J Shoulder Elbow Surg (2012) 21, 1177-1183

www.elsevier.com/locate/ymse

SHOULDER

Defining functional shoulder range of motion for

activities of daily living
Surena Namdari, MD, MSa, Gautam Yagnik, MDb, D. David Ebaugh, PhD, PTc,
Sameer Nagda, MDd, Matthew L. Ramsey, MDe, Gerald R. Williams Jr, MDe,
Samir Mehta, MDa,*

a
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
b
DRMC Orthopaedics, DuBois, PA, USA
c
Programs in Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA
d
Anderson Orthopaedic Clinic, Arlington, VA, USA
e
Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

Introduction: The range of motion (ROM) in the wrist and elbow required for daily activities has been
reported to be less than the normal anatomic ROM. This functional ROM has not been defined for the
shoulder. Many shoulder outcome assessment tools use specific functional tasks of daily living to score
functional results of treatment. This study quantified the total shoulder ROM required to perform the func-
tional tasks of the American Shoulder and Elbow Surgeon (ASES), Simple Shoulder Test (SST), and
University of Pennsylvania (U-Penn) Shoulder Score (PSS).
Materials and methods: The FASTRAK electromagnetic tracking system (Colchester, VT, USA) was
used to test 40 shoulders in 20 volunteers with no shoulder pathology found on physical examination.
Three sensors were used: 1 each on the T3 spinous process, the scapular spine, and the arm over the distal
humerus. Subjects performed each functional task of the ASES, SST, and PSS while flexion, extension,
abduction, adduction, external rotation, and internal rotation were recorded.
Results: Average shoulder motions required to perform the 10 functional tasks were flexion, 121
 6.7
;
extension, 46
 5.3
; abduction, 128
 7.9
; cross-body adduction, 116
 9.1
; external rotation with
the arm 90
abducted, 59
 10
; and internal rotation with the arm at the side, 102
 7.7
.
Conclusion: Although attaining full motion is a reasonable goal of all shoulder treatment, our results indi-
cate that less ROM is required to perform the functional tasks used in common outcome tools.
Level of evidence: Basic Science Study, Kinesiology Study.
Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Normal shoulder; range of motion; activities of daily living

Functional joint range of motion has been defined as the

This study was approved by the University of Pennsylvania Office of
Regulatory Affairs (No. 803027).
*Reprint requests: Samir Mehta, MD, Assistant Professor, Department
of Orthopaedic Surgery, Chief, Orthopaedic Trauma Service, Hospital of the
University of Pennsylvania, 3400 Spruce St, 2 Silverstein, Philadelphia, PA
19104, USA.
E-mail address: samir.mehta@uphs.upenn.edu (S. Mehta).
minimum range of motion (ROM) necessary to comfortably
and effectively perform activities of daily living.30 Several
clinical studies have examined wrist4,23,27 and elbow22,29,30
functional ROM and showed the functional ROM was less
than the normal, full ROM. Clinicians have used data from
these studies to dictate clinical care and assess outcomes.

