Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Current Concepts: The Stabilizing Structures of the Glenohumeral Joint

Kevin E. Wilk, PT' Christopher A. Arrigo, MS, PT, A T C ~ lames R. Andrews, MD
houlder instability is a vague, nonspecific term which actually represents a wide spectrum of clinical pathologies, ranging from gross instability to subtle subluxation. Patients exhibiting shoulder instability are commonly encountered by therapists, athletic trainers, and physicians in both the general orthopaedic and sports medicine population. Often, an appropriate clinical diagnosis is difficult due to the excessive amount of capsular laxity normally seen and appreciated during clinical examination of the glenohumeral joint. Clinicians may become perplexed when attempting to determine the amount of normal acceptable laxity vs. pathological ligamentous laxity. The purpose of this paper is to discuss current concepts related to the anatomic stabilizing structures of the glenohumeral joint. The glenohumeral joint is inherently unstable and exhibits the greatest amount of motion found in any joint in the human body (116). Additionally, the glenohumeral joint is the most commonly dislocated major joint in the human body (20,47). Thus, the shoulder joint sacrifices stability for mobility. Although the glenohumeral joint exhibits significant physiologic motion, only a few millimeters of humeral head displacement occur during these movements in the normal individual (1,35,36,40, 75,76,103). Conversely, on clinical examination, Matsen et al (55) have
Significant contemporary advances have permitted a more comprehensive understanding and development of some interesting concepts about the glenohumeral joint. The purpose of this review paper was to discuss current concepts related to the anatomic stabilizing structures of the shoulder joint complex and their clinical relevance to shoulder instability. The clinical syndrome of shoulder instability represents a wide spectrum of symptoms and signs which may produce various levels of dysfunction, from subtle subluxations to gross joint instability. The glenohumeral joint attains functional stability through a delicate and intricate interaction between the passive and active stabilizing structures. The passive constraints include the bony geometry, glenoid labrum, and the glenohumeral joint capsuloligamentous structures. Conversely, the active constraints, also referred to as the active mechanisms, include the shoulder complex musculature, the proprioceptive system, and the musculoligamentous relationship. The interaction of the active and passive mechanisms which provide passive and active glenohumeral joint stability will be thoroughly discussed in this paper.

Key Words: glenohumeral joint, anatomy, instability

National Director, Research and Clinical Education, HealthSouth Rehabilitation Corporation, Gimingham, Al; Associate Clinical Director, HealthSouth Sports Medicine and Rehabilitation Center, Birmingham, AL; Director, Rehabilitative Research, American Sports Medicine Institute, 1313 13th Street South, Birmingham, A1 35205 Physical Therapy Coordinator, HealthSouth Spom Medicine and Rehabilitation Center, Birmingham, AL; Coordinator of Rehabilitation, Texas Rangers Baseball Club, Arlington, JX Clinical Professor, Orthopaedics and Sports Medicine, University of Virginia Medical School, Charlottesville, VA; Medical Director, American Sports Medicine Institute, Birmingham, AL; Orthopaedic Surgeon, Alabama Sports Medicine and Orthopaedic Center, Birmingham, AL

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demonstrated excessive passive displacement (10 mm inferiorly and 8 mm anteriorly) in normal asymptomatic shoulders. Therefore, stabilization of the humeral head within the glenoid is accomplished through the combined efforts of the ligamentous structures and the surrounding shoulder musculature. Matsen et al have defined instability as a clinical condition in which unwanted translation of the humeral head on the glenoid compromises the comfort and function of the shoulder (55). Conversely, laxity refers to the ability of the humeral head to be passively translated on the

glenoid fossa (55). The amount of translation that is "normal" for any given individual varies (35,37). Relative laxity may exist without the accompanying symptoms of instability. Harryman et al, in an in v i v o assessment of glenohumeral translation, noted wide variations in anterior, posterior, and inferior translation among normal individuals (35). These findings were reconfirmed recently by Wuelker et al (117), who also reported wide variations in translations in cadaveric shoulders. Despite the individual differences noted in passive translation, the pathomechanical condition that uniVolume 25 Number 6 June 1997 JOSFT

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LITERATURE
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3ony Zlenoid labrum ntraarticular pressure oint cohesion Jlenohumeral capsule Zlenohumeral ligaments

Jointcompression Dynamic ligament tension Neuromuscular control Scapulothoracic joint (base of support)

TABLE. The passive and active mechanisms for glenohumeraljoint stability.

fies patients with shoulder instability is an increase in glenohumeral trans lation, which leads to the develop ment of symptoms. In all instability patients, some component of the stabilizing complex has become dysfunctional. Thus, no single "essential lesion" is responsible for all cases of instability (70). The pathologic condition produced varies with both the direction and degree of instability. Additionally, various structures play differing stabilizing roles as the position of the shoulder changes. Therefore, the pathology for the atraumatic, multidirectional instability patient is different from that exhib ited by the posttraumatic unidirectional instability patient. For purposes of discussion in this paper, we will divide our comments into two broad categories: the passive stabilizers (bony architecture, ligamentous structures) and the active stabilizers (neuromuscular system). The static and dynamic stabilizers of the shoulder can be classified as passive and active mechanisms for stability (Table). We will discuss the various mechanisms which contribute to shoulder stability and the effects of pathologic changes on glenohumeral stability.

THE STATIC STABILIZERS Bony Geometry

The bony geometry of the glenohumeral joint is conducive to excessive joint mobility but sacrifices osseJOSlT Volume 25 Number 6 June 1997

humeral head and glenoid has been referred to as the glenohumeral index (maximum diameter of the glenoid/maximum diameter of the humeral head) (84,85). This ratio is approximately 0.75 in the sagittal plane and approximately 0.6 in the transverse plane (84). Additionally, at any given time during normal motion, only 2530% of the humeral head is actually in contact with the glenoid (13,22,95). This lack of articular contact contributes to the inherFIGURE 1. The glenoid cavity is shaped like an in- ent instability of the glenohumeral verted comma with the inferior half being larger than joint (32). the superior half. The glenoid faces superiorly, anteriorly, and laterally. Saha (84) has investigated the effect of variation in ous stability. The glenoid's articular glenoid version (orientation), size, surface is pear-shaped, with its infeshape, and tilt as well as humeral verrior half being 20% larger than its sion on shoulder stability. Basmajian superior half (70) (Figure 1). Ianand Bazant (10) have noted that the notti et al have demonstrated the superior tilt of the inferior glenoid ratio of the lower half to the top half limits inferior translation of the huwas 1:0.80 2 0.01 (43). The glenoid's merus on the glenoid. The glenoid articular surface is much smaller than fossa does not always lie in a plane that of the humeral head, and the perpendicular to the axis of the scap surface area of the humeral head is ular body. Most commonly, there is approximately three to four times some degree of anterior or posterior that of the glenoid (91) (Figure 2). angulation referred to as the version. The surface area ratio between the The glenoid articular surface is within 10" of being perpendicular to the blade of the scapula; thus, the glenoid fossa is retroverted approximately 6" (84). Brewer et al (17) reported that excessive retroversion of the glenoid is considered a primary etiology predisposing one to posterior glenohumeral instability. In addition, Saha (84) has suggested that increased glenoid anteversion is found in patients who had recurrent dislocations. Therefore, patients exhibiting a relatively shallow glenoid fossa with abnormal size or angulation may be at greater risk for instability. This situation is most applicable in cases of developmental anomaly, such as Erb's palsy and bony dysplasia. A wide range of version angles exists in asymptomatic subjects (42), and measurements of glenoid version are often difficult to FIGURE 2. An anterior view of theglenohumeral joint determine, unreliable, and inconsistent (106). articulation.

