J Shoulder Elbow Surg (2014) 23, 1136-1142

www.elsevier.com/locate/ymse

The role of pectoralis major and latissimus dorsi

muscles in a biomechanical model of massive rotator
cuff tear
Sean T. Campbell, BSa, Kier J. Ecklund, MDa,b, Eileen H. Chu, MDa,
Michelle H. McGarry, MSa, Ranjan Gupta, MDa,b, Thay Q. Lee, PhDa,b,*
a
b

Orthopaedic Biomechanics Laboratory, VA Healthcare System, Long Beach, CA, USA

Department of Orthopaedic Surgery, University of California, Irvine, Irvine, CA, USA
Background: Superior migration of the humeral head after massive rotator cuff tear (mRCT) is thought to
lead to cuff tear arthropathy. Previous biomechanical studies have demonstrated the ability of the pectoralis
major and latissimus dorsi (PM/LD) muscles to resist this migration. This study examined the role of PM/
LD muscles on glenohumeral joint forces and acromiohumeral contact pressures in a mRCT model.
Methods: Six cadaveric shoulders were tested using a custom shoulder-testing system. Muscle insertions
of the rotator cuff, deltoid, and PM/LD were preserved and used for muscle loading. Specimens were tested
in 3 different humeral rotation positions at 0
abduction and 2 rotation positions at 60
abduction. Testing
was performed for intact specimens, after supraspinatus removal, and after supraspinatus/infraspinatus/
teres minor removal. PM/LD were loaded or unloaded to determine their effect. Humeral head kinematics,
glenohumeral joint forces, and acromiohumeral contact area and pressure were measured.
Results: For the mRCT condition at 0
abduction, unloading the PM/LD resulted in superior shift of the
humeral head. Acromiohumeral contact pressures were undetectable when the PM/LD were loaded but
increased significantly after PM/LD unloading. After mRCT, superior joint forces were increased and
compressive forces were decreased compared with intact; loading the PM/LD resolved these abnormal
forces in some testing conditions.
Conclusion: In mRCT, the PM and LD muscles are effective in improving glenohumeral kinematics and
reducing acromiohumeral pressures. Strengthening or neuromuscular training of this musculature, or both,
may delay the progression to cuff tear arthropathy.
Level of evidence: Basic Science Study, Biomechanics.
2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Massive rotator cuff tear; rotator cuff tear arthropathy; latissimus dorsi; pectoralis major; acromiohumeral pressure

Institutional Review Board approval was not required for this basic science
study.
*Reprint requests: Thay Q. Lee, PhD, Orthopaedic Biomechanics
Laboratory, VA Long Beach Healthcare System (09/151), 5901 E 7th St,
Long Beach, CA 90822, USA.
E-mail address: tqlee@med.va.gov (T.Q. Lee).

Cuff-tear arthropathy (CTA), as originally described by

Neer,21 involves subacromial impingement of the humeral
head, acetabularization of the acromion, and glenoid
erosion after a massive tear of the rotator cuff.4,5,20 These
sequelae are thought to be caused by the loss of stabilizing
compressive forces across the glenohumeral joint after a

1058-2746/$ - see front matter 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2013.11.030

Pectoralis and latissimus in cuff tear

massive cuff tear, followed by superior migration of the
humeral head in the direction of deltoid pull.4,5,15,19-21
The term massive rotator cuff tear (mRCT) is often
defined as a tear involving the detachment of at least 2 cuff
muscle tendons, most commonly the infraspinatus and
supraspinatus (SS).9 Radiographic features of CTA include
superior migration of the humeral head, narrowing of the
glenohumeral joint space, and occasionally, degenerative
changes to adjacent bony structures such as the clavicle or
coracoid process.5,12,15,20 Clinical symptoms include pain,
loss of motion, weakness, and swelling of the affected
joint.5,15,20 Treatment of such pathology has traditionally
included hemiarthroplasty6,21,26,27; more recently, reverse
total shoulder arthroplasty has shown promising clinical
and biomechanical results.1,8,14,16,22,25
Previous biomechanical studies have identified the
important role of the rotator cuff and shoulder muscles as
stabilizers of the glenohumeral joint.2,3,11,18,23,24,28 One
biomechanical study by Halder et al11 found that the latissimus dorsi (LD) is the most effective depressor of the
humeral head, and others have shown by electromyography
(EMG) that activation of the LD and teres major is
increased after a mRCT.13 Another biomechanical study
demonstrated that tears of the SS and infraspinatus muscles
result in superior shift of the humeral head and that loading
of the pectoralis major (PM) and LD (PM/LD) muscles
plays a role in reducing this elevation.23 Other work has
shown that the subscapularis is an important stabilizer and
the most powerful of the rotator cuff muscles.17,29 Subscapularis function has been shown to be especially
important in shoulders undergoing LD transfer for large
cuff tears, where a deficiency results in an uncentered humeral head and poor clinical outcome.10,30
Although previous work has described the importance of
the PM/LD muscles in resisting superior migration of the
humeral head, no biomechanical studies to date have
evaluated the role of these muscles on acromiohumeral
contact pressure and glenohumeral joint forces after mRCT,
including the degree to which loading of this musculature
alters such biomechanical properties. The purpose of this
study was to examine the biomechanics of mRCT and the
role of the PM/LD muscles in a cadaveric model, including
measurement of kinematics, acromiohumeral contact pressures, and glenohumeral joint forces.

