavicle can rotate about its Ion-
gitudirlal axis (1,46,54,67).
Acromioc~avicu~ar
Joint
'l'he AC joint is also a plane syl-
ovial joint betweell a srliall co~ivex
facet on the lateral end o f t h e clavi-
cle and a small concave hcet on the
acromion of the scapula (45). Both
surfaces are covered with fibrocarti-
\.age (69). T h e nledial end of the
clavicle rises above the acromion,
and the joint surfaces are angled in
an inferior, n~edialdirection, result-
ing in a terlderlcv for the acroniion
to be driven under the clavicle when
excessive forces are transmitted
through the joint (69). l'his joint
also coiltai~lsa fibrocartilagirlous
disc, but it is variable in size arid
does not completely separate the
joint into two cotiipartlnents
(45,46).
Stability of the AC joint is de-
pendent on the superior and inftrior
acroniioclavicular ligiin~entsthat
reinforce the weak joint capsule (1).
In addition, the strong coracocla-
vicular ligament, uniting the clavicle
and the coracoid process, is inipor-
taut in nlaintaining the relationship
of the two bones (46.69). l'his liga-
ment consists of two portions. l'he
trapezoid ligament, the anterolateral
co~nponent,runs from the anterior
part of the coracoid process and
passes upward and laterally to attach
to the inferior surhce of ~ h clavicle
e
(36,69). T h e primary function of this
ligament is to prevent overriding of
the clavicle on the acroiilion (5,37).
l'he colloid portion lies posterior
and niedial to the trapezoid liga-
~nent.It runs upward arid slightly
backward froni the upper surface of
the coracoid process to attach to the
undersurface of the clavicle (36).
Tension in the conoid ligament dur-
ing arm elevation results in dorsal
axial rotation of the clavicle about its
long axis (I ,24). l'his rotation is nec-
essary for full elevation of the upper
extreniity.
'I'he AC joint allows movement
of the scapula on the clavicle in
three planes. Rotati011 occurs about
corotlal, sagittal, and vertical axes as
previouslv described.
GLENOHUMERAL IOINT
l'he glenohunleral joint is a syn-
ovial ball-and-socket joint bet\veer~
Volu111e 18 Number 1 July 1993 JOSPT

