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Anteroposterior Centering of the Humeral Head on the Glenoid In Vivo

Shadley C. Schiffern, Richard Rozencwaig, John Antoniou, Michael L. Richardson and Frederick A. Matsen III
Am J Sports Med 2002 30: 382
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0363-5465/102/3030-0382$02.00/0
THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 30, No. 3
2002 American Orthopaedic Society for Sports Medicine

Anteroposterior Centering of the Humeral

Head on the Glenoid In Vivo
Shadley C. Schiffern,* Richard Rozencwaig,* MD, John Antoniou,* MD, FRCSC,
Michael L. Richardson, MD, and Frederick A. Matsen III,* MD
From the *Department of Orthopaedics and Sports Medicine and the Department of
Radiology, University of Washington, Seattle, Washington
Much of the practice of shoulder surgery concerns glenohumeral instability; many procedures are performed in
the hope of maintaining the normal relationships of the
humeral head to the glenoid at rest and during a wide
variety of shoulder functions. The stabilizing role of the
glenohumeral capsule and ligaments has been explored
extensively, especially at the extremes of motion, in which
positions patients with glenohumeral instability are characteristically symptomatic.17 There is less understanding
of the mechanisms for stabilization of the humeral head in
positions in which the glenohumeral ligaments are lax
and, therefore, unable to contribute to joint stability.
The upper extremity is able to function with both precision and force in midrange positions in which the glenohumeral capsule and ligaments are unloaded.16, 17 In
these positions the hand and upper extremity can be accurately positioned while holding something as light as a
paintbrush or something as heavy as a dumbbell. Remarkably, few studies have been published in the clinical literature regarding the degree to which the humeral head of
the living shoulder remains centered in the glenoid while
the shoulder is in midrange positions.
With the use of single-plane axillary radiographs,
Howell et al.11 investigated the anteroposterior relationships of the humeral head and the glenoid with the arm
actively positioned in various positions near the extremes
of external rotation. With the use of single-plane AP radiographs in the plane of the scapula, Poppen and Walker20 investigated the superior-inferior relationships of the
humeral head and glenoid in different positions of active
abduction. More recently, Beaulieu et al.2 used MRI to
demonstrate that, during active abduction and adduction
and internal and external rotation maneuvers, the humeral head remained centered on the glenoid fossa. Rhoad
et al.21 used MRI to examine normal relationships about
the glenohumeral joint in internal and external rotation.
They found that during active motion the humeral head
translation averaged 2.1 mm in the anterior-posterior
plane and that during passive positioning average translations increased to 8.2 mm in the anterior-posterior

ABSTRACT
Background: The capsule and ligaments are generally viewed as the primary stabilizers of the glenohumeral joint, but many important activities are performed
in midrange positions in which these structures are lax.
Hypothesis: In vivo, the humeral head can be centered in the glenoid, even when the shoulder is in
positions in which the capsule is lax and even when the
shoulder is passively positioned.
Study Design: Controlled laboratory study.
Methods: We documented the centering of the humeral
head in the relaxed shoulders of six subjects using openmagnet magnetic resonance imaging scans.
Results: While these shoulders were passively placed in
midrange positions (those not at the extremes of motion),
the humeral head center was never more than 2.2 mm
from the glenoid center (mean 0.1 1.2 mm).
Conclusions: The results suggest that mechanisms
other than ligamentous restraint, such as the compressive effect of resting muscle tone into the conforming
concavity of the glenoid, may be sufficient to maintain
centering of the glenohumeral joint. Further exploration of
these mechanisms may lead to methods other than ligament tightening or capsular shrinkage for restoration of
stability to joints that are unstable in the midrange of
motion.
Clinical Relevance: In that many patients with unstable
shoulders demonstrate instability in midrange positions, it
is hoped that further study of living shoulders will lead to
a more effective understanding of the nonligament mechanisms of shoulder stability and the ways in which these
stabilizing mechanisms can be restored.

