4
Anatomy and Kinesiology of the Shoulder
Rebecca Edgeworth Ditwiler, Angela Stagliano, Dustin Hardwick
OUTLINE
Range of Motion, 38
Glenohumeral Anatomy, 38
Glenohumeral Biomechanics, 39
CRITICAL POINTS
• S houlder motion is a result of the complex interactions of the
individual joints and muscles of the shoulder girdle.
• Shoulder motion is measured and described in multiple planes of
motion.
• Stability of the shoulder is conferred by dynamic and static
constraints.
The shoulder is the most mobile joint in the body. Motion occurs
through complex interactions of the individual joints of the shoulder
girdle, including the glenohumeral joint, the sternoclavicular (SC)
joint, the acromioclavicular (AC) joint, and the scapulothoracic articu-
lation. Together the coordinated interaction of these structures allows
for an extraordinary freedom of movement and function.
RANGE OF MOTION
Normal Range of Motion
Traditionally, shoulder motion has been described by measuring the
angle formed by the arm relative to trunk. Forward elevation, or flex-
ion, of the shoulder is in the sagittal plane and may reach 180 degrees
in some individuals. The normal range of motion (ROM) of the shoul-
der complex varies but has been reported to average 165 to 170 degrees
in men and 170 to 172 degrees in women.1 The glenohumeral joint
alone contributes about 120 degrees to this complex shoulder motion.2
Posterior elevation or extension in the sagittal plane has been found to
average 62 degrees, with the majority of this motion coming from the
glenohumeral joint.3 Axial rotation of the arm is described by degrees
of internal and external rotation. With the arm at the side, an average
external rotation measures 67 degrees.4 Estimates of total axial rota-
tion (the sum of internal and external rotation) with the arm at the
side range from 150 to 180 degrees. Total axial rotation with the arm
abducted to 90 degrees is reduced to about 120 degrees. In the horizon-
tal plane with the arm perpendicular to the trunk, motion is commonly
described as horizontal abduction and adduction.
Range of motion is influenced by several factors, including the
determination of the endpoint, the plane in which the motion is tested,
and whether the scapula is stabilized.4 By comparing the relative contri-
butions of passive and active arcs of motion, McCully and colleagues4
38
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Acromioclavicular Joint, 41
Biomechanics of the Shoulder Complex, 42
Summary, 43
• S capular motion is a complex interaction of motion in three planes.
• The coordinated movement of the clavicle, scapula, and humerus
involves a complex interaction of more than 20 muscles.
• Scapulothoracic motion significantly affects glenohumeral motion.
• Scapulohumeral rhythm is a dynamic state adapting to varying
speed, load, and stability.
concluded that scapulothoracic motion significantly influences gleno-
humeral ROM measurements.
Factors such as age, gender, and hand dominance also affect shoul-
der ROM. Normal shoulder ROM decreases with age. Boone and
Azen5 reported on two groups of males with an age difference of 12.5
years. The younger group averaged 3.4 degrees more flexion and inter-
nal rotation, 8.4 degrees more external rotation, and 10.2 degrees more
extension. 
Functional Range of Motion
Functional ROM of the shoulder has also been studied to determine how
much motion is needed to participate in daily activities. Namdari and
colleagues6 viewed common functional tasks, including placing objects
on a shelf, tucking in one’s shirt, combing hair, and placing objects on
shelves above and below shoulder level. The shoulder ROMs needed to
achieve these tasks are 120 degrees of flexion, 45 degrees of extension,
130 degrees of abduction, 115 degrees of cross-body adduction, and 60
degrees of external rotation with the shoulder abduction to 90 degrees.6 
GLENOHUMERAL ANATOMY
Glenoid
The glenoid arises laterally from the scapular neck at the junction of
the coracoid, scapular spine, and lateral border of the scapular body. It
is a pear-shaped structure forming a shallow socket that is retroverted
on average 7 degrees with respect to the scapular plane but maintains
an overall anteversion of about 30 degrees with respect to the coronal
plane of the body.7 The glenoid also maintains a superior tilt of about
5 degrees in the normal resting position of the scapula. It is thought
that this superior inclination contributes to inferior stability via a cam
effect that is a function of the tightening superior capsular structures.8
 CHAPTER 4  Anatomy and Kinesiology of the Shoulder
The glenoid surface area is about one third that of the humeral
head. The depth of the glenoid measures about 9 mm in a superoin-
ferior direction but only 5 mm in an anteroposterior direction, half of
which is constituted by the labrum.9 In addition, the glenoid cartilage
is thicker peripherally than centrally, further deepening the socket. The
glenoid socket is therefore significantly more concave and congruous
with the humerus than the bony anatomy would suggest. 
Humeral Head
The humeral head is oriented with an upward tilt of about 45 degrees
from the horizontal, and it is retroverted about 26 degrees10 with
respect to the intercondylar axis of the distal humerus. The articular
surface forms approximately one third of a sphere. Using stereophoto-
grammetric studies, Soslowsky and associates11 demonstrated that the
glenohumeral joint congruence is within 2 mm in 88% of cases, with a
deviation from sphericity of less than 1% of the radius.  Axillary pouch
GLENOHUMERAL BIOMECHANICS
The glenohumeral joint functions as a ball-and-socket joint with three
degrees of freedom. The convex glenoid articulates with a concave
glenoid. The biomechanics of the glenohumeral joint depends on the
interaction of static and dynamic stabilizers during shoulder move-
ment. Static stabilizers include the bony structure of the glenoid and
the humeral head, the glenoid labrum, the glenohumeral capsule, and
the glenohumeral ligaments. Dynamic stabilizers include the rotator
cuff and the surrounding musculature.12
The interaction of these constraining elements is complex. In the
pathologic state, when one or more constraining factors is abnormal,
instability may occur. Instability may lead to shoulder dislocation,
which is the most common form of joint dislocation with an average
incidence of 1.7%.13 Restoring normal anatomic constraints is critical
to the successful treatment and rehabilitation of the shoulder.
