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Normal and abnormal motion of the shoulder

NK Poppen and PS Walker J Bone Joint Surg Am. 1976;58:195-201.

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CORTICAL

BONE

ATROPHY
. and the ulti-

SECONDARY

TO

FIXATION

195

(2)
P.

showed
Hence,

one-to-one
the stress

correspondence
calculated when P

between
=

Or, (4)
E=

maz

Pa
6IY,
.

mate

bending strength (or stress crc). The flexural modulus of elasticity

can also be calculated using

(E) the

of

the

bone
=

specimen

following

8.64

(-i-\Y(,(
A!

(L

\bh3

formula (3)
where

: wherea Yq(4
Y(,(
.4 5
=

(L.)()
vertical deformation

(a

+--) at point
A (Fig.

Now the initial 2).

at A-

at
A

1.2 cm. the Instron cross-head ofthe load-deformation

E can be calculated

slope Therefore,

displacement, diagram (Fig.

from equation

and 2) is
(4).

the

References
W. H., Woo. S. L-Y; COUTTS, R. D.; MATTHEWS, J. V. ; GON5ALVES, M.; and AMIEL, D.: Quantitative Histological Evaluation of Early Fracture Healing of Cortical Bones Immobilized by Stainless Steel and Composite Plates. CaIc. Tissue Res. , 19: 27-37, 1975. 2. BARDOS, D. L.: An Evaluation ofTi-6Al-4V Alloy forOrthopedic Applications. In Proceedings ofthe Orthopaedic Research Society. J. Bone and Joint Surg. 56-A: 847, June 1974. 3. BAUMF.ISTER, T.: Marks Standard Handbook for Mechanical Engineers. Ed. 7, chapters 5-31. New York, McGraw-Hill, 1967. 4. BYNUM. D. . JR.: ALLEN, G. F.; RAY, D. R.; and LEDBETTER, W. B.: In Vitro Performance of Installed Internal Fixation Plates in Compression. J. Biomed. Mat. Res., 5: 389-405, 1971. 5. CURREY, J. D.: The Mechanical Properties of Bone. Clin. Orthop., 73: 210-231, 1970. 6. GODFREY. J. L.: Looking at Bone Plates and Screws. Eng. in Med., 1: 17-18, 1971. 7. HICKS, J. H.: The Fixation of Fracture Using Plates. Eng. in Med., 2: 60-63, 1973.
I
.

AKESON,

8. 9. 10. 11. 12.

LINDAHI.,
ROMANUS,

OLov:

The

Rigidity

of Fracture

Immobilization

with

Plates.

Acta

Orthop.

Scandinavica,
Bone Internal in

38:
Nutritional Fixation.

101-114,

1967.
Acta Orthop. Scan-

Fixation Plate on Long Bone Remodeling. published in Proceedings of the Twenty-eighth meeting of ACEMB, p. 150, New Orleans, Louisiana, September 1975. Woo, S. L-Y: AKESON. W. H.; LEVENETZ, B.; COUTTS, R. D.; MATTHEWS, J. V.; and AMIEL, D.: Potential Application ofGraphite Methyl Methacrylate Resin Composites as Internal Fixation Plates. J. Biomed. Mat. Res., 8: 321-338, 1974.

Physical dinavica, Supplementum UHTHOFF, H. K., and Woo, S. L-Y; SIMoN,

B.:

Properties and Chemical Content of Canine Femoral Cortical 155, 1974. DUBUC, F. L.: Bone Structure Changes in the Dog Under Rigid B. R.; and AKESON, W. H.: Evaluation of Rigidity of Internal

Osteopenia. Clin. Orthop.,

81: 165-170,

1971.
Abstract and

Fiber

Normal
BY NORMAN
From

and Abnormal
K. POPPEN,
The Hospitalfor Cornell M.D.*, Special Unisersitv AND Surgery, Medical

Motion
PETER S. Affiliated College. WALKER, with New

of the Shoulder
PH.D.t, The York New Cit York NEW HospitalYORK, N.Y.