Address correspondence and reprint requests to Frederick A. Matsen III,

MD, Department of Orthopaedics and Sports Medicine, University of Washington, Box 356500, 1959 NE Pacific, Seattle, WA 98195-6500.
No author or related institution has received any financial benefit from
research in this study. See Acknowledgments for funding information.

382
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Vol. 30, No. 3, 2002

AP Centering of the Humeral Head on the Glenoid

plane. Graichen et al.7 used three-dimensional MRI to

demonstrate the centering of the humeral head during
abduction and rotation. They found that during passive
elevation the humeral head translated slightly anteriorly
at low angles of elevation and slightly posteriorly at
higher angles of elevation. With muscle activity, the respective translations were less, particularly at low angles
of elevation. All of these studies support the view that the
humeral head is centered on the glenoid during voluntary
positioning of the joint. They do not, however, indicate the
degree to which the humeral head is centered in the absence of voluntary positioning.
The authors tested the hypothesis that, in vivo, the
humeral head can be centered in the glenoid, even when
the shoulder is in positions in which the capsule is lax and
even when the shoulder is passively positioned by the
examiner, rather than being voluntarily positioned by the
subject.

MATERIALS AND METHODS

We recruited six men, aged 25 to 54, for this study. Each
subject had at least one shoulder that was uninjured and
asymptomatic; three of the subjects had experienced unilateral shoulder injuries. We tested all nine asymptomatic
shoulders. A statistical consultant advised us that six
shoulders would be sufficient for testing our hypothesis.
We selected MRI as the imaging modality for this study
because it did not expose the volunteer subjects to ionizing
radiation and it provided three-dimensional imaging of
the soft tissues of the glenohumeral joint socket. The
Toshiba Opart Open-Design MRI with a standard Toshiba
Shoulder Coil (Toshiba America Medical Systems, Inc.,
Tustin, California) was used with a two-dimensional field
echo dynamic with six repetitions of five slices each; 77
seconds were required per repetition, with a manual start.
Images were obtained with the following MRI protocol:
echo time, 7.2 ms; repetition time, 106 ms; flip angle, 70;
slice thickness, 4 mm; slice gap, 0.8 mm; field of view, 20
cm; matrix, 224 256; number of acquisitions, three; and
acquisition mode, normal. In-plane resolution was 0.9
0.8 mm. The total imaging time per position was 7 minutes, 12 seconds. All images were performed in the axial
plane.
The subject was positioned with the scapular plane parallel to the MRI table. The humerus was supported by the
table in a position of 35 of abduction in the scapular
plane, a position which the investigators previous cadaver
studies have shown to be that of maximal capsular laxity.16, 17 While the subject allowed his arm to relax, one of
the investigators placed it sequentially in six different
positions of rotation, starting with 15 of internal rotation
and progressing in 15 increments of external rotation to a
maximum of 60 of external rotation (Fig. 1). These positions were selected because they center on the position in
which the glenohumeral capsule is the most lax and are
the positions in which many activities of daily living (such
as eating, combing hair, and washing the face) are performed.16 Magnetic resonance imaging scans were ob-