Static Stabilizers
Early investigators focused on the articular components of glenohu-
meral stability. The humeral head retroversion roughly matches the
glenoid orientation on the chest wall. Saha9 emphasized the contri-
bution of this articular retroversion to stability, noting that individu-
als with congenital anteversion of the glenoid had a greater tendency
for recurrent dislocation. Subsequent studies have not confirmed this
hypothesis.14–16 In any position of rotation, only about 25% to 30% of
the humeral head surface is in contact with the glenoid. The glenohu-
meral index is calculated by measuring the diameter of the humeral
head relative to the glenoid. It was hypothesized that individuals with
larger heads relative to their glenoid would be unstable; however, inves-
tigators have made no such correlation.17
The relatively smaller surface area of the glenoid relative to the
humeral head emphasizes the importance of soft tissues surrounding
the joint, including the labrum, capsular, and ligamentous structures.
The labrum is composed of dense collagen fibers that surround and
attach to the glenoid rim, creating a deeper and broader glenoid sur-
face. Functionally, the labrum increases the articular contact of the gle-
noid with the humerus to about one third and improves the articular
conformity and thereby stability.18 Lippitt and Matsen19 demonstrated
the contribution of the labrum to joint stability in cadavers. Excision
of the labrum resulted in a 20% decrease in stability as measured using
the stability ratio defined by Fukuda and coworkers.20
Slight mismatch of the articular surface diameter of curvature
between the glenoid and humeral head may have a significant effect
on glenohumeral stability. Saha9 initially described three types of gle-
nohumeral articulations: type A had a shallow glenoid, type B had
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39
Biceps
tendon
SGHL
Posterior
capsule MGHL
Posterior band
IGHL
Anterior band
IGHL
IGHL
Fig. 4.1  The glenohumeral joint is stabilized by discrete capsular liga-
ments, each of which has a separate role in maintaining stability. IGHL,
Inferior glenohumeral ligament; MGHL, middle glenohumeral ligament;
SGHL, superior glenohumeral ligament.
conforming surfaces, and type C had a humeral radius greater than that
of the glenoid. Soslowsky and associates,11 using stereophotogrammet-
ric studies of fresh-frozen cadaveric shoulders, found that 88% of gle-
nohumeral articulations are perfectly congruent. Kim and colleagues,21
however, recently analyzed magnetic resonance imaging (MRI) scans
in patients with multidirectional instability (MDI) and compared
them with normal MRI scans. They determined that the diameter of
curvature of the glenoid surface in MDI patients was greater than the
humeral diameter, suggesting that this loss of conformity may play a
role in instability.
A slightly negative intraarticular pressure of the glenohumeral joint
also acts to maintain joint stability.22 Normally, the shoulder contains
about 1 mL of synovial fluid, which is maintained at a lower atmo-
spheric pressure by high osmotic pressures in the surrounding tissues.
Warner and coworkers23 demonstrated that in normal shoulders an
inferiorly directed force of 16 N generated an inferior translation of 2
mm; however, if the capsule of the same shoulder is vented, the same
force generates an inferior translation of 28 mm.
The conformity of the glenohumeral joint combined with the pres-
ence of synovial fluid generates adhesion and cohesion between the
humeral head and the glenoid in much the same fashion as a moist glass
sticks to a coaster. Adhesion is caused by the material properties of the
synovial fluid, but cohesion is caused by the conformity of the joint. The
compliant labrum further potentiates these stabilizing effects.
Glenohumeral Ligaments
The superior ligaments comprise the coracohumeral ligament (CHL)
and the superior glenohumeral ligament (SGHL) (Fig. 4.1). The CHL
is a broad, thin, extraarticular structure originating on the coracoid
process and inserting broadly on the greater and lesser tuberosities,
intermingling with the fibers of the supraspinatus and subscapularis.
The SGHL, which lies deep to the CHL, is present in more than 90% of
cases, originating on the superior tubercle of the glenoid and inserting
anteriorly just medial to the bicipital groove. Together these structures
resist inferior translation with the arm in adduction.
40 PART 1  Anatomy and Biomechanics
The middle glenohumeral ligament (MGHL) has the greatest
variation both in size and presence of all glenohumeral ligaments. It
is absent in up to 30% of shoulders.24 The morphology of the MGHL
may be sheetlike or cordlike, and it usually originates along with the
SGHL on the superior glenoid tubercle, inserting just medial to the
lesser tuberosity. Although the MGHL limits inferior translation in
the adducted and externally rotated shoulder, the ligament primarily
functions to limit anterior translation of the humerus on the glenoid
with the shoulder abducted 45 degrees.25 In individuals with a more
cordlike MGHL, it may also function to limit anterior translation in the
60- to 90-degree abduction range with the arm externally rotated.25,26
The inferior glenohumeral ligament (IGHL) is likely the most
important ligament complex of the glenohumeral joint. The IGHL is
composed of thickened bands that form a sling, or “hammock,” that cra-
dles the humerus inferiorly in what is referred to as the axillary pouch.