Materials and methods

Specimen preparation
The study used 6 fresh frozen cadaveric shoulders from male
donors (average age, 79.3 years; range, 76-85 years) with no evidence of musculoskeletal pathology. Specimens were dissected
free of overlying skin and soft tissue while preserving the insertions of the rotator cuff, deltoid, PM, and LD muscles as well as
the coracoacromial and coracohumeral ligaments and the long
head of the biceps tendon. The glenohumeral joint capsule was

1137

Figure 1 Photograph shows a specimen mounted to the custom

testing system after the creation of a supraspinatus lesion.
also resected to eliminate its effect on joint forces and humeral
head kinematics at the various positions tested.
A modified Kessler stitch was used to tie No. 5 Ethibond suture
(Ethicon, Somerville, NJ, USA) to each muscle insertion. Each
scapula and corresponding humerus were placed in a custom
aluminum testing box and section of polyvinyl chloride pipe,
respectively; care was taken to keep the glenoid surface parallel to
the top opening of the box and the humerus centered in the pipe
with the long axis of the humeral shaft parallel to the side of the
pipe. The scapula and humerus were secured within their containers using plaster of Paris. Specimens were kept moist with
0.9% normal saline during all phases of testing.

Biomechanical testing
After preparation, specimens were mounted to a custom shouldertesting system (Fig. 1). The testing system allowed the glenohumeral joint to be positioned with 6 degrees of freedom and for
muscle loading using LabVIEW (National Instruments, Austin, TX,
USA) controlled pneumatic cylinders. The rotator cuff muscles
(subscapularis, SS, and infraspinatus/teres minor) were loaded with
40 N, the deltoid was loaded with 80 N or 40 N, and the PM/LD
were loaded with 40 N or left unloaded. These parameters were
similar to those used in previous work and allowed multiple loading
conditions for the deltoid and PM/LD to be tested with reproducible
results.23,24 The teres minor and infraspinatus were loaded in a
combined fashion due to their similar function and orientation.
Glenohumeral joint forces in the anterior-posterior, superiorinferior, and medial-lateral directions were measured using a
multiaxis load cell (Assurance Technologies, Garner, NC, USA).
Joint force was normalized by calculating force as a percentage of
the resultant. Humeral kinematics were measured using a Microscribe 3DLX system (Revware Inc, Raleigh, NC, USA) by digitizing 3 constant points on the humerus and scapula under each
testing condition, followed by digitization of the humeral head and
glenoid geometry. Acromiohumeral contact pressure and area
were measured using a Tekscan 4000 (Tekscan Inc, South Boston,
MA, USA) pressure measurement system inserted between the
acromion and the superior aspect of the humeral head. All data
were recorded twice to ensure repeatability.
Testing was carried out in the following positions: 0
abduction-60
external rotation, 0
abduction-0
external rotation,

1138

S.T. Campbell et al.

Figure 2 Histogram demonstrates the effect of pectoralis (PM)/latissimus dorsi (LD) unloading on humeral head apex position for the
massive rotator cuff tear condition with 80 N and 40 N deltoid loads. P values are shown overlying the corresponding data; all shifts
displayed are significant. The error bars represent standard error of the mean. ER, external rotation; IR, internal rotation.
0
abduction-30
internal rotation, 60
abduction-90
external
rotation, and 60
abduction-30
external rotation. These were
meant to represent a range of functional anatomic positions at the
waist and overhead level. This was repeated for (1) intact specimens, (2) after removal of the SS muscle (SS tear), (3) and after
removal of the SS/infraspinatus/teres minor muscles (mRCT).

Data analysis
A repeated measures analysis of variance was used for statistical
analysis to compare the 3 cuff conditions: intact, SS tear, and
mRCT. A paired Student t test was used to evaluate the differences
between biomechanical data collected under different muscleloading conditions.

