Determinants of Shoulder and Elbow
Flexion Range: Results from the San Antonio
Longitudinal Study of Aging
Agustı́n Escalante, Michael J. Lichtenstein, and Helen P. Hazuda
Objective. To gain a knowledge of factors associ-
ated with impaired upper extremity range of motion
(ROM) in order to understand pathways that lead to
disability.
Methods. Shoulder and elbow flexion range was
measured in a cohort of 695 community-dwelling
subjects aged 65 to 74 years. Associations between
subjects’ shoulder and elbow flexion ranges and
their demographic and anthropometric characteris-
tics, as well as the presence of diabetes mellitus or
self-reported physician-diagnosed arthritis, were ex-
amined using multivariate regression models. The
relationship between shoulder or elbow flexion range
and subjects’ functional reach was examined to ex-
plore the functional significance of ROM in these
joints.
Supported by NIA award 1-RO1-AG-10444 and by NIH grant
M01-RR-01346 for the Frederick C. Bartter General Clinical Re-
search Center. Dr. Escalante’s work is supported in part by a grant
from the Robert Wood Johnson Minority Medical Faculty Devel-
opment Program.
Agustı́n Escalante, MD, Division of Clinical Immunology and
Rheumatology, and Helen P. Hazuda, PhD, Division of Clinical
Epidemiology, Department of Medicine, The University of Texas
Health Science Center at San Antonio; and Michael J. Lichten-
stein, MD, Division of Geriatrics and Gerontology, Department of
Medicine, The University of Texas Health Science Center at San
Antonio, and Geriatric Research and Education Clinical Center,
South Texas Veterans Health System–Audie L. Murphy Division,
San Antonio, Texas.
Address correspondence to Helen P. Hazuda, PhD, 7703 Floyd
Curl Drive, San Antonio, TX 78284-7873.
Submitted for publication August 3, 1998; accepted in revised
form April 19, 1999.
© 1999 by the American College of Rheumatology.
0893-7524/99/$5.00
Results. The flexion range for the 4 joints studied
was at least 120° in nearly all subjects ($99% of the
subjects for each of the 4 joints). Multivariate models
revealed significant associations between male sex,
Mexican American ethnic background, the use of
oral hypoglycemic drugs or insulin to treat diabetes
mellitus, and a lower shoulder flexion range. A lower
elbow flexion range was associated with male sex,
increasing body mass index, and the use of oral
hypoglycemic drugs or insulin. A higher shoulder or
elbow flexion range was associated with a lower
likelihood of having a short functional reach.
Conclusions. The great majority of community-
dwelling elderly have a flexion range of shoulder and
elbow joints that can be considered functional. Dia-
betes mellitus and obesity are two potentially treat-
able factors associated with reduced flexion range of
these two functionally important joints.
Key words. Shoulder; Elbow; Joint range of mo-
tion; Diabetes; Mexican Americans.
INTRODUCTION
The range of motion (ROM) of the joints of the
upper extremities is important for normal physical
function, in particular for the performance of activ-
ities of daily living such as feeding, dressing, bath-
ing, and many others. Impairments in joint ROM
may result in physical function limitations in basic
physical actions (e.g., reaching, lifting) required to
perform these activities, which can then lead to dis-
ability (1). Passive joint ROM is a direct measure of
articular function, and impaired ROM probably re-
flects underlying pathology of the joints or other
277
278 Escalante et al
organ systems. In spite of the importance of joint
ROM for daily functions, there are few published
studies focusing on joint ROM in healthy persons.
Most information available about joint ROM comes
from populations affected by diseases of the joints.
The purposes of the present analyses are to describe
the upper extremity articular ROM in a representa-
tive sample of community-dwelling elderly persons,
and to identify associations between articular ROM
and individual demographic and anthropometric
characteristics, diabetes mellitus, and self-reported
physician-diagnosed arthritis.
SUBJECTS AND METHODS
The San Antonio Longitudinal Study of Aging
(SALSA). SALSA is a sequel to the San Antonio
Heart Study (SAHS) (2). The relationship between
these two studies has been described previously (3).