Typically, the IGHL originates broadly at the equatorial to inferior half
of the anterior glenoid adjacent to the labrum and inserts just inferior to
the MGHL medial to the lesser tuberosity. In a histologic and anatomic
study by O’Brien and coworkers,24 they demonstrated that the posterior
and anterior portions of the IGHL contain thickened bands of dense
collagen fibers. Gohlke and coworkers27 confirmed the existence of the
anterior band but found the posterior band to be present in only 62.8%
percent of individuals. The stabilizing function of the IGHL complex
increases as the arm is elevated in abduction. With external rotation
of the arm in 90 degrees of abduction, the anterior band broadens and
tightens, forming a taut sling that prevents anterior translation. Simi-
larly, with internal rotation of the abducted arm, the posterior band fans
out and tightens.28 The IGHL is also the primary restraint to inferior
translation of the humerus with the arm in 90 degrees of abduction.  rior translation.42 The primary constraint to posterior translation is
Laxity versus Instability
Shoulder laxity is a normal property that varies widely within the gen-
eral population.29–32 It is often measured as increased passive transla-
tion of the humeral head on the glenoid and may be affected by several
factors, including age, gender, and congenital factors.33 In cadaveric
shoulders, average passive humeral translation of 13.4 mm anteriorly
and 10.4 mm posteriorly has been demonstrated with a 20-N force.34
In a study of healthy unanesthetized volunteers, passive humeral
translation averaged 8 mm anteriorly, 9 mm posteriorly, and 11 mm
inferiorly.35 Far less translation occurs with normal glenohumeral
kinematics. Radiographic analysis of normal volunteers demonstrates
that the humeral head is centered in the glenoid in all positions except
simultaneous maximal horizontal abduction and external rotation.36
In this extreme position, an average of 4 mm of posterior translation
occurred. These studies demonstrate that despite the great potential for
translational motion in the shoulder, the combined stabilizers of the
glenohumeral joint act in concert to maintain centricity.
Instability is a pathologic condition involving active translation of
the humeral head on the glenoid. Unlike laxity, instability is usually
symptomatic. It represents a failure of static and dynamic constraints
to maintain the humeral head precisely centered within the glenoid.
Instability may occur in one direction, such as anterior instability after
a traumatic anterior dislocation, or it may be multidirectional, occur-
ring in any combination of anterior, posterior, or inferior directions.
Patients with multidirectional instability often have asymptomatic lax-
ity of the contralateral shoulder.37 What distinguishes these shoulders
from normally functioning shoulders is a complex interaction of mus-
cular, neurologic, and structural factors.
Interplay Between Static and Dynamic Constraints
Ligaments only function under some degree of tension. However,
during normal motion of the glenohumeral joint, the ligaments remain
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under little to no tension. In addition, a large amount of passive trans-
lation is commonly possible in multiple directions. Yet the humeral
head remains centered in the glenoid during normal active motion.
Therefore, it seems that factors other than the capsule and ligaments
must contribute to the lack of translation observed with normal
motion. The factor responsible for maintaining the humeral head cen-
tered in the glenoid is therefore the interplay between the remaining
static stabilizers (adhesion, cohesion, negative intraarticular pressure,
and the congruency of the joint) and the dynamic stabilizers (the rota-
tor cuff muscles, biceps brachii, the scapular rotators, and coordinated
proprioceptive feedback) of the shoulder.
Despite the complex dynamic and static constraints that main-
tain the humeral head centered in the glenoid, pathologic translation
of the humeral head does occur. Shoulder dislocations often result in
tearing or fracturing of the glenohumeral architecture.38 Selective cut-
ting experiments have demonstrated the potential instability that may
result from sectioning individual capsular and ligamentous structures
of the glenohumeral joint.
Cadaveric experiments have demonstrated the primary ligamen-
tous constraints to translation of the humeral head on the glenoid in
the anterior, inferior, and posterior directions. The anterosuperior
band of the IGHL is the primary ligamentous constraint to anterior
translation with the arm abducted and externally rotated.39 As abduc-
tion decreases, the MGHL is of increasing importance in resisting
anterior translation.40 The primary constraints to inferior translation
in the adducted arm are the superior structures, particularly the SGHL,
which is maximized by external rotation.25,41 With increasing abduc-
tion to 90 degrees, the IGHL becomes the primary constraint to infe-
the posterior band of the IGHL. Although resection of the posterior
capsule increases posterior translation, it is not sufficient for a poste-
rior glenohumeral dislocation to occur.43 However, posterior disloca-
tion is possible if the same shoulder is incised anterosuperiorly, cutting
the SGHL and MGHL. Posterior translation increases with the arm in
30 degrees of extension if the anterior band of the IGHL is incised or
detached from its glenoid insertion.42,44 
Dynamic Stabilizers
The rotator cuff muscles are the primary dynamic stabilizers of the gle-
nohumeral joint. The rotator cuff muscles act to compress the humeral
head on the glenoid increasing stability. More important, they act to
provide a superior and posterior pull that counteracts the superior pull
of the deltoid muscles.45 Lippitt and Matsen19 found that tangential
forces as high as 60% of the compressive force were required to dislo-
cate the glenohumeral joint in a cadaveric study, finding also that joint
stability was reduced with removal of a portion of the anterior labrum.
Similarly, Wuelker and associates46 noted a nearly 50% increase in
anterior displacement of the humeral head in response to a 50% reduc-
tion in rotator cuff forces. The glenohumeral joint reaction force has
been calculated in a cadaveric model to reach a maximum of 0.89 times
body weight.47 Glenohumeral joint contact pressures measure a max-
imum of 5.1 MPa in cadavers using pressure-sensitive film with the
arm in 90 degrees of abduction and 90 degrees of external rotation.48
Joint reaction forces increase with increasing abduction angle and peak
at 90 degrees of abduction.49 Increasing joint compression appears to
increase the centering of the humeral head, thereby providing a stable
fulcrum for arm elevation.50,51
Other factors may also contribute to dynamic glenohumeral sta-
bility. Ligament dynamization through attachment to the rotator
cuff muscles has been postulated, whereby rotator cuff contraction
may affect tensioning of the glenohumeral capsuloligamentous com-
plex.52 Similarly, Pagnani and colleagues53 hypothesized that biceps
 CHAPTER 4  Anatomy and Kinesiology of the Shoulder
contracture may tension the relatively mobile labrum and thereby
tension the associated SGHL and MGHL, potentially enhancing sta-
bility. They also conclude that the long head of the biceps may itself
stabilize the joint depending on shoulder position. Whether this is a
true dynamic function is controversial. Yamaguchi and coworkers54
observed no biceps muscle activity with normal arm motion in both
normal rotator cuffs and deficient cuffs.