383

Figure 1. Position of the subjects for MRI scans of the glenohumeral joint; the scapular plane is parallel to the MRI
table. The arm was abducted 35 in the scapular plane and
placed in one of six positions of rotation. (Reproduced with
permission from Matsen FA III, Lippitt SB, Sidles JA, et al:
Practical Evaluation and Management of the Shoulder. Philadelphia, WB Saunders Co, 1994.)
tained while the investigator stabilized the arm in each of
the six desired positions.
We followed the precedent of Howell et al.,11 Poppen
and Walker,20 and Beaulieu et al.2 and selected an MRI
section passing through the superior-inferior midpoint of
the glenoid for analysis. Three separate MRI prints were
made for each shoulder to allow measurements to be made
by three independent observers (SCS, RR, and JA) who
were blinded to the results obtained by the others. Each
observer identified the humeral head center by marking
the circumference of the humeral head on the MRI prints
and aligning a translucent template marked with concentric circles to these marks. The center point was then
marked through a hole in the center of the template. As a
check, the distances from the center point to four points on
the humeral head circumference were measured to verify
that the chosen point was the true center.
Two methods for identifying the center of the glenoid
fossa have been described in the literature. One is that of
Beaulieu et al.,2 who wrote, The margins of the glenoid
were used to construct a line along and parallel to the
glenoid fossa; the geometric center of this line determined
the center of the glenoid. To do this, care was taken to not
include the glenoid labrum or portions of the joint capsule
in the line. This is the MRI analog of the radiographic
method used by Howell et al.11 The other method is described briefly by Graichen et al.,7 After 3D reconstruction, the articular surface of the glenoid was separated
interactively from the body of the scapula, and its center of
mass calculated. This method seemed less intuitive to us
and did not seem inherently more robust than the method
of Beaulieu et al., which we decided to use. The observer
identified the anterior and posterior margins of the glenoid cavity and drew a line connecting these points. A
perpendicular line bisecting this line, the glenoid center
line, was drawn and extended over the humeral head (Fig.

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Schiffern et al.

American Journal of Sports Medicine

Figure 3. Graph of the humeral head translation from the

glenoid center at each of the six positions of rotation for the
nine normal shoulders examined. Anterior () and posterior
(-) translation are plotted on the y-axis, and the rotational
position is plotted on the x-axis.
Figure 2. Magnetic resonance imaging scan showing markings for the humeral head center and perpendicular bisector
of the glenoid used to measure anterior or posterior translation of the humeral head from the glenoid center. In this
position, the humeral head is centered.

et al.2 It is less than the 0.01-mm accuracy reported in the

MRI study of Graichen et al.7

RESULTS
The centering of the humeral head for the different positions of the shoulder is shown in Table 1 and in Figure 3.
In each of the nine shoulders examined, the humeral head
remained centered within the glenoid, especially in the
midrange positions of passive rotation in which the glenohumeral ligaments and capsule are known to be lax (from
0 to 45 of external rotation, 35 of glenohumeral abduction). Within this midrange of rotation, none of the humeral heads tested translated more than 2.2 mm either
anteriorly or posteriorly in relation to the glenoid center.
Mean translation for all shoulders in the midrange positions was 0.1 1.2 mm, with a range from 2.2 to 1.9
(a positive number indicates translation in an anterior
direction).
Analysis of variance was performed to compare translations in midrange positions to those observed in 60 of
external rotation and in 15 of internal rotation. The re-

2). Although we could have determined the glenoid center

line from cartilaginous or soft tissue landmarks, the bony
landmarks proved unambiguous and consistent between
positions.
The displacement of the humeral head from the glenoid
center line was measured as described by Howell et al.11
and by Beaulieu et al.2 The perpendicular distance from
the center of the mark, indicating the center of the humeral head to the center of the glenoid center line, was
measured with a caliper in 0.1-mm increments as either a
positive (anterior translation) or negative (posterior translation) number, making appropriate corrections for the
magnification of the print. The average of the measurements of the three observers was recorded. The data
are reported to within 0.1 mm, which is the same accuracy
reported in the radiographic studies of Howell et al.11 and
Poppen and Walker20 as well as the MRI study of Beaulieu

TABLE 1
Glenohumeral Translation Measured in Nine Normal Shoulders at Six Positions of Rotation
Translation (mm)a
Shoulder

Position (degrees of external rotation)

15

1
2
3
4
5
6
7
8
9
a

0
2.2
4.4
1.9
1
0
0
0
1

0
1.1
0
0
0
0
0
1
0

15

30

45

60

1.1
1.9
0
1.9
1.9
1.9
0
0
1

0
0
1.1
1.9
1
1.9
0
0
0

2.2
1.1
0
1.9
1.9
1.9
0
1.6
1.6

2.2
0
2.2
3.8
5.7
1.9
2
5
5

Positive measurements denote anterior translation and negative measurements denote posterior translation.

