Glenohumeral motion in patients with rotator cuff tears:
A comparison of asymptomatic and symptomatic
shoulders
Ken Yamaguchi, MD, Jerry S. Sher, MD, William K. Andersen, MD, Ralph Garretson, MD,
John W. Uribe, MD, Keith Hechtman, MD, and Robert J. Neviaser, MD, St Louis, Mo; Coral Gables
and Miami, Fla; and Washington, DC
The purpose of this study was to determine whether there
was a relationship between altered scapular plane gleno-
humeral kinematics end shoulder pain. Subjects were divid-
ed into 3 groups: normal volunteers (n = 10), patients with
symptomatic rotator cuff tears severe enough to warrant
surgery (n = 10), and subjects with no symptoms who had
tears documented on magnetic resonance imaging and
normal examination (n = 10). Humeral kinematics were
observed with a computer-enhanced modification of the
Poppen and Walker technique. Scapular plane x-ray films
were obtained at 0, 30, 60, 90, 120, and 150 of ing active elevation in subjects with rotator cuff tears,
elevation. Measurements were made by 3 independent
observers blinded to the diagnosis, and data interpretation
was performed based on mean values for independent
observers. Results showed a high degree of interobserver
and intraobserver reliability (coefficients = 0.96 and 0.95,
respectively). The symptomatic and asymptomatic groups
showed progressive superior translation of the humeral
head on the glenoid with increasing arm elevation. The
normal group, in contrast, maintained a constant center of
rotation along the geometric center of the glenoid. Sympto-
matic and asymptomatic rotator cuff tear groups showed
superior head migration from 30 to 150, which was sig-
nificantly different from those seen in the normal group. No
significant difference between the symptomatic and asymp-
tomatic groups was demonstrated with the small numbers
used in this study. The presence of a rotator cuff tear was
associated in a disruption of normal glenohumeral kinemat-
ics in the scapular plane. Because significant superior
From the Shoulder and Elbow Service, Department of Orthopaedic
Surgery, Washington University School of Medicine, St Louis,
Mo; Orthopedic Specialists of Miami Beach; the Department of
Orthopaedic Surgery, George Washington University School of
Medicine, Washington, DC; and the Department of Orthopaedic
Surgery, University of Miami, Coral Gables, Fla.
Reprint requests: Ken Yamaguchi, MD, Washington University
School of Medicine, Shoulder and Elbow Service, Department
of Orthopaedic Surgery, One Barnes-Jewish Hospital Plaza,
Suite 11300 West Pavilion, St Louis, MO 63110.
Copyright 2000 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2000 $12.00 + 0 32/1/101011
6
migration of the humeral head was seen in both the asymp-
tomatic and symptomatic rotator cuff groups, painless and
normal shoulder motion is possible in the presence of
abnormal glenohumeral kinematics. Abnormal glenohumer-
al kinematics alone was not an independent factor, which
could explain the occurrence of symptoms. (J Shoulder
Elbow Surg 2000;9:6-11.)
P revious studies of shoulder kinematics have shown
abnormal superior migration of the humeral head dur-
impingement, or fatigue of the shoulder muscula-
ture.1,2,12,16,18,19 In normal shoulders the geometric
center of the humeral head remained centered on the
glenoid during scapular plane abduction.2,12,16,19
Some authors have suggested that abnormal kinemat-
ics in these individuals with rotator cuff tears may pre-
cipitate shoulder symptoms.1,12,19 However, some full-
thickness cuff tears are associated with normal motion
and no pain.7,9,11,17
The purpose of this study was to determine whether
there was a relationship between altered glenohumeral
kinematics and shoulder pain. With a modification of
the technique described by Poppen and Walker,12 we
compared scapular planar glenohumeral motion in nor-
mal volunteers with that in subjects with asymptomatic
full-thickness rotator cuff tears and subjects with symp-
tomatic cuff tears.
MATERIAL AND METHODS
Clinical
Research subjects evaluated in this study were divided
into 3 groups. The first group consisted of 10 subjects with
clinically normal shoulders. There were 5 women and 5
men 20 to 29 years of age with no history of shoulder
injury or shoulder pain, a normal physical examination,
and no evidence of ligamentous laxity or instability on stan-
dardized examination.