The capsuloligamentous structures may also provide propriocep-
tive feedback on joint position. Vangsness and associates55 found
low-threshold, rapid-adapting pacinian fibers in the glenohumeral
ligaments. Others have found diminished proprioception in shoul-
ders with instability, with subsequent improvement after repair.56 Pro-
prioceptive feedback likely helps not only to tension the rotator cuff
muscles but also to position the scapula and clavicle appropriately in
space.  sternal
Anatomy and Biomechanics of the Clavicle
The clavicle connects the appendicular skeleton to the axial skele-
ton. Positioning of the clavicle is in the horizontal plane and has an
S-shaped appearance.57 A double curve is apparent in the shaft of the
clavicle. The lateral half of the clavicle is concaved anteriorly and has a
flat articulation with the acromion, which makes up the AC joint.57 The
medial end is convex anteriorly and articulates with the manubrium
of the sternum to form the SC joint.57,58 The curvatures in the clavicle
allows it to serve as a moveable but rigid support in which the scapula
and upper extremity are suspended while allowing freedom of motion.
Movement at the clavicle takes place in three planes of movement,
including the sagittal, transverse, and frontal planes.58 The motions
that occur at the clavicle are elevation, depression, protraction, retrac-
tion, and rotation.58
There are several muscular and ligamentous attachments to the
clavicle. On the superior medial surface of the clavicle, there are prox-
imal attachments for the sternocleidomastoid and pectoralis major.
The lateral end has the proximal attachment for the anterior deltoid
and distal attachment for upper trapezius. The inferior surface has a
costal facet, which rests directly on top of the first rib.57,58 Posterolat-
eral to the costal facet is the costal tuberosity, which is the attachment
site for the costoclavicular ligament. The subclavius muscle attaches
to the inferior medial surface of the clavicle and plays an important
role in first rib elevation and depression of the clavicle.57,58 The conoid
tubercle lies on the inferior lateral surface and is the attachment site
for the conoid ligament and the medial part of the coracoclavicular
ligament.57 Another ligament that attaches at the acromion (lateral)
end is the trapezoid ligament, which is a part of the coracoclavicular
ligament.57  Acromion
Sternoclavicular Joint
The SC joint is composed of the medial end of the clavicle, manubrium
portion of the sternum, and the cartilage of the first rib57 (Fig. 4.2).
This saddle-shaped synovial joint attaches the appendicular skeleton
and the axial skeleton. Between the sternum and the medial end of the
clavicle, there is an articular disc and ligaments that provide static sup-
port to the joint.57 The ligaments at the SC joint are the anterior and
posterior SC, the interclavicular and costoclavicular ligaments. Ante-
rior stabilization of the SC joint is provided by the sternocleidomastoid
(sternal head) and posteriorly by the sternothyroid and sternohyoid
muscles.59 The costoclavicular ligament firmly stabilizes the SC joint
and limits all clavicular motions, except depression.58,59 At this joint,
there are three degrees of freedom, and the motions are elevation and
depression, protraction and retraction, and rotation.57 All functional
movement of the shoulder involves at least some movement of the clav-
icle about the SC joint.59  ligaments) (Fig. 4.3).60,61 Movements at the AC joint are minimal yet
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41
Sternal end
of clavicle
Cartilage
of first rib
Manubrium
Fig. 4.2  The sternoclavicular joint is stabilized by the strongest ligamen-
tous complex in the body. (Reprinted from Drake RL, Vogl AW, Mitchell
AW, et al. Gray’s Atlas of Anatomy. 1st ed. London: Churchill Living-
stone; 2007.)
TABLE 4.1  Range of Motion at the
Sternoclavicular (SC) Joint
Action at the SC Joint Degrees of Motion
Protraction 15–30
Retraction 15–30
Axial rotation 40–50
Elevation 45
Depression 10
Clavicular Motions at the Sternoclavicular Joint
The maximum at the SC joint is 45 degrees of elevation and 10 degrees of
depression.58,59 During elevation, the clavicle rolls superiorly and glides
inferiorly.58 When this occurs, the costoclavicular ligament becomes
taught, stabilizing the clavicle. At full depression of the clavicle, the inter-
clavicular and superior portion of the capsular ligament are placed on
stretch.58,59 There is 15 to 30 degrees of protraction and retraction of the
clavicle around the SC joint.58,59 Protraction may be limited by the poste-
rior bundle of costoclavicular ligament, the posterior capsular ligament,
or the scapular muscles.60 During shoulder abduction or flexion, the clav-
icle can rotate posteriorly at the SC joint 40 to 50 degrees58,59 (Table 4.1).
The acromion is a continuum of the spine of the scapula. This bony
process is located anterolateral portion of the shoulder girdle. The acro-
mion is important to assess when treating the upper extremity because
it is a site of origin and insertion of numerous muscles and ligaments.
