Clinical Biomechanics 22 (2007) 495–501

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The role of the subscapularis in preventing anterior glenohumeral

subluxation in the abducted, externally rotated position of the arm
C.M.L. Werner *, P. Favre, C. Gerber
Department of Orthopaedics, University of Zurich, Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland

Received 1 July 2006; accepted 11 December 2006

Abstract

Background. Current literature suggests that the subscapularis muscle is the main active stabilizer when the humerus is abducted and
externally rotated. Conservative treatment of anterior shoulder instability therefore aims at strengthening this muscle. Empirical models,
however, have questioned the role of the subscapularis muscle as it has been observed to potentially support dislocation of the subluxated
humeral head.
Methods. Ten human shoulders were loaded with an anterior dislocating force and the effect of different subscapularis tensions on
humeral translation was measured with the Motion Analysis system, for the abducted and externally rotated arm and neutral positions.
Also, lines of action of the subscapularis segments were measured on a 3D epoxy model.
Findings. Shoulders in which the humeral head migrated antero-superiorly under an external antero-inferior load were observed to
dislocate under simulated active subscapularis tension in both positions. In contrast, shoulders in which the head migrated antero-infe-
riorly remained stable. Twice as many specimens dislocated in the abducted – externally rotated position than in the neutral position. The
change in line of action of the subscapularis may account for this change.
Interpretation. Exercises alone are unlikely to be adequate for all patients with anterior instability symptoms. Passive motion pattern
of the humeral head might serve as an indicator as to whether the effect of strengthening the subscapularis might stabilize a shoulder
without further operation. Development of a clinical test based on these findings might differentiate the non-operative from operative
candidates among patients presenting with anterior instability of the shoulder.
Ó 2007 Elsevier Ltd. All rights reserved.

Keywords: Shoulder; Instability; Luxation; Bankart; Subscapularis; Latarjet

1. Introduction
Glenohumeral joint stability is provided by several
mechanisms: bony surfaces, the capsulo-ligamentous struc-
tures, the glenoid labrum, the negative intraarticular pres-
sure, and active centering of the humerus mainly by the
rotator cuff muscles (concavity compression) (Lippitt
et al., 1993; Branch et al., 1995; Thompson et al., 1996;
Pouliart et al., 2006). The subscapularis muscle has been
reported to be the main muscular stabilizer (Malicky
*
Corresponding author.
E-mail address: cwerner@gmx.ch (C.M.L. Werner).
et al., 1996; Itoi et al., 1994) of the abducted and externally
rotated humerus, a position known to be critical for shoul-
ders with antero-inferior instability. This contention is sup-
ported by electromyographic findings (Jobe et al., 1983;
Gowan et al., 1987; Glousman et al., 1988). Therefore,
patients presenting with antero-inferior instability of the
shoulder may be considered for conservative treatment to
strengthen the rotator cuff muscles (Burkhead and Rock-
wood, 1992; Matsen et al., 1998). The same strengthening
program may be proposed in situations with partial tearing
of the subscapularis with the hope to recenter an anteriorly
subluxated humeral head.
On the other hand, a destabilizing effect of the subscap-
ularis muscle was found in biomechanical models of the