Briefly, 5,158 community-dwelling subjects were en-
rolled from randomly sampled households in San
Antonio, Texas, to assemble a cohort with compara-
ble numbers of Mexican Americans and European
Americans. The first phase of enrollment was from
October 1979 to November 1982, and the second
from October 1984 to October 1988.
In 1991, the oldest subjects, aged 64 to 79 years,
were recruited for SALSA to participate in a com-
prehensive 2-part evaluation. The first part was a
home-based assessment. The second part was a per-
formance-based assessment conducted in a clinical
research center. Of 1,247 eligible SAHS subjects, 166
(13.1%) died prior to the start of SALSA. Of the
1,081 survivors, 888 were recruited successfully,
and 833 (77.1% of survivors) completed the home-
based assessment. Passive joint ROM was measured
at the clinical research center on 695 of these sub-
jects, or 64% of the survivors. An analysis of poten-
tial response bias between subjects who attended
each of the assessments and those who did not
showed that nonresponders to both assessments had
significantly fewer years of education than respond-
ers, and that nonresponders to the performance-
based assessment were more likely to be Mexican
American. There were no differences in age, sex, and
prevalence of diabetes mellitus or arthritis between
responders and nonresponders to either assessment.
Home-based assessment. The home-based assess-
ment consisted of a comprehensive, 3-hour inter-
view that assessed chronic diseases, impairments,
functional limitations, disability, and various modi-
fiers of the disablement process (1). Variables mea-
Vol. 12, No. 4, August 1999
sured during the assessment that were employed in
the current analyses are listed below.
Demographic characteristics. Age, sex, and eth-
nicity were noted. Ethnicity was classified as Mexi-
can American or European American according to
the definitions of the SAHS (4).
Pain. The presence or absence of pain was as-
sessed using the first question of the McGill Pain
Questionnaire (MPQ), “Are you ever troubled with
pain?” (5). Subjects responding affirmatively and
who also reported pain in the past week were ad-
ministered the full MPQ, including the pain map.
The map consists of anterior and posterior projec-
tions of the human body, on which subjects’ painful
areas are marked. The map is scored by overlying a
plastic template of the map, divided into 36 ana-
tomic areas, on the marked figure (6,7). Using a con-
firmatory factor analysis, these 36 areas have been
grouped into 7 broad areas of pain clustering: head
and neck, arms, hands, anterior trunk, upper and
lower back, upper leg, and lower leg (8). A Spanish-
language version of the questionnaire was used for
Spanish-speaking subjects (9).
Arthritis. Arthritis was ascertained by self-report,
using the question, “Have you ever been told by a
doctor that you have arthritis?” Subjects answering
in the affirmative were considered to have arthritis.
Diabetes. Diabetes was classified using the World
Health Organization (WHO) criteria (10), i.e., diabe-
tes was considered present if any of the following
criteria were met: 1) a fasting blood glucose of 140
mg/dl or greater; 2) a plasma glucose of 200 mg/dl or
greater 2 hours after an oral glucose load; 3) current
use of antidiabetic medications. Diabetes was con-
sidered absent if the above criteria were not met. In
the subjects for whom plasma values were not ob-
tained (19% of the total sample), diabetes was con-
sidered absent if no antidiabetic medications were
observed and the subject answered “no” to the ques-
tion, “have you ever been told by a doctor that you
have diabetes?”
Performance-based assessment. The full assess-
ment took approximately 3 hours in each subject and
included anthropometric features, physical mea-
sures of cardiovascular disease, cardiopulmonary,
neurosensory, and musculoskeletal impairments,
and performance-based measures of upper and lower
extremity functional limitations. The following vari-
ables measured during the assessment were em-
ployed in the current analysis.
Body mass index. Body mass index (BMI) was
calculated by dividing the weight in kilograms by
the squared value of the height in meters. In regres-
Arthritis Care and Research Determinants of Shoulder and Elbow ROM 279