The lateral border has four tubercles for the origins of the deltoid mus-
cle. The medial border has attachments of the trapezius and articulates
with the lateral clavicle. There are three different classifications of the
acromion which have implications for pathology: type I (flat), type II
(curved), and type III (hooked).60,61 
ACROMIOCLAVICULAR JOINT
The AC joint is a diarthrodial joint surrounded by a capsule and has
both intraarticular synovium and articular cartilage.59 The capsule
around the AC joint is reinforced by the superior and inferior liga-
ments, as well as the coracoclavicular ligament (trapezoid and conoid
42 PART 1  Anatomy and Biomechanics
Trapezoid
Conoid
AC capsule
Fig. 4.3  The ligamentous anatomy of the acromioclavicular (AC) joint.
(Reprinted from Gray’s Anatomy, 2007.)
important in providing maximum mobility at the scapulothoracic
joint. The three degrees of freedom of the AC joint are upward and
downward rotation, horizontal plane rotational adjustments, and sagit-
tal plane rotational adjustments.60
Anatomy of the Scapula
The scapula is predominately a thin sheet of bone loosely attached
and congruent to the posterior chest wall, which serves to stabilize the
upper extremity against the thorax. The scapula thickens along its bor-
ders at the site of muscle attachments and along its four projections:
the spine of the scapula, the coracoid, the glenoid, and the acromion.
Scapulothoracic Articulation
Although the scapulothoracic articulation is not a true joint, its motion
is integral to positioning the arm in space. The scapula essentially
glides over a muscle bed on the posterior chest wall, its shape conform-
ing to the underlying ribs. At rest, the scapula is internally rotated 35
to 45 degrees as viewed from above, upwardly rotated about 3 degrees
with respect to the sagittal plane, and tilted forward about 15 to 20
degrees.62  bination of stereophotogrammetry and EMG recordings. Inman and
Scapular Motion
Motion of the scapula is complex and has been historically difficult
to quantify. However, it has been known for some time that normal
scapular motion is needed for full and pain-free elevation of the arm.63
Using sensors attached to percutaneous pins, McClure and associ-
ates64 demonstrated that scapular motion is three dimensional and
task dependent. With arm elevation in the scapular plane, the scapula
rotates upward on average 50 degrees, posteriorly about a mediolateral
axis about 30 degrees, and externally about 24 degrees about a vertical
axis (Fig. 4.4).64  using selective nerve blocks in healthy volunteers. Blocks of either
BIOMECHANICS OF THE SHOULDER COMPLEX
More than 20 muscles coordinate their function to move the shoul-
der joint complex. Based on these muscles’ origins and insertions,
they may be categorized as glenohumeral, scapulothoracic, or
thoracohumeral.
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Internal/external
rotation
Anterior/posterior
tilting
Upward–downward
rotation
Fig. 4.4  The definitions of scapular motion.
The relative function of each individual muscle depends on three
factors: the cross-sectional area, the vector angle of pull, and the per-
centage recruitment of muscle fibers (or intensity of contraction).
Electromyography (EMG) is useful in determining the relative level of
activity within a particular muscle group, but it cannot measure the
force of contraction. To understand the forces generated requires a cal-
culation of the moment arm of the muscle as well as the physiologic
cross-sectional area, both of which are dynamic, making accurate cal-
culations challenging. Anatomic studies have calculated the cross-sec-
tional area of several muscles of the shoulder girdle.65 Cross-sectional
measurements and approximations of force vectors have been used to
calculate glenohumeral joint reaction forces. Current research is focus-
ing on in vivo calculations.
Active Arm Elevation
During active forward elevation of the arm, synchronous activity of
the deltoid and rotator cuff muscles has been measured using a com-
colleagues63 demonstrated that the deltoid and supraspinatus act syn-
ergistically during forward elevation of the arm. Synchronous func-
tion of the remaining rotator cuff muscles provides the humeral head
depression necessary to prevent superior migration of the humeral
head.51
The supraspinatus has traditionally thought to initiate abduction
because the force vector of the deltoid is nearly vertical with the arms
at rest; however, it is now accepted that the deltoid and all four rotator
cuff muscles are active throughout the full range of forward arm ele-
vation. The specific contributions of each muscle have been studied
the suprascapular nerve or the axillary nerve demonstrate that both
the deltoid and supraspinatus are responsible for generating torque
during active forward elevation of the arm.66 Full abduction has been
shown to be possible with an axillary nerve block with a reduction
of strength of about 50% of normal.66 Similarly, suprascapular nerve
block allowed full abduction with diminished strength. However,
simultaneous axillary and suprascapular nerve blocks eliminated
 CHAPTER 4  Anatomy and Kinesiology of the Shoulder
all active elevation, demonstrating that the deltoid, supraspina-
tus, and infraspinatus are essential for active shoulder elevation.67
With a suprascapular nerve block, strength is reduced about 50% at
30 degrees, 35% at 90 degrees, and 25% at 120 degrees of forward
elevation.67
Classically, the contributions to arm elevation are thought to be a
2:1 ratio of glenohumeral to scapulothoracic motion.63 This relation-
ship is called scapulohumeral rhythm. More recent investigations
suggest a more complex interaction with motion during the first 30
degrees as mostly glenohumeral,47,68,69 whereas the last 60 degrees
comprises a near equal contribution by the glenohumeral and scapu-
lothoracic joints. McClure and coworkers64 measured a ratio of 1.7 to 1
of glenohumeral motion to scapulothoracic motion with arm elevation
in healthy volunteers. The speed of arm elevation also affects the rel-
ative contribution of each joint, with predominance of glenohumeral
motion at high speeds.70 With age, the ratio of glenohumeral to sca-
pulothoracic motion remains relatively constant; however, the ROM
is diminished.71
Upward rotation is not the only scapular motion that is required
for glenohumeral elevation. As the humerus is elevated, the scapula
must also posterior tilt, which is movement in the sagittal plane about
a mediolateral axis where the acromion rotates posterior. The scapula
sits on the thorax at rest in a small amount of anterior tilt and posterior
tilts linearly with elevation of the humerus, particularly after 20 degrees
of elevation.72,73
In summary, as the arm is elevated overhead, the scapula must rotate
upwardly and tilt posteriorly. For this coupling to occur, there must be
timely and proper activation of the scapulothoracic muscles, particu-
larly the serratus anterior and the trapezius.74 The serratus anterior and
upper and lower fibers of the trapezius are primarily responsible for
upward rotation, whereas the serratus anterior and lower trapezius are
responsible for posterior tilting. The middle fibers of the trapezius act
isometrically as a stabilizer.74  glenohumeral joint. Clin Orthop Relat Res. 1992;285:181–190.
