Normal Mechanics and

Pathophysiology of the
Shoulder

Robert Donatelli PhD PT OCS

The Complex Shoulder
Anatomy and mechanics of movement
Component movements of elevation
Muscle function and dysfunction
Pathophysiology
Evaluation
Treatment
 Shoulder
Pathophysiology
Abnormal movement patterns
Hypermobility of the glenohumeral joint
-Translations of the humeral head
-Dislocations and Subluxations
-Multidirectional instability
Hypermobility of the glenohumeral joint
Stiff and painful shoulder movements
 Medical Diagnosis
Instability-Impingement-Rotator cuff tears
Bankhart lesions
Hill Sacks
SLAP lesions
Capsular Instability -Inferior capsule shift vs
thermal assisted shift -Rotator cuff interval `
Joints of the Shoulder
Glenohumeral
Scapulothoracic
Sterno-clavicular
Acromio-clavicular
Clinical Biomechanics of
Shoulder Movement
Osteokinematics vs Arthokinematics
Plane of the Scapula
Roll – Spin – Slide
Forces during shoulder elevation
Muscle forces and actions during
elevation
Rotational movements and the clinical
significance.
 Osteokinematics
Movement of the Bone
Elevation of the
shoulder and the
Body Planes of
Movement- 1600
planes of elevation
one degree per plane
Plane of the Scapula
(POS) 30-45 degrees
anterior to the frontal
plane
 Scaption - POS
Johnston Brit J Surg 1937 “A Plea” the
true abduction range
Poppen and Walker Clin Orth 1978
Kondo Surgery of the Shoulder
Medial titling angle is always
40 degrees anterior to the frontal plane
Clinical Significance of
the POS
Length tension of
the rotator cuff and
shoulder abductor is
optimal -Exercise and
testing
Capsule is untwisted
Stretching/ mobilization
Joint Congruity is
optimal Joint stability
 Research
Torque production between Scaption and other
body plane movements
Greenfield and Donatelli Am J Sports Med 1990 --
Significant increase in strength of the external
rotators in the POS – 30 degrees anterior to the
frontal plane
Tata et al., J Ortho Sports PT 1993 Better Ratio of ext/int
at 35 deg anterior
Soderberg et al., J Ortho Sports PT 1987 No difference
from sagittal, frontal, neutral, POS 45 degrees
anterior to the frontal plane
 Arthrokinematics
ROLL – SPIN – SLIDE
Direction and the
amount of humeral
head translation maybe
a function of the soft
tissue tension rather
than the joint surface
geometry. McClure &
Flowers PT 1992
Convex surface Roll
and Slide occur in
opposite directions
 Principle of Shoulder
Elevation
Poppen and Walker 1. True abduction is in
the POS
2. Humeral head excursion 1.5 mm in a
superior and inferior glide during elevation
– Roll and Slide occur in opposite
directions
3. External rotation of the humerus and
scapula is important to elevation
Osteokinematics and Arthrokinematics
What are the Important
Principles of Shoulder
Elevation?
What are the muscles that elevate the
shoulder?
What are the action of the muscles that
elevate the shoulder?
What Forces are produced during
shoulder elevation?
Why is ROTATION so important to
elevation?
Primary Elevators of the
Shoulder
Deltoid Muscles are primary shoulder
elevators that provide stability and
mobility
Supraspinatus elevates the humeral
head 3mm into a central position on the
glenoid
Superior fibers of the subscapularis and
infraspinatus
 Rotator Cuff Assist
Elevation
Otis JBJS 1994 –
Demonstrated that external
and internal rotation of the
humerus was important to
enhancing the moment arm
of the subscapularis and
infraspinatus during
elevation
Movement of the insertion
laterally increased the
distance from the axis of
elevation
 Scapular Rotators
Upper traps
Lower traps
Serratus
Levator scapulae
Middle Traps and
Rhomboids
(stabilize)
 Scapula Rotators
Bagg and Forest - Am
J Sports Med 1986
Biomechanical
analysis of scapular
rotators during arm
abd. In the POS
Scapula rotators 80-
140 greater moment
arm than the Deltoid
and the supraspinatus
Scapula Rotators
Scapula muscles
Rotation of the Scapula
Increased tension on the
concoid and trapezoid
ligaments resulting in axial
rotation of the clavicle.
Clavicle forms a double
curve creating a
crankshaft effect
Rotation produces
elevation at the AC end to
allow the scapula to rotate
the last 30 deg
 Role of the Scapula
Stable part of the glenohumeral joint
Retraction and protraction along the
thoracic wall
Elevation of the Acromion – reduces
impingement
Base of muscle attachment
Link of proximal and distal segments
 AC and SC Joints
Axial rotation of the
clavicle secondary to
scapula rotation
Rotation and elevation at
the AC end – very mobile
joint limited ligament
support
SC joint is the hinge
mechanism for elevation –
costoclavicular ligament
SC strong ligament
support and meniscus
Forces During Elevation
Muscle forces produce
parallel and
perpendicular forces to
the GH joint
The RC muscles = a
parallel force to the GH
joint = compression and
depression
The Anterior Deltoid
produces a perpendicular
force to the GH joint =
shear (Max shear 60 deg)
Muscle Forces parallel &
perpendicular to the joint
 Stabilizing Effect of Deltoid