Figure 1. Range of motion (ROM) of shoulders and elbows is measured with subjects in the supine position. A, Shoulder
ROM is measured with the arm starting from a neutral position and the elbow fully extended (A1). A goniometer is placed
with its axis overlying the acromion process, its fixed arm aligned parallel to the mid-axillary line of the thorax, and its
moving arm parallel to the humerus, aimed at the lateral epicondyle. The subject is then given the following instructions:
“Just relax your arm and let me move it over your head.” The examiner then grasps the arm just proximal to the elbow and
moves the shoulder into flexion (A2). Full flexion is reached when the shoulder cannot be further moved without
accompanying spinal extension. B, Elbow ROM is measured with the elbow at full extension (B1). A goniometer is placed
with its axis overlying the lateral epicondyle of the humerus, its fixed arm parallel to the humerus, aimed at the acromion,
and its moving arm parallel to the dorsal aspect of the forearm. Subjects are then given the instructions: “Just relax your
arm.” The examiner then grasps the subject’s forearm just proximal to the wrist and moves the elbow to full flexion (B2).
Full flexion is reached when the elbow cannot be flexed further without accompanying shoulder flexion.

sion models, BMI was entered as a continuous vari-
able. For descriptive purposes, subjects were classi-
fied as overweight if BMI $27.8 kg/m2 in men, and
$27.3 kg/m2 in women. Severely overweight was
defined as $31.1 kg/m2 in men and $32.3 kg/m2 in
women (11).
Joint range of motion. Passive flexion/extension
or forward elevation of the shoulders and elbows
was measured in the clinical research center with
subjects supine, using a standard goniometer, as
shown in Figure 1 (12). Agreement between the 4
examiners who measured ROM was evaluated in a
sample of 24 ambulatory adults between the ages of
65 and 80 years. Intraclass correlation coefficients
among the 4 examiners were 0.42 for shoulder flex-
ion, and 0.84 for elbow flexion. Extrapolating termi-
nology employed for the interpretation of weighted
kappa (13), these values were considered to repre-
sent “fair to good” (14) and “excellent” (15) agree-
ment, respectively, and thus were satisfactory for the
present analysis.
Functional reach. With the right arm straight and
the hand held in a fist, subjects were asked to flex
their shoulder to 90° and then reach forward as far as
possible without taking a step or losing their bal-
ance. The starting and ending positions were marked
at the metacarpophalangeal joints for each of 3 trials.
The results are expressed in centimeters as the dis-
tance between the starting position of the fist and the
farthest point reached on a horizontal yardstick, and
are reported as the average of the 3 trials (16).
Analyses. For comparisons of dichotomous vari-
ables, odds ratios (OR) and 95% confidence intervals
(95% CI) were employed. Pearson correlation coeffi-
cients were calculated to examine the associations
between shoulder and elbow ROM. To quantify the
associations among the ROM of shoulders and el-
bows, 4 separate linear regression models were fit,
successively placing the ROM of each of the right or
left shoulders or elbows as the dependent variable,
with the remaining 3 joints as independent vari-
ables. For all the remaining analyses aimed at iden-
tifying potential determinants of shoulder or elbow
ROM, the unit of analysis was the individual joint,
using generalized estimating equations as suggested
by Zhang et al (17). This approach permits modeling
of joint ROM on joint-specific independent variables
280 Escalante et al
Table 1. Shoulder and elbow range of motion among San Antonio Longitudinal Study of Aging subjects (n 5 687)
Variable Mean SD Median
Shoulders
Right 156° 12° 158°
Left 158°* 12° 160°
Elbows
Right 150° 11° 151°
Left 152°* 12° 154°
* P # 0.0001 compared with right side.
such as joint pain, as well as on person-specific
variables such as age, sex, and the presence of dia-
betes mellitus. In these models, standard errors are
robust, adjusting for the fact that the ROM of a per-
son’s joints are correlated with each other (18).
Bivariate and multiple regression models were fit
to quantify the association of each variable of inter-
est with shoulder or elbow ROM. Logistic regression
models were used to quantify the association with
shoulder or elbow ROM on the likelihood of a sub-
ject’s being in the lowest 10th percentile in terms of
functional reach. One-way analysis of variance was
used to compare shoulder or elbow ROM between
subgroups of patients defined by the number of risk
factors for decreased ROM present, and confirmed
using the Kruskal-Wallis test for nonparametric data
(19). Regression coefficients were considered signif-
icant if their 95% CI excluded the value of zero. Due
to the non-normality of the ROM data, confirmatory
analyses of each model were performed using Box–
Cox transformed values for the ROM of each joint
(20). All parts of the analysis were performed on a
personal computer using the Intercooled Stata statis-
tical software, version 5.0 (College Station, Texas).
RESULTS