the humeral head and the glenoid
fossa of the scapula. T h e shallowness
of the glenoid fossa and the dispro-
portionate size and lack of con-
gruency of the articular surfaces
make the joint inherently unstable.
Stability is primarily dependent on
capsuloligamentous structures and
the musculotendinous cuff. T h e ma-
jor structures providing joint stabil-
ity are summarized in Table 1.
Stability of the Glenohumeral Joint
Osseous Morphology T h e sur-
face of the glenoid fossa is only one-
third t o onequarter that of the hu-
meral head (53,62,65), which means
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that only part of the humeral head is
in contact with the glenoid in any
particular position of the joint (6 1).
T h e glenohumeral index, calculated
by dividing the maximum transverse
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
diameter of the glenoid by the maxi-
mal transverse diameter of the hu-
meral head. was found t o be 57.5 in
Factors Limiting Anterior Translation
Coracohumeral and superior glenohumeral
ligaments
Subscapularis muscle and middle
Journal of Orthopaedic & Sports Physical Therapy
glenohumeral ligament
Anterior band of the inferior
glenohumeral ligament
lnfraspinatus and teres minor muscles
Factors Limiting Posterior Translation
lnfraspinatus and teres minor muscles
Subscapularis muscle
Inferior glenohumeral ligament
Anterior superior capsule
Retrotilt of the glenoid fossa
Factors Limiting lnferior Translation
Superior joint capsule and superior
glenohumeral ligament
Negative intra-articular pressure
Inferior glenohumeral ligament
TABLE 1. Stability of the glenohumeral joint.
JOSPT Volume 18 Number 1 -July 1993
5 0 normal shoulders (59). It has
been suggested that low values of
this index indicate glenoid dysplasia
and are associated with anterior in-
stability. This theory, however, has
not been supported by research (1 9.
59). Although the glenohumeral in-
dex was slightly lower in shoulders
with recurrent anterior dislocation
compared to normal shoulders, the
difference was due t o erosion of the
anterior glenoid margin and labrum
d u e to recurrent trauma rather than
to developmental dysplasia of the
glenoid fossa (1 9.59).
T h e humeral head faces medi-
ally, superiorly, and posteriorly with
respect to the shaft of the bone
(34.50). T h e normal angle of retro-
torsion of the head with respect t o
the shaft is between 25 and 35"
(1 9,59). A high retrotorsion angle
has been implicated as a causative
factor in recurrent anterior disloca-
tion (62). However, n o difference in
the retrotorsion angle was found be-
Limit external rotation between 0 and 60"
elevation (68)
Effective stabilizers between 0 and 90'
elevation (68)
Primary stabilizer above 90' elevation (68)
Prevent anterior translation of humeral
head in abducted, externally rotated
position (14)
Static stabilizers in all positions of
abduction (52)
Prevents posterior translation of humeral
head on glenoid (52)
Most effective stabilizer at 90'
abduction (51)
Disruption necessary for posterior
dislocation to occur (52)
Excessive retrotilt implicated in posterior
subluxation (11)
Main structures limiting inferior
subluxation in the dependent position (9)
Limits inferior displacement of the
adducted humerus (39)
Most effective stabilizer above 45" of
abduction (51,68)
LITERATURE REVIEW
tween normal shoulders and shoul-
ders with anterior instability meas-
ured radiographically and by com-
puted tomography (19.59).
Several studies have confirmed
that the glenoid fossa is retrotilted
with respect t o the plane of the s c a p
ula in most normal shoulders
(19,59,62). Saha (62) suggested that
a ventral tilt o r anteversion of the
glenoid was associated with anterior
instability of the joint. However, this
has not been supported in subse-
quent studies (19,59). Randell and
Gambrioli (59) measured anteropos-
terior tilt of the upper, middle, and
lower regions of the glenoid in nor-
mal and unstable shoulders using
computed tomography. No cases of
anteversion were found in either sta-
ble o r unstable shoulders a t any level
of the glenoid. Excessive retrover-
sion, however, was reported t o be
the primary etiology associated with
nontraumatic posterior instability in
a study by Brewer e t al (1 1).
Glenoid Labrum T h e glenoid
labrum is a rim of fibrocartilage at-
tached around the margin of the gle-
noid fossa. T h e labrum is lined by
synovial membrane internally, is at-
tached to the capsule externally, and
is continuous with the periosteum of
the scapular neck (53). It is generally
accepted that the labrum helps
deepen the glenoid cavity, thus, con-
tributing t o the stability of the joint
(30,43-45.55). T h e average depth
of the socket, including the labrum,
measured in 25 cadaver shoulders
was 9 mm and 5 mm in a superior-
inferior and anterior-posterior direc-
tion, respectively (30). T h e labrum
was found t o contribute approxi-
mately 50% of the total depth of the
socket (30). Based on these anatomi-
cal findings, the authors concluded
that the labrum is important in gle-
nohumeral joint stability (30). Con-
versely, Moseley and dvergaard (47)
stated that the labrum contained lit-
tle fibrocartilage. T h e labrum was
described as a redundant fold of fi-
brous capsule that stretched out an-
teriorly with external rotation and
 posteriorly with internal rotation of
the huri~erus(47).
Capsuloligamentous Mechanism
l'he ciipsule is attached medially to
the margin of the glenoid fossa arid
of the hunieral head in the ad-
ducted, depende~ita r ~ n(9,68). A le-
sion of the rotator i~iterval,defined
as the space between the superior Poshrior
border ofthe subscapularis muscle Caprub

laterally to the circumference of the arid the supraspinatus tendon, is as-

anaton~icalneck, desceridirig about sociated with a~iteriorand inferior
instability oftlie glenohunieral joint Poahrhw
1.3 cm onto the shaft of the hu- Band
merus. It is thin and large, allowing (49). l'his lesion may be due to a IGHL Anlorlor Band