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Instability may not be solely attributable to a lack of congruence between the articulating surfaces. Normally, the corresponding articular surfaces of the humeral head and glenoid are very nearly congruous. Soslowsky et al (90.91). using a stereophotopmmetric technique to examine the three-dimensional geometry of the glenohumeral joint, found that the radius of curvature of the humeral head and glenoid are not significantly different. Additionally, they showed that both surfaces a p proximated the surface of a sphere, with only a small deviation from sphericity, less than 1% of the total radius. Iannotti et al (43) reported that the humeral head approximates a sphere in central areas of its articular surface but becomes slightly ellip tical peripherally. Despite these findings, other investigators report that the surfaces are not conforming and the contact between them is variable (14). Pagnani and Warren (70) suggest the perception of i n c o n p i t y that is obtained from radiography of the shoulder is due in part to the presence of cartilage that is not visible on plain radiographs (Figure 3). Matsen et al noted that the articular cartilage of the glenoid fossa is thickest in the periphery and thinnest in the center (56). Thus, the glenoid joint surface may be more concave than the underlying bone would first indicate, and, thus, the gienohumeral joint may be slightly more congruent than it appears on radiographs. The areas of contact between the articular surfaces of the humeral head and the glenoid vary based on arm position. Soslowsky et al have reported, using cadaveric specimens and simulated joint forces, that the greatest amount of articular contact area occurs in midelevation between 60 and 120" (91). With increasing arm elevation, contact points on the humeral head move from inferior to posterosuperior, whereas the glenoid contact shifts from a central location posteriorly.

FIGURE 3. A plain radiograph (antemposterior view) of the glenohumeral joint taken in the plane of the scapula. (From Rockwood CA, Green DP (eds):Fractures in Adults (2nd Ed), Philadelphia: Lippincott-Raven Publishers, 1984, reprinted with permission).

Though the relationship of the humeral head to the glenoid fossa remains relatively constant through much of the arc of motion, the shoulder joint does not act in a strictly ball-and-socket fashion. At the extremes of normal motion, rotation is coupled with humeral head translation upon the glenoid (34,39,40,76). Howell et al (40) radiographically studied the translation of the humeral head on the glenoid during arm rotation. The investigators noted in the normal shoulders that the humeral head translated 4 mm posteriorly when the arm was positioned at 90" of abduction, full external rotation, and maximum horizontal a b duction. Conversely, in subjects with known anterior instability, the humeral head translated anteriorly when placed in the same position. Bowen et al (14) reported a mean anterior translation of 5 mm with internal rotation and a posterior translation of 5 mm with external rotation. Harryrnan et al (34) analyzed the biomechanics of the glenohumeral joint on cadaveric specimens. The authors noted a posterior translation of the humeral head with

external rotation and an anterior translation with internal rotation with the arm at the side. Additionally, the investigators noted a significant increase in anterior translation when they tightened the posterior capsule. Thus, the direction of the translation is determined by the capsuloligamentous complex. During arm movements, the passive restraints act not only to restrict movement but also to reverse the humeral head movement. If the passive restraints are "stretched outwor their attachment to bone compromised, such as in a Bankart lesion, abnormal translation occurs. A description of a Bankart lesion will be discussed later in this manuscript. Furthermore, if one portion of the capsule is tighter than the other portions, this can also cause the humeral head to translate excessively. This is referred to by the authors of this paper as "asymmetrical capsular tightness." Lastly, bony defects on the humeral head and on the glenoid are commonly associated with glenohumeral instability. With recurrent anterior instability, an osseous defect or lesion is commonly noted on the posVolume 25 Number 6 June 1997 JOSFT

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FIGURE 4. Axillary view of the glenohumeral joint showing the posterior humeral head osseous defect (HillSachs lesion), secondary to anterior glenohumeral dislocations. (From Rockwood CA, Green DP (&: Fractures in Adults (2nd Ed), Philadelphia: Lippincon-Raven Publishers, 1984, reprinted with permission).

terolateral portion of the humeral head (HillSachs lesion) (38) (Figure 4). This osseous defect most often represents a groove worn into the humeral head as the humeral head subluxes and reduces over the glenoid rim. In contrast, an anteromedial lesion is often noted with recurrent posterior instability (reverse Hill-

Sachs lesion). Bony defects of the anterior or posterior glenoid rim may also occur with recurrent instability (71,81,82). These lesions represent impaction fractures, occumng as the humeral head moves over the glenoid rim and are the result, not the cause, of the underlying instability. Townley, in cadaveric experiments,

FIGURE 6. The vascularity of the glenoid labrum. (From Cooper DE, Arnoczky SP, O'Brien S), Warren RF, DiCarlo E, Allen AA: Anatomy, histology and vascularity of the glenoid labrum: An anatomical study. ) Bone joint Surg 74A:46-52, 1992, reprinted with permission),

showed that a HillSachs lesion did not result in anterior dislocation unless capsular disruption was present (98).

The Glenoid Labrum

The glenoid labrum is a fibrous rim that serves to slightly deepen the glenoid fossa and allows for the attachment of the glenohumeral ligaments to the glenoid (Figure 5). Several investigators have reported that a small amount of fibrocartilage exists at the junction of the glenoid and fibrous capsule (29,61,98). The vast majority of the labrum consists of dense fibrous tissue with few elastic fibers. The labrum does receive a blood supply to its periphery. Cooper et a1 (23) recently examined the vascular supply of the labrum and found that the superior and anterosuperior portions of the labrum were less vascular than the posterosuperior and inferior portions (Figure 6). This c o incides with the capsular labrum at-

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POSTERIOR

FIGURE 5. The glenoid labrum, which serves to deepen the glenoid and provides attachment to the glenohumeral capsule.

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ous anterior capsular detachment in instability and stated that the labrum could be excised so long as the c a p sule was firmly attached to bone without instability being present (6). Townley has illustrated that labral detachment by itself is insufficient to cause anterior dislocation unless accompanied by disruption of the anterior capsule and ligamentous structures (98). The role of the labrum as a stabilizing structure has been debated in the literature (41,54,61,109). The labrum functions to deepen the glenoid, from 2.5 to approximately 5 mm (39). The labrum may function in combination with joint compression forces to stabilize the joint FIGURE 7. The glenoid labrum. The labral sulcus lowithin the midrange of glenohumeral cated in the anterosuperior aspect. (From Cooper DE, Arnoczky SP, O'Brien S/, Warren RF, DiCarlo E, Allen motion where the ligamentous capsuAA: Anatomy, histology and vascularity of the glenoid lar structures are lax (52). Biomelabrum: An anatomical study. j Bone joint Surg 74A: chanical studies have indicated that 46-52, 1992, reprinted with permission). resection of the labrum can reduce the effectiveness of the compression stabilization by 20% (100). The latachments to the glenoid. Additionbrum appears to serve as a buttress ally, Prodromos et al (77) reported assisting in controlling glenohumeral that the vascularity of the labrum detranslation, similar to a chock-block, creases with age. which would prevent the wheel of a The superior attachment of the tractor from rolling downhill (Figure labrum is loose and resembles the 8). Additionally, Bowen et al have mobility of the meniscus located stated that the labrum may also conwithin the knee joint (64). In contribute to stability by increasing the trast, the inferior attachment of the surface area and acting as a loadlabrum is firm and unmoving (Figure bearing structure for the humeral 7). Labral mobility above the horihead (14). zontal midline of the glenoid is norThe long head of the biceps mal and not pathologic; in contrast, brachii muscle inserts onto the supeinferior mobility is abnormal. The rior portion of the labrum. Recently, labrum frequently forms a "labral Pagnani et a1 (69) created superior sulcus" in the anterosuperior aspect labral lesions in cadaveric specimens, of the glenoid (2 o'clock position for where they detached the biceps from the right shoulder) (64). This is a the labrum, producing a superior normal variant and should not be labral tear anterior to posterior (slap confused with a pathologic change or lesion). This induced pathology proa Bankart lesion during arthroscopic duced mild to moderate multidirecexamination. tional increases in translations, particSeveral authors (13.60) have inularly at lower to midpositions of arm terpreted Bankart's original descrip tion of the "essential lesion" in recur- elevation only (69). This may assist in the explanation of various symptoms rent anterior instability as being the associated with slap glenoid labral detachment of the glenoid labrum (106). However, Bankart actually em- lesions, such as pain or a feeling of instability while reaching to the side phasized the importance of an obvi368