Description of the study sample: anthropometric,
demographic, and clinical characteristics. The
characteristics of the SALSA cohort have been sum-
marized in a prior report (3). Eight hundred thirty-
three community-dwelling persons were evaluated.
Their age averaged 69.2 years, ranging from 64 to 79;
482 were women (57.9%), and 457 were Mexican
American (54.9%).
Pain during the past week was present in 366, or
43.9%, of the subjects. Elbow pain was significantly
more frequent among Mexican Americans than
among European Americans (5.9% versus 2.7%,
OR 5 2.20, 95% CI 5 1.12 to 4.75), while pain in the
Vol. 12, No. 4, August 1999
Minimum Maximum Pain, %
81° 187° 8.8
66° 193° 7.8
0° 180° 3.4
9° 179° 2.8
hands was less frequent in Mexican Americans
(6.6% versus 11.1%, OR 5 0.56, 95% CI 5 0.34 to
0.91). There were no additional differences related to
sex or ethnicity in shoulder, arm, elbow, or hand
pain in this cohort (7). Severely obese subjects were
more likely to report pain in shoulders (17.7% ver-
sus 11.4%, OR 5 1.68, 95% CI 5 1.04 to 1.69), arms
(20.7% versus 14.2%, OR 5 1.59, 95% CI 5 1.02 to
2.47), and elbows (7.9% versus 3.7%, OR 5 2.26,
95% CI 5 1.12 to 4.56), but not hands.
Self-reported physician-diagnosed arthritis was
present in 382, or 46.7%, of the 818 subjects in
whom information on this variable was available. As
reported in a previous article, self-reported physi-
cian-diagnosed arthritis was more frequent in
women than men (OR 5 2.05, 95% CI 5 1.54 to
2.72), and in obese subjects (OR 5 1.65, 95% CI 5
1.25 to 2.18 compared with the non-obese). There
was no difference in the frequency of self-reported
physician-diagnosed arthritis according to ethnicity.
Diabetes mellitus according to WHO criteria was
present in 248, or 29.9%, of the 829 subjects in
whom this data were known. As reported (3), diabe-
tes mellitus was present in 41.3% of Mexican Amer-
icans, but only in 16.0% of European Americans
(OR 5 3.68, 95% CI 5 2.64 to 5.13). Similarly, dia-
betes mellitus was more frequent among obese sub-
jects (OR 5 1.63, 95% CI 5 1.20 to 2.21). There was
no difference in the frequency of diabetes mellitus
according to sex. Among diabetic subjects, 105 were
receiving oral hypoglycemic drugs (42.3%), and 50
were receiving insulin (20.2%).
Shoulder and elbow ROM. Table 1 shows the
ROM for both shoulders and elbows. The frequency
distribution of the ROM of each joint is shown in
Figure 2. The ROM of joints on the left side averaged
2° to 3° higher than the joints on the right (P #
0.0001). A ROM of at least 120° was observed in 686
of the 693 right shoulders (99%), 683 of the 691 left
shoulders (98.8%), 685 of 692 right elbows (99%),
Arthritis Care and Research
Figure 2. Frequency distributions of shoulder and elbow range of motion in 687 community-dwelling persons aged 65 to
74 years. Mean, standard deviation, median, and range values for each of the 4 joints are shown in Table 1.
and 682 of 694 left elbows (98.3%) measured. A
ROM of at least 120° in both shoulders and both
elbows was recorded in 1,348 of the 1,382 joints
measured (97.5%).
Relationships among right and left shoulders and
elbow ROM. Table 2 shows the Pearson correlation
coefficients between shoulders and elbows. The cor-
relation was good between contralateral shoulders
(r 5 0.60, P # 0.0001) and moderate between
contralateral elbows (r 5 0.44, P # 0.0001), but the
correlation between ipsilateral shoulders and el-
bows, although significant, was modest (r 5 0.18
and 0.18, respectively, P # 0.0001). Linear regres-
sion models exploring the relationships among the
Table 2. Correlations among shoulder and elbow ranges
of motion in San Antonio Longitudinal Study of Aging
subjects*
Right shoulder Left shoulder
Left shoulder 0.60
Right elbow 0.18 0.16
Left elbow 0.18 0.17
* Values shown are Pearson correlation coefficients. P # 0.0001 for all
coefficients.
Determinants of Shoulder and Elbow ROM 281
ROM of these 4 joints are shown in Table 3. The
strongest associations noted were between contralat-
eral joints.
Relationships between shoulder or elbow ROM
and demographic, anthropometric, and clinical
variables. Generalized estimating equation models
measuring the associations between the demo-
graphic, anthropometric, and clinical variables and
shoulder or elbow ROM are shown in Tables 4 and 5.
In these models that employed the individual joint
as the unit of analysis, male sex was associated with
a ROM that was lower by 3° in both shoulders and
elbows (Tables 4 and 5). Bivariate comparisons re-
vealed that Mexican Americans had a ROM that was
lower by 2° to 3° for both shoulders and elbows
compared with European Americans, but in the mul-
tivariate model this reduction remained significant
only for shoulders and not for elbows (Table 4). The
BMI also had a significant effect on ROM, being
inversely associated with elbow, but not shoulder,
Right elbow ROM. Among disease state variables, diabetes melli-
tus treated with oral hypoglycemic drugs or insulin
led to an average loss of shoulder and elbow ROM
0.44 that approximates 4° for each of those joints (Tables
4 and 5).
We devised a risk factor score for reduced ROM by
282 Escalante et al Vol. 12, No. 4, August 1999