Results
Humeral head position
When the PM/LD were unloaded in the SS tear condition, a
significant superior shift of the humeral head occurred
when 80 N deltoid loads were applied (P < .05), but not
with 40 N deltoid loads. When the PM/LD were unloaded
in the mRCT condition, a significant superior shift of the
humeral head occurred under all testing conditions at
0
abduction (Fig. 2). In all but 1 of the 12 conditions tested
at 0
abduction, creation of a mRCT resulted in a significant superior shift of the humeral head compared with the
intact condition (P < .05).

Acromiohumeral contact pressure and area

For the SS tear condition, acromiohumeral contact pressure
and area were not measurable under most of the conditions.
For the mRCT condition at 0
abduction, no acromiohumeral contact pressure or area were recorded at any
rotation position when PM/LD were loaded. When PM/LD
were unloaded, significantly increased mean and peak
acromiohumeral contact pressure and decreased contact
area were observed with 80 N deltoid loads (Fig. 3, A-C).

Glenohumeral joint forces

Superior glenohumeral joint forces increased significantly
from the PM/LD loaded to PM/LD unloaded state under all
conditions tested (Table I). Compressive forces decreased
from the PM/LD loaded to the PM/LD unloaded state under
80 N deltoid loads but not under 40 N deltoid loads (Table II).
No difference in superior glenohumeral joint forces was
observed after creation of the SS tear at 0
abduction
compared with intact. Creation of a mRCT significantly
increased superior glenohumeral joint forces compared with
intact under all but 1 testing condition at 0
abduction. At
60
abduction, creation of the SS lesion resulted in significantly different superior forces compared with intact in 4 of
the 8 conditions tested, which increased to 6 of 8 after
creation of the mRCT lesion (Table I). Creation of an SS
tear alone did not significantly alter compressive forces, but
mRCT resulted in significantly decreased force compared
with intact in 15 of the 20 conditions tested (Table II).

Discussion
This biomechanical study evaluated the role of the PM/LD
muscles on humeral head translation, glenohumeral joint
forces, and acromiohumeral contact pressure in the setting
of a mRCT. After the creation of a mRCT, we found significant superior shifts of the humeral head, increased superior and decreased compressive glenohumeral joint
forces, and elevated acromiohumeral pressures, especially
at 0
glenohumeral abduction. When the PM/LD were
loaded after injury, the humerus did not exert pressure
against the acromion at these positions.
A recent study by Hawkes et al13 used EMG to evaluate
shoulder muscle activation after mRCT. EMG results from
13 shoulder muscles during arm elevation were compared in
13 healthy volunteers and 11 patients with a mRCT
involving at least 2 tendons. The authors found increased
signal amplitude in multiple shoulder muscles, including the

Pectoralis and latissimus in cuff tear

1139

Figure 3 Histogram shows (A) mean acromiohumeral contact pressure, (B) peak acromiohumeral contact pressure, and (C) acromiohumeral contact area with 80 N deltoid loads and unloaded pectoralis major/latissimus dorsi at different shoulder positions in the intact
condition and after creation of a massive rotator cuff tear (mRCT) by removal of the supraspinatus/infraspinatus/teres minor muscles.
P values are shown overlying the data, with boldface values representing a significant change. The error bars represent standard error of the
mean. ER, external rotation; IR, internal rotation.

LD, in patients with mRCT and also identified a correlation

between deltoid and LD activation. They went on to suggest
increased activation of the LD results from an attempt to

stabilize the humeral head and limit superior translation.13

Although the current study did not isolate the PM from
the LD when muscle loading was tested, we did demonstrate

1140
Table I

S.T. Campbell et al.

Superior glenohumeral joint forcesdpercentage of resultant)