0268-0033/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.clinbiomech.2006.12.007
496 C.M.L. Werner et al. / Clinical Biomechanics 22 (2007) 495–501
shoulder for the abducted and externally rotated position
of the arm (Kozdera, 1999; Werner et al., 2004a). The sub-
scapularis muscle might facilitate antero-inferior disloca-
tion of a subluxated shoulder joint in certain positions
depending on yet unidentified anatomical or biomechanical
factors, so that there might be patients who would not ben-
efit from strengthening exercises and for which the proce-
dure might even increase the redislocation rate.
In this study, we used a cadaver model to clarify the role
of the subscapularis muscle when the humeral head is ante-
riorly subluxated. The ability of the subscapularis to recen-
ter the subluxated humeral head of a glenohumeral joint
was assessed by measuring the magnitude and direction
of the humeral head displacement for two glenohumeral
positions.
In a second part, the lines of action of the subscapularis
segments were measured on a three-dimensional model to
assess the changes of their stabilizing effect.
2. Methods
2.1. Cadaver model
Ten fresh frozen human cadaver shoulders (5 right, 5 left
shoulders) from patients with a mean age of 75 years (range
67–84 years), stored at 20 °C, were thawed to room
temperature overnight prior to testing and were kept moist
with an antibacterial solution during preparation and
experiments. All shoulders showed no limitations in range
of motion. All specimens were examined radiographically.
There was no macroscopic evidence of cuff disease, prior
injury or surgery. The skin, subcutaneous tissue and del-
toid muscle were carefully excised, leaving the insertions
of the rotator cuff muscles, the long head of the biceps,
the capsule, the coracoacromial and coracohumeral liga-
ments intact. The clavicle was removed at the acromiocla-
vicular joint and the humerus cut at the mid-diaphyseal
level. The muscular belly of the subscapularis muscle was
detached at its origins on the scapula, while ensuring that
the tendinous insertion on the capsule and humerus
remained intact. Three Ethibond No. 2 sutures (Ethicon,
Spreitenbach, Switzerland) were fixed with Mason–Allen
stitches to the subscapularis tendon and passed through
eyelet screws fixed to the fossa subscapularis. These repre-
sented the lines of action of three equal muscle segments of
the subscapularis: the cranial, middle and caudal segments
(Fig. 1). The scapula was rigidly fixed to a mounting rig. As
the subscapularis links the humerus to the scapula, move-
ments of the latter does not change the relative direction
of action of the muscle segments. Scapular positioning
was carried out with the glenoid horizontal. This allowed
compensating for any inadvertent translation induced by
gravity or by tension exerted by other muscles than the
subscapularis (other rotator cuff or secondary shoulder
muscles not investigated in the model; Werner et al.,
2006). To allow measurement of humeral rotation, the dis-
tal humerus and forearm with the elbow flexed at 90° were
represented by means of steel rods fixed to the humeral
diaphysis. Three reflecting markers were attached to the
humeral rod representing the local orthogonal coordinate
system used for three-dimensional tracking of humeral
motion with the Motion Analysis system (Motion Analysis
Corporation, Santa Rosa, CA, USA). Calibration of the
measurements was performed using markers of known spa-
tial relations. The reproducibility and accuracy of this three
dimensional motion tracking system has been reported by
the manufacturer and other investigators before (Van der
Linden et al., 1992; Ehara et al., 1995, 1997; Kofman
et al., 1998; Wilson et al., 1999) to be as precise as
0.1 mm within 3 m of distance object to camera, which
was the case in this investigation.
Two supports were mounted on a stand allowing posi-
tioning of the glenohumeral joint via the metal rod in 0°
and 90° of abduction without rotational restriction. This,
along with the horizontal mounting of the glenoid, allowed
to eliminate any confounding induced by the weight of the
arm. A cord was attached to the humeral metaphysis and
traction of 10 N at 45° in the antero-inferior direction
was applied to obtain an initial constant antero-inferior
dislocation of the glenohumeral joint (avoiding natural
recentering of the humeral head in the glenoid as a conse-
quence of gravity compression into a matched concave
articulation). This force is arbitrary but was chosen based
on prior experiments with cadaveric shoulders (Werner
et al., 2006). The amount of force was chosen so as to
induce an antero-inferior displacement of the humeral head
without disrupting or elongating the soft tissues.
Two positions of interest were studied. The neutral
position of the arm (position 1), defined as 0° elevation
and 0° axial rotation, where passive examination of the
shoulder is carried out clinically. Position 2 was defined
as 60° elevation in the scapular plane, corresponding to
90° of clinical abduction, and 90° axial external rotation,
where anterior shoulder dislocation usually takes place.
Both abduction and rotation angles were measured with
a goniometer.
The ability of different parts of the subscapularis to cen-
ter the humeral head after glenohumeral subluxation was
measured by the translations of the center of the humeral
head for both positions of interest. The humeral head cen-
ter coordinates were determined by recording motion of
the three markers during small axial rotations of the
humerus and then small rotations in abduction. The trajec-
tories of the three markers allowed calculating two rotation
axes, one for each rotation, which would ideally intersect at
the center of rotation in the case of a perfect sphere. As this
is not the case for the humeral head, the midpoint of the
shortest connection between the two rotation axes was cal-
culated, representing the locus in the humeral head which
moved least during the rotations. The translations of the
humeral head were carried out by recording the changes
of the 3D coordinates of the humeral head center from
the stable position (reference starting position), in the dis-
located position, and after loading of the subscapularis.
 C.M.L. Werner et al. / Clinical Biomechanics 22 (2007) 495–501 497