1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2011.07.032

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1178
Studies examining the functional ROM of the shoulder have
been mostly limited to the biomechanics literature.15,16,19,28
These studies are difficult to interpret clinically and fail to
offer clinical guidelines regarding daily motion require-
ments of the shoulder.
The purpose of this study was to analyze the total shoulder
motion required to perform a variety of functional tasks of
daily living and provide this information in a clinically
relevant format. Rather than arbitrarily selecting tasks of
daily living, our tasks were taken directly from the functional
assessment section of the American Shoulder and Elbow
Surgeons (ASES) Standardized Shoulder Assessment
Form,25 the University of Pennsylvania (U-Penn) Shoulder
Score (PSS),13 and the Simple Shoulder Test (SST).17 These
commonly used outcome tools use a patients’ self-reported
ability to perform certain tasks of daily living as a means of
assessing function; however, the ROM required to perform
these tasks has not been described. We sought to verify that
all clinical planes of motion were adequately tested and to
quantify the amount of total shoulder ROM needed to
complete these functional tasks. We hypothesized that the
functional ROM of the shoulder would be less than the
reported normal, full ROM.
Materials and methods
Informed consent was obtained from 20 healthy volunteers (18 men,
2 women) who were a mean age of 29.2  1.9 years (range, 26-34)
years, a mean height of 178.3  7.5 cm, a mean weight of 79.8 
14 kg, and mean body mass index of 25.1 kg/m2. Two subjects were
left-hand dominant and 18 were right-hand dominant.
The volunteers, who were residents and medical students from
the University of Pennsylvania Health System, were recruited via
e-mail. A preparticipation assessment of each individual included
a thorough history. Participants were excluded if they had had
previous upper extremity surgery, a history of fracture or dislo-
cation, or shoulder pain that did not allow them to easily perform
all of their tasks of daily living in either extremity.
Tasks
Ten activities of daily living were selected for the subjects to
perform. These 10 tasks (Table I) were taken directly from the
functional assessment section of the ASES,25 PSS,13 and the
SST.17 These valid and reliable outcome tools have been used to
assess shoulder function.3,14,21 Although the functional assessment
of these shoulder scores includes 20 tasks, we excluded 10 tasks
because of minimal shoulder motion to be completed, inability to
standardize (eg, perform necessary toileting activities), and atyp-
ical activities of daily living (eg, throwing a ball overhand). The
10 selected tasks represented activities of daily living requiring the
completion of variable ranges of shoulder motion.
Data collection
Three-dimensional (3D) kinematic data from the humerus, scapula,
and trunk were collected with the Polhemus 3Space FASTRAK
(Colchester, VT, USA) during performance of the tasks. The
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S. Namdari et al.
Table I Activities of daily living from the Functional
Assessment Section of the American Shoulder and Elbow
Surgeons, Simple Shoulder Test, and University of Pennsylvania
Shoulder Scores that were performed by the subjects
1. Place a can of soup can on an overhead shelf
without bending the elbow
2. Reach the small of one’s back to tuck in one’s
shirt with one’s hand
3. Wash the middle of one’s back/unhook one’s own
bra (middle of back)
4. Wash the back of the opposite shoulder
5. Place hand behind one’s head with the elbow held
straight out to the side
6. Comb hair
7. Place a can of soup on a shelf at shoulder level
without bending the elbow
8. Place a 1-gallon container (8-10 lbs) on a shelf at
shoulder level without bending the elbow
9. Reach a shelf above one’s head without bending
the elbow
10. Place a 1-gallon container on an overhead shelf
without bending the elbow
Polhemus is an electromagnetic tracking device that has been used
to study shoulder motion in a number of studies.6,10,11,15,16,18,24 It
consists of a transmitter, 3 receivers, and a digitizing stylus, all of
which are hardwired to an electronic unit. The transmitter emits
electromagnetic fields that are detected by the digitizer and
receivers. The system’s electronic unit determines the relative
orientation and position of the receivers and sends this information
to a computer where the data are collected. The manufacturer has
reported an accuracy of 0.15
for orientation and 0.8 mm for
position with this device.1
Three Polhemus receivers were attached to each volunteer
(Fig. 1). The anatomic axis system has been described previously
and was determined from 3 points on the thorax, scapula, and distal
humerus.12,32 The humeral receiver was attached to a thermoplastic
cuff, which was placed on the distal humerus just proximal to the
epicondyles.18 The scapular receiver was mounted to a scapular
tracker device,12 which was secured to the scapular spine and to the
superior aspect of the acromion. Double-sided tape was used to
secure the thoracic receiver to the skin overlying the third thoracic
spinous process. The transmitter was attached to an upright plastic
pole, and its axes were aligned with the cardinal planes of the body.
With volunteers in a standing position, several bony landmarks
on the humerus, scapula, and thorax were palpated and digitized to
allow the arbitrary axis system defined by the Polhemus to be
converted to a meaningful anatomic axis system.12 The anatomic
axis system was determined from the 3 points on the thorax,
scapula, and humerus.12,32 A least-squares algorithm was used to
calculate the center of the humeral head, which was defined as the
point that moved the least during several small arcs of motion.9
Once the receivers were secured to the subject, testing was
initiated. The participants were asked to perform each of the 10
functional tasks with both their dominant and nondominant arm.
All 10 tasks were completed with 1 arm before tasks were initiated
with the other arm. The dominant arm was tested first in alter-
nating participants.
Normal shoulder ROM
Figure 1 Clinical photograph of a subject performing a task
with the electromagnetic sensors from the Polhemus FASTRAK
System in place on the T3 spinous process, on the scapular spine,
and on the arm over the distal humerus.
The task was demonstrated to each participant. The participant
then performed the task as simply and naturally as possible.
Subjects performed a practice task before each trial and started
and ended each task with their arm at their side. Each task was
performed 3 times in succession, and mean values were used as
representative data.
Data reduction and analysis
Humeral motion relative to the trunk, or total shoulder motion
(glenohumeral plus scapulothoracic motion), was described using
a globe-based system.5,24 This system describes humeral rotations
by longitude and latitude along a globe centered about the center of
rotation at the shoulder. A Euler angle sequence was used, in which
the first rotation describes the plane of elevation (longitude), the
second rotation describes the amount of elevation (latitude), and the
third rotation describes the amount of external/internal rotation
along the long axis of the humerus. After kinematic data were
collected, a linear interpolation program was used to obtain data in
5
increments. The data from the 3 trials were averaged.
To make the data clinically relevant and allow comparison with
established normative data for shoulder ROM,8 the 3D humeral
kinematic data were described using conventionally accepted
shoulder motions. These motions include:
 forward elevation: humeral elevation that occurs anterior to
the coronal plane;
 extension: humeral elevation that occurs posterior to the
coronal plane;
 abduction: humeral elevation in the coronal plane;
 cross-body adduction: humeral motion occurring in the
transverse plane; and
 internal and external rotation: humeral rotation that occurs
along the long axis of the humerus.
The data were grouped and analyzed by task after data
collection was completed for all participants. The primary
humeral motions needed to complete each task (eg, forward
elevation, abduction) were identified, and the maximum amount of
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1179
motion needed to complete the task was determined. The mean
maximum values and standard error of the mean were calculated
for each task. Data were also separated according to dominant and
nondominant extremity and compared using a paired t test.
Results
The plane of shoulder motion and the maximum amount of
shoulder motion needed to complete each task is listed in
Table II. Functional tasks were completed using less than full
shoulder motion.8 Subjects required a minimum of 57% and
a maximum of 76% of full shoulder motion to successfully
complete a task. To successfully complete all tasks, a subject
required approximately 120
of forward elevation, 45
of
extension, 130
of abduction, 115
of cross-body adduction,
and 60
of external rotation with the arm abducted to 90
.
These functional arcs of shoulder motion are represented in
(Fig. 2). Normative data7 for ROM in internal rotation with
the arm at the side (posterior reach) was not available;
however, a maximum of 102.2
of internal rotation with the
arm at the side was necessary for functional tasks. No
functional task evaluated external rotation with the arm at the
side.
For 8 of the tasks, the quantity of motion needed to
complete the task did not differ significantly between the
dominant and nondominant arm. There was a statistically
significant difference (P < .05) between dominant and
nondominant limbs for forward flexion and external rota-
tion for 2 tasks: task 9, reaching up to an overhead shelf
without bending the elbow, and task 10, placing a 1-gallon
container on an overhead shelf. However, this difference
was less than 5
and not felt to be clinically significant
(Table II).
Discussion
Although wrist and elbow functions have been well studied,
less is known about the daily ROM requirements of the
shoulder.2,26 Using clinical studies of the wrist and elbow as
a model,4,22,23,27,29,30 we sought to characterize the func-
tional ROM of the shoulder. In this study, we described the
motion required to successfully complete 10 tasks of daily
living taken directly from the functional assessment section
of the ASES,25 PSS,13 and SST17 scoring systems. We found
that in most planes of motion, full ROM was not needed to
successfully complete all 10 tasks, consistent with previ-
ously published data from the wrist and elbow.4,22,23,27,29,30
Most tasks required humeral elevation to be completed.
The mean maximum humeral elevation was comparable for
forward flexion (120
) and abduction (130
). Magermans
et al19 also used an electromagnetic tracking device to study
functional upper limb motion and found that 121
was the
maximum glenohumeral elevation needed to complete all
the tasks. The data from our study are consistent. The slight
 1180
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Table II Average range of motion in dominant and nondominant arms while performing tasks of daily living, along with a percentage of the American Academy of Orthopedic
Surgeons (AAOS) estimate of normal shoulder motion6
Tasks of daily living Measured humeral Maximum motion to complete task (mean  SEM) AAOS estimate of Percentage of full
motion Dominant arm Nondominant normal shoulder motion6 ROM to complete task