2-3 11111i of distraction of the head deficiency in the superior glenohu-

from the glenoid (69). By itself', the
capsule would contribute little to the
stability of the joint. It is stretigth-
ened by ligamerits and by the inser-
tions of the rotator cuff tendons.
The coracohumeral ligament
originates from the base and lateral
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nwxl liganie~it,one of the ariato~iii-
cal structures comprising the rotator
interval (9).
*l'he niiddle glenohuineral liga-
riient passes horn the anterior mar-
gin ofthe glenoid hssa to the ante-
rior aspect of the anatoriiical neck FIGURE 4. Clenohumeral joint capsule and

boi'der of the coracoid process and
passes laterally to insert on the hu-
nieral tuberosities (25). ?'he coraco-
humeral ligament checks lateral rota-
tion of the hunierus between 0 atid
60" of arm elevation (25). A second
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
and lesser tuberosity of the hunierus
(68). I t lies under the subscapularis
tendon arid is intimately attached to
it (25,65). The subscapularis tend011
and ~iiiddleglenohunieral ligamer~t
are iri~portaritanterior stabilizers of
ligaments. SCHL-superior glenchumeral ligament,
MLHL-middle glenohumeral ligament, ICHL-
inferior glenohumeral ligament. (Adapted from
O'Brien et a1 (5 1 j, with permission).

function generally attributed to this
ligament is providing support for the
dependent arm by resisting the
dowiward pull of' gravity on the hu-
meral head (25,50,53). Bowen and
Warner (9), however, concluded that
this ligament had little or no func-
tional significance in limiting inferior
tra~islationof the hunieral head in
Journal of Orthopaedic & Sports Physical Therapy
the glenohurneral joint and function
to limit lateral rotation of the hu-
merus between 0 arid 90" of eleva-
tion (1 7,25.52,68). The middle gle-
nohunieral liganient may be atten-
uated or absent (9,25), leading to
anterior instability, particularly be-
tween 60 arid 90" of elevation (25).
'I'he inferior glenohunieral liga-
translation of the humeral head on
the glenoid during arni elevation;
the anterior and posterior bands be-
came taut with external and internal
rotation, respectively (5 1).
Intra-articular Pressure Experi-
mentation on cadaver shoulders indi-
cates that nornial negative intra-ar-
ticular pressure may coritribute to
the stability of the glenohumeral

the adducted arm, based on selective
cutting and static translatiori experi-
n~entationin cadavers.
l'he three glenohumeral liga-
nie~its-superior, niiddle, and infe-
rior-are thickened areas of the an-
terior, inferior, and posterior joint
capsule. The subscapular bursa co111-
~nuriicateswith the joint cavity be-
tween the superior and middle gle-
nohumeral ligament and, in sorile
cases, between the middle and infe-
rior ligament (25).
The superior gle~iohun~eral liga-
ment runs from the superior glenoid
tubercle, the upper part of the gle-
rioid lab run^, and the base of the
coracoid process to the hunierus be-
tween the upper part of the lesser
tuberosity and the anatomical neck
(25,68). l'he prirnary function of the
superior glenohunieral liganient is
preveritiori of inferior displacement
ment attaches to the anterior, infe-
rior, and posterior riiargins of the joint (29,39). Kunlar and Balasubra-
glerioid labruni mediallv and to the niania~n(39) reported significant in-
anato~nicaland surgical neck of the ferior subluxation following percuta-
humerus laterally. 'l'urkel et al (68) neous puncture of the capsule, allow-
described a thickened superior por- ing atniospheric air to enter the joint
tion called the superior band and a
thi~ibroad inferior portion termed
the axillary pouch. Both parts sup-
port the j o i ~ in ~ t the upper ranges of Experimentation on
elevation and prevent anterior sub-
luxatiori and dislocation in this part cadaver shoulders
of the range (52.68). O'Brien et al
(5 1). i l l ari arthroscopic and histo- indicates that normal
logic study of 1 1 cadaver shouldc~~s. negative intra-articular
idelltitied a posterior band in addi-
tion to the anterior band and axil- pressure may
lary pouch (Figure 4). 'l'he posterior
band acted as a stabilizer against pos- contribute to the
terior subluxation ot' the huineral stability of the
head during liiovements ofabduc-
tion and internal rotation. Both glenohumeral joint.
bands fu~ictiowdto liiiiit i n k rior