Table 3. Relationships among the ranges of motion of shoulders and elbows in San Antonio Longitudinal Study of
Aging subjects*

Dependent joint

Independent joints Right shoulder Left shoulder Right elbow Left elbow

Right shoulder – 0.59 (0.53, 0.65)† 0.07 (20.01, 0.15)‡ 0.06 (20.02, 0.15)
Left shoulder 0.57 (0.51, 0.63)† – 0.04 (20.04, 0.12) 0.06 (20.02, 0.14)
Right elbow 0.07 (20.01, 0.14)‡ 0.04 (20.03, 0.11) – 0.49 (0.38, 0.52)†
Left elbow 0.05 (20.02, 0.12) 0.05 (20.02, 0.12) 0.39 (0.33, 0.46)† –
Adjusted R2 0.36 0.36 0.20 0.20
* Values shown are linear regression coefficients (95% confidence intervals). Coefficients can be interpreted as the change in the dependent joint, in fractions
of a degree, associated with each degree change in independent joints.
† P # 0.0001.
‡ P 5 0.07.

adding the number of characteristics identified in
the multivariate models that were present in each
subject. The results of these analyses are shown in
Table 6. The factors added were male sex, Mexican
American ethnic background, a BMI $31.1 in men or
$32.3 in women, and diabetes mellitus treated with
pharmacologic agents. For example, an obese Mexi-
can American man with insulin-treated diabetes
mellitus would have a risk factor score of 4 for de-
creased shoulder or elbow ROM. We collapsed the
upper two strata of the risk factor score (scores of 3
and 4) because there were few subjects with 4 risk
factors. Thus, a risk factor score of 3 was associated
with an incremental loss of ROM of nearly 9° from
both shoulders and elbows (P # 0.001 by one-way
analysis of variance or Kruskal-Wallis test for non-
parametric data, Table 6).
To assess the functional significance of shoulder and
elbow ROM, we studied their association with func-
tional reach (16). We hypothesized that persons with a
reduced shoulder or elbow ROM would have a short-
ened reach. Functional reach in our cohort ranged from
3 cm to 55 cm, with a mean of 34.8 cm and a median of
35 cm. We fit a logistic regression model on the likeli-
hood of subjects being in the shortest 10th percentile of
reach, i.e., below 26 cm. Independent variables in the
model were age, sex, ethnicity, height, weight, and hip
ROM, in addition to right shoulder and right elbow
ROM. In this model, both right shoulder and right
elbow ROM were inversely associated with a short
reach (OR 5 0.97, 95% CI 5 0.94 to 0.99, P 5 0.006 for
shoulder, and OR 5 0.98, 95% CI 5 0.95 to 1.00, P 5
0.06 for elbow). Thus, for each degree increase in
shoulder ROM, the likelihood of having a short reach

Table 4. Factors associated with shoulder range of motion among San Antonio
Longitudinal Study of Aging subjects*

Change in shoulder ROM

Bivariate regression Multivariate regression

Independent variables coefficient (95% CI) coefficient (95% CI)

Age, years 0.17 (20.41, 0.07) 20.20 (20.43, 0.04)