The Middle &

Posterior Deltoid
more compressive
forces, lower shearing
Lee et al Dynamic GH
stability provided by the 3
heads of the Deltoid
Muscle. Clin Ortho Rel
Research 2002
Gagey & Hue 2000 Clin
Orth Rel Res Mechanics of
the Deltoid Muscle
 Role of the Biceps
The long and short head of
the biceps at 60 and 90
degrees of abduction and
external rotation is an
important stabilizer by
increasing torsional rigidity
Itio et al JBJS 93
The long head of the biceps
during internal & external
rotation is anterior/posterior
to the joint, producing
compressive forces
restraining the translations
of the humeral head Abboud &
Soclowsky Clin Ortho Rel Res 2002
Dynamic Stability of GH
Deltoid and the Rotator cuff muscles produce
shearing, compressive, and depressive
forces to the GH joint
These forces will vary as the muscles’
alignment change.
A larger superior shearing force will produce
impingement
A larger compressive force will center the
humeral head on the glenoid creating stability
Muscle Forces Changing
Acromial Pressure
Payne et al. Am J Sports Med 1997
Muscle reducing acromial pressure:
-Biceps 10% (6 shoulder 34% dec)
-Rotator Cuff 52% dec without supraspinatus
(type III acromion)
Muscle increasing acromial pressure:
-Supraspinatus – superior shear forces
-Deltoid abduction force inc. 17% and the average
pressure under the acromion increased 1240%
Internal rotation increased pressure 33%
Anterior (G-H Joint) Posterior
Scapula Rotators Effect
on Increasing GH Forces
Serratus anterior and trapezius weakness will
reduce upward scapular rotation and increase
the risk of rotator cuff and bicipital
impingement DeVita et al. Phys Therapy 1990
Weakness of scapula retractors will result in
excessive protraction and narrow the
subacromial space McQuade et al. Clin Biomech 95
Kibler Am J Sports Med 1998
 Scapular Dysfunction