ABSTRACT:

The

motion

in normal

roentgenographic parameters of and abnormal shoulders, including

the movement of the scapula, arm angle, glenohumeral angle, scapulothoracic angle, excursion of the humeral head, and instant center of motion for abduction in the plane of the scapula, were determined in twelve normal subjects and fifteen patients. The scapula rotated externally with abduction.
movement

of the humeral head. An abnormal glenohumeral-toscapulothoracic ratio was associated with significant pain in the shoulder. The fact that these various parameters were sensitive indicators of normal and abnormal motion clinical application. Many authors raises the possibility of diagnostic

The

ratio
5:4

scapulothoracic

was

grees of abduction. glenohumeral joint scapula geometric

for

The center abduction

of glenohumeral to after about 30 deof rotation of the in the plane of the the ex-

2,3.4.5.6.7,8,1O.II.I2,13

have

pointed

out the

was located within six millimeters of center of the humeral ball. The average

complexity of the shoulder and nearly a century ago 2.3 the interplay of the sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joints was described. It has been suggested 11.12 that true abduction of the arm should not be in the coronal plane, but rather in the plane

cursion of the humeral ball on the face of the glenoid in the superoinferior plane between each 30-degree arc of motion was less than 1 .5 millimeters in normal subjects. Significant previous injury resulting in abnormal mechanics of the shoulder joint was associated with abnormal values for excursion of the instant center and

of the

scapula to the coronal

ferior part of
supraspinatus arm. Inman the
motion

which is angled 30 to 45 degrees anterior plane, because in the scapular plane the inthe capsule is not twisted and the deltoid and are optimally co-workers move aligned showed simultaneously, joint Saha for elevation of the that all of the joints in and

and

shoulder

girdle

that

in the

535

East

70th

Street,

New

York,

N.Y.

t Reprint requests Randolph, Massachusetts

VOL. 58-A, NO. 2, MARCH

to Dr.
02368.
1976

Walker,

10021. Codman and Shurtleff,

of abduction the glenohumeral as much as the scapulothoracic joint.

Inc.,

moves twice described a based at the

zero

position
much

on

how

of the humeral head rolling and sliding

on the glenoid takes place

I 96

N.

K.

POPPEN

AND

P.

5.

WALKER

FIG.

Three sets of x-y fixed in the thorax,

axes are taken to define the joints positions. XY is xy is fixed in the scapula, and ,y is fixed in the humerus. 0A #{176}GH #{176}ST#{149} The arm angle (eA) is the angle formed by the y-axis of the humerus and a line parallel to the Y-axis of the body. The glenohumeral angle (O(;H) 15 defined as the angle formed by the y-axis of the humerus and the y-axis of the scapula. The scapulothoracic angle (O) is the angle formed by the y-axis of the scapula and a line parallel to the Y-axis of the body.

tients seventeen to seventy-two years old who had lesions of the shoulder and were about to have arthrography. We adopted a technique similar to that of Freedman and Munro to obtain roentgenograms in the plane of the
FIG. I

scapula tenor
patient

with
standing

the

arm
with

in neutral was
the

rotation. of each
at a 30-degree

An shoulder

anteroposwith
angle

in the humerus: x.y, scapula x,y, and body x,Y. The line x is a perpendicular to the true )Fthe axis ofThe humerus) through O. the center of the humeral head. The line v passes through the superior and inferior edges of the glenoid and .v is the mid-line of the scapular spine. O is chosen at the center of the glenoid fossa and hence

Reference

axes

are taken

roentgenograrn

made
torso

the

to the

the x-axis

passes through

this

point

perpendicular

to the

y-axis.

plane of the roentgenogram. When the arm was abducted to each of the required positions, the plane of abduction was parallel to the plane of the roentgenogram and the amount of the
Selection

glenohumeral joint. Dernpster applied the concept of treating the upper extremity as a series of rigid links to measure the contributions made by each joint of the upper extremity to bring the hand to a position where it can perform a required task. Freedman and Munro and Doody and associates found analyzed a ratio abduction in the scapular plane of 3:2 between glenohumeral and and

of abduction body.
of Reference

was

gauged

with

reference

to the axis

Axes

A study of the motion of the shoulder must start with a definition of the axes in each of the two moving parts (humerus and scapula) relative to the stationary part, the torso (Fig. 1). The as one
close

scapulothoracic motion. This ratio was not substantially affected when there was resistance to movement. In this study we attempted to measure two other parameters of motion, as well as the angular movements of

geometric reference
to uniform

center point
for

of the because
this

humeral
and

head the

(Oh) is chosen is sufficiently

the curvature construction. to be fossa.