Sex, 0 5 men, 1 5 women 3.49 (1.91, 5.07)† 3.47 (1.90, 5.05)†
Ethnicity, 0 5 EA, 1 5 MA 22.85 (24.42, 21.28)† 22.32 (23.93, 20.71)†
Body mass index, kg/m2 20.12 (20.27, 0.03) 20.09 (20.24, 0.06)
Arthritis, 0 5 no, 1 5 yes 1.21 (20.36, 2.78) 0.88 (20.72, 2.48)
Diabetes mellitus on medication, 0 5 no,
1 5 yes 24.27 (26.33, 22.20)† 23.56 (25.62, 21.49)‡
Shoulder pain, 0 5 no, 1 5 yes 22.91 (25.32, 20.49)‡ 22.56 (25.20, 0.08)§
Elbow pain, 0 5 no, 1 5 yes 24.58 (28.29, 20.88)‡ 21.89 (26.01, 2.22)
Adjusted R2 of multivariate model 0.06
* Values shown are linear regression coefficients (95% confidence intervals [95% CI]). Coefficients can be
interpreted as the change in shoulder range of motion (ROM) associated with each unit of change in independent
variables. EA 5 European American; MA 5 Mexican American.
† P # 0.001.
‡ P # 0.05.
§ P 5 0.057.
Arthritis Care and Research Determinants of Shoulder and Elbow ROM 283

Table 5. Factors associated with elbow range of motion among San Antonio
Longitudinal Study of Aging subjects*

Change in elbow ROM

Bivariate regression Multivariate regression

Independent variables coefficient (95% CI) coefficient (95% CI)

Age, years 0.06 (20.16, 0.29) 0.01 (20.21, 0.23)

Sex, 0 5 men, 1 5 women 4.08 (2.65, 5.50)† 4.09 (2.65, 5.55)†
Ethnicity, 0 5 EA, 1 5 MA 22.46 (23.89, 21.03)† 21.07 (22.55, 0.40)
Body mass index, kg/m2 20.26 (20.40, 20.13)† 20.22 (20.36, 20.08)†
Arthritis, 0 5 no, 1 5 yes 0.35 (21.10, 1.79) 20.40 (21.87, 1.07)
Diabetes mellitus on medication, 0 5 no,
1 5 yes 25.15 (21.02, 23.28)† 24.26 (26.15, 22.35)†
Shoulder pain, 0 5 no, 1 5 yes 0.58 (21.68, 2.83) 1.23 (21.24, 3.71)
Elbow pain, 0 5 no, 1 5 yes 20.69 (24.16, 2.79) 20.43 (24.32, 3.47)
Adjusted R2 of multivariate model 0.07
* Values shown are linear regression coefficients (95% confidence intervals [95% CI]). Coefficients can be
interpreted as the change in elbow range of motion (ROM) associated with each unit of change in independent
variables. EA 5 European American; MA 5 Mexican American.
† P # 0.001.

was reduced by 3%, while for each degree increase in
elbow ROM, the likelihood of having a short reach was
reduced by 2%.
DISCUSSION
The ROM of shoulders and elbows is important for
normal physical performance because these two
joints place the hand in the proper position in space
to perform basic physical actions required to carry
out various activities of daily living. A normal shoul-
der and elbow ROM is needed to perform actions
such as reaching, which in turn are required for
social role activities (e.g., bathing, dressing, groom-
ing, feeding, and many others). Impaired shoulder or
elbow ROM may thus be a direct cause of physical
functional limitations that lead to disability. Con-
versely, an impaired ROM of these joints may coexist
with impairments of other organ systems that cause
physical function limitations (e.g., a decreased el-
bow ROM associated with diabetes mellitus coexist-
ing with peripheral vascular disease causing inter-
mittent claudication) (1). Thus, knowing the factors
associated with the ROM of these joints is important
to understand the process that leads to functional
limitations (restrictions in basic physical and mental
actions used in many different situations in daily
life) and subsequent disability (difficulty performing
a person’s expected social role activities in regular
daily life due to a health or physical problem) (1).
In our prior report on hip and knee ROM, we
found that a rising BMI and female sex were associ-
ated with reduced flexion ROM of both hips and
knees. Mexican American ethnic background was
associated with decreased hip flexion ROM, and
knee pain was associated with decreased knee flex-
ion ROM. Here, we presented population-based in-