FIGURE 8. A) The triangular shape of the glenoid labrum, acting similar to a "chock-block" in controlling humeral head displacement. (From O'Brien 51, Amoczky SP, Warren RF, Rozbmch SR: Developmental anatomy of the shoulder and anatomy of the glenohumeral joint. In: Rockwocd CA, Matsen FA (eds): The Shoulder, Philadelphia: W.B. Saunders Company, 1990, reprinted with permission). B) The "chockblock" effect. (From Warner llP: The gross anatomy of the joint surfaces, ligaments, labrum, and capsule. In: Matsen FA, Fu FH, Hawkins R/ (eds): The Shoulder: A Balance Bebeen Mobility and Stability, Rosemont, / I : American Academy of Orthopaedic Surgeons, 1993, reprinted with permission).

with the arm in midpositions of elevations (2-4,79,89). During arm movements, the humeral head articulates with the periphery of the glenoid and may actually articulate with the capsulolabral structures as well (91). Thus, the labrum increases the total surface area available for humeral articulation. Additionally, the inferior glenohumeral ligament blends into the inferior labrum. Pathologically, anteroinVolume 25 Number 6 June 1997 JOSPT

ferior labral detachment is usually associated with some degree of capsular disruption from the glenoid neck (105). This capsular-periosteal separation creates laxity in an important stabilizer, the inferior glenohumeral ligament, which is normally intimately attached to the glenoid labrum (59).

Shoulder Capsule and Ligaments

The shoulder joint capsule is large, loose, and redundant, thereby allowing for the large range of glenohumeral motion naturally available. The shoulder joint capsule is composed of multilayered collagen fiber bundles of differing strength and ori-

circular radial f
FIGURE 9. The pattern of collagen fiber bundles (consisting of radial and circular elements) to cross-link the B, glenohumeral joint capsule. (From Gohlke F, Essigk~g Schmih F: The pattern of the collagen fiber bundles of the capsule of the glenohurneral joint. /Shoulder Elbow Surg 3(3):111-128, 1994, reprinted with permission).

The joint capsule collagen fiber orientation is comprised of radial fibers that are linked to each other by circular elements.
entation. Gohlke et a1 (31) have reported the anteroinferior capsule as the thickest and strongest portion of the capsule due to the densely organized collagen fibers, evident by the reinforcing ligaments of the inferior glenohumeral ligament complex. The joint capsule collagen fiber orientation is comprised of radial fibers that are linked to each other by circular elements (Figure 9). Thus, rotational forces produce tension within the fibers, which leads to compression of the joint surfaces but also a centering of the joint (31) (Figure 10). Within the joint capsule, many of the fiber bundles d o not connect bone to bone but rather are circular in form. This appears to play an important
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role in the capacity of the capsule. These circular collagen fibers appear to play a significant role in absorbing stress and tension. The spiralshaped, cross-linked capsular collagen structure assists in providing joint stability. Distractive force leads to an increase in longitudinal stretching of the c a p sule and, thus, constriction of the cylinder, resulting in greater joint compression and enhanced effects of negative intraarticular pressure (31). The capsule is reinforced with capsular ligaments which contribute greatly to joint stability. There is a wide variation in the size, strength, and orientation of these capsular lig-

aments (24,61,65). These ligaments function when the joint is placed in extremes of motion to protect against instability. The anterior glenohumeral joint capsule exhibits three distinct ligaments: the superior glenohumeral ligament, the middle glenohumeral ligament, and the inferior glenohumeral ligament complex (24,65,99) (Figure 11). The superior glenohumeral ligament arises from the anterosuperior labrum anterior to the biceps tendon and inserts superior to the lesser tuberosity. The middle glenohumeral ligament originates adjacent to the superior glenohumeral

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internal rotation.

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FIGURE 10. During rotational movements, such gs internal and external rotation, the collagen fiber bundles tighten, thus centering the hurneral head and reducing humeral head displacement. (From Gohlke F, Essigkrug B, Schrnih F: The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint. /Shoulder Elbow Surg 3(3):111-128, 1994, reprinted with permission).

FIGURE 12. The circle stability concept. Translation of the humeral head is resisted by structures on both sides of the joint. (From Bowen MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin Spom Med 1O:757-782, 199 1, reprinted with permission).

shoulder position and the direction of the translating force. The "circle stability concept" was formulated by Warren et al (107) to pathomechanically describe the degree of tissue FIGURE 11. The glenohumeral ligaments: The inferior damage necessary for the glenohuglenohumeral ligament complex (IGHLC)consisting of meral joint to dislocate (Figure 12). an anterior band (AB),posterior band (PB), andaxillary Additionally, the investigators repouch (AP). The middle (MGHL) and superior (SGHL) ported, in a cadaveric study, that the glenohumeral ligaments are also represented. B = shoulder capsule had to be damaged long head of the biceps brachii tendon; PC = Posteon both the posterior and anterior rior capsule. (From O'Brien SI, Neves MC, Arnouky SP, Rozbruch SR, DiCarlo EF, Warren RF, Schwartz R: sides to allow posterior dislocation. The anatomy and histology of the inferior glenohu- Recently, several investigators have meral ligament complex of the shoulder. Am I Spom also validated the circle stability conMed 18:449-456, 1990, reprinted with permissionl. cept in the pathomechanics of anterior instability (12.97). Presently, the authors classify the structures in the ligament and extends laterally to atdirection of the translation as the tach on the lesser tuberosity with the primary restraints and the structures subscapulaxis tendon. The inferior on the opposite side of the joint as glenohumeral ligament complex is composed of three functional porthe secondary restraints. tions: an anterior band, a posterior The constraints to inferior transband, and an axillary pouch (Figure lation of the humeral head on the 11). There is great variation in these glenoid vary based on arm position and degree of rotation. Selective tisstructures, with the middle glenohusuecutting studies by Warner et al meral ligament exhibiting the greatest degree of variation (24,25). Poste- (103) have demonstrated that the riorly, the capsule is the thinnest and primary and secondary restraints preexhibits no capsular ligaments except venting inferior translation with the for the posterior band of the inferior arm in the adducted position are the superior glenohumeral ligament and glenohumeral ligament complex. the coracohumeral ligament (Figure The role the shoulder capsule and anterior glenohumeral ligaments 13). When the arm is abducted to 45" and neutrally rotated, the anteplay in stabilizing the glenohumeral rior band of the inferior glenohujoint is complex and varies with both

FIGURE 13. ligamentous constraints to inferior-superior translation; stability testing performed at 0' of abduction and neutral rotation. SGHL = Superior glenohumeral ligament; MGHL = Middle glenohumeral ligament; AB = Anterior band of the inferior glenohumeral ligament complex; PB = Posterior band of the inferior glenohumeral ligament. (From Bowen MK, Warren RF: ligamentous control of shoulder stability based on selective cuffing and static translation experiments. Clin Spom Med 1 O:757-782, 199 1, reprinted with permission).

meral ligament complex is the primary restraint to inferior translation (Figure 14). At 90" of abduction, the posterior band of the inferior glenohumeral ligament complex is the primary stabilizer against inferior motion of the humeral head on the glenoid (Figure 15). The anterior glenohumeral ligaments function as primary restraints to anterior translation (66,86). The superior and middle glenohumeral ligaments are the primary restraints to anterior translation with the arm fully adducted (16). The middle glenohumeral ligament plays a significant role in limiting anterior translation within the midrange of shoulder abduction (l6,25,68). The inferior glenohumeral ligament complex, particularly the anterior band, is responsible for preventing anterior translation of the humeral head with the arm abducted to 90" or greater (66, 86). The constraints to posterior translation are also based on arm position. O'Brien et al (66) have reported that the inferior glenohumeral ligament complex (with the posteroinferior capsule) is the priVolume 25 Number 6 June 1997 JOSPT

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FIGURE 14. ligamentous constraints to inferior-superior translation at 4S0 of abduction and neutral rotation. SGHl = Superior glenohumeral ligament; MGHL = Middle glenohumeral ligament; AB = Anterior band of the inferior glenohumeral ligament complex; PB = Posterior band of the inferiorglenohumeral ligament. (From Bowen MK, Warren RF: ligamentous control of shoulder stability based on selective cuning and static translation experiments. Clin Sports Med 1O:757-782, 1991, reprinted with permission).

