J Shoulder Elbow Surg (2009) 18, 386-390

www.elsevier.com/locate/ymse

The anatomy of the deltoid insertion

Damian M. Rispoli, MD*, George S. Athwal, MD, John W. Sperling, MD,
Robert H. Cofield, MD

The Mayo Clinic, Rochester, MN

Hypothesis: The deltoid muscle is in continuity with the distal arm fascia and musculature.
Materials and methods: Ten fresh-frozen upper extremity cadaveric specimens were dissected to deter-
mine the insertional anatomy of the deltoid muscle. Measurements were made with micro-calipers and
acetate grid sheets. The deltoid tendon and fibrous aponeurosis was in continuity with the lateral intermus-
cular septum posteriorly and the lateral aspect of the brachialis and deep brachial fascia anteriorly in all
ten specimens. This interconnection remained in continuity following complete release of the deltoid
insertion.
Results: The width of the insertion of the anterior head of the deltoid was a mean of 7.3 mm, the middle
averaged 4.7 mm, and the posterior averaged 7.8 mm. The mean length of the anterior insertion was
70 mm, the middle was 48.4 mm, and the posterior was 63.4 mm. The mean width of the deltoid tendon
and the investing fascia at the superior margin of the insertion was 21.9 mm and at the inferior margin
13.1 mm.
Discussion: Deltoid muscle integrity is critical to shoulder function. The deltoid insertion, however, is
often partially released during surgical approaches for internal fixation of proximal humerus fractures
and shoulder arthroplasty. Partial detachment without repair as performed during surgical approaches
should not result in complete loss of continuity of the deltoid insertion.
Conclusion: Knowledge of the distal insertion and interconnections of the deltoid allows for more
anatomic repair following extended releases during complex fracture fixation or revision surgery.
Level of evidence: Basic science study.
Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Shoulder; anatomy; deltoid; shoulder arthroplasty; fracture; humerus

It has been noted that preservation of anterior deltoid
function is critical to the success of shoulder arthroplasty3;
however, during fracture fixation and shoulder arthroplasty,
the anterior aspect of the insertion is often released. Various
amounts of release have been suggested to obtain adequate
exposure for humeral plating.10,13 Some authors have
*Reprint requests: LtCol Damian M Rispoli, MD, Wilford Hall
Medical Center, 59ORS/SGOYO, 2200 Bergquist Drive, Suite 1, Lackland
AFB, TX 78236-5300.
E-mail address: damian.rispoli@lackland.af.mil (D.M. Rispoli).
advocated alternative approaches to prevent this potential
complication.4,6,7 Notably, sub-periosteal release of the
deltoid insertion has been performed for deltoid contracture
without measurable decrement in deltoid function.2 The
investing fascia of the deltoid has been noted to contribute
to the brachial fascia in continuity with both the medial and
lateral intermuscular septii. The tendon itself has also been
shown to give off extensions to the brachial deep fascia,
which can extend to the forearm. Distal interconnection of
the deltoid and pectoralis major insertion has been docu-
mented.12 Our experience in humeral fractures has revealed