Place soup can on shoulder-level shelf Forward flexion 105.4  1.8 108.2  1.7 167 65
External rotation 33.9  1.9 30.8  1.2 No data N/A
Tuck in shirt behind back Extension 45.5  2.4 45.9  3.2 62 74
Internal rotation 88.3  9.1 86.9  8.7 No data N/A
Wash the middle of the back/unhook bra Extension 46.8  1.8) 45.8  2.3 62 76
Internal rotation 98.8  10.0 102.2  10.9) No data N/A
Wash the back of the opposite shoulder Forward Flexion 94.9  2.4 92.6  2.5 167 57
Adduction 115.8  2.2 115.9  1.9) 140 83
Place hand behind head with elbow out to side Abduction 127.3  2.0 128.7  1.5) 184 70
External rotation 61.3  2.3) 56.3  2.2 104 59
(arm at 90
)
Comb hair Forward Flexion 107.8  3.0 109.0  2.6 167 65
Adduction 86.1  2.9 91.3  2.4 140 64
Place soup can on overhead shelf Forward Flexion 120.7  1.5 125.6  1.8 167 75
External rotation 38.1  2.2 32.1  1.7 No data N/A
y
Place 1-gallon container on shoulder level shelf Forward Flexion 105.9  1.6 107.3  2.3y 167 64
External rotation 39.1 2.1 38.5 1.9 No data
Reach overhead shelf without bending elbow Forward Flexion 118.6  1.4y 123.1  1.6y 167 74
External rotation 29.5  2.0 26.2  1.6 No Data N/A
Place 1-gallon container on overhead shelf Forward flexion 119.9  1.9 126.8  1.8) 167 76
External rotation 41.8  2.6 41.6  1.6 No Data N/A
ROM, range of motion; SEM, standard error of the mean.
) Maximum values for given humeral motion in any one plane.
y
Statistically significant difference (P < .05).