Table 6. Association between the number of risk factors present and shoulder or elbow range of motion

Shoulder† Elbow†
Number of risk
factors Range of motion, Range of motion,
present* Number of joints mean 6 SD Number of joints mean 6 SD

0 290 160° 6 11° 351 156° 6 9°

1 523 157° 6 12° 602 152° 6 9°
2 395 156° 6 11° 346 149° 6 12°
$3 176 151° 6 14° 88 146° 6 17°
* Risk factors included were male sex, Mexican American ethnic background, obesity, and use of oral hypoglycemic drugs or insulin for treatment of diabetes
mellitus.
† P # 0.0001 for both shoulder and elbow.
284 Escalante et al
formation on the ROM of shoulder and elbows, and
their associations with each other and with age, sex,
ethnicity, BMI, presence of pain in the joints, and the
existence of diabetes mellitus or self-reported arthri-
tis. The SALSA cohort is composed of neighbor-
hood-dwelling aged subjects, and was not selected
from clinical sources. Thus, our findings approxi-
mate those that would be observed in the general
aged population of these two ethnic groups.
Shoulder and elbow ROM are remarkably well
maintained in this community-dwelling elderly pop-
ulation. Nearly all subjects studied had a ROM of
120° or greater in both shoulders and both elbows. A
shoulder elevation or forward flexion of 120° would
be sufficient to permit overhead reaching and hair
grooming. For the elbow, placing the hand near
enough to the mouth for feeding with a fork or spoon
is possible with a ROM of 120° degrees. The remark-
able preservation of shoulder and elbow ROM in this
elderly population shows that reductions in the
ROM of these joints are not normal age-associated
processes, but are more likely to be due to disease or
trauma.
A flexion range of $170° was recorded from at
least 1 elbow in 8 individuals (1.2%). Because this
range of flexion would seem beyond normal ana-
tomic constraints, we reviewed the beginning and
ending measurements in elbow flexion in these sub-
jects. In 4 of the 8, measurement of passive elbow
flexion began in a position of hyperextension, and
thus the final flexion reading was adjusted as if it had
started at a value of 0°. The remaining 4 elbows with
a flexion range $170° probably reflect measurement
error.
We previously described clinically and statisti-
cally important associations between the ROM of
contralateral and ipsilateral hips and knees (3). As in
those major lower extremity joints, we discovered a
pattern of significant associations between the ROM
of each shoulder or elbow and its contralateral coun-
terpart (Table 3). However, associations between the
ipsilateral shoulders or elbows were not as strong as
those observed in the lower extremity joints, where
significant associations between ipsilateral hips and
knees exist. Thus, the interrelated mechanical sys-
tem that could be demonstrated among lower ex-
tremity joints is less evident, although still present,
in the upper extremities. This suggests that the up-
per extremity joints are more independent of each
other than are the lower extremity joints. Alterna-
tively, lower extremity joints may be linked to each
other because of the pervasive effect of BMI on these
joints, while the effect of the BMI on shoulder and
elbow ROM is much smaller. Also, in contrast with
Vol. 12, No. 4, August 1999
our findings for hip and knee ROM, our model for
shoulder and elbow ROM explained a smaller pro-
portion of the variance (0.06 and 0.07) than did the
model for the lower extremity joints (0.20 for each of
hip and knee ROM).
A rising BMI was associated with significant re-
ductions in elbow, but not shoulder, ROM (Tables 4
and 5). Since elbow ROM was well maintained in
this population, it is likely that the effect of BMI is
due to excessive fat deposits in the flexor aspect of
the elbow, preventing the elbow from reaching its
full flexion. A similar effect was not observed in the
shoulder, which is understandable in light of the
lack of an anatomically constrained space in the
shoulder analogous to the flexor surface of the el-
bow. Nevertheless, the significant effect of obesity on
elbow flexion adds reduced ROM in this joint, to-
gether with reduced ROM in the hips and knees, to
the list of negative health effects of obesity.
Diabetes mellitus was associated with significant
reductions in the ROM of these two important upper
extremity joints. Diabetes treated with oral hypogly-
cemic agents or insulin was independently associ-
ated with reductions in elbow or shoulder ROM
(Tables 4 and 5). In our earlier report, diabetes mel-
litus was associated with reductions in hip and knee
ROM in the bivariate analysis only, the association
being lost when the BMI was included in a multivar-