FIGURE 16. The function of the inferior glenohumeral ligaments are demonstrated in the illustration during
neutral rotation (A), abduction (ABD) and internal rotation (IR) (C), and abduction and external rotation (ER)(0). (From O'Brien S), Neves MC, Arnoczky SP, R o z b ~ c h DiCarlo EF, Warren RF, Schwartz R: The anatomy and SR, histology of the inferior glenohumeral ligament complex of the shoulder. Am j Sports Med 18:449-456, 1990, reprinted with permission).

FIGURE 15. Inferior ligamentous constraints at 90" of abduction and neutral rotation. SGHl = Superior glenohumeral ligament; MGHL = Middle glenohumeral ligament; AB = Anterior band of the inferior glenohumeral lizament com~lex:PB = Posterior band of the inferior'~lenohume~a1 ligament. (From Bowen MK, Warren RF: ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin Sports Med 10:757-782, 1991, reprinted with permission).

mary passive stabilizer against posterior instability with the arm in 90" of abduction. When the arm is positioned below 90" of abduction, the posterior capsule provides the primary restraint to any posterior force. Recently, the functional relationships between the static ligamentous
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structures and arm motions have been better defined. With abduction and external rotation, the anterior band of the inferior glenohumeral ligament complex fans out and surrounds the anteroinferior aspect of the humeral head much like a hammock, thus, restraining anterior displacement, while the posterior band prevents inferior displacement (65) (Figure 16). With internal rotation and abduction, the anterior band of the inferior glenohumeral ligament complex moves inferiorly to resist inferior translation as the posterior band shifts posterosuperiorly to prevent posterior translation (65). With the shoulder in 90" of abduction and

30" of extension, the anterior band of the inferior glenohumeral ligament complex becomes the primary stabilizer against both anterior and posterior translation. As a general rule, the superior capsular structures play significant roles in joint stability when the arm is adducted. Conversely, the inferior structures are preeminent in joint stability from 90" of abduction t e ward full elevation. O'Connell et a1 (67) recorded the amount of strain present within the glenohumeral ligaments in various arm positions. They reported a concentration of strain in the inferior glenohumeral ligament complex at 9 0 " of glenohumeral a b

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enhancing stability. Normally, there is duction; at 45", the inferior glenohu- Grade 111: capsular tears with labral very little fluid present in the capsule meral ligament complex and middle detachments (complete capsule/ (less than 1 ml) (56). This limited glenohumeral ligament developed labral detachments). In addition, the the highest strain; and at 0" of abduc- degree of instability noted on exami- volume of joint fluid assists in providing joint stability, similar to a syringetion, strain was concentrated within nation under anesthesia varied detype suction, by holding the articular the superior and middle glenohupending on the grade of the lesion. surfaces together with viscous and meral ligaments. Grade Is were stable, Grade 11s were The forces required to dislocate mildly unstable, and Grade I11 lesions intermolecular forces (56). Additionally, the normal intraarticular presthe shoulder change with age, with were grossly unstable. Matsen et al sure is negative, creating a relative less force required in subjects under (56) say that in approximately 85% vacuum that resists glenohumeral 20 and over 40 years of age (46,78). of patients with traumatic anterior joint translation (18,30,49). The magBigliani et al (11) recently investidislocations, the glenoid labrum is nitude of this stabilizing pressure is gated the response of the inferior detached from the anterior glenoid small, approximately 20-30 Ibs. If glenohumeral ligament complex to rim. In the remaining cases, the c a p these properties are disrupted by a tensile loading. They found that the sule may undergo interstitial stretchpuncture or tear in the capsule, inferior glenohumeral ligament com- ing or rupture without loosening or which introduces air or fluid, subluxplex demonstrated considerable plas- detachment of the labrum. The autic deformation (up to 24%) before thors propose this as a possible expla- ation tends to occur (30,49). Kumar ultimate failure. Additionally, it nation for the decreased incidence of and Balasubramianium noted that when the capsule was punctured would appear that gradual stretching recurrent dislocations in older pa(with an l8-gauge needle), the huof the capsule can occur with repetitients (older than 40 years). meral head tended to sublux regardtive microtrauma. Speer et al (93) The rotator interval is the space simulated a Bankart lesion by detach- located between the superior border ing the anterior half of the inferior of the subscapularis and the anterior glenohumeral ligament complex margin of the supraspinatus. The sufrom the glenoid. By doing so, they perior glenohumeral ligament and noted only a minimal increase in ancoracohumeral ligament are located terior translation. Thus, it was postuin this region of the capsule. There is lated that additional plastic deformaa large anatomic variation in the size tion of the inferior glenohumeral of the rotator interval found in indiligament complex and other portions viduals, ranging from a narrow interof the capsule is necessary to permit val to large lesions, where most or all complete anterior dislocation (106). of the rotator interval capsule is abRankart (6,7), expounding on a sent (92). Nobuhara and Ikeda (63) concept originally published by Perhave reported an association between thes (73), reported the "essential leinferior instability and a large intersion" responsible for shoulder instaval. Harryman et al (36) reported this less of the location of the puncture bility was the detached labrum and in the capsule (49). Gibb et al (30) capsule from the glenoid (referred to portion of the capsule plays a signifi- found that venting (making a small cant role in preventing inferior subby subsequent authors as a Bankart hole or puncture within the capsule) luxation in the adducted shoulder lesion). However, the Bankart lesion the capsule reduced the force necesand is a secondary restraint to posteis not one specific anatomic defect, sary to translate the humeral head rior translation. Recently, Field et a1 but describes a wide spectrum of pa(26) reported on the isolated closure anteriorly by 55%. Warner et a1 (103) thology related to detachment of the of the rotator interval in patients with reported that venting the capsule led capsulolabral complex. Rowe classito a significant increase in inferior recurrent instability. The authors fied several types of Bankart lesions translation in the adducted shoulder. noted good to excellent results in depending on how the labrum and Recently, Wuelker et al (117) reselected patients when performing capsule detached from the glenoid ported venting the capsule increased the closure. (80,119). Baker et al (5) have identidisplacement by 47% anteriorly, 49% fied three types of Bankart lesions posteriorly, and 61% inferiorly. present in acute anterior initial dislo- lntraarticular Pressure and Joint Habermeyer et al (33) noted that the cations. These are described as: Cohesion vacuum effect of viscous and intermoGrade I: capsular tears with no labral lecular forces was lost in the unstable In the normal glenohumeral lesions; Grade 11: capsular tears with shoulder (Bankart lesion) and that joint, the capsule is sealed airtight, partial labral detachments; and
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Once a labral tear occurs, it results in atmospheric pressure changes and a loss of passive glenohumeral joint stability.

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FIGURE 17. Dynamic joint stability. Muscular cocontradionof the rotator cuff anddeltoid muscles produce compression of the humeral head with the glenoid cavity, thus 1 minimizing humeral head displacement. A1 Posterior view, B anterior view, and Cj superior view. Anterior deltoid (I), infraspinatus (21, teres minor (3), subscapularis (4), supraspinatus (51, and long head of the biceps (6).

the labrum acted much like a seal or gasket. Thus, once a labral tear occurs, it results in atmospheric pres sure changes and a loss of passive glenohumeral joint stability. Speer and Urmey (unpublished data, 1992) in clinical studies have not seen the resumption of negative intra-articular pressure following an arthrotomy of the joint.