purpose,

center

can

be found

by a simple

geometric
(Os)

the humerus and scapula when the arm is abducted in the scapular plane: namely, the centers of rotation of the humeral ball in relation to the scapula, and the excursion of the ball on the face of the scapula. Using the various measurernents we were able to compare the motion of the normal and the abnormal shoulder. Materials
Subjects Studied

The reference point for the scapula the center of a line joining the limits On each the axes scapula, Because with angle, the

was chosen of the glenoid

roentgenogram the three sets of axes were drawn; of the torso were designated X,Y, the axes of the x,y, and the axes of the humerus, x,y (Fig. 2). Figure 2 was drawn from a roentgenograrn made subject facing the x-ray source at a 30-degree

and

Methods

The
of whom

main
twelve

motion
were

we studied We years
asymptomatic,

was

abduction
normal

ofthe
volunteers

arm

in other words in the plane of the scapula, the XY axes are in this plane and not in the coronal plane of the body. The arm angle, glenohurneral angle, and scapulothoracic Several angle are defined in Figure 2. roentgenograms were made for each intervals
THE

in the plane twenty-two

of the scapula. to sixty-three

had twenty-seven old, and fifteen

subjects, were pa-

subject, up

at 30-degree

from

the dependent
OF BONE

arm
AND

position

JOURNAL

JOINT

SURGERY

NORMAL

AND

ABNORMAL

MOTION

OF

THE

SHOULDER

I 97 subject, the center

of rotation

to maximum

abduction

in the

plane

of the

scapula.

Beset satisA
at 60

roentgenograrns humerus scapula nique. appears on the

of the same

cause of the inevitable minor of roentgenograms, a method factory

master

variations in a sequential was needed to obtain sets of roentgenograms.

and humerus scapula

for that arc of motion

thorax

is the pivot point about which the to rotate. The center of rotation of the was determined by a similar tech-

superposition
tracing was made

of

the
of the

degrees marked.

of Each

abduction of the other

(mid-range) roentgenograms

and

the (made

axes

were Results A typical subject set of sequential roentgenograms (Fig. 4) illustrates the information from oba

at 0, 30,
normal

90, 1 20, and I 50 degrees and at maximum abduction) was superimposed over the master tracing as closely as possible and the individual axes then were drawn. In this way, sequential patterns of movement were obtained.
Definitions of Parameters

tamed. subject normal was grees. -4.7

In the relaxed position of the extremity with the standing, the average arm angle (OA) for the fifteen subjects was 2.5 degrees, with a range of from -3 The degrees, average scapulothoracic with a range of from angle (OsT) I I to + 10 de-

to +9 degrees.
2, various parameters
ofthe scapula

Still
terest

referring

to Figure

of in-

the angle,

can now be defined. thorax can be defined that is, O and on the rotation the center interval
in and

The tnosement by following

ofthe scapula

on
one In-

Freedman
degrees,

one

point

and (OST).

-5.3

and although somewhat

Munro obtained a mean value of Basmajian and Bazant stated that it upward. in normal subjects the rela-

the scapulothoracic of rotation The

angle

invariably

faced

formation determining 30-degree ment

changes (OA)

can be obtained by of the scapula for each directions of measureAlso, angle

on the

In moving

the extremity,

considered. relative #{176}ST can

tionships among 0A #{176}GH and #{176}ST were different (Fig. 5) in the arc of motion between 0 and 30 degrees of abduction, as compared with the arc of motion between 30 and 120 degrees. In all of our twenty-seven subjects as well as in those of Inman and associates, Freedman and Munro, and Saha

must

be defined

to the several axes. be related to the arm

face

and the ratio OGH:OST can be determined. The excursion or sliding of the hurneral head of the glenoid (the rise and fall of the geometric
Oh)

center the
the

arm angle

results are measured

in reasonable from our

agreement. roentgenograms

The

average with the

of the ball, distance on center

scribed

the

can be expressed as the parameter e, y-axis that #{176}h lies above or below (Os). on the glenoid
of rotation. The