External Rotation of the Humerus
Maximal forward elevation of the arm requires external rotation
of the humerus.75 Early observers concluded that external rotation
was necessary for the tuberosity to clear the acromion, but more
recent clinical and cadaveric studies suggest other factors play a
significant role. Maximal external rotation may confer greater sta-
bility to the glenohumeral joint in the elevated position.76 Jobe and
Iannotti conclude,77 based on a cadaveric range-of-motion study in
three planes, that obligate external rotation makes more humeral
head cartilage available for articulation with the glenoid. A cadav-
eric study using magnetic three-dimensional tracking devices
determined maximal elevation was associated with approximately
35 degrees of external rotation.75 In  vivo data suggest a greater
amount of external rotation exists. Using a magnetic field around
volunteers, Stokdijk and colleagues78 found an average external
rotation of 55 degrees. 
SUMMARY
Shoulder motion is a result of the complex interactions of the glenohu-
meral, AC, SC, and scapulothoracic joints. The shoulder is powered by
the coordinated motion of more than 20 muscles interacting to confer
stability under varying speeds and loads. Shoulder motion is measured
and described in discrete planes of motion with motion at each joint
affecting the measure of each other joint. The shoulder’s inherent lack
of stability allows for the freedom of movement needed to optimize
function of the upper extremity, therefore making it essential in any
hand rehabilitation.
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
43
ACKNOWLEDGMENT
The authors would like to thank Drs. Mark Lazarus, MD, and Ralph
Rynning, MD, for their previous work on this book chapter.
REFERENCES
1. Murray MP, Gore DR, Gardner GM, Mollinger LA. Shoulder motion
and muscle strength of normal men and women in two age groups. Clin
Orthop Relat Res. 1985;192:268–273.
2. Lucas D. Biomechanics of the shoulder joint. Arch Surg. 1973;107:425.
3. Barnes CJ, Van Steyn SJ, Fischer RA. The effects of age, sex, and shoulder
dominance on range of motion of the shoulder. J Shoulder Elbow Surg.
2001;10(3):242–246.
4. McCully SP, Kumar N, Lazarus MD, Karduna AR. Internal and external
rotation of the shoulder: effects of plane, end-range determination, and
scapular motion. J Shoulder Elbow Surg. 2005;14(6):602–610.
5. Boone DC, Azen SP. Normal range of motion of joints in male subjects.
J Bone Joint Surg Am. 1979;61(5):756–759.
6. Namdari S, Yagnik G, Ebaugh DD, et al. Defining functional shoulder
range of motion for activities of daily living. J Shoulder Elbow Surg.
2012;21(9):1177–1183.
7. Pearl ML, Harris SL, Lippit SB, et al. A system for describing positions
of the humerus relative to the thorax and its use in the presentation of
several functionally important arm positions. J Shoulder Elbow Surg.
1992;1:113–118.
8. Pearl ML, Jackins S, Lippit SB, et al. Humeroscapular positions in
a shoulder range-of-motion examination. J Shoulder Elbow Surg.
1992;1:296–305.
9. Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop Scand.
1971;42(6):491–505.
10. Matsumura N, Ogawa K, Kobayashi S, et al. Morphologic features of
humeral head and glenoid version in the normal glenohumeral joint.
J Shoulder Elb Surg. 2014. https://doi.org/10.1016/j.jse.2014.02.020.
11. Soslowsky LJ, Flatow EL, Bigliani LU, Mow VC. Articular geometry of the
12. Lugo R, Kung P, Ma CB. Shoulder biomechanics. Eur J Radiol.
2008;68:16–24.
13. Hovelius L. Incidence of shoulder dislocation in Sweden. Clin Orthop
Relat Res. 1982;166:127–131.
14. Boileau P, Walch G. The three-dimensional geometry of the proximal hu-
merus. Implications for surgical technique and prosthetic design. J Bone
Joint Surg Br. 1997;79(5):857–865.
15. Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version:
an anatomic study. J Shoulder Elbow Surg. 2001;10(4):327–332.
16. Pearl ML, Volk AG. Coronal plane geometry of the proximal humerus rel-
evant to prosthetic arthroplasty. J Shoulder Elbow Surg. 1996;5(4):320–326.
17. Randelli M, Gambrioli PL. Glenohumeral osteometry by computed
tomography in normal and unstable shoulders. Clin Orthop Relat Res.
1986;(208):151–156.
18. Lazarus MD, Sidles JA, Harryman 2nd DT, Matsen 3rd FA. Effect of a
chondral-labral defect on glenoid concavity and glenohumeral stability.
A cadaveric model. J Bone Joint Surg Am. 1996;78(1):94–102.
19. Lippitt S, Matsen F. Mechanisms of glenohumeral joint stability. Clin
Orthop Relat Res. 1993;(291):20–28.
20. Fukuda K, Chen CM, Cofield RH, Chao EY. Biomechanical analysis of
stability and fixation strength of total shoulder prostheses. Orthopedics.
1988;11(1):141–149.