THE DYNAMIC STABILIZERS Neuromuscular Control

The dynamic stabilizers contrib Ute several active mechanisms to the inherent stability of the shoulder joint (Table). The primary active stabilizers of the glenohumeral joint include the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis), the deltoid, and the long head of the biceps brachii. Secondary stabilizers include the teres major, latissimus dorsi, and pectoralis major muscles. The primary role of the before-mentioned muscles is the production of a combined m u s cular contraction which enhances the
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The authors describe one group of stability of the humeral head during the force couple at the glenohumeral active arm movements. These muscles act together in an joint to be the prime movers and its agonist/antagonist relationship to synergists, and the other involves components of the rotator cuff which provide movement of the arm but establish a stable fulcrum for motion also to stabilize the glenohumeral to occur between the humeral head joint. In the past, these muscles were thought to function as part of a force and glenoid. Perry (72) has reported, couple relationship (44). A force cou- using dynamic electromyography, ple, by definition, occurs when two that all muscles of the rotator cuff and the deltoid are active throughout parallel forces of equal magnitude the full range of motion of flexion but opposite direction are applied to and abduction. Thus, it appears the a structure at equal distances from rotator cuff muscles act to counteract the center of the mass (27). The two force couples most commonly dethe shearing force generated by the scribed at the shoulder have been the deltoid muscles (118). This comsubscapularis counterbalanced by the bined effect of the rotator cuff synerinfraspinatus/teres minor in the gistic action creates humeral head transverse plane and the deltoid compression within the glenoid, counterbalanced by the inferior rota- which is a major contributor to joint tor cuff muscles in the coronal plane stability (Figure 17). Thus, it would (44). It appears that the function of appear that perhaps a more a p p r e these force couples serves to establish priate term for the counterbalancing a dynamic equilibrium of glenohuaction of the rotator cuff and deltoid meral joint forces in any arm posimuscles would be a "balance of tion. forces," rather than a force couple relationship. Speer and Garrett (94) have described a force couple as two groups Lippitt et al reported joint comof muscles contracting synchronously pression resisted up to 60% of the transglenoid force (53). Additionally, to enable a specific motion to occur.
373

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Bowen et al (15) have noted that a joint compression load of 111 N continued to stabilize the shoulder despite a 50-N displacement force and sectioning of three-fourths of the joint capsule. Increasing the joint compressive load appears to "center" the humeral head within the glenoid and, subsequently, reduces the magnitude of aberrant translations. Clinically, the authors feel that when these forces are not properly balanced or equalized, either between the prime movers and stabilizers or between the anterior and posterior stabilizing muscles, abnormal glenohumeral mechanics occur. Frequently, the overhead athlete exhibits significant posterior shoulder weakness (ie., external rotator weakness) and pain, which the authors feel results in a temporary loss of stability secondary to a force couple imbalance between the anterior and posterior rotator cuff musculature (113). Cain et al (19) and later McKernan et al (58), in cadaveric experiments, demonstrated maximal contraction of the posterior rotator cuff muscles reduced anterior ligamentous strain. Blasier et al (12) biomechanically studied the role of the rotator cuff and concluded the muscles of the entire rotator cuff contributed to stability by equal contributions. If tension on any one of the components of the cuff was omitted or significantly reduced, there was a s u b stantial reduction in anterior joint stability compared with when tension was applied to all components. Several investigators have noted that the entire rotator cuff contributes in performing arm elevation (72,87). Sharkey et al (87) studied the effects of specific muscle forces about the shoulder joint in cadaveric shoulders. The investigators reported that the infraspinatw, teres minor, and subscapularis all contribute significantly to shoulder abduction. Additionally, Sharkey et al (87) noted that selective strengthening of these muscles may compensate for residual impairment of the supraspinatus. This dy-

Golgi mechanoreceptors within the namic stability of the glenohumeral capsulolabral structures, especially in joint is accomplished through the the inferior aspect of the glenohucombined efforts of all the muscles around the shoulder joint stabilizing meral joint capsule. Terry et al (97) have theorized that stretch-sensitive the humeral head within the glenoid mechanoreceptors within the capsuthrough compressive forces. Wickiewicz et al (108) examined the eflar ligaments could be activated by tension, thus, producing a muscular fects of muscle fatigue on glenohucontraction to protect the ligaments meral kinematics and humeral head at the extremes of motion. Smith and position in normal individuals Bmnolti (88) reported shoulder kinthrough radiographs. The authors noted an increase in superior migraesthetic deficits in patients up to .3-4 months following traumatic anterior tion of the humeral head at 45,90, and 125" of abduction once the dyshoulder dislocation. Recently, L e p namic stabilizers were fatigued. These hart et a1 (51) measured the joint position sense of healthy, unstable. studies document the importance of and surgically repaired shoulder parotator cuff strength, dynamic effitients. The authors noted a differciency, and endurance in providing ence in position sense in the unstable stability and unloading stress on the shoulder compared with the unincapsular ligaments. The second method of active gle- jured shoulder. Voight et al (102) have documented proprioception nohumeral joint stability is provided (joint repositioning) is significantly through the blending of the rotator cuff tendons into the shoulder c a p affected by muscular fatigue. Thus, sule. Thus, as the rotator cuff musthe muscular mechanoreceptors a p pear to play an important role in cles contract, tension is produced within the capsular ligaments, actively proprioception. The muscle spindle contains afferent and efferent innertightening the glenohumeral ligavation and provides information on mentous capsule, again promoting a centering of the humeral head within joint position sense (50) and repositioning abilities (102). Numerous authe glenoid fossa. The rotator cuff muscles blend with the capsule, creat- thors have recommended that funcing both an active and passive barrier tional joint stability of other joints can be enhanced through facilitating to resist humeral head translation proprioceptive skills and proper mus(21). Additionally, the authors feel cular coordination (8,9,28,48,57,62, these tissues act to absorb and dissi74,83). Thus, it would appear that pate repetitive microtraumatic shoulder joint proprioception plays a stresses at the shoulder during varivital role in dynamic joint stability. ous activities. The ability to control the shoulder The third component contributing to dynamic shoulder stability has joint during active motions is referred to by the authors as "reactive been termed "neuromuscular control" (111,112). This concept refers neuromuscular control," and we feel it is more important to normal shoulto the continuous interplay of afferder function than joint position or ent input and efferent output. Thus, repositioning abilities (112). Proprioit is the individual's awareness of ception is a complex somatosensory joint position (proprioception) and ability which involves the cumulative the ability to produce a voluntary afferent neural input to the central muscular contraction to stabilize the nervous system from the mechanorejoint and/or to alter that joint posiceptors. Reactive ne~~romuscular contion that can prevent excessive hutrol describes the individual's ability meral head displacements. Recently, to integrate the proprioceptive inforseveral investigators (96,lO1) have mation and the motor control to redocumented the presence of Ruffinact to the information. Advanced exian and Pacinian corpuscles and
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ercises, such as plyometrics, proprioceptive neuromuscular facilitation movements, and reactive muscular training drills, may assist in reestablishing the reactive neuromuscular control abilities at the shoulder joint (115). The functional ability of the rotator cuff muscles are significantly affected by joint position. McKernan et al (58) stated that the stabilizing effect of these muscular contractions is dependent on arm position. For instance, in the lower ranges of elevation, the subscapularis tendon lies anterior to the joint where its contraction would appear to be effective in limiting anterior translation (58). Conversely, as the arm is elevated, the line of action of the subscapularis moves superior to the joint, and, thus, becomes less effective in limiting anterior translation. This may explain both the inability of dynamic muscular forces to adequately stabilize the glenohumeral joint once a capsulolabral injury (ie., Bankart lesion) has occurred and the propen-

FIGURE 18. The function of the long head of the biceps brachii changes based on arm position. A) Tension on the biceps reduces anterior translation when the a n is internally rotated; 6) neutral rotation, resting position, illustrates orientation of the long head of the biceps brachii; and C)the long head of the biceps brachii reduces posterior translation when the humerus is externally rotated. H = Humeral head. G = Glenohumeral joint capsule. (From ltoi E, Motzkin NE, Morrey BF, An KN: Stabilizing function of the long head of the biceps in the hanging arm position. / Shoulder Elbow Surg 3:13 1-139, 1994, reprinted with permission).

The scapulothoracic musculature plays a significant role in shoulder stability.