Fig. 1. Laboratory set-up with scapula mounted on a plate. The glenoid is placed horizontally to avoid unintentional bias through gravity or other rotator
cuff muscles than the subscapularis. Motion AnalysisÒ markers are fixed to a rod representing the humeral axis and are detected by the four cameras. The
subscapularis muscle has been cut at the musculo-tendinous junction and the three main portions of the muscles represented by sutures firmly attached to
the tendon which could be loaded individually.

Loading of the subscapularis was simulated by applying
a 30 N constant traction by means of weights to the whole
subscapularis (10 N per suture), as well as to single seg-
ments of the muscle only (30 N applied either to the cra-
nial, middle, or caudal suture). All forces were chosen to
obtain reproducible translations without disruption of the
tendons.
Two repetitions of each loading cycle were performed
for each test, and the corresponding spatial motion of the
three markers recorded. Preconditioning of the specimens
was carried out by cycling through a range of motion prior
to each test, as forces required to strain cadaveric soft tis-
sues to a given extent decrease significantly after the first
few loading cycles before reaching a plateau (Malicky
et al., 1996; Gerber et al., 2003).
Statistical analyses were performed by means of SPSS
(Vers. 11.5, SPSS Inc., Chicago, USA) using the Wilcoxon
Signed Rank and Kruskall–Wallis test. Significance level
was set to P < 0.05.
2.2. Epoxy model
The cadaver study indicated that dislocation in posi-
tion 2 occurred twice more frequently than in position
1. In an attempt to assess the role of the subscapularis
muscle alone, it becomes interesting to isolate its biome-
chanical effect on the stability of the joint, taking away
the influence of all passive soft-tissue mechanisms. To
do so, a three dimensional full size epoxy model of the
shoulder described previously (Werner et al., 2004a;
Favre et al., 2005) was used. This model, based on a fresh
cadaver specimen, incorporates muscle segments simu-
lated by braided cords and enables measurement of lines
of action of individual segments in any position of the
humerus relative to the scapula. In this model, the sub-
scapularis was also segmented in three parts. The three
dimensional direction of muscle action of each subscapu-
laris segment was measured with the optical Motion
Analysis system by means of a pointer equipped with
two markers. Two points on each simulated tendons were
registered, in position 1 and 2. A vector for the muscle
segments line of action could then be calculated. The
measurements were performed with the humeral head
centered in the glenoid, i.e. with a stable joint (since the
glenoid labrum was also represented in the epoxy model,
correct centering of the humeral head could be easily
accomplished; Favre et al., 2005). This makes any com-
parison with the cadaver part difficult and hazardous,
as translations and rotations of the joint would change
the muscle lines of action, but it should be considered
as the general starting configuration, from which the
humeral head will dislocate under an external load. The
vector coordinates were finally imported in the Matlab
software (The MathWorks, Natick, MA, USA) for nor-
malization, resultant calculation and graphical display.
The resultant line of action was calculated under the
assumption that all segments contract simultaneously
and exert the same force.
498 C.M.L. Werner et al. / Clinical Biomechanics 22 (2007) 495–501