1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2008.10.012
Anatomy of deltoid insertion
Figure 1 Pictorial representation of the partial release of the
anterior deltoid used to enhance glenoid exposure in total shoulder
arthroplasty.
strong interconnections requiring division between the
insertion of the deltoid and both the arm fascia and
surrounding musculature. Additionally, we have bluntly
released portions of the anterior insertion for improved
exposure in shoulder arthroplasty (Figure 1). The purpose
of this study was to evaluate the gross anatomy of the
deltoid insertion and determine its relationship with both
the investing fascia of the arm and the distal musculature.
Materials and methods
Ten fresh-frozen cadaveric specimens, consisting of the entire
upper extremity from the medial border of the scapula to the
fingers, were obtained with institutional review board approval
through our tissue repository. There were 7 female and 3 male
specimens. The average age was 84 years (range, 57-98). Four
specimens were of the left and 6 of the right side. No specimen
had prior history of significant trauma or previous upper extremity
387
Figure 2 Posterior margin of the deltoid in continuity with the
lateral intermuscular septum.
Figure 3 Deltoid detached from its proximal origin and released
from its insertion distally. Its continuity with distal arm is shown
to be intact.
surgery. The skin and subcutaneous tissue from the level of the
medial scapula to the proximal forearm was removed. The deltoid
muscle was delineated from its origin to its insertion, with care not
to disturb the fascial interconnections of the muscle distally
(Figure 2). The insertion was left attached to the lateral humerus.
The deltoid was then detached from its origin on the clavicle,
acromion, and scapular spine. The planes dividing the anterior,
middle, and posterior deltoid were identified and marked. The
axillary nerve was transected at the level of the quadrilateral space
to allow full proximal to distal retraction of the muscle. The
pectoralis major tendon was identified and traced to its insertion
on the humeral shaft.
The deltoid was then released from its insertion on the humeral
shaft and the insertions measured (Figure 3). The length and width
of each insertion was recorded (Figure 4). All measurements were
made with the use of micro calipers (General Tools, New York,
NY). The tendon footprint was measured by sharply incising the
tendon and marking the insertion with a permanent, ultra-fine
tipped marker. The marked area was measured by laying an
388
Figure 4 Deltoid shown released from both is proximal origin
and its distal insertion. Measurement of the insertion as shown.
acetate grid sheet over the deltoid insertion and counting the
number of 1 x 1-mm squares occupied by the marked area. The
measurements were repeated 3 times by the same investigator for
accuracy. The connections from the deltoid fascia were then
D.M. Rispoli et al.
inspected and followed distally. The deltoid, with its distal
connections, was then reflected from the humerus and the
macroscopic appearance recorded. Specifically, the characteristics
and presence of interconnections of the anterior and posterior
aspects of the deltoid and its insertion to the brachialis fascia
anteriorly and lateral intermuscular septum posteriorly were
recorded. The distance from the medial epicondyle to the superior
tip of the greater tuberosity was measured for comparison of the
specimen size.
Institutional Review Board approval: IRB# 2611-04 Mayo
Clinic, Rochester, MN.
Results
Average humeral length was 306 mm (range, 280- 332). A
clearly definable separation between the anterior and
middle tendons of the deltoid was discernible macroscop-
ically in 5 of the 10 specimens. The mean width, length,
and area are noted in Table I. Five specimens were found to
have a grossly indefinable separation between the anterior
and middle insertions of the deltoid tendon and are recor-
ded as a dual insertion. Triple insertion denotes a grossly
definable separation into 3 discrete tendinous insertions.
The width at the superior border of the deltoid insertion
had a mean of 21.9 mm (range, 20-25). At the inferior
border, the mean insertion width was 13.1 mm (range,
12-14.5).
The width of the soft tissue bridge spanning from the
posterior connection to the lateral intermuscular septum to
the anterior fascia that remained in continuity with the
investing fascia of the brachialis was a mean of 24.5 mm
(range, 20-29.1). Nine of 10 specimens had a robust tissue
bridge spanning between the anterior and posterior fascial
connections (Figure 5). One specimen lacked the inter-
vening tissue, while still maintaining the robust anterior and
posterior fascial connections. All specimens had strong
proximal to distal continuity. The distal interconnections of
the deltoid tendon and its fascia with the lateral inter-
muscular septum and the brachialis remained in continuity
following release of the deltoid insertion (Figure 6).