21. Kim SH, Noh KC, Park JS, et al. Loss of chondrolabral containment of
the glenohumeral joint in atraumatic posteroinferior multidirectional
instability. J Bone Joint Surg Am. 2005;87(1):92–98.
22. Kumar VP, Balasubramaniam P. The role of atmospheric pressure in
stabilising the shoulder. An experimental study. J Bone Joint Surg Br.
1985;67(5):719–721.
23. Warner JJP, Deng X, Warren RF, et al. Superoinferior translation in the
intact and vented glenohumeral joint. J Shoulder Elbow Surg. 1993;2:
99–105.
44 PART 1  Anatomy and Biomechanics
24. O’Brien SJ, Neves MC, Arnoczky SP, et al. The anatomy and histology of
the inferior glenohumeral ligament complex of the shoulder. Am J Sports
Med. 1990;18(5):449–456.
25. Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous
restraints to superior-inferior translation of the glenohumeral joint. Am J
Sports Med. 1992;20(6):675–685.
26. O’Connell PW, Nuber GW, Mileski RA, Lautenschlager E. The contribu-
tion of the glenohumeral ligaments to anterior stability of the shoulder
joint. Am J Sports Med. 1990;18(6):679–684.  plane. J Shoulder Elbow Surg. 1995;4(3):199–208.
27. Gohlke F, Essigkrug B, Schmitz F. The pattern of the collagen fiber
bundles of the capsule of the glenohumeral joint. J Shoulder Elbow Surg.
1994;3:111–128.
28. O’Brien SJ, Schwartz RS, Warren RF, Torzilli PA. Capsular restraints to
anterior-posterior motion of the abducted shoulder: a biomechanical
study. J Shoulder Elbow Surg. 1995;4(4):298–308.
29. Cofield RH, Irving JF. Evaluation and classification of shoulder instability.
With special reference to examination under anesthesia. Clin Orthop Relat
Res. 1987;(223):32–43.
30. Gerber C, Ganz R. Clinical assessment of instability of the shoulder. With
special reference to anterior and posterior drawer tests. J Bone Joint Surg
Br. 1984;66(4):551–556.
31. Harryman 2nd DT, Sidles JA, Clark JM, et al. Translation of the humeral
head on the glenoid with passive glenohumeral motion. J Bone Joint Surg
Am. 1990;72(9):1334–1343.
32. Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the gleno-
humeral joint with the patient under anesthesia. J Shoulder Elbow Surg.
1996;5(4):286–292.
33. Emery RJ, Mullaji AB. Glenohumeral joint instability in normal adoles-
cents. Incidence and significance. J Bone Joint Surg Br. 1991;73(3):
406–408.
34. Tibone JE, McMahon PJ, Shrader TA, et al. Glenohumeral joint transla-
tion after arthroscopic, nonablative, thermal capsuloplasty with a laser.
Am J Sports Med. 1998;26(4):495–498.
35. Lippitt SB, Vanderhooft JE, Harris SL, et al. Glenohumeral stability from
concavity-compression: a quantitative analysis. J Shoulder Elbow Surg.
1993;2:27–35.
36. Howell SM, Galinat BJ, Renzi AJ, Marone PJ. Normal and abnormal
mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint
Surg Am. 1988;70(2):227–232.
37. O’Driscoll SW, Evans DC. Contralateral shoulder instability following
anterior repair. An epidemiological investigation. J Bone Joint Surg Br.
1991;73(6):941–946.
38. Speer KP, Deng X, Borrero S, et al. Biomechanical evaluation of a simulat-
ed Bankart lesion. J Bone Joint Surg Am. 1994;76(12):1819–1826.
39. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms
preventing anterior dislocation of the glenohumeral joint. J Bone Joint
Surg Am. 1981;63(8):1208–1217.
40. Debski RE, Wong EK, Woo SL, et al. In situ force distribution in the gle-
nohumeral joint capsule during anterior-posterior loading. J Orthop Res.
1999;17(5):769–776.
41. Jost B, Koch PP, Gerber C. Anatomy and functional aspects of the rotator
interval. J Shoulder Elbow Surg. 2000;9(4):336–341.
42. Schwartz E, Warren RF, O’Brien SJ, Fronek J. Posterior shoulder instabili-
ty. Orthop Clin North Am. 1987;18(3):409–419.
43. Bowen MK, Warren RF. Ligamentous control of shoulder stability based
on selective cutting and static translation experiments. Clin Sports Med.
1991;10(4):757–782.
44. Ovesen J, Nielsen S. Posterior instability of the shoulder. A cadaver study.
Acta Orthop Scand. 1986;57(5):436–439.
45. Halder AM, Zhao KD, O’Driscoll SW, Morrey BF, An KN. Dynamic
contributions to superior shoulder stability. J Orthop Res. 2001. https://
doi.org/10.1016/S0736-0266(00)00028-0.
46. Wuelker N, Korell M, Thren K. Dynamic glenohumeral joint stability.
J Shoulder Elbow Surg. 1998;7(1):43–52.
47. Poppen NK, Walker PS. Normal and abnormal motion of the shoulder.
J Bone Joint Surg Am. 1976;58(2):195–201.
48. Conzen A, Eckstein F. Quantitative determination of articular pressure in
the human shoulder joint. J Shoulder Elbow Surg. 2000;9(3):196–204.
Downloaded for Leanna Nyoman (leannanyoman@gmail.com) at National University of Singapore from ClinicalKey.com by Elsevier on December 29, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
49. Apreleva M, Parsons 4th IM, Warner JJ, et al. Experimental investigation
of reaction forces at the glenohumeral joint during active abduction.
J Shoulder Elbow Surg. 2000;9(5):409–417.
50. Thompson WO, Debski RE, Boardman 3rd ND, et al. A biomechanical
analysis of rotator cuff deficiency in a cadaveric model. Am J Sports Med.