Volume I X Nunher I Julv 1993 *JOSPT


cavity. Similarly, puncture of the
capsule resulted in an increase in an-
teroposterior translation of the hu-
meral head on the glenoid during
humeral flexion, extension, external
rotation, and cross body flexion (29).
Musculotendinous Cuff Stability
of the glenohumeral joint is also de-
pendent on muscular control, pri-
marily provided by the musculoten-
dinous cuff (38,43,53,62,63).T h e
tendons of the cuff muscles, supra-
spinatus, infraspinatus, teres minor,
and subscapularis, blend with and
reinforce the joint capsule (53).
They provide active support for the
joint and can be considered true dy-
Downloaded from www.jospt.org at on November 5, 2016. For personal use only. No other uses without permission.
namic ligaments (32).
It is generally accepted that the
deltoid and supraspinatus muscles
are the prime movers for glenohu-
meral abduction ( I 7.2 1,26,31,32).
With the arm at the side, the direc-
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
tional force of the deltoid muscle is
almost vertical (43,65). Thus, the
majority of the deltoid force causes
upward translatory motion of the
humeral head, which if unopposed
would lead t o contact between the
humeral head and coracoacromial
arch resulting in impingement of
soft tissues (43.58.65). T h e action
Journal of Orthopaedic & Sports Physical Therapy
lines of the infraspinatus, subscapu-
laris, and teres minor muscles each
tend to have compressive and down-
ward translatory components, that
offset the upward translation force
of the deltoid (43,54,65). T h e infra-
spinatus, subscapularis, and teres mi-
nor thus form a force couple with
the deltoid and stabilize the humeral
head on the glenoid, allowing the
deltoid and supraspinatus t o act as
abductors of the humerus
(43,54,65). Comtet e t al (17), in
studies on a mechanical model, de-
termined that the depressor forces
are a t their maximum between 60
and 80" of elevation and disappear
beyond 120".
T h e infraspinatus and teres rni-
nor muscles also contribute t o ante-
rior stability of the glenohurneral
joint when the shoulder is abducted
and externally rotated ( I 4). It was
IOSPT Volume 18 Nunher I-July 1993
postulated that these muscles restrict
anterior translation of the hunieral
head on the glenoid in this position,
thus reducing strain on anterior joint
structures (1 4).
T h e tendon of the long head of
the biceps brachii also contributes t o
the dynamic stability of the glenohu-
meral joint. This tendon prevents
upward migration of the humeral
head on the glenoid fossa during
powerful elbow flexion and forearm
supination (40).
Mobility of the Glenohumeral Joint
T h e glenohumeral joint is de-
scribed as having three degrees of
freedom: flexion/extension, abduc-
tion/adduction, and rotation. T h e
amount of glenohumeral abduction
in the coronal plane is limited t o 60-
90" if the humerus is maintained in
internal rotation (1 2,43). This limita-
tion is due t o impingement of the
greater tubercle of the humerus on
the acromion process and tension in
the inferior glenohumeral ligament
(28). If the humerus is allowed t o
externally rotate, abduction range
increases to between 90 and 120"
(1 2,43,67). Elevation of the humerus
in the sagittal plane is accompanied
by medial rotation of the humerus
(8,33,53).According t o Cagey et al
(28), the medial rotation occurs be-
cause of increasing tension in the
coracohunieral ligament as the hu-
merus flexes in this plane.
When the hunlerus is elevated in
the scapular plane, a nlovement
termed scapular plane abduction, lat-
eral rotation is not required t o pre-
vent the greater tubercle from im-
pinging up011 the acromion (2533).
In addition, the glenohumeral joirit
capsule is not twisted when elevation
occurs in the scapular plane and the
deltoid and supraspinatus are opti-
mally aligned to perform hu~neral
abduction (53,57). In normal shoul-
ders, the humeral head re~nainscen-
tered on the glenoid fossa through-
out elevation in the scapular plane,
with the exception of upward glide
LITERATURE REVIEW