arm in approximately 30 degrees of abduction was in fact 24 degrees. For the arm angle range of 2.5 to 24 degrees, the ratio of the glenohumeral angle to the scapulothoracic angle was 4.3: 1 . In other words, the scapula moved only slightly compared with the humerus. The mean regression lines were drawn for the range 24 degrees duction. For the twelve normal subjects, three patients the equations + 12.6 and that range glenohumeral who were found of the regression
#{176}ST #{176}-40A

of the The

glenoid
of the

motion
in terms

of the humerus
center

can
method

be defor

determining interval

it is shown of the arm

in Figure 3. For each angle between two

30-degree sequential

to maximum abas well as for in all respects,

#{176}(;H

to be normal lines were: 12.4. These arm motion

indicate

that

in

A1

(24 degrees to maximum to scapulothoracic

angle) was

the ratio of actually 5:4

or 1 .25: 1 , meaning that there was not a great deal of difference in the amounts by which they rotated. Freedman
and Munros grees, which ever, found ratio was is not very an average 1.35:1 for the range different from ours. ratio of 2.34: 0 to 135 deSaha howrange 30 to

A2

1 for the

135 degrees for abduction in the plane of the scapula. Our data are in contrast to the findings of Inman and associates for abduction in the coronal plane; they stated that at the glenohumeral and scapulothoracic articulations, the ratio, from almost the beginning to the termination of the arc, is respectively two to one Typically, as abduction progressed the glenoid face moved
FIG.

medially, somewhat

then

tilted arm

upward, was

and brought

finally

moved

3
individual with different angles of

upward

as the

to maximum

Two
abduction moved. humerus

roentgenograms

of

the same

(OA)
those

can be used to determine the center of rotation for the angle This is done as follows: Draw the set of axes based on the for the tWo roentgenograms; select a single arbitrary interval which is measured on the four lines of the two axes (A,01, B1,01, BI)4; bisect the lines A,.A and B,B: erect perpendiculars to lines: and C (center of rotation) is the intersection of those perpen-

elevation (Fig. 6). These motions can be expressed in terms of the center of rotation of the scapula with respect to the fixed axes in the body. From 0 to 30 degrees, the scapula rotated about its lower mid-portion, and then from 60 degrees the glenoid, onward so that the center of rotation about shifted that area, towards resultit was rotating

diculars.
VOL.

58-A.

NO.

2.

MARCH

976

198

N.

K.

POPPEN

AND

P.

S.

WALKER

Sequential

roentgenograms

made

in

abduction

in

the

plane

of

the

scapula.

ing in a large scapula. By plotting

lateral the

displacement positions

of the inferior of the tips of the

tip of the acromion

to rotate slightly downwards, 6 and 7). This is consistent

tion (twisting) of the scapula

as would be predicted with a counter-clockwise

on abduction of the

(Figs. rotaarm that normal

0xs
=

and the coracoid it was clear that the scapula twisted about its x-axis. Figure 7 shows how this was detected on a plain roentgenogram. Assume that there is rotation about O in a
counter-clockwise direction. The coracoid tip will move

occurs
subjects,
#{176}590ST

in the
the

plane
regression

of the
line

scapula.
for the

For

the

fifteen
was:

twisting

This

means

that

with a correlation the twisting angle

coefficient was 0.59

of 0.83. times the

predominantly
backwards face of the

upward,
in the glenoid. same

while
transverse Hence,

the
by

acromion
plane measuring

tip will
in relation the

move
to the upward

movement glenoid,
tion could,

the

of the angle

coracoid with respect to the of rotation can be calculated.

be about the same axis

face of the The rotaparallel to x.

of course,

For all subjects, patients as well as normal acrornion remained stationary with respect the glenoid except at high abduction angles
GLtNO-HUStFRA A\C11 OGH SCAPUO-THORACI( A.GF Si
120
-.-

individuals, the to the face of when it tended

Tfus stud Inman Sarclers

H.

Abbott

1H44 / IH7O

SaGa 11 U
Doodv

freedar) \lunro

Valerland

00

.Freedman

1%6
V

60

30 x
800

0
ARM ANGLE 9

FIG.