.--.--..
. . ...---

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sity of anterior dislocations occurring above 90" of elevation. In our laboratory, we have noted as the arm elevates, the amount of rotator cuff dynamic electromyography activity also increases to a point, then gradually declines as the arm continues to elevate. Furthermore, internal and external rotation strengthening exercises performed at 90" of abduction have been shown to have greater electromyography activity of all the rotator cuff muscles (especially the infraspinatus and supraspinatus) compared with 45 or 0" of abduction (114). As the arm elevates to 90, the
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demands on the rotator cuff muscles increase to dynamically control and stabilize the humeral head (110). The role of the biceps brachii in shoulder stability has been a source of debate in the literature. Andrews et al have suggested that the biceps brachii functions as a shoulder stabilizer (3). Pagnani et al have recently examined the effects of the biceps contraction on glenohumeral translation (69). The investigators noted that a simulated contraction of the long head of the biceps has a significant effect on glenohumeral translation and is dependent on arm position. Tension within the biceps reduces anterior translation when the arm is internally rotated and diminishes posterior translation when the arm is externally rotated (Figure 18). Additionally, the biceps brachiis' effects appear more significant in midelevation. The biceps brachiis' stabilizing effect in midelevation may be related to the biceps orientation onto the labrum near the superior and middle glenohumeral ligaments,

both of which also play significant roles in midelevation stability (Figure 11). Thus, once a labral tear occurs at the insertion of the biceps brachii (long head), the fixation of the superior glenohumeral ligament and middle glenohumeral ligament is compromised, and its ability to stabilize the glenohumeral joint is significantly affected. The scapulothoracic musculature plays a significant role in shoulder stability by providing a stable base of support for the glenohumeral muscles to fixate and function from. Wilk and Arrigo (112) have stated that one of the primary roles of the scapulothoracic joint is to dynamically maintain a consistent lengthtension relationship for the shoulder girdle muscles, and, once altered, shoulder girdle function may be significantly reduced. Clinically, the lead author (KEW) has noted a correlation between weak scapular musculature and multidirectional shoulder instability. Furthermore, often, voluntary subluxors cannot voluntarily sub-

L I T E R A T U- R- E--- R-E -V- I E W -

al (104) also reported a relationship between scapular muscle dysfunction and anteroinferior shoulder instability. It remains unclear whether this represents a primary or secondary phenomenon. In either case, the relationship appears to exist; thus, it is paramount for the patient with shoulder instability (especially atraumatic instability) to routinely perform scap ular strengthening exercises. The authors strongly recommend emphasizing the scapular retractors (rhomboids, middle fibers of the trapezius), protractors (serratus anterior, pectoralis minor), and the upward rotators (upper and lower fibers of the trapezius and lower serratus anterior). The authors have clinically noted these muscle groups appear routinely weak in the atraumatic multidirectional shoulder instability patient. Thus, by strengthening these muscles, it may both directly and indirectly assist in enhancing glenohumeral joint stability. Scapulothoracic joint stability is greatly dependent on the scapulothoracic musculature, and weakness of these muscles or muscle groups may contribute to a lack of functional stability of the scapula which directly affects the ultimate function of the glenohumeral joint musculature.

tures and functions, we feel this will assist the clinician in the evaluation IOSpT and treatment approaches.

RFRNE EE E C S
1. Altchek OW, Schwartz E, Warren RF: Radiologic measurement of superior migration of the humeral head in impingement syndrome. Presented at the annual meeting of the American Shoulder and Elbow Surgeons, New Orleans, LA, February 8-12, 1990 2. Andrews JR, Carson WG: The arthroscopic treatment of glenoid labrum tears in the throwing athlete. Orthop Trans 8:44 -49, 1 984 3. Andrews JR, Carson WG, McLeod WD: Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 13:337-34 1, 1985 4. Andrews JR, Kupferman SP, Dillman C]: Labral tears in throwing and racquet sports. Clin Sports Med 10:901907, 1991 5. Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med l8(1):25-28, 1990 6. Bankart ASB: Discussion on recurrent dislocation of the shoulder. J Bone Joint Surg 30B:46-47, 1948 7. Bankart ASB: The pathology and treatment of recurrent dislocation of the shoulder joint. Br Med J 2: 1 132- 1133, 1923 8. Barrack RL, Skinner HB, Brunet DW: Joint kinesthesia in the highly trained knee. J Sports Med Phys Fit 24(1):1820, 1984 9. Barrack RL, Skinner HB, Brunet OW: Joint laxity and proprioception in the knee. Physician Sports Med 1l(6): 130-135, 1983 10. Basmajian JV, Bazant FJ: Factors preventing downward dislocation of the adducted shoulder joint. J Bone Joint Surg 41A:1182-1186, 1959 1I . Bigliani L V, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 10:187197, 1992 12. Blasier RB, Goldberg RE, Rothman ED: Anterior shoulder stability: Contributions of rotator cuff forces and the capsular ligaments in a cadaver model. J Shoulder Elbow Surg 1:140150, 1992 13. Bost FC, lnman VT: The pathological changes in recurrent dislocation of the shoulder: A report of Bankart's operative procedure. ] Bone Joint Surg 24A: 595- 6 13, 1 942

SUMMARY
FIGURE 19. The scapular inclination angle (the degree of superior tilt of the glenoid fossa).A) A normal n scapular inclination angle (3-5");and B) a abnormal inclination angle (<3') which can lead to inferior displacement of the humeral head in the adducted arm.

lux the glenohumeral joint when the scapula is fixed by the examiner. Itoi et a1 (45) examined the effects of the scapular inclination angle and inferior instability. Using cadaveric shoulders and an electromagnetic tracking device, the authors reported that the scapular inclination angle had a significant effect in preventing inferior translation of the adducted arm (Figure 19). Warner et

Numerous anatomic structures contribute to the stability of the glenohumeral joint, including the passive restraints (osseous, labrum, ligamentous) and the active restraints (neuromuscular system). It is the interaction of these structures which provide functional glenohumeral joint stability. Due to the joint geometry of the glenohumeral joint, it is best suited for mobility, and it is the complex and dedicated interaction of the ligamentous and neuromuscular systems which provide the majority of the stabilizing effect. In this paper. we have discussed and described the various stabilizing structures about the glenohumeral joint. Through a thorough understanding of the struc-

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14. Bowen MK, Deng XH, Hannafin JA, O'Brien SJ, Altchek DW, Warren RF: An analysis of the patterns of glenohumeral joint contact and their relationship to the glenoid "bare area." Trans Orthop Res Soc l7:496, 1992 (abstract) 15. Bowen MK, Deng XH, Warner JJP, Warren RF, Torzilli PA: The effect of joint compression on stability of the glenohumeral joint. Trans Orthop Res Soc 17:289, 1992 (abstract) 16. Bowen MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin Sports Med 10:757782, 1991 17. Brewer BJ, Wubben RG, Carrera GF: Excessive retroversion of the glenoid cavity. J Bone Joint Surg 68A:724726, 1986 18. Browne AO, Hoffmeyer P An KN, , Morrey BF: The influence of atmospheric pressure on shoulder stability. Orthop Trans 14:259-263, 1990 19. Cain PR, Mutsehler TA, Fu FH: Anterior stability of the glenohumeral joint. A dynamic model. Am J Sports Med 15:144-148, 1987 20. Cave EF, Burke JF, Boyd RJ: Trauma Management, p 437. Chicago: Yearbook Medical Publishers, 1974 2 1. Clark M, Harryman DT: Tendons, ligaments and capsule of the rotator cuff. J Bone Joint Surg 74A:7 13-725, 1 992 22. Codman EA: The Shoulder, Boston: Thomas Todd, 1934 23. Cooper DE, Arnoczky SP, O'Brien SJ, Warren RF, DiCarlo E, Allen AA: Anatomy, histology and vascularity of the glenoid labrum: An anatomical study. J Bone Joint Surg 74A:46-52, 1992 24. DePalma AF, Callery G, Bennett GA: Variational anatomy and degenerative lesions of the shoulder joint. lnstr Course Lect 6:255-28 1, 1949 25. Ferrari DA: Capsular ligaments of the shoulder: Anatomical and functional study of the anterior superior capsule. Am J Sports Med 18:20-24, 1990 26. Field LD, Warren RF, O'Brien SJ, Altchek DW, Wickiewicz TL: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 23 :557-563, 1995 27. Frankel VH, Nordin M: Basic Biomechanics of the Skeletal System, p 293. Philadelphia: Lea & Febiger, 1980 28. Freedman L, Munro RL: Abduction of the arm in the scapular plane. J Bone Joint Surg 48A: 1503- 15 10, 1966 29. Gardner E: The prenatal development of the human shoulder joint. Surg Clin North Am 43: 1465- 1470, 1963