Group 2 consisted of 10 volunteers who had complete-
ly asymptomatic shoulders despite the presence of full-thick-
ness rotator cuff tears. These patients had been previously
described as research subjects detected during a study on
the prevalence of asymptomatic rotator cuff tears.1 All had
full-thickness tears of the rotator cuff diagnosed by mag-
J Shoulder Elbow Surg
Volume 9, Number 1
netic resonance imaging (MRI). None of them showed evi-
dence of atrophy of shoulder musculature, tenderness, or
loss of motion or strength on standardized examination. In
addition, all were specifically examined for impingement,
drop-arm, and apprehension signs.
The third group of 10 patients had symptomatic full-
thickness rotator cuff tears diagnosed by arthrogram or
MRI. All of these patients were examined and treated by
the senior author (RJN). Each of these patients had painful
arcs of motion significant enough to warrant surgical con-
sideration. Every patient in this group had sufficient
strength for full elevation but had varying amounts of exter-
nal rotation, internal rotation, and abduction weakness.
Radiographic analysis
The evaluation of all groups involved x-ray films taken
during active isometric abduction of the arm in the scapu-
lar plane at 0, 30, 60, 90, 120, and 150. The ref- used in this study. Digitized anteroposterior radiograph of normal
erence axes chosen were identical to previous stud-
ies.1,12,16,19 To standardize the x-ray evaluations, a proto-
col was followed to control focal point (centered on the
glenoid) precisely and magnification, abduction of the
arm, and rotation of the arm and forearm.
Subjects were in the standing position rotated 30 so
that the plane of the scapula was parallel to the plane of
the x-ray cassette. The distance between the shoulder and
the cassette was kept constant to avoid magnification
errors. Radiographs were taken with the arm in neutral
rotation (forearm in neutral rotation with the palm facing
forward). The patients actively abducted the arm in the
plane of the scapula for the six x-ray films. A grid was con-
structed to control arm abduction angle precisely. Only 2
radiographic technicians trained on the research protocol
were used for the duration of the study. One of the authors
was present at all times.
The x-ray films were digitized with a CCD camera
(Sony). A standard length bar was included to eliminate
magnification error caused by variations in the camera
zoom setting or the distance from the camera to the x-ray.
Measurements were taken from the digitized x-ray films
after the images were imported into standard radiograph-
ic measuring software (NIH Image 1.59).
Three independent observers blinded to the clinical
data for each patient took measurements on all x-ray films.
Measurements were made in a semiautomated fashion
determined by macroprogramming of the measurement
software (Figure 1). The geometric center of the humeral
head was found with the use of the center point of a best-
fit circle positioned on the humeral articular surface. The
superior and inferior end points of the glenoid articular sur-
face were then marked to demarcate the glenoid line and
the center point automatically determined by the software.
A line drawn along the long axis of the humerus was com-
pared with the glenoid line to calculate the glenohumeral
angle. The perpendicular distance from the center of the
humeral head to a perpendicular line drawn from the cen-
ter of the glenoid line was calculated by the software for
each arm abduction angle. The arm abduction angle was
compared with the measured glenohumeral angle.
The measurements for each observer were analyzed for
interobserver and intraobserver reliability. Linear regres-
sion analysis was used to view trends in humeral head
Yamaguchi et al 7
Figure 1 Radiographic representation of measuring technique
patient was imported into program NIH Image 1.59. Program was
used to form best fit circle A around proximal humerus. Next, line
B is formed by plotting 2 points at superior and inferior margins of
glenoid. This is followed by line C drawn by placing 2 points along
long axis of humerus. Line D is formed by marking medial and lat-
eral extent of marker to standardize for magnification differences
among x-ray films. Computer automatically plots and measures
humeral translation by measuring any shift from center of circle A
to perpendicular line drawn from center of line B. Glenohumeral
angle is calculated as angle between lines B and C.
motion among individual subjects. Values for glenohumer-
al translation and glenohumeral angle versus arm elevation
were also analyzed for averaged values among the 3
groups. A high degree of interobserver and intraobserver
agreement was observed. The coefficients obtained were
0.96 and 0.95, respectively.
RESULTS
Normal volunteers displayed ball-in-socket kinematics
after the first 30 of abduction (Figure 2). In some sub-
jects the humeral head was slightly subluxed inferiorly at
rest and elevated to become centered on the glenoid with
abduction. The linear regression trend lines for this group
varied <1 mm through the entire range of abduction.
In the symptomatic group the linear regression trend
lines showed superior migration of the head with
abduction in all but 1 of the patients. The patient who
was the exception had a superiorly positioned humer-
al head in the resting position that tended to migrate
inferiorly with increasing arc of motion. Variability was
relatively small as all but 1 of the patients showed pro-
gressive superior migration of the humeral head. Max-
imum superior migration in this group was to 8.8 mm.