6 plane is defined by the position of relative to fixed XY axes in the

begins low the glenoid. in the body of the (Asterisk denotes

Fi;.

The motion of the scapula the glenoid and the centers angle
(();j)

in its own of rotation

The
angle

relationships
(OA) and

between
between the

the glenohumeral
scapulothoracic

angle. patient

Each letter 0 denotes for the corresponding

the O
#{176}A#{149}

value

for

angle (O) a representative

the arm and the arm

individual

and

body. scapula

The center of rotation of the scapula and progresses upwards toward

center of rotation for the specific intervals, The outlines of the scapula corresponding
duction positions are shown.

0 to 30 degrees and so on.) to the 0 and I 50-degree ab-

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

NORMAL

AND

ABNORMAL

MOTION

OF

THE

SHOULDER

199

ferior
Acromion 30600 150..120 .90 60. up

angle

tation sidered often

moving into the body wall, that is, external roof the scapula. This is of significance when conwith the external rotation of the humerus which

occurs

after

90 degrees

of abduction.

It now

is evi-

150

dent that the humerus and the scapula move synchronously to some extent, so that the relative amount of rotation may be small,
instant

0Coracoid x

depending
centers

on how
of rotation

much
and

the
ball

humerus
excursion:

rotates. In all variation, and to the of the conK,

of the

of the normal subjects, although there was some the instant centers lay quite close to each other center patients of the hurneral ball. In contrast displayed centers of rotation

to this, many which deviated (Table

was

siderably from the center of the ball 0, V, W, X, Y, and Z).

In order to assign a value which

I, Subjects
descriptive

instant located measured.

or down
FIG.

center patterns, and the distance The distances to correspond for the normal value

the center of the humeral from it to each instant were then

The

head center scaled

was was up

averaged
average

and
instant

to an average subjects for instant was center 6.0

humeral-head

diamecenter

ter of forty-four
value cated An abnormal

millimeters.

1 .8 millimeters. one that was lo-

Rotation or twisting of the scapula about the x-axis is shown by the upward movement of the coracoid and little shift in the acromion relative to the face of the glenoid (left). If the scapula is viewed in the lateral projection (right), the coracoid would be seen to move upward with the acromion remaining on the same horizontal plane relative to the glenoid.

was

ten millimeters or more from the center of the ball. The ball excursions showed an interesting feature. From 0 to 30 degrees, and often from 30 to 60 degrees, the humeral ball moved upwards three millimeters. Thereafter only one downward normal millimeter between individuals on the glenoid face it remained constant, by about moving upward For position or the to

scapulothoracic angle. The mean maximum abduction was 40 degrees deviation). This the scapula twisting moving can be described from the

amount of twisting at ( 9 degrees standard as the superior body wall and angle the of inTABLE

or at most two millimeters each successive position. the average movement from

away

I
AND

VARIOUS

PARAMETERS

AND

CLINICAL

DETAILS

OF

THE

PATIENTS

Two

NORMAL

VOLUNTEERS

(SUBJECTS

AND

N)

Subject

Maximum Arm Angle

(Degrees)

30#{176} to Max. Glenohumeral to Scapulothoracic Ratio

Instant Center
(nun)

Excursion

of Clinical Findings

Ball

on Glenoid
(in,i)

Average

of

Normals

ISO

.25

0.25

6.0

1.85

1.09

0.475

Normal Normal
Rotator-cuff

volunteers

N CL
E H J M 0

I 56 150
112 150 137 147 155 156

1.00 1.87 1.00

0.99 1.14 1.36 1.15 1.38 A

8.7 A* 4.4
7.1 4.8 6.5 6.6 10.7 A

1.2 1.2
4.OA 1.0 0.8 1 .0 2.OA 1.45

Old GH dislocation volunteer

tear

(normal

volunteer)