3. Results translation of 3.8 mm. This was also significantly different

from the non-dislocating specimens (P = 0.04).
3.1. Cadaver model After completion of the testing, the humeral head diam-
eters and glenoid widths were measured with a depth gage,
The 10 N antero-inferior force applied prior to loading and the soft tissues assessed for unexpected soft-tissue
of the subscapularis lead in none of our trials to a complete damage (could be excluded). The stable and unstable
dislocation of the joint, so that all specimens could be fur- groups differed significantly in humeral head diameter
ther analyzed. (41.3 mm in the stable group, 39.6 mm in the unstable
In position 1, partial recentering (motion from the sub- group; P = 0.005) as well as in the antero-posterior width
luxated position towards the center of the glenoid) of the of the glenoid (26.6 mm in the stable group, 29.8 mm in
humeral head occurred in 8 specimens, while complete the unstable group, P = 0.005).
anterior dislocation of the joint occurred in 2. In the stable
specimens (n = 8), the initial dislocating force lead to a 3.2. Epoxy model
mean displacement of the humeral head center of
19.9 mm anteriorly and 2.6 mm inferiorly away from the The vectors for each segment line of action and for the
initial position. Loading of the whole subscapularis muscle resultant are projected on the glenoid plane (Figs. 2a and
caused a mean recentering of 11.6 mm posteriorly but a 2b) to show the destabilizing antero-posterior and infero-
further dislocation of 0.2 mm inferiorly. The data obtained superior components. In both positions and for all seg-
by loading of individual segments of the muscle are given in ments, the largest component is directed perpendicularly
Table 1. In the unstable specimens (n = 2 for position 1) the to the glenoid plane, from lateral to medial and was not
mean dislocation before loading of the subscapularis was displayed, as little changes were observed.
of 42.3 mm anteriorly and 19.6 mm superiorly (note that
the dislocation surmounts the glenoid width – a fact that
is possible since displacement was measured at the center 0.05
of the humeral head and includes rotation of the humerus). cranial SSC
This displacement is significantly different from the stable 0
shoulders (P = 0.005). Loading of the subscapularis lead
to complete dislocation of the joint, again independent -0.05
middle SSC
from whether the whole tendon or only parts were loaded.
-0.1
In position 2, partial recentering (movement from the
subluxated position towards the centered position on the Resultant
-0.15
glenoid, but not complete recentering) of the humeral head
occurred in six specimens, while partial further subluxation -0.2
(movement further away from the centered position on the
glenoid) was observed in two, and total dislocation of the -0.25
joint in two other specimens (which were the same two that
dislocated in position 1). In the six stable specimens, the -0.3
initial dislocating force lead to an anterior dislocation of caudal SSC
16.9 mm and to inferior subluxation of 8.5 mm. Loading -0.35
-0.35 -0.3 -0.25 -0.2 -0.15 -0.1 -0.05 0
of the whole subscapularis recentered the humeral head Posterior
posteriorly by 14.5 mm and superiorly by 5.2 mm. In the
Fig. 2a. Components of the normalized segments line of action and
specimens with either reinforced subluxation or total dislo- resultant vector in the glenoid plane, with the humerus in position 1. On
cation (n = 4 in position 2), the initial dislocating force the vertical axis, positive values indicate superior direction, negative values
induced an anterior translation of 3.0 mm and a superior indicate inferior direction.