The 3 tendons of the deltoid formed an arch-like
configuration at the insertion, with the tendon fibers of the
undersurface acting to restrain the adjacent tendon.
Detachment of the deltoid insertion and examination of the
undersurface revealed the arch-like configuration of the
tendon (Figure 7).
Discussion
The deltoid originates from the clavicle and the acromion
anteriorly, the acromion laterally, and the spine of the
scapula posteriorly. It is well documented that disruption of
the deltoid from its origin is a serious and often cata-
strophic problem.1,5,9,11 It has been hypothesized that the
Anatomy of deltoid insertion
Table I Mean (range) width, length, and area of the deltoid insertion.
Insertion [mean (range)]
Anterior
Width (mm)
All (10) 7.3 (4.2-11.5)
Dual (5) 9.2 (5.2-11.5)
Triple (5) 5.4 (4.2-7.3)
Length (mm) 70 (51-87)
Area (mm2)
All (10) 363 (212-586)
Dual (5) 424 (242-586)
Triple (5) 302 (212-414)
Dual denotes that the anterior and middle portions of the deltoid tendon inserted into a single portion of the deltoid tuberosity. Triple denotes a separate
insertion for anterior, middle, and posterior tendons.
Figure 5 The undersurface of the deltoid. The strong anterior
and posterior fascial connections and the intervening tissue bridge.
distal detachment of the anterior deltoid carries the same
dire prognosis.6 Preserving or reattaching the deltoid
insertion has been highlighted in various studies.1,5,11
Others have evaluated the deltoid insertion to ascertain the
cross-sectional footprint to guide detachment with respect
to compression plating.8 Our clinical and research experi-
ence, as well as that of others, reveals that the deltoid
inserts into a wide area on the lateral aspect of the humerus.
Klepps et al, in a cadaveric study, noted that release of
greater than 1/5 of the anterior deltoid insertion could
compromise the anterior deltoid.6 Their study did not
characterize the fascial interconnection of the deltoid to the
distal arm musculature. Our results specifically delineate
the deltoid tendon and the investing fascia as being in
continuity with the lateral intermuscular septum posteriorly
and blending with the lateral aspect of the brachialis and
brachial fascia anteriorly.
Morgan et al described the deltoid insertion as 3 tendons
inserting onto the humerus via a single broad insertion.8
Our macroscopic evaluation of the composition of the
deltoid insertion reveals that the tendon inserts onto the
humerus in 2 or 3 macroscopically discernable insertions
with clearly definable separation and an arch-like
389
Middle Posterior
7.8 (4.1- 13.5)
6 (4.3-7.3)
4.7 (2-7.3) 9.5 (4.1-13.5)
48.4 (39.5-55) 63.4 (56.2-87.5)
344 (212-677)
422 (303-677)
211 (131-343) 267 (131-374)
Figure 6 Deltoid and its interconnections detached from the
humerus. The robust character of the connections is shown.
configuration among the 3 converging musculotendinous
units. Subtotal release of the insertion theoretically prevents
loss of deltoid length through the arcade-like anatomy of its
multipennate muscular structure and the arch-like conflu-
ence of its tendon at the insertion. Lastly, even total release
of the deltoid insertion did not completely detach the
muscle from the distal arm tissues. The thickness of the
distal interconnections varied, with the posterior tissues
having a more robust appearance than the anterior tissues.
The microanatomy of the tissue connections was not
evaluated by this study, and no biomechanical testing was
performed to evaluate the strength of this tissue. Further
evaluation to delineate the relative strength of the deltoid
insertion and its interconnections would contribute further
to the understanding and the consequences of partial
release.
Although this study identified fascial connections of the
deltoid to the lateral intermuscular septum and the investing
fascia of the brachialis, we do not advocate complete
release of the deltoid insertion without repair. When indi-
cated, we do, however, partially release the anterior
390
Figure 7 The deltoid tendon at its insertion is shown on the left with the most robust insertion points occurring in three macroscopically
discernable areas. The arch-like configuration of the deltoid insertion is shown on the right.
insertion of the deltoid while maintaining the distal fascial
interconnections. In these circumstances, repair of the
anterior deltoid insertion is not absolutely required due to
the distal interconnections. In our experience, this has not
resulted in functional or cosmetic deficits. In cases where
the distal fascial interconnections are disrupted by trauma
or surgery, we recommend anatomic repair of even partial
anterior deltoid detachments.
In conclusion, the configuration of the deltoid tendon
and its distal fascial interconnections has been identified.
Knowledge of this anatomy enhances the surgeon’s ability
to obtain adequate exposure and perform anatomic repairs
without compromise to patient function or cosmesis.
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