Shoulder Rotator-cuff Painful Shoulder Rotator-cuff

pain;
tear

normal

arthrogram

shoulder; pain;

previous normal

injury

arthrogram

1 1.2 A 4.2 8.2

4.0 4.9 12.1 10.8 14.2 A 13.25 A A A A

tear

Q
R T
U

137 152
128 99 123

0.99 A 2.24 A
0.68 0.72 0.83 0.93 1.41 0.236 A A A A

0.8 1.1
0.6 1.0

Rotator-cuff tear Shoulder pain; normal

arthritis in cervical

arthrogram:
spine

Rotator-cuff

tear normal arthritis arthrogram: GH joint

Shoulder pain; degenerative GH dislocation

tear

V W

2.7 A
2.2 4.OA A

164
129 99

Rotator-cuff

x
Y

Rotator-cuff GH
dislocations

tear

2.2 A 2.2 A

z_
*

148
Designates 58-A, NO.
a value outside of one standard

0.826 A
deviation of the normal.

12.7 A

Painful

shoulder;

previous

injury_______

VOL.

2.

MARCH

1976

200 position
pected stant

N.

K.

POPPEN

AND

P.

S.

WALKER

was only 1 .09 that there would

0.47 millimeters. It was exbe a correlation between the in-

instant

center a significant

value

(more

than

ten

centimeters)

and resulting

in adin

dition
ters),

an abnormal mechanics

ball
previous

excursion
injury

(more
has

than

I .5 millime-

when
subjects

center and the ball excursion, the abnormal values were Only seven
showed

and this was borne compared (Table I). our series

instant

out

occurred

abnormal
ex-

of the

shoulder

joint. ratio ratio of the

shoulders
distinctly

from
greater

of twenty-seven
centers and

was

An abnormal glenohumeral-to-scapulothoracic associated with significant disease, but a normal kind did joint. not rule out significant disease

cursions than the remainder. Analysis of the seven abnormal and one borderline abnormal shoulder was revealing (Table I). All had either a previous glenohumeral dislocation (Subjects V and Y), a rotator-cuff shoulder (Subjects tear (Subjects CL, with patients did not center, a W, and previous with have X), or significant history of injury pain associated M and Z).

of this shoulder

Discussion The measurements which have been described depended primarily on the selection of reference axes drawn in the thorax, scapula, and humerus. With careful roentgenographic and graphic techniques these axes could be drawn accurately and reproducibly. The glenohumeralto-scapulothoracic ratio in abduction motion was found to It is that
the

Three (Subjects H, Q, and T) of the seven rotator-cuff tears documented by arthrogram abnormal values for ball excursion and instant
Q) was

and one of these (Subject nificant tear of the rotator All of the three dislocation (Subjects for the instant center ball excursion. asymptomatic eral dislocation.
In the analysis

cuff with

also noted to have a sigat the time of surgery. a previous glenohumeral

patients

be 5:4 after 30 degrees of abduction was reached. emphasized that for a given arc of motion, this means the humerus moves 5 degrees on the scapula moves 4 degrees on the thorax. of Figure in about
is that glenoid, while

K, V. and Y) had abnormal values and only one had a normal value for

In contrast,

a study

This sixty-one-year-old patient had been for thirty-six years following a glenohumthe ratios of glenohumeral to in the ten individuals with abnormal patients. Two had had previous
of

5 reveals that the absolute angles O; to #{176}STare a two-to-one ratio. The reason for this difference from 0 to 30 degrees most of the movement is

glenohumeral,

elevating line explain

that

line,

while

there from

is lowering 30 degrees mentioned at

between

scapulothoracic ratios, none glenohumeral rotator-cuff

roentgenographic arthritis of the

angle were tears

of the scapulothoracic upwards. This may the outset. There

for the motion the discrepancy

degree of

dislocations (Subjects
changes glenohumeral

(Subjects
Q,

V and and W),

with (Subject

Y), and

three one

had had

T,
joint

is a surprising

conformity

compatible

degenerative

U), one had cervical osteoarthritis (Subject R), and two had significant shoulder pain associated with a history of injury to the shoulderjoint (Subjects Z and E). One individual with an abnormal value was an asymptomatic volunteer (Subject N). All but one of these ten subjects had significant shoulder pain or neck and shoulder pain. The five subjects with abnormal glenoh umeral-toscapulothorac ic ratios , but normal values for instant center and ball excursion, included glenohumeral tears,
N).