Figure 3 shows a radiograph from a representative
patient in this group.
In the asymptomatic group increased variability was
seen. Some patients had nearly normal kinematics,
whereas others had either normal or superior transla-
tion of the humeral head with increasing abduction.
Superior head migration varied from 0 to 5.6 mm.
8 Yamaguchi et al J Shoulder Elbow Surg
January/February 2000

Figure 2 Average for humeral translation in millimeters seen for 3 groups: normal, symptomatic rotator cuff tears,
and asymptomatic rotator cuff tears. Normals showed inferior subluxation of head in first 30 followed by nearly per-
fect bond socket kinematics at higher arm elevations (<0.5 mm translation). Symptomatic and asymptomatic groups
both had superior head migration with higher arm elevations. Difference between symptomatic and asymptomatic
groups and normal group was statistically significant. No statistically significant difference was detected between
symptomatic and asymptomatic groups with small numbers used in this study.

Multivariate analysis demonstrated that in the range
of 60 to 150 of abduction, the superior translation of
the head was significantly different (P < .05) in normal
shoulders compared with each of the rotator cuff tear
groups. However, the asymptomatic and symptomatic
cuff tear groups were not significantly different from
each other.
All 3 groups showed similar trends in the relation-
ship between glenohumeral and arm abduction angle
(Figure 4). All 3 groups showed increasing values of
glenohumeral angle with increasing arm abduction
angle. However, patients with symptomatic shoulders
had a relative drop-off in slope at increasing arm
angles. Although this result suggests that symptomatic
shoulders required more scapulothoracic rotation to
achieve similar arm abduction, the results were not sta-
tistically significant.
DISCUSSION
It has been widely known that some people may
have rotator cuff tears without pain. Several studies
including a recent one with MRI, have demonstrated a
significant prevalence of full-thickness rotator cuff tears
in individuals with no symptoms.7,9,10,17 Why some
rotator cuff tears are painful and others remain asymp-
tomatic remains unclear but may have important clini-
cal implications. One possible explanation is that some
rotator cuff tears are compatible with normal gleno-
humeral kinematics.4
Previous studies have investigated glenohumeral
kinematics in living subjects with scapular plane x-ray
films. Poppen and Walker12 found that normal subjects
actively abducting the arm above 30 displayed ball-
in-socket glenohumeral kinematics. Abnormal gleno-
humeral translation occurred in 3 of their 7 subjects
with arthrogram-documented rotator cuff tears. Abnor-
mal superior migration of the humeral head has also
been shown with chronic impingement, which was sug-
gested to be caused by weakening of the rotator cuff
mechanism. In a follow-up study superior migration of
the head was demonstrated in otherwise normal shoul-
ders fatigued by an exercise protocol.19 The authors
suggested that abnormal kinematics caused by fatigue
alone may predispose patients to impingement symp-
toms. Burkhart3,4 performed fluoroscopic imaging on
14 patients with known rotator cuff tears and found 6
had qualitatively normal motion and the others had
variable patterns of abnormal translation of the head.
In this study we identified a subject group that has
not been previously tested: patients with asymptomatic
shoulders and excellent motion but with MRI-document-
ed full-thickness rotator cuff tears.17 We hypothesized
that if abnormal glenohumeral kinematics caused or
was a significant precipitating factor to the develop-
J Shoulder Elbow Surg
Volume 9, Number 1
A B
Figure 3 Representative of measurements from patient with symptoms at 30 of elevation. A, Digitized radiographic
image before measurements. B, Measurement in place with obvious superior translation of humeral head.
ment of shoulder pain, the asymptomatic group would
be expected to have less significant alteration of gleno-
humeral kinematics than the symptomatic group.
Although we examined glenohumeral motion in the
scapular plane only, it was believed that this method,
which should detect superior head migration, would be
the most sensitive for kinematic alterations caused by
rotator cuff tears.11,12,16
Our measurement method, a modification of that
established by Poppen and Walker12 for studying kine-
matic patterns in rotator cuff deficient shoulders, proved
to be reproducible and reliable. Although our methods
appear to be accurate for measuring bony landmarks,
it should be noted that the geometric centers calculated
were based on subchondral bone and not articulate
cartilage surface. It is conceivable that some error could
have been introduced by the exclusion of articular sur-
face defects. However, because it was a comparative
study using the same methods for all 3 groups, the
potential errors from excluding articular surface mea-
surements should have been minimized. In contrast to
previous studies with hand measurements with Mose cir-
cles, modem techniques with computer-driven measure-
ments were used in a blinded fashion to minimize
human error and bias. Radiographs were digitized,
allowing use of software (NIH Image 1.59) to draw an
exact circle over the articular surface of the humeral
head. The x-ray film could be digitally enhanced or
enlarged to improve visualization of the landmarks. The
excellent interobserver and intraobserver reliability
coefficients (0.96 and 0.95, respectively) seen with the
3 independent observers appeared to substantiate the
reliability of these methods.