Table 1
Data of antero-posterior and supero-inferior dislocation and possible relocation by different parts of the subscapularis muscle for stable shoulders
Direction of Initial dislocation Whole Cranial Middle Caudal
translation [mm], (SD) subscapularis [mm], subscapularis [mm], subscapularis [mm], subscapularis [mm],
(SD) (SD) (SD) (SD)
Neutral position Anterior 19.9 (12.0) 11.6 (7.6) 7.6 (7.9) 7.9 (8.8) 5.6 (6.6)
Inferior 2.6 (7.9) 0.2 (0.6) 0.5 (0.8) 0.9 (0.8) 0.1 (0.2)
Abduction and Anterior 16.9 (11.8) 14.5 (9.4) 12.9 (5.8) 11.7 (4.1) 8.1 (9.8)
external rotation Inferior 8.5 (8.0) 5.2 (13.2) 6.2 (16.4) 5.3 (13.8) 1.9 (13.6)
Data from luxating shoulders are not presented, as the luxated position was not within the glenoid plane any longer and therefore hardly comparable to
the stable shoulders. Positive values indicate translations in the anterior or inferior direction, negative values indicate relocations in the respective
direction.
 C.M.L. Werner et al. / Clinical Biomechanics 22 (2007) 495–501
0 of a previous investigation (Werner et al., 2004b) indicating
-0.05
-0.1
-0.15
-0.2
-0.25
-0.3 middle
SSC cranial SSC
-0.35 Resultant
caudal SSC
-0.4
-0.5 -0.4 -0.3 -0.2 -0.1 0 0.1 0.2
Posterior Anterior
Fig. 2b. Components of the normalized segments line of action and
resultant vector in the glenoid plane, with the humerus in position 2. On
the vertical axis, positive values indicate superior direction, negative values
indicate inferior direction.
In position 1, all three segments pull posteriorly. The
cranial segment possesses a small component oriented in
the superior direction, opposed to the inferior pulling effect
of the middle and caudal segments.
In position 2, all subscapularis segments act in an infe-
rior direction. Unlike the other two segments, the cranial
segment presents an anteriorly directed component.
4. Discussion
4.1. Cadaver model
Two different patterns of humeral head translation were
induced by the loading of the subscapularis in both
assessed positions. Tension exerted by the subscapularis
either led to partial recentering of the humeral head or to
further dislocation, even totally dislocating the glenohu-
meral joint in some specimens.
The unstable group combined a slightly larger glenoid
with a smaller humeral head than the stable group
although larger glenoids are usually known to enhance sta-
bility (Morrey et al., 1998). This finding should still be con-
firmed with a larger series of specimens. In position 1,
dislocation caused by loading of the subscapularis was
detected twice, preceded by a significantly larger antero-
superior translation due to the initial dislocation force. In
position 2, the humeral head translations caused by the ini-
tial dislocation force in the stable and unstable groups
(n = 4) did not only differ in magnitude, but in direction
also. Interestingly, in both positions, the humeral head of
stable shoulders moved antero-inferiorly when the initial
force was applied, but it translated antero-superiorly in
unstable shoulders, although the initial force was directed
antero-inferiorly. This could be explained by the findings
499
capsular tightness of the whole inferior (and especially the
postero-inferior) capsule. When the humeral head moves to
the narrow antero-superior area of the glenoid (smaller
antero-posterior diameter), the support provided by the
antero-superior glenoid rim might not be sufficient to resist
dislocation.
Since no geometrical differences but humeral head and
glenoid diameters were apparent in the specimens used,
the properties of the capsule-ligamentous structures or
the specific segment of the subscapularis that might lead
to antero-inferior instability of the shoulder could not be
determined with this cadaver study. However, it suggested
the importance of the underlying capsular structures in pre-
venting abnormal translations and providing stability of
the joint. Dislocations may be caused in the abducted
and externally rotated position by a more pronounced infe-
rior effect of the subscapularis segments together with a
smaller posteriorly directed influence. This phenomenon
combined with antero-superior capsular translation pat-
terns might cause a cut-off between a stabilizing and desta-
bilizing action of the muscle.
4.2. Epoxy model
In both positions and for all segments, the main force
component is directed perpendicularly to the glenoid plane,
enhancing stability through concavity compression by
pressing the humeral head into the glenoid. This confirms
the stabilizing function of the subscapularis in these two
positions.
The most important change in muscle line of action
from position 1 to position 2 concerns the cranial segment.
Although the middle segment pulls more inferiorly in posi-
tion 2, the middle and caudal segments line of action
remain postero-inferiorly directed, while the cranial seg-
ment switches from a postero-superior to an opposed
antero-inferior direction. This orients the resultant accord-
ingly more anteriorly and inferiorly. Moreover, it was
shown that neuromotor control strategies differ across
the breadth of a muscle and all fibers in a given muscle
must not necessarily contract simultaneously (Fick and
Weber, 1877; Van der Helm and Veebaas, 1991; Johnson
et al., 1996; Wickham and Brown, 1998; Favre et al.,
2005). Depending on the load configuration, a (theoretical)
isolated contraction of the cranial segment of the subscap-
ularis would enhance antero-inferior translation of the
humeral head.
However, the predominance of the compressing compo-
nent of the subscapularis let us think that this muscle acts
mainly as a stabilizer, although changes in the destabilizing
component can be observed between the two assessed posi-
tions. This model could not tell if the more antero-inferi-
orly directed component of the resultant in position