S. Namdari et al.
Normal shoulder ROM 1181

Figure 2 Diagrams show the functional arcs of shoulder motion (shaded) compared with the normal anatomic range of motion in (A)
forward flexion and extension, (B) abduction, (C) cross-body adduction, (D) and external rotation with the arm abducted at 90
.

difference may be explained by the variability in tasks per-
formed in the 2 studies. Magermans et al19 measured
humeral motion relative to the scapula (glenohumeral
motion), whereas we measured humeral motion relative to
the thorax.
Clinically, our data may be more applicable because
humeral motion relative to the thorax is what is classically
measured with a goniometer in an office setting. To control
for excessive thoracic motions, our reference sensor was
placed on the thorax itself. Therefore, even if a subject flexed
or extended at the thorax to complete a task, his or her
humeral motion was always measured relative the thorax.
The amount of humeral rotation needed to complete the
various tasks was dependent on the position of the arm in
space. The maximum amount of internal rotation occurred
with the arm at the side, also known as posterior reach.
Historically, internal rotation has been defined as the highest
midline segment of the back that is reached by the hitch-
hiking thumb.8 For successful completion of 2 of the tasks in
our study, the subjects needed approximately 100
of internal
rotation with the arm at the side. Using similar methodology,
Magermans et al19 reported maximum internal rotation of
105
, whereas Pearl et al24 reported that 145
was needed to
complete functional tasks. Although no published normative
data exist, some authors believe that posterior reach in most
adults ranges from the T6 to T10 spinous process.8 Work by
Mallon et al,20 Ginn et al,7 and Wakabayashi et al31 calls into
question the accuracy of posterior reach as a true measure of
internal rotation. Mallon et al20 used computed tomography
scans of the shoulder in different positions and determined
that maximal internal rotation behind the back occurs in
approximately a 2:1 ratio between glenohumeral and scap-
ulothoracic articulations. Further research is needed to
effectively compare functional internal rotation with normal
anatomic motion. However, it does appear that approxi-
mately 100
of total shoulder (glenohumeral plus scap-
ulothoracic) internal rotation with the arm at the side is
required to successfully complete tasks from the 3 scoring
systems evaluated.
We were surprised to find that none of the selected tasks
evaluated external rotation with the arm at the side.
Although this motion is often tested clinically and regarded
by the ASES as 1 of 4 functionally important motions,25
none of the tasks on the functional assessment section of
the 3 major scoring systems required this motion. We
believe that this reflects an oversight in these sections, and
we propose the addition of at least 1 additional task to this
section to assess this plane of motion. Two proposed tasks