iate model. In the case of shoulder and elbow ROM,
diabetes mellitus probably retained a significant as-
sociation because of the smaller effect of the BMI on
these joints. The effect of the BMI on hip and knee
ROM was large enough to obscure any effect of dia-
betes mellitus. These findings provide population-
based confirmation of the existence of a syndrome of
limited joint mobility, or diabetic cheiroarthropathy,
which has been described among clinical popula-
tions affected by severe diabetes mellitus (21–25).
One earlier community-based study alluding to the
limited joint mobility of diabetes mellitus found an
inability to approximate the palmar surfaces of
the hands among diabetic women, but not diabetic
men (26).
To our knowledge, our study is the first large-scale
population-based study to examine the association
of diabetes mellitus with shoulders and elbows.
Mechanisms for this effect of diabetes mellitus on
joint mobility probably involve biochemical reac-
tions such as nonenzymatic glycosylation of proteins
important in joint mobility (27), increased hydration
(28), cross-linking and resistance of collagen to col-
lagenase (29), and swelling of connective tissue
through the aldose reductase pathway (30). Microan-
giopathy probably also plays a role, as it does in
Arthritis Care and Research
fibrotic disorders such as scleroderma and Du-
puytren’s contracture (31). Our findings underscore
the role of diabetes as a source of pathology leading
to musculoskeletal impairments in population-based
studies.
Women averaged 3° greater shoulder ROM and 4°
greater elbow ROM than did men. This is contrary to
our observations in hip and knee ROM, where men
averaged 7° and 2° greater ROM, respectively, than
did women (3). Men in general tend to have less
articular ROM than do women (32), and in one study
hypermobile joints occured in 72% of young women
but only in 47% of young men (33). Against this
tendency toward articular hypermobility in women
is their higher BMI, which has a negative effect on
articular ROM. Our findings of greater upper extrem-
ity and lesser lower extremity ROM among women is
probably due to their higher BMI. Fat deposits in
women tend to center in the lower body, affecting
hip and knee ROM but sparing shoulder and elbow
ROM.
The role of the factors we identified in our multi-
variate models is statistically and functionally im-
portant. Depending on the number of risk factors
for reduced shoulder or elbow ROM present, a
person could lose up to 12° of shoulder ROM. This
loss could be translated into the loss of functional
independence in feeding, dressing, or other impor-
tant activities. We have also shown that shoulder
and elbow are significantly related to functional
reach, an important functional measure among the
elderly (16).
Our study has some limitations. The most impor-
tant is our reliance on self-report of physician diag-
nosis to define arthritis, without the type of arthritis
or, more importantly, without its anatomic location
being specified. This could lead to a masking of the
effect of arthritis. For example, a person with arthri-
tis only in the knees would not be expected to have
any arthritis-related upper extremity ROM impair-
ments, even in the presence of substantial arthritis.
Osteoarthritis, which is the type of joint disease most
likely to be prevalent in the elderly SALSA popula-
tion, does not commonly affect the shoulders or el-
bows. Accordingly, neither self-reported arthritis
nor pain in upper extremity areas were associated
with reductions in elbow ROM, and only elbow pain
was associated with reduced shoulder ROM. We did
not assess our patients for the presence of myopathy,
either inflammatory or neurogenic, and thus may
have missed an alternative cause of reduced shoul-
der ROM. An additional limitation is imposed by the
cross-sectional nature of our analysis, which impairs
Determinants of Shoulder and Elbow ROM 285
our ability to examine causal associations between
variables.
In summary, the great majority of neighborhood-
dwelling elderly persons have a functional shoulder
and elbow ROM. However, health care professionals
should be aware of the negative influence of diabetes
mellitus and obesity, two conditions potentially
amenable to preventive and therapeutic measures,
on upper extremity ROM. Further study is needed to
understand the mechanisms that lead to the reduced
ROM associated with these two conditions, and with
male sex and Mexican American ethnicity. The path-
ways to disability associated with male sex, diabetes
mellitus, obesity, and upper extremity pain may be
mediated in part through impairments of shoulder
and elbow ROM.
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