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AP Centering of the Humeral Head on the Glenoid

385

sults are shown in Table 2. These data demonstrate the

tendency of the humeral head to translate away from the
side of the joint on which the capsule is tightened by
rotation (for example, external rotation tightens the anterior capsule, creating a tendency for posterior translation).

DISCUSSION
Previous studies of in vivo shoulder motion indicate that
many important activities of daily living are performed
with the glenohumeral joint in midrange positions in
which the capsuloligamentous structures are lax.16 In
these positions, centering of the humeral head must depend on mechanisms other than ligament stabilization.
Previous investigators have observed the precision of
centering of the humeral head in the glenoid when the
arm is voluntarily positioned. Howell et al.10, 11 used single-plane axillary radiographs to determine the anteriorposterior glenohumeral relationships during active positioning in extreme positions, such as maximum extension
and maximum external rotation, maximum extension and
neutral rotation, maximum external rotation and neutral
extension, and flexion and maximum internal rotation.
Under these circumstances, they found that the humeral
head was centered in the glenoid cavity except when the
arm was in maximum extension and external rotation. In
the latter position, they observed an average posterior
translation of 3.9 mm. Using AP radiographs in the plane
of the scapula, Poppen and Walker20 observed only minimal superior-inferior translation of the humeral head on
the glenoid during voluntary abduction. Paletta et al.19
used two-plane radiographs to demonstrate the restoration of biplanar glenohumeral kinematics and glenohumeral-scapulothoracic motion relationships in patients
with anterior shoulder instability after open anterior
stabilization.
Beaulieu et al.,2 Rhoad et al.,21 and Graichen et al.7
used MRI to demonstrate the centering of the humeral
head during active abduction and rotation. Their studies
did not consider in detail the anterior-posterior centering
of the humeral head in the absence of voluntary positioning. The findings of the present study are important in
that they demonstrate that active muscle effort is not
required to stabilize the shoulder in midrange positions.
We have demonstrated that the humeral head remains
centered in the glenoid in the absence of voluntary muscle
contraction when the shoulder is passively positioned in
midrange positions in which the capsule and ligaments
are lax. This observation leads to the consideration of

Figure 4. The local stability ratio (force necessary to translate the shoulder divided by the load compressing the humeral head into the glenoid) predicted for a humeral head
with a radius of curvature of 25 mm translated different
distances away from the center of a glenoid with the same
radius of curvature. Note that the stability ratio is highest
when the humeral head is centered. (Based on Fig. 14 36 in
Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Volume
2. Second edition. Philadelphia, WB Saunders, 1998, p 628.)
what mechanisms other than ligament stabilization or
dynamic neuromuscular control might maintain the desired position of the humeral head in the glenoid.
An explanation for this accurate centering may well lie
in the observation from our previous work that, in a highly
conforming joint, the stability ratio (the ratio of force
necessary to translate the humeral head to the load compressing the humeral head into the glenoid) is maximal
when the humeral head is centered in the glenoid (Fig.
4).17 In such a system, the stabilizing effect of a given
compressive load is greatest when the head is centered in
the glenoid concavity, and very low compressive loads,
such as those from resting muscle tone, may be sufficient
to center the humeral head.
Thus, a high degree of conformation of the glenoid concavity to the humeral head provides an anatomic situation
that optimizes the centering effect of concavity compression. Although Saha23 found substantial variation in the
conformity of the glenoid to the humerus in cadaveric
specimens, more recent authors have found a much
greater consistency in conformity.8, 18, 24 These investigators have pointed out that although the subchondral bone
of the glenoid is relatively flat, the cartilage surface is
thicker peripherally than in the center, producing a radius
of curvature that closely matches the curvature of the
humeral head.8, 18, 24 The conformity of the glenoid cavity
is further enhanced by the thick labrum, which contrib-

TABLE 2
Analysis of Variance Comparing Translation in Midrange Positions with That in Internal and External Rotation
Translation (mm)a
Position

15 of internal rotation
0 to 45 of external rotation
60 of external rotation
a
b

P valueb

Number

9
36
9

Mean

SD

0.9
0.1
3.1

1.7
1.2
1.9

Anterior translation is indicated by a positive sign.