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1182
that would evaluate external rotation with the arm at the
side are having subjects simulate tossing a coin into a toll
both from a seated position or attempting to reach behind
the ipsilateral shoulder for a seatbelt.
Determining the functional ROM of the shoulder has
many important clinical applications. With the increased
emphasis on evidence-based medicine, outcome measure-
ment tools have an important role in quantifying, standard-
izing, and evaluating the results of medical treatment.
Adding objective criteria to assess a patient’s functional
status will only serve to strengthen these outcome measures.
The information may also provide an objective basis for
estimating the percentage of impairment related to loss of
shoulder motion. Our data provide tangible clinical guide-
lines with respect to the functional arc of shoulder motion
that can be used by surgeons, therapists, and patients. Finally,
it is sometimes not possible to perform clinical examinations
in the office when conducting clinical research, and patients
are often surveyed via the telephone. The functional ROM
that we describe can be used to reflect the minimum motion
that patients would need to complete certain tasks and can
provide useful information regarding functional ROM that
can be extrapolated from telephone surveys using the 3
scoring systems we evaluated.
Our study does have some limitations, and our results may
have been influenced by several factors. First, our study
group consisted of 20 healthy volunteers and was over-
represented by men (90%). However, previously published
data examining the functional ROM of the elbow and wrist
found no difference with regards to sex.4,22,30 Furthermore,
because our normative data for full ROM from the American
Academy of Orthopaedic Surgeons (AAOS)8 does not
distinguish demographic variances between men and
women, it is unclear whether a difference between men and
women should be expected for functional ROM, and if so, it
is unknown what degree of power would be necessary to
determine this variability. Our subjects were also relatively
young (range, 26-34 years). Extrapolating this data to indi-
viduals outside of this age range may not be accurate.
Most importantly however, the goal of this study was to
define the functional ROM of the shoulder in healthy,
nonpathologic shoulders to serve as a baseline for future
studies. As a result, we believe the raw data for functional
ROM in this study to represent a best-case scenario.
Finally, several factors could have influenced the
measurements obtained, including the choice of bony
landmarks used to create local coordinate frames, the
method used to calculate angles and describe motion, the
choice of a fixed reference frame, and the specific methods
used to reduce and present the data. We attempted to follow
a system and technique that has been previously used and
validated in the literature.
We also note that the data we used for describing normal
anatomic shoulder ROM have some limitations. These
normative data published by the AAOS are currently the best
available data for anatomic shoulder ROM.8 The data are not
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S. Namdari et al.
from one database or study but instead are a compilation of
previous studies examining normal shoulder motion in
healthy individuals. We compared functional ROM in our
population with normative data for full ROM in an older
population; thus, we may be overestimating the percentage
of ROM necessary to perform functional tasks because our
population may have higher values for full ROM.
In addition, because these normative data exclude data
for external rotation with the arm at the side and internal
rotation (posterior reach), we were unable to provide
comparison of functional ROM vs normal ROM in these
planes. Furthermore, in addition to the lack of demographic
data, the exact methodology used to obtain this normative
data is not available.
Conclusion
To successfully complete all tasks of daily living, a person
requires approximately 120
of forward elevation, 45
of
extension, 130
of abduction, 115
of cross-body
adduction, 60
of external rotation, and 100
of internal
rotation. Although attaining full motion is a reasonable
goal of all shoulder treatment, our results indicate that
substantially less ROM is required to perform the func-
tional tasks used in common outcome tools.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this article.
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