Variable

80 N deltoid

40 N deltoid

40 N PM/LD

PM/LD unloaded

40 N PM/LD

PM/LD unloaded

11.9  2.8
13.1  3.3
19.0  4.0y,z

39.6 3.4
44.7 3.6
64.7 6.7y,z

4.7  2.3
6.8  4.1
0.8  5.6

13.3 3.2
18.3 5.2
32.1 6.5y,z

12.7  2.6
15.4  3.7
29.6  4.2y,z

39.1 2.8
42.0 2.4
71.8 5.8y,z

4.7  2.0
3.5  4.6
12.0  7.3y,z

11.8 2.8
16.7 5.2
41.4 5.6y,z

13.0  2.0
14.4  3.1
26.3  4.7y,z

31.4 2.6
39.6 3.2
68.8 8.6y,z

3.2  2.1
5.8  2.7
22.2  7.2y,z

8.4 2.0
12.4 5.8
44.3 5.1y,z

7.4  1.8
7.0  2.1
9.4  2.1

22.6 2.2
26.0 2.1y
37.2 2.4y,z

3.4  1.8
7.5  1.9y
7.0  2.1y

9.8 2.4
8.7 2.5
18.3 2.9y,z

9.2  1.6
8.8  2.1
16.4  2.6y,z

22.4 2.0
26.3 2.1y
43.1 3.0y,z

1.4  1.7
4.9  2.1y
0.2  3.0z

9.2 2.3
9.1 3.0
27.6 4.3y,z

0 Abduction, 60 ER
Intact
SS tear
mRCT
0
Abduction, 0
rotation
Intact
SS tear
mRCT
0
Abduction, 30
IR
Intact
SS tear
mRCT
60
Abduction, 90
ER
Intact
SS tear
mRCT
60
Abduction, 30
ER
Intact
SS tear
mRCT

ER, external rotation; IR, internal rotation; mRCT, massive rotator cuff tear; PM/LD, pectoralis major/latissimus dorsi; SS, supraspinatus.
) Data are expressed as the mean percentage (%) of resultant  standard error of the mean. The boldface data represent a significant difference
(P < .05) between the PM/LD loaded and unloaded conditions under equivalent deltoid loads.
y
Significantly different (P < .05) from intact under same loading conditions.
z
Significantly different (P < .05) from SS tear under same loading conditions.

that combined loading of the PM/LD decreases superior

humeral head translation and acromiohumeral pressure.
Previous biomechanical work has addressed the contribution of individual muscles to shoulder stability in the setting of
superior decentralization of the humerus. One cadaveric model
that used intact specimens under constant superior force found
the LD was the most effective depressor of the humerus,
especially with the arm hanging. With shoulder abduction, the
LD maintained a role in depression initially but became
increasingly important in glenohumeral compression.11 Our
findings demonstrated the capacity of the LD, in combination
with the PM, for depression of the humeral head after superior
migration. The compressive effect of the PM/LD was also
observed: PM/LD loading after mRCT restored compressive
glenohumeral joint forces to the intact state in many testing
conditions at neutral or externally rotated shoulder positions.
Another recent biomechanical study evaluated the progression of rotator cuff injuries and the involvement of the
PM/LD. Using a cadaveric model, the authors sequentially
created and tested 4 different stages of rotator cuff injury,
beginning with a partial SS tear and culminating with tear of
the entire SS and infraspinatus.23 Tear of the entire SS
significantly altered glenohumeral rotational range of motion
and abduction capacity, whereas progression to a tear
involving half of the infraspinatus resulted in a shift of the
humeral head. The authors also demonstrated restoration of
humeral head kinematics with PM/LD loading and suggested

the use of rehabilitation in nonoperative management of patients with RCTs. In the current study, we identified superior
shift of the humeral head with SS lesions alone at some
testing positions, but found that combined SS and infraspinatus tears resulted in superior translation during all but 1
testing condition at 0
abduction. SS tears alone also had
minimal effect on glenohumeral joint forces and acromiohumeral contact pressures, but combined tears resulted in
decreased glenohumeral joint forces and increased acromiohumeral contact pressures, which had previously not been
measured and only assumed secondary to superior migration.
The change in glenohumeral joint forces was similar
regardless of arm position in the PM/LD unloaded conditions.
Acromiohumeral contact pressures were most often elevated
in neutral or internal rotation; this is consistent with radiographic studies demonstrating movement of the greater tuberosity directly beneath the acromion with internal rotation.7 We
also demonstrated that loading the PM/LD resulted in improved
glenohumeral kinematics and resolution of the increased
acromiohumeral pressures seen after mRCT, suggesting that
rehabilitation of the PM/LD in patients with mRCT may help
decrease pressure and slow the progression to CTA.
We acknowledge several limitations of this study. The
cadaveric nature of the RCT model means that physiologic
factors, such as neuromuscular coordination and shoulder
pain, that may play a role in glenohumeral biomechanics
after mRCT in patients could not be studied.