the humeral head plane. Therefore,

acting, be stable, the and the

and the glenoid as long as there

articulation humeral head

in the frontal is a compressive

would will rotate on

scapular force
to or a more

glenohumeral

be expected

less fixed center with little, if any, excursion. For the normal shoulder this was found to be the case. The upward excursion occurring in the early range of motion would
probably be due would to an initial if the sag of the ball in the depen-

dent lost

position. or if the

Excessive
occur

excursion.
conformity

along force

varying
of the joint

centers
were

of rotation,

one

with joint

degenerative (Subject U),

osteoarthritis two with

of rotator-cuff

the

component

of shear

acting

upward could tears

or arise or if

and A

one

with

no known

shoulder

symptoms

(Subject

downward were excessive. The latter due to an imbalance of forces caused

pain sitive nostic motion disturbed the muscle coordination.

situation by muscle seem

they can

normal value for the glenohumeral-to-scapulothoracic ratio was not significant because four subjects with rotator-cuff tears (Subjects CL, 0, W, and X), one subject with previous glenohumeral dislocation (Subject K), and one with normal motion values and a painful shoulder (Subject M) had normal glenohumeral-toscapulothoracic
It may

The
use.

fact

that

these
of motion

various
means

parameters
that

to be senbe of diag-

indicators

For instance, as an adjunct study may indicate whether rotator-cuff tear producing abnormality
NoTF:

to arthrography, or not there of motion.

is

a a

ratios.
be concluded that if a patient has an abnormal

Wt.
and
0

thus ork.
Dr.
%

ire gratelul Dr. Rohc for and

Bernard

Ghcfman Organl/att()n

oh the

fir a grant mm Sir. and Mrs. Skcn C. Clarke. Jr .. in support of L. Paucrson. Jr. . for hi guidance. S5.. faflk Sir. Ray Scafea and carrysng out the radiography . Mrs. Margaret Erkrnan greatfy a%sisted analysis of the materiaf

References
I 2.
.

BASMAJIAN,

cal

Study.

CATHCART,
CLELAND,

3.

and BAZANT, F. J.: Factors Preventing J. Bone and Joint Surg.. 41-A: I 82-I 86. C. W.: Movements of the Shoulder Girdle JOHN: Shoulder-Girdle and Its Movements.

J. V.,

Downward

Dislocation in Those of the

ofthe Arm

ShoulderJoint. and Trunk. J.

An Anat.

Electromyographic and Physiol.. 18:

and

Morphologi1884.

Oct.

1959.
21 1-218,

Involved Lancet,

I: 283-284,
Med.

1881.
and Rehab.
,

4. CODMAN, 5. DEMPSTER,

E. A.:
W.

T.:

The Shoulder. Mechanisms

Boston, Thomas Todd of Shoulder Movement.

Co. . 1934. Arch. Phys.

46:

49-70, THE

1965. JOURNAL OF BONE AND JOINT SURGERY

NORMAL

AND

ABNORMAL

MOTION

OF

THE

SHOULDER

201

6.

7.
8. 9. 10. 1 1.

12.
13.

DOODY, S. 0.; FREEDMAN, LEONARD; and WATERLAND, J. C.: Shoulder Movements During Abduction in the Scapular Plane. Arch. Phys. Med. and Rehab. , 51: 595-604, 1970. FISK, G. H.: Some Observations of Motion at the Shoulder Joint. Canadian Med. Assn. J. , 50: 213-216, 1944. FREEDMAN, LEONARD, and MUNRO, R. R.: Abduction ofthe Arm in the Scapular Plane: Scapular Glenohumeral Movements. J. Bone and Joint Surg., 48-A: 1503-1510, Dec. 1966. GRAVES, W. W.: The Types of Scapulae. A Comparative Study of Some Correlated Characteristics in Human Scapulae. Am. J. Phys. Anthropol., 4: 111-128, 1921. INMAN, V. T.; SAUNDERS, J. B. DEC. M.; and ABBOTT, L. C.: Observations on the Function ofthe ShoulderJoint. J. Bone and Joint Surg.. 26: 1-30, Jan. 1944. JOHNSTON, T. B.: The Movements of the Shoulder Joint. A Plea for the Use of the Plane of the Scapula as the Plane of Reference for Movements Occurring at the Humero-scapular Joint. British J. Surg. , 25: 252-260, 1937. SAHA, A. K.: Mechanism of Shoulder Movements and a Plea for the Recognition of Zero Position of Glenohumeral Joint. Indian J. Surg. , 12: 153-165, 1950. SAHA, A. K.: Theory of the Shoulder Mechanism: Descriptive and Applied. Springfield, Illinois, Charles C Thomas, 1961.