at the beginning of the movement
(57)-
Regardless of the plane of eleva-
tion of the humerus, the end posi-
tion is the same at full elevation. T h e
medial epicondvle faces forward and
the humerus is in the plane of the
scapula (28,33,64). This is the posi-
tion of nlaxinium osseoliganlentous
stability and greatest congruellcy be-
tween the articular surfaces (2833).
Little o r no active rotation of the hu-
merus is permitted in this close-
packed position (26,33).
CORACOACROMIAL ARCH
T h e coracoacroniial arch is
formed by the coracoid and acro-
mion processes of the scapula and
the coracoacromial ligament that
unites them (7.69). T h e base of this
triangular ligament attaches t o the
lateral aspect of the coracoid pro-
cess, and its apex attaches t o the su-
perior aspect of the acromiorl (69).
T h e subacromial space between the
coracoacromial arch and the hu-
meral head is occupied Sv the rota-
tor cuff tendons and the subacromial
bursa. T h e bursa separates the ac-
romial arch and the deltoid nluscle
superiorly from the rotator cuff and
biceps tendons below, allowing
smooth gliding between these struc-
tures and reducing friction on the
tendons as they pass under the cora-
coacromial arch (7). T h e bursa nor-
mally does not communicate with
the glenohumeral joirit cavity but
may d o so following rotator cuff
tears.
-1'he distance between the irife-
rior surface of the acromion and the
hunleral head, measured radiograph-
icallv, averages 9- 10 mm in ~lolmal
shoulders (56). A reduction in this
distance is associated with tears of
the rotator cuff tendons and of the
long head of the biceps brachii
(7,56,70). Conlpression of these
structures occurs most often under
the anterior one-third of the acro-
rnion process, the coracoclavicular
ligament, o r the AC joint (48). Any
 LITERATURE REVIEW
abnormality that decreases the vol-
ume of the subacromial space in this
region may lead t o impingement of
its contents (7). A reduction in space
may result from inflammation of the
rotator cuff tendons due t o repeti-
tive overhead activity o r osteophyte
formation on the inferior surface of
the medial acromion o r lateral clavi-
cle. T h e incidence of rotator cuff
tears due t o impingement also a p
pears to be related t o the shape and
slope of the acromion process (7).
Hypovascularity of the supraspinatus
tendon near its insertion into the hu-
merus may predispose this region of
the tendon t o degenerative changes
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(1 5,42,60).
INTEGRATED FUNCTION OF THE
SHOULDER COMPLEX
Full elevation of the upper ex-
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
tremity requires scapular rotation
through movement a t both the SC
and AC joints such that the glenoid
fossa tilts progressively upward, pro-
viding a base upon which the hu-
meral head moves. T h e term scapu-
lohumeral rhythm is believed t o
have been first introduced by Cod-
man (16) t o describe the integrated
Journal of Orthopaedic & Sports Physical Therapy
movement at the glenohumeral and
scapulothoracic joints during upper
extremity elevation. Inman et al (32)
studied glenohumeral and scapular
motions during arm elevation in the
coronal and sagittal planes. They
concluded that glenohumeral and
scapular rotation contributed a maxi-
mum of 120 and 6 0 , respectively,
to total arm motion. T h e first 30" of
abduction and 60" of flexion, in
which the scapula moved medially o r
laterally o r remained fixed, was
identified as the initial scapular "set-
ting phase." Most of the motion dur-
ing this phase occurred at the gleno-
humeral joint. T h e overall ratio of
glenohumeral t o scapular thoracic
rotation was 2: 1 (32).
More recent studies have exam-
ined scapulohumeral rhythm during
arm elevation in the scapular plane
(3.23,27). Total range of elevation
measured in these studies was 168-
1 72 " . Scapular rotation was found t o
contribute 60" t o the total arm ele-
vation, whereas glenohumeral ro-
tation varied from 103 t o 1 13 "
(3.23.27). T h e ratio of glenohumeral
t o scapulothoracic motion was found
t o vary throughout the range and