Pectoralis and latissimus in cuff tear

1141

Table II

Compressive glenohumeral joint forcesdpercentage of resultant)

Variable

80 N Deltoid

40 N Deltoid

40 N PM/LD

PM/LD unloaded

40 N PM/LD

PM/LD unloaded

98.9  0.4
98.7  0.4
97.5  0.6y,z

91.3 1.3
88.8 1.8
72.8 6.1y,z

99.7  0.2
99.3  0.3
99.0  0.4

98.7  0.4
97.5  1.0
92.9  2.3y,z

98.8  0.3
98.1  0.4
94.9  1.2y,z

91.2 1.0
90.0 2.2
66.4 6.5y,z

99.6  0.2
99.2  0.3
97.8  1.3

98.8  0.3
97.5  0.9
89.9  2.5y,z

98.5  0.2
98.0  0.3
95.3  1.2y,z

93.8 0.7
90.2 1.2
66.3 8.0y,z

99.6  0.2
99.4  0.2
95.7  1.3y,z

99.0  0.3
97.7  0.7
88.3  2.6y,z

99.6  0.1
99.6  0.2
99.3  0.2z

97.1 0.4
96.3 0.5
92.4 0.9y,z

99.8  0.1
99.6  0.2
99.5  0.1

99.2  0.2
99.3  0.1
97.9  0.5y,z

99.3  0.2
99.3  0.2
98.4  0.4y,z

97.0 0.5
96.0 0.5
89.7 1.4y,z

99.8  0.1
99.6  0.1
99.7  0.1

99.2  0.2
99.1  0.3
95.4  1.3y,z

0 Abduction, 60 ER
Intact
SS tear
mRCT
0
Abduction, 0
rotation
Intact
SS tear
mRCT
0
Abduction, 30
IR
Intact
SS tear
mRCT
60
Abduction, 90
ER
Intact
SS tear
mRCT
60
Abduction, 30
ER
Intact
SS tear
mRCT

ER, external rotation; IR, internal rotation; mRCT, massive rotator cuff tear; PM/LD, pectoralis major/latissimus dorsi; SS, supraspinatus.
) Data are expressed as mean percentage of resultant (%)  standard error of the mean. The boldface data represent a significant difference (P < .05)
between the PM/LD loaded and unloaded conditions under equivalent deltoid loads.
y
Significantly different (P < .05) from intact under same loading conditions.
z
Significantly different (P < .05) from SS tear under same loading conditions.

In addition, the testing system was not capable of

reproducing scapulothoracic motion, meaning that the
movement permitted by our system represented a simplified
version of true in vivo scapular motion. Also, although
resection of the capsule allowed for isolated evaluation of
the cuff muscles and the PM/LD at the various positions
tested, it also represented a simplification of the in vivo
state. However, testing was not performed in certain positions (maximum internal or external rotation) at which the
lack of a capsule might dramatically alter joint biomechanics from the in vivo state.
Our study did not attempt to evaluate deficiency of the
subscapularis or the effect of PM/LD loading in the absence
of subscapularis function because we chose to focus on
loading/unloading of the humerothoracic musculature. Previous biomechanical work by Werner et al30 evaluated the
effect of subscapularis loading on cadaveric specimens that
underwent LD transfer after the creation of a mRCT.
That study showed significantly altered humeral head
translation and rotation when the subscapularis was not
loaded, especially in the neutral and abducted/externally
rotated positions.30 Clinical studies have corroborated this
conclusion, including a study by Gerber et al10 that demonstrated no clinical improvement after tendon transfer in
patients with a subscapularis deficiency. Future studies
evaluating the role of the subscapularis in massive cuff tears
and its contribution to the prevention of CTA are indicated,

especially given its previously demonstrated importance in

the setting of LD transfer.
Another limitation of our study is that loading of the PM/LD
was done in combined fashion; controlling the load of these
muscles individually in future studies may provide valuable
information regarding their individual role in the prevention of
CTA. Future work could also include an evaluation of the teres
major because it has a similar orientation and function.
Finally, RCTs in this study were created in a controlled
environment with surgical tools. This is not the mechanism
of injury causing RCTs in patients, and these laboratorygenerated lesions may not have been completely accurate
representations of patient pathology.

Conclusion
In this biomechanical model, SS tears alone produced
superior translation of the humeral head at some
shoulder positions. When a massive tear was created,
this superior translation increased, and increases in superior glenohumeral joint forces and acromiohumeral
pressures were also observed. Loading of the PM and
LD muscles resulted in improved glenohumeral kinematics and joint forces and decreased acromiohumeral
pressures. These findings may lend weight to previous

1142
literature suggesting that treatment focusing on rehabilitation of this musculature may decrease acromiohumeral contact pressures in patients with mRCTs and
may help in delaying the progression to CTA.

S.T. Campbell et al.

13.

14.

Disclaimer
Funding was provided by Veterans Affairs Rehabilitation Research and Development Merit Review. The
funding source did not play a role in the investigation.
The authors, their immediate families, and any
research foundations with which they are affiliated have
not received any financial payments or other benefits from
any commercial entity related to the subject of this article.

15.
16.

17.

18.

19.

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