Difference from midrange.

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0.113
0.0001

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Schiffern et al.

American Journal of Sports Medicine

utes up to 50% to the depth of the glenoid fossa.10, 13 A

defect in the labrum lessens the effective depth of the
fossa and reduces the effectiveness of concavity
compression.14, 15, 18, 22
Apreleva et al.1 found in vitro that glenoid centering
could be maintained by simulated rotator cuff muscle
action in the absence of capsuloligamentous restraints.
In a cadaver study with simulated muscle forces, Karduna et al.12 found large translations at the extremes of
the range of motion when the joint was positioned passively. With active positioning, muscle forces and joint
conformity tended to limit humeral head translations.
Wuelker et al.25 also demonstrated in cadavers that
rotator cuff force significantly contributes to stabilization of the glenohumeral joint during arm motion. Debski et al.5 studied the contribution of the passive properties of the rotator cuff to glenohumeral stability
during anterior-posterior loading and found that passive tension in the rotator cuff plays a significant role in
resisting posterior loads at the glenohumeral joint.
Chen et al.4 sought to document the effect of muscle
fatigue on glenohumeral kinematics in male volunteers
without shoulder disease. They found essentially no
change in position of the humeral head in the prefatigue
state as the arm was abducted from 0 to 135. After
fatigue, excursion of the humeral head increased to an
average of 2.5 mm between the tested positions.
Our observation of the tendency for shoulders to translate posteriorly near the extreme of external rotation is
consistent with observations of other authors.3, 6, 9, 11 This
tendency for the glenohumeral joint to become uncentered
in positions near the end of the range of motion is thought
to be related to an unopposed translatory force applied to
the humeral head, forcing it from the centered position.16, 17 This phenomenon has been referred to by Harryman et al.9 as obligate translation.
We acknowledge certain shortcomings of this study.
Only nine shoulders in six subjects were analyzed; thus,
the results may not be generalizable to the population
as a whole. The resolution of our low-field MRI images
was limited. The identification of the anterior-posterior
margin was based on the analysis of one image for each
position in each shoulder and was limited by our ability
to define the margins of the glenoid. This ability was
constrained by the fact that contrast solution, such as
saline solution or gadolinium, was not injected into the
joint space. The methods used for detecting the humeral
head and the glenoid centers were two-dimensional,
rather than the full three-dimensional anatomy of the
joint. However, none of these limitations negate the
observation that under the conditions of this study, the
humeral head remained in the anteroposterior center of
the glenoid in midrange positions without the stabilizing effects of ligament tension or voluntary muscle
control.
By avoiding the need for active muscle balancing, the
shoulder can achieve midrange stability while economizing on the amount of energy required. This economy
may be related to the efficiency of the concavity compression mechanism of joint stabilization through which

the compressive effect of resting muscle tone may be

sufficient for humeral head centering. It is of note that
most techniques for repairing unstable joints focus on
alterations of glenohumeral ligaments. Further study of
living shoulders may lead to a more effective understanding of the nonligament mechanisms of shoulder
stability and the ways in which these stabilizing mechanisms can be restored to unstable joints. Such procedures may include those that re-establish the glenoid
concavity, such as restoring the fossa-deepening effect
of the glenoid labrum after a Bankart lesion or restoring
a deficient glenoid lip with an anatomically contoured
extracapsular iliac crest bone graft.

ACKNOWLEDGMENTS
We thank Thurman Gillespy III, MD, of the University of
Washington Department of Radiology for his assistance
with this study. This research was supported by the Douglas T. Harryman II/DePuy Endowed Chair for Shoulder
Research at the University of Washington, the Orthopaedic Research and Education Foundation, and the BristolMyers Squibb/Zimmer Institutional Award for Excellence
in Orthopaedic Research.

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