Kebaestse et al Arch of Phys

Med Rehab 1999 – Thoracic
posture effects position of
the scapula and ROM of the
G-H joint
Warner et al Clin Ortho Rel
Res 1992 Asymmetry of the
scapula is 32-57% of
shoulder instability &
Impingement groups
Wadsworth & Bullock-
Saxton Int J Sports Med
1997 Serratus recruitment
delayed in impingement
group
 External/Internal
Rotation
Concomitant External Rotation of the humerus is necessary for
abduction in the coronal plane. Inman, Poppen & Walker,
Johnston
Maximum elevation in all planes anterior to the POS require
external axial rotation of the humerus. Browne et al. J Orthop Res
1991
Maximum elevation 35 degrees Ext. Rotn
Internal rotation required for elevation posterior to the POS.
Browne et al JBJS 1990
Direct correlation between passive external rotation in the
adducted position and active elevation in the POS Donatelli et al.
Orthopedic Research Society Annual Meeting – Poster
presentation
Rotation of the Humerus
Brems et al Clin Ortho 1994
- Key component to elevation in shoulder
arthroplasty patients.
-External rotation is possibly the most
important functional motion that the shoulder
complex allows.
-Loss of greater than 45 degrees could result
in significant functional impairment
 Ratio Of Rotator Cuff
Muscles
Average strength of the external to internal
rotators approximately 60%
Ellenbecker JOSPT 1997 demonstrated that
in professional baseball pitchers the external
to internal rotator ratio was 70%.
If the external to internal rotator ratio is less
than 50% a muscle imbalance is present that
could effect function. Especially in overhead
throwing athletes.
Stabilizing Mechanisms of the
G-H joint/ Turkel JBJS 1981
36 cadaver shoulders embalmed
Relative soft tissue contributions to limiting
external rotation at the G-H joint.
Dissections of Subscapularis, Shoulder capsule,
Superior, middle and inferior G-H ligaments.
At Zero degrees of abduction subscapularis most
significant restriction in ext. rotn
45 degrees abd middle G-H ligament
90 degrees abd superior band of the inferior G-H
ligament checked external rotation
Restricted External Rotation in
zero degrees of abduction
Subscapularis Muscle
Largest muscle mass of the RC
Two muscle bellies with multiple nerve
innervations
Forms medial wall for long head biceps stability
Muscle arises from the scapula foss – posterior
and attaches to the G-H joint – anterior.
Depressors of the humeral head
Midrange and end-range stabilityLee et al JBJS 2000
Subscapularis
 Subscapularis and
Surrounding Muscles
Subscapularis Fascial
Tissue
Subscapularis Syndrome
Limited passive external rotation in the adducted position
or zero degrees of abd.
Lack of disassociation of the humerus from the scapula
with active elevation
Poor lift off test – pain, weakness, and/or restrictions
Asymmetrical scapula (inferior angle) – weak
supraspinatus and ext. rotators poor length tension
Positive Impingement tests Hawkins impingement of deep
surface of Subscapularis – Gerber & Sebesta J Sh Elbow
Surg 2000
 Subscapularis
Syndrome Doctoral
Research M. Zazzeli DcS
6 patients MRI compared to Clinical testing
3 out of 6 patients subscapularis involved
Fatty fibrous infiltration (1) Tendinosis (2)
5 out of 6 had tears of supraspinatus
All patients/ pain & weakness Lift-off test
ER in zero degrees of abd. = 29.7
Positive Impingement tests-Hawkins, Yokums, Neer
+ Lift off test & Limited ER in zero deg abd
suspect Supraspinatus lesion
 Phases of Elevation
Initial Phase 0-60 degrees active
elevation
Middle or critical phase 60-140 degrees
active elevation
Final Phase 140-180 degrees of active
elevation
 Initial Phase
0-30 humeral head moves superior by the
action of the supraspinatus 3mm to position
the head of the humerus in a central position
on the glenoid – Important for stability
0-60 SC joint mobility
Ratio 4:29:1 AA:SR Arm abduction to scapula
rotation
3:29:1 GH:ST - G-H joint movement to
Scapula-thoracic joint movement
 Middle Phase
Maximum forces at the G-H joint 60-90
- Shearing forces of the Deltoid
-Weight of the arm
80-140 degrees greatest relative amount
of scapula rotation
130-150 clavicular elevation at the AC is
complete
 Middle Phase
Arthrokinematics Superior/inferior glides
1.5mm – Poppen and Walker
1:71:1 AA/SR
0.71:1 GH/ST
Rotation-Rotation-Rotation important
component movements of the G-H,
scapula, and the clavicle
 Final Phase
Disassociation of the humerus from the
scapula
Good extensibility of the subscapularis,
teres major, pectoralis minor
4:5:1 AA/SR
3:5:1 GH/ST
 Summary
Clinical Biomechanics of Shoulder Motion
1. Osteokinematics / Arthrokinematics
2. POS
3. Roll Spin Slide
4. Parallel and Perpendicular Forces during
shoulder elevation Stability / Instability
5. Muscle forces and actions during elevation
6. Internal and external rotation of the
Glenohumeral – Scapula - Clavicle