In agreement with previous studies,2,12,16,19 normal
subjects had ball-in-socket kinematics after the first 30
to 60 of abduction. Both cuff tear groups displayed
variability in the amplitude of humeral head translation
on the glenoid. However, greater variability was seen
Yamaguchi et al 9
in the asymptomatic group, with some displaying supe-
rior and some nearly normal motion. Nevertheless, the
average motion of both cuff tear groups was signifi-
cantly different from that in the normal group in the
range between 60 to 150 of abduction (multivariate
analysis, P < .05). Although patterns of variation were
seen between asymptomatic and symptomatic cuff
tears, no significant differences were detected with the
small numbers used in this study.
One possible explanation for the increased variabil-
ity seen in the asymptomatic group was difference in
size of the rotator cuff tear. Those patients in the asymp-
tomatic group displaying nearly normal glenohumeral
kinematics may have had significantly smaller tears
than those with altered glenohumeral kinematics in the
same group. Because this group of patients did not
require surgery, we do not have accurate information
about tear size and cannot address this issue. In addi-
tion, the uniform disruption of glenohumeral kinematics
seen with the symptomatic group may indicate the pres-
ence of larger tears in this group. As with the asymp-
tomatic group, many of the patients in this group did
not have surgery, and uniform information on tear size
was unavailable. Because of a lack of reliable infor-
mation on tear size, no attempt was made to correlate
it to altered glenohumeral kinematics.
Regardless of potential differences in tear size, sig-
nificant alterations were seen in uniplanar gleno-
humeral kinematics for both asymptomatic and symp-
tomatic groups compared with the normal group. The
relevance of these variations from normal would
depend on the accuracy of modalities used to detect
the rotator cuff tears. In contrast to information about
tear size, we believed the radiographic modalities
used in this study (MRI and arthrography) were highly
reliable for detecting full-thickness tears.5,6,13-15 The
accuracy for detection of the asymptomatic tears has
been previously documented and included internal
10 Yamaguchi et al J Shoulder Elbow Surg
January/February 2000

Figure 4 Relationship between glenohumeral angle and arm angle. As arm angle increased, glenohumeral angle
also increased in relatively linear fashion. Glenohumeral angle was used as indicator of scapulothoracic rotation. At
higher elevations slight drop-off was seen in patients with symptomatic rotator cuff tears. This may have indicated
more scapulothoracic rotation was needed at higher elevations to accomplish similar arm angles. Differences were
not statistically significant in small numbers used in study.

controls.17 Symptomatic tears were detected by both
MRI and arthrography, which were performed in an
academic setting previously demonstrated for high
accuracy.5,6,13,14,15 In addition, all studies were fur-
ther reviewed by the senior author. Hence, the pres-
ence of a rotator cuff tear, aside from tear size,
appeared to correlate with a significant alteration of
glenohumeral kinematics in at least 1 plane.
Examination of the relationship between gleno-
humeral angle and arm angle was used to compare
scapulothoracic kinematics among the 3 groups.
Again, no significant differences were detected. How-
ever, patients with symptomatic rotator cuff tears dis-
played a lower slope for increasing glenohumeral
angle as arm angle increased (Figure 4). This result
suggested that patients with symptomatic rotator cuff
tears required more scapulothoracic rotation to achieve
similar arm angles.
In conclusion, although subtle differences were
detected between asymptomatic and symptomatic rota-
tor cuff tears, we were not able to demonstrate statisti-
cal significance. It is possible that average statistical
differences may be demonstrated with larger samples.
Both study groups were significantly different from the
normal group, which displayed ball-and-socket kine-
matics. The presence of rotator cuff tears was associat-
ed with a disruption of this normal pattern in at least the
scapular plane. In addition, the loss of normal gleno-
humeral kinematics alone did not correlate with the
occurrence of symptoms. Because significant superior
migration was seen in some individuals in the asymp-
tomatic rotator cuff group, painless and excellent func-
tion is possible in the presence of abnormal gleno-
humeral kinematics.
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