30. Gibb TD, Sidles JA, Harryman DT, McQuade KJ,Matsen FA: The effect of capsular venting on glenohumeral laxity. Clin Orthop 268: 120- 127, 1991 3 1. Gohlke F, Essigkrug B, Schmitz F: The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint. J Shoulder Elbow Surg 3:111128, 1 994 32. Gray's Anatomy of the Human Body (30th Ed), Clemente CA (ed), Philadelphia: Lea & Febiger, 1985 33. Habermeyer P, Schuller U, Wiedemann E: The intra-articular pressure of the shoulder: An experimental study on the role of the glenoid labrum in stabilizing the joint. Arthroscopy 8~166-172, 1992 34. Harryman DT 11, Sidles JA, Clark JA, McQuade KJ, Gibb TD, Matsen FA: Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg 72A: 1334- 1343, 1990 35. Harryman DT 11, Sidles JA, Harris SL, Matsen FA: Laxity of the normal glenohumeral joint. A qualitative in vivo assessment. J Shoulder Elbow Surg 1:66 -76, 1992 36. Harryman DT 11, Sidles JA, Harris SL, Matsen FA: Role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg 74A:53-66, 1992 37. Hawkins RJ, Schutte JP, Huckell CJ: The assessment of glenohumeral translation using manual and fluoroscopic techniques. Orthop Trans 12: 727-728, 1988 38. Hill HA, Sachs MD: The grooved defect of the humeral head. A frequently unrecognized complication of dislocations of the shoulder joint. Radiology 35:690-700, 1940 39. Howell SM, Galinet BJ: The glenoid labral socket: A constrained articular surface. Clin Orthop 243: 122- 125, 1989 40. Howell SM, Galinet BJ, Renzi A), Marone PJ:Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg 7OA:227-232, 1988 4 1. Howell SM, Krafi TA: The role of the supraspinatus and infraspinatus muscles in glenohumeral kinematics of anterior shoulder instability. Clin Orthop 263: 128-1 34, 1991 42. Hurley JA, Anderson TE, Dean W, Andrish JT, Bergfeld JA, Weiker GG: Posterior shoulder instability: Surgical versus conservative results with evaluation of glenoid version. Am J Sports Med 20:396-400, 1992

43. Ianotti JP, Gabriel JP, Schneck SL, Evans BG, Misin S: The normal glenohumeral relationships: An anatomical study of one hundred and forty shoulders. J Bone Joint Surg 74A:491-500, 1992 44. lnman VT, Saunders JR, Abbott JC: Observations on the function of the shoulder joint. J BoneJoint Surg 26(A): 1-30, 1994 45. ltoi E, Motzkin NE, Morrey BF, An KN: Scapular inclination and inferior stability of the shoulder. J Shoulder Elbow Surg 1:131-139, 1992 46. Kaltsas DS: Comparative study of the properties of the shoulder joint capsule with those of other joint capsules. Clin Orthop l73:20-26, 1983 47. Kazar B, Relouszky E: Prognosis ofprimary dislocation of the shoulder. Acta Orthop Scand 40:2 16-2 19, 1 969 48. Kennedy JC, Alexander I), Hayes KC: Nerve supply of the human knee and its functional significance. Am J Sports Med 10:329-335, 1982 49. Kumar VP, Balasubramianium P: The role of atmospheric pressure in stabilizing the shoulder. An experimental study. J Bone Joint Surg 67B:719-72 1, 1 985 50. Lehmkuhl L D, Smith L K: Some aspects of muscle physiology and neurophysiology. In: Brunnstrom C (ed), Clinical Kinesiology, pp 69- 1 17. Philadelphia: F.A. Davis Compan;~1983 51. Lephart SM, Warner JJP,Borsa PA, Fu FH: Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders. J Shoulder Elbow Surg 3(6):371-380, 1994 52. Lippett FG: A modification of the gravity method of reducing anterior shoulder dislocations. Clin Orthop 165: 259-260, 1982 53. Lippett SB, Vanderhoofi E, Harris SL, Sidles JA, Harryman DT, Matsen FA: Glenohumeral stability from concavity-compression. J Shoulder Elbow Surg 2:27-35, 1993 54. Lombardo SJ, Kerlan RF, lobe FW: The modified Bristow procedure for recurrent dislocations of the shoulder. J Bone Joint Surg 58A:256-26 1, 1976 55. Matsen FA, Harryman DT, Sidles JA: Mechanics of glenohumeral instability. Clin Sports Med 10:783-788, 1991 56. Matsen FA, Thomas SC, Rockwood CA: Anterior glenohumeral instability. In: Rockwood CA, Matsen FA (eds), The Shoulder, Philadelphia: W.B. Saunders Company, 1990 57. McClosky Dl: Kinesthetic sensibility. Physiol Rev 58:763- 820, 1978 58. McKernan Dl, Mutschler TA, Rudert

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MI, Klein AH, Harner CD, Fu FH: The characterization of rotator cuff muscle forces and their effect on glenohumeral joint stability. A biomechanical study. Orthop Trans 14:237-238, 1990 Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3:111-122, 1987 Moseley HF: The basic lesions of recurrent anterior dislocation. Surg Clin North Am 43:163 1-1 634, 1963 Moseley HF, Overgaard B: The anterior capsular mechanism in recurrent dislocation of the shoulder: Morphological and clinical studies with special reference to the glenoid labrum and glenohumeral ligaments. J Bone Joint Surg 44 B: 13-27, 1962 Newton RA: joint receptor contributions to reflexive and kinesthetic response. Phys Ther 62:22-29, 1982 Nobuhara K, lkeda H: Rotator cuff interval lesion. Clin Orthop 223:44-50, 1987 O'Brien SJ: Glenoid labral lesions. Presented at the 1994 Advances of the Knee and Shoulder, Hilton Head, SC, May, 1994 O'Brien SJ, Neves MC, Arnoczky SP, Rozbruch SR, DiCarlo EF, Warren RF, Schwartz R: The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 18:449-456, 1990 O'Brien SJ, Schwartz RE, Warren RF, Torzilli PA: Capsular restraints to anterior/posterior motion of the shoulder. Orthop Trans 12:143, 1988 (abstract) O'Connell PW, Nuber GW, Mileski RA, Lautenschlager E: The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint. Am J Sports Med 18579-584, 1991 OvesonJ, Nielson S: Anterior and posterior instability of the shoulder: A cadaver study. Acta Orthop Scand 57: 324 -327, 1 986 Pagnani MJ, Deng XH, Warren RF, Torzilli PA: Effect of the long head of the biceps brachii on glenohumeral translation. Presented at The Hospital for Special Surgery Fellows Research Symposium, New York, NY, August, 1993 Pagnani MI, Warren RF: Stabilizers of the glenohumeral joint. J Shoulder Elbow Surg 3:173-190, 1994 Pavlov H, Warren RF, Weiss CB, Dines DM: The roentgenographic evaluation of anterior shoulder instability. Clin Orthop 194: 153- 158, 1985