was highly variable between subjects
(3.23.27). Most typically, glenohu-
meral motion exceeded scapular mo-
tion during initial arm elevation.
The ratio of
glenohumeral to
scapulothoracic
m o t h was found to
vary throughout the
range and was highly
variable between
subjects.
Doody et al (23) reported a glenohu-
meral to scapulothoracic ratio as
high as 7.29: 1 during the first 30'
of elevation. T h e ratio of 3.29: 1 was
reported by Bagg and Forrest (3) be-
tween 20 and 80" of elevation.
Doody et al(23) and Bagg and For-
rest (3) reported glenohumeral t o
scapulothoracic ratios of .79:1 and
.7 1 :1 , respectively, between 80 and
140" of elevation. Above 140 o r
150". glenohumeral motion again
predominates (3.23). T h e ratio re-
ported by Bagg and Forrest (3) for
this phase was 3.49: 1 for subjects
demonstrating the most typical pat-
tern of movement.
T h e 60" of scapular rotation is a
result of movement at both the SC
and AC joints. T h e movement is
brought about by the action of the
upper and lower portions of the tra-
pezius combined with the serratus
anterior muscle, particularly the
powerful lower digitations (2,3,54).
During arm elevation from 0 t o SO0,
the instant center of rotation of the
scapula is located a t o r near the root
of the spine of the scapula (3,24).
During this phase, scapular rotation
is predominantly a result of elevation
of the clavicle at the SC joint. T h e
upper fibers of the trapezius and
lower fibers of the serratus anterior
are primarily responsible for scapu-
lar rotation during this phase (3).
Bagg and Forrest (3) described a
middle phase of arm elevation occur-
ring between 80 and 140". During
this phase, the instant center of rota-
tion migrates toward the AC joint
along the upper central scapular area
(3). Scapular rotation is d u e t o con-
tinued elevation of the clavicle a t the
SC joint and rotation of the scapula
on the clavicle a t the AC joint (3).
This is described as the most stress-
ful phase of arm elevation and is the
phase when most scapular rotation
occurs (3.23). T h e moment arm of
the lower trapezius lengthens, and
this muscle becomes increasingly ac-
tive during this period t o assist the
upper trapezius and the serratus
anterior in rotating the scapula
upward (3).
In the final phase of arm eleva-
tion, the instant center of rotation is
located a t the AC joint (3). Clavicu-
lar elevation becomes increasingly
limited by tension in the costocla-
vicular ligament (24,50). T h e power-
ful scapular muscles continue t o ro-
tate the scapula upward. T h e
amount of movement of the scapula
on the clavicle at the AC joint is lim-
ited by the coracoclavicular ligament
(66). T h e tension generated in this
ligament as the coracoid process
moves away from the clavicle causes
dorsal rotation of the clavicle about
its long axis (1,24,32,41).Since the
clavicle is crank-shaped, this long
axis rotation causes the acromial end
of the clavicle t o elevate further
without any additional elevation
of the clavicle at the SC joint
(24.4 1.53).
Volume 18 Number I July 1993*JOSPT

SUMMARY
T h e shoulder complex is t h e
lnost mobile region i n t h e body d u e
t o combined movement at t h e scapu-
lothoracic and glenohumeral articu-
lations. Simultaneous, coordinated
m o t i o n o f t h e scapula, clavicle, and
humerus is necessary f o r full eleva-
t i o n and normal function of t h e up-
per extremity. T h e glenohumeral
j o i n t is inherently unstable d u e t o
t h e shallowness o f t h e glenoid fossa,
t h e disproportionate size o f t h e hu-
meral head and glenoid, and t h e
poor congruency between t h e articu-
lar surfaces. Stability of t h e humeral
head o n t h e glenoid fossa b o t h at
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rest and d u r i n g movement is de-
pendent o n t h e j o i n t capsule, t h e gle-
noid l a b r u m , t h e coracohumeral and
glenohumeral ligaments, and t h e ro-
tator c u f f musculature. JOSPT
Copyright 1993 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
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