Electromyography
A
BY JOHN PLUT, JACQUELIN M.D.*,

before in Children
COMPARISON PERRY, GORDON OF M.D.*, LEWIS,

and after with

AND MARK AND M. M.D.*,

Surgery

for Hip Palsy

FINDINGS

Deformity

Cerebral
ELECTROMYOGRAPHIC M.D.*, GREENBERG,

CLINICAL

HOFFER, RON

DANIEL R.P.T.*,

ANTONELLI, DOWNEY,

M.5.*, CALIFORNIA

ABSTRACT: Twenty-three ambulatory children with spastic diplegic cerebral palsy were evaluated clinically and by electromyography before and after hip-muscle

as the

findings

by

clinical

stretch

tests, of

gait

examination,

and

gait
In

films
each

were
patient,

recorded wire

(Table were gluteus gracilis, activity

I and inserted medius,

Chart in

VI). the rectus ham-

electrodes

fifty-micrometer

surgery.

The

stretch

tests originally

designed

to distin-

nylon-shielded femoris, strings, iliacus gluteus

copper maximus,

guish specific muscle tightness and found to be non-specific when tested graphy. Ambulatory electromyograms electrodes
activity in and the

spasticity were by electromyousing needle decreased

occasion, on

lateral

medial hamstrings, assuming iliacus

adductor longus, and to be similar to that of

telemetry
released changes after

generally
muscles release

showed
and, may

changes
unanticipated

in activity

in muscles of results

not operated of such

on.
explain

These
some

of the unpredictability cerebral palsy. Currently children are evaluated by of stretch tests

procedures

in

the psoas and hence representative of the activity of the iliopsoas. Our testing system permitted only eight muscle tests per run. We therefore selected the eight muscles that we considered to be the most significant hip or knee musdes affecting gait. Prior to the selection, we tested four children with cerebral palsy and found that the activity of the tensor fasciae femoris roughly paralleled that of the

gait series ment sults.

tests sion

with cerebral palsy observation of their

15,8

and a spastic gait and by a surgical treat-

gluteus
ing

medius during gait and stretch tests. Furthermore, that the activity of the

that

of the hip flexors this preselection muscles

durstudy

Unfortunately,

showed

vastus

roughly

based on these criteria may produce unpredictable reWe hoped that electromyography during the stretch and and during gait might clear up some of the confuand aid in planning operative procedures that would

give

predictable

results. and Methods

Initial

work

in this

area

was

done

by Sutherland

associates. and 1971 Clinical to August Material 1974, with old, twenty-three spastic diplegic were evaluated posture rotated (walking thighs). as well
Hospital,

paralleled that of the rectus femoris during gait. Precise definition of the contribution of these and other muscles should, of course, await testing systems with twelve or more testing channels. The following stretch tests were carried out while recordings were made: straight-leg-raising, hip flexion with knees flexed, adductor stretch with hips and knees flexed, Thomas test , external rotation of the extended hip, external test sion
18

From

January

rotation

of the

flexed

hip,

Phelps-Baker

gracilis

ambulatory children cerebral palsy, five and treated with flexed Their
*

(Cases 1 to 23) to eighteen years

(extension and abduction),

of the knee with the hip flexed in extenand prone flexion of the knee with the

for their hips and class

crouched walking knees and internally of gait

Downey,
1976 6

functional
The Professional Golondrinas
58-A, NO.

and

use of apparatus
Rancho 90242. Los Amigos

Staff

Association, California

7413 VOL.

Street,
2, MARCH

hip extended (prone rectus test of Duncan or Ely) . These tests were carried out in a standardized fashion for both the clinical and the electromyographic evaluations. Each patient was first positioned in the testing posture and then slow stretch was applied for four seconds as indicated by a