72. Perry J: Muscle control of the shoulder. In: Rowe CR (ed), The Shoulder, pp 17-34. New York: Churchill Livingstone, 1988 73. Perthes G: Uber operationen bei habitueller schulterluxation. Deutsch Ztschr Chir 85:199-227, 1906 74. Pope MH, Johnson RJ, Brown DW: The role of the musculature in injuries to the medial collateral ligament. ) Bone Joint Surg 6 1A:398-402, 1979 75. Poppen NK, Walker PS: Forces at the glenohumeral joint in abduction. Clin Orthop 135:165- 170, 1978 76. Poppen NK, Walker PS: Normal and abnormal motion of the shoulder. J Bone Joint Surg 58A: 195-20 1, 1976 77. Prodromos CC, Perry JA, Schiller A L, Zarins BA: Histological studies of the glenoid labrum from fetal life to old age. ) Bone Joint Surg 72A:13441352, 1990 78. Reeves B: Experiments on the tensile strength of the anterior capsular structures in man. J Bone joint Surg SOB: 858 -865, 1990 (abstract) 79. Rodosky MW, Rudert MJ, Horner CH, Luo L, Fu FH: Significance of a superior labral lesion of the shoulder: A biomechanical study. Trans Orthop Res Soc 15:276, 1990 (abstract) 80. Rowe CR: Dislocations of the shoulder. In: Rowe CR (ed), The Shoulder, pp 165-1 92. New York, NY: Churchill L ivingstone, 1988 81. Rowe CR: Prognosis in dislocation of the shoulder. J Bone Joint Surg 38A: 957-977, 1956 82. Rowe CR, Pate1 D, Southmayd WW: The Bankart procedure: A long term end-result study. J Bone Joint Surg 6OA:l-16, 1978 83. Rowinski MI: Afferent neurobiology of the joint. In: GouldJA, Davies GJ (eds), Orthopaedic and Sports Physical Therapy (2nd Ed), pp 5064. St Louis: C.V. Mosby Company, 1985 84. Saha AK: Dynamic stability of the glenohumeral joint. Acta Orthop Scand 42:49 1-505, 1971 85. Saha AK: Mechanism of shoulder movements and a plea for the recognition of the "zero position" of the glenohumeral joint. Clin Orthop 173: 3-10, 1987 86. Schwartz RE, O'Brien SJ, Warren RF: Capsular restraints to anterior-posterior motion of the abducted shoulder. A biomechanical study. Orthop Trans 12:727, 1988 (abstract) 87. Sharkey NA, Marder RA, Hanson PB: The entire rotator cuff contributes to elevation of the arm. J Orthop Res 12:699-708, 1994 (abstract)

: 88. Smith RH, Brunolti ) Shoulder kinesthesia after anterior glenohumeral joint dislocation. Phys Ther 69:lO6112, 1989 89. Snyder S), Karzel RP, DelPizzo W, Ferkel JF: Slap lesions of the shoulder. Arthroscopy 6374 -279, 1990 90. Soslowsky LJ, Flatow EL, Bigliani LU, Mow VC: Articular geometry of the glenohumeral joint. Clin Orthop 285: 181-190, 1992 91. Soslowsky LJ, Flatow EL, Bigliani LU, Pawluk RJ, Ateshian GA, Mow VC: Quantitation of in situ contact areas at the glenohumeral joint: A biomechanical study. J Orthop Res 10:524535, 1992 92. Speer KP: Anatomy and pathomechanics of shoulder instability. Oper Tech Sports Med 1:252-255, 1993 93. Speer KP, Deng X, Borrero S, Torzilli PA, Altcheck DW, Warren RF: A biomechanical evaluation of the Bankart lesion. J Bone Joint Surg (Am), 1994 (in press) 94. Spew KP, Garrett WE: Muscular control of motion and stability about the pectoral girdle. In: Matsen FA, Fu FH, Hawkins R (eds), The Shoulder: A BalJ ance of Mobility and Stability, pp 162164. Rosemont, IL: American Academy Orthopaedic Surgeons, 1993 95. Steindler A: Kinesiology of Human Body Under Normal and Pathological Conditions, Springfield, IL: Charles C. Thomas, 1955 96. Tearse DS, Robinson A, Koch B, Callaghan JJ, Brand RA: Mechanoreceptors in human shoulder capsule and labrum. Presented at the annual meeting of the American Orthopaedic Society, New Orleans, LA, February, 1994 97. Terry GS, Hammon D, France P, Norwood LA: The stabilizing function of passive shoulder restraints. Am J Sports Med 1 9:26 -34, 1 99 1 98. Townley CO: The capsular mechanism in recurrent dislocation of the shoulder. ) Bone Joint Surg 32A:370380, 1950 99. Turkel S), Panio MW, MarshallJL, Girgis FG: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg 63A:1208-1217, 1981 100. Vanderhooft E, Lippett S, Harris S, Sidles J, Harryman DT, Matsen FA: Glenohumeral stability from concavity-compression: A quantitative analysis. Orthop Trans l6:774, 1992 (abstract) 101. Vangsness CT, Ennis M : Neural anatomy of the human shoulder ligaments and glenoid labrum. Presented at the annual meeting of the American

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LITERATURE

REVIEW

Academy of Orthopaedic Surgeons, Washington, DC, February, 1992 Voight ML, Harden ]A, Blackburn TA: The effects of muscle fatigue on the relationship of arm dominance to shoulder proprioception. Orthop Sports Phys Ther 23:348-352, 1996 Warner JJP,Deng XP, Warren RF, Torzilli PA: Static capsular ligamentous constraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 20:675- 685, 1 992 Warner JJP, Micheli LJ, Arslanian LE, Kennedy I, Kennedy R: Scapulothorack motion in normal shoulders and shoulders with glenohumeral instability and impingement: A study using Moire topographic analysis. Clin Orthop 28.5:1 9 1- 1 99, 1 992 Warren RF: Anterior shoulder instability: Arthroscopic stabilization capsular repair. Presented at Controversies in Arthroscopy and Sports Medicine, Bermuda, August, 1990 Warren RF: Shoulder instability. Presented at the American Sports Medicine Institute Distinguished Lecture, Birmingham, AL, March, 1994 Warren RF, Kornblatt IS, Morehand R: Static factors affecting posterior shoul-

der stability. Orthop Trans 8239-93, 1984 Wickiewicz TL, Chen SK, Otis JC, Warren RF: Glenohumeral kinematics in a muscle fatigue model: A radiographic study. Presented at the 1994 Specialty Day meeting, American Orthopaedic Society for Sports Medicine, New Orleans, LA, February, 1994 Wiley AM: Arthroscopy for shoulder instability and a technique for arthroscopic repair. Arthroscopy 1:250-330, 1988 Wilk KE: Current concepts in the rehabilitation of athletic shoulder injuE ries. In: Andrews JR, Wilk K (eds), The Athlete's Shoulder, New York: Churchill Livingstone, 1994 1 1 1. Wilk KE, ~ r r i g oAn integrated ap~ ~ : proach to upper extremity exercises. Orthop Phys Ther Clin North Am 9:337-360, 1992 1 12. Wilk KE, Arrigo CA: Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther 18:365-378, 1 993 113. Wilk KE, Arrigo CA, Andrews JR, Keirns MA, Erber DA: The strength characteristicsof internal and external muscles in professional baseball

pitchers. Am J Sports Med 2 1:6 1- 66, 1993 Wilk KE, Fleisig GS, Escamilla RF, Andrew JR: The electromyographic activity of the shoulder muscles during various exercises, 1994 (unpublished data) Wilk KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman CJ: Stretch-shortening drills for the upper extremities: Theory and clinical application. J Orthop Sports Phys Ther 17: 225-239, 1993 Williams PL, Warwick R: Gray's Anatomy (36th Ed, British), Philadelphia: W.B. Saunders Company, 1986 Wuelker N, Brewe F, Sperveslage C: Passive glenohumeral joint stabilization: A biomechanical study. J Shoulder Elbow Surg 3:129- 134, 1994 1 18. Wuelker N, Wirth CJ,Plitz W, Roetman B: A dynamic shoulder model: Reliability testing and muscle force study. Biomech 28(5):489-499, 1995 1 19. Zarins B, Rowe CR: Current concepts in the diagnosis and treatment of shoulder instability in athletes. Med Sci Sports Exerc 16(15):444-448, 1 984

JOSPT Volume 25 Number 6 June 1997