1996;24(3):286–292.
51. McMahon PJ, Debski RE, Thompson WO, et al. Shoulder muscle forces
and tendon excursions during glenohumeral abduction in the scapular
 
52. Clark J, Sidles JA, Matsen FA. The relationship of the glenohumeral joint
capsule to the rotator cuff. Clin Orthop Relat Res. 1990;254:29–34.
53. Pagnani MJ, Deng XH, Warren RF, et al. Role of the long head of the bi-
ceps brachii in glenohumeral stability: a biomechanical study in cadavers.
J Shoulder Elbow Surg. 1996;5(4):255–262.
54. Yamaguchi K, Sher JS, Andersen WK, et al. Glenohumeral motion in
patients with rotator cuff tears: a comparison of asymptomatic and symp-
tomatic shoulders. J Shoulder Elbow Surg. 2000;9(1):6–11.
55. Vangsness Jr CT, Ennis M, Taylor JG, Atkinson R. Neural anatomy of the
glenohumeral ligaments, labrum, and subacromial bursa. Arthroscopy.
1995;11(2):180–184.
56. Tibone JE, Fechter J, Kao JT. Evaluation of a proprioception pathway in
patients with stable and unstable shoulders with somatosensory cortical
evoked potentials. J Shoulder Elbow Surg. 1997;6(5):440–443.
57. Moore KL, Dalley AF. Clinically Oriented Anatomy. 6th ed. Philadelphia:
Lippincott Williams & Wilkins; 2010:672–676.
58. Oyama S, Myers J, Wassinger C, Lephar S. Three-dimensional scapular
and clavicular kinematics and scapular muscle activity during retraction
exercises. J Orthop Sports Phys Ther. 2010;40(3):169–179.
59. van Tongel A, MacDonald P, Leiter J, Pouliart N, Peeler J. A cadaveric
study of the structural anatomy of the sternoclavicular joint. Clin Anat.
2012;25(7):903–910.
60. Patel B, Gustafson PA, Jastifer J. The effect of clavicle malunion on shoul-
der biomechanics; a computational study. Clin Biomech. 2012;27(5):
436–442.
61. Kongmalai P, Apivatgaroon A, Chernchujit B. Morphological classifi-
cation of acromial spur: correlation between Rockwood tilt view and
arthroscopic finding. SICOT J. 2017;3(4):1–7.
62. Ludewig P, Cook T. Alterations in shoulder kinematics and associated
muscle activity in people with symptoms of shoulder impingement. Phys
Ther. 2000;80:276–291.
63. Inman V, Saunders JR, Abbott LC. Observations on the function of the
shoulder joint. J Bone Joint Surg Am. 1944;26:1–31.
64. McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional
measurement of scapular kinematics during dynamic movements in vivo. J
Shoulder Elbow Surg. 2001;10(3):269–277.
65. Bassett RW, Browne AO, Morrey BF, An KN. Glenohumeral muscle force
and moment mechanics in a position of shoulder instability. J Biomech.
1990;23(5):405–415.
66. Howell SM, Kraft TA. The role of the supraspinatus and infraspinatus
muscles in glenohumeral kinematics of anterior should instability. Clin
Orthop Relat Res. 1991;263:128–134.
67. Colachis Jr SC, Strohm BR. Effect of suprascapular and axillary nerve
blocks on muscle force in upper extremity. Arch Phys Med Rehabil.
1971;52(1):22–29.
68. Doody SG, Freedman L, Waterland JC. Shoulder movements during
abduction in the scapular plane. Arch Phys Med Rehabil. 1970;51(10):
595–604.
69. Harryman DT, Walker ED, Harris SL, et al. Residual motion and function
after glenohumeral or scapulothoracic arthrodesis. J Shoulder Elbow Surg.
1993;2:275–285.
70. Sugamoto K, Harada T, Machida A, et al. Scapulohumeral rhythm:
relationship between motion velocity and rhythm. Clin Orthop Relat Res.
2002;(401):119–124.
71. Talkhani IS, Kelly CP. Movement analysis of asymptomatic normal shoul-
ders: a preliminary study. J Shoulder Elbow Surg. 2001;10(6):580–584.
72. Braman JP, et al. In vivo assessment of scapulohumeral rhythm during
unconstrained reaching in asymptomatic subjects. J Shoulder Elbow Surg.
2009.
 CHAPTER 4  Anatomy and Kinesiology of the Shoulder 45

73. Ludewig PM, et al. Motion of the shoulder complex during multiplanar
humeral elevation. J Bone Joint Surg Am. 2009.
74. Phadke V, Camargo P, Ludewig P. Scapular and rotator cuff muscle activi-
ty during arm elevation: a review of normal function and alterations with
shoulder impingement. Rev Brasil Fisioterapia (Sao Carlos (Sao Paulo, Bra-
zil)). 2009;13(1):1–9. https://doi.org/10.1590/S1413-35552009005000012.
75. Browne AO, Hoffmeyer P, Tanaka S, et al. Glenohumeral elevation stud-
ied in three dimensions. J Bone Joint Surg Br. 1990;72(5):843–845. 
76. Dvir Z, Berme N. The shoulder complex in elevation of the arm: a mecha-
nism approach. J Biomech. 1978;11(5):219–225.
77. Jobe CM, Iannotti JP. Limits imposed on glenohumeral motion by joint
geometry. J Shoulder Elbow Surg. 1995;4(4):281–285. 
78. Stokdijk M, Eilers PH, Nagels J, Rozing PM. External rotation in the gle-
nohumeral joint during elevation of the arm. Clin Biomech (Bristol, Avon).
2003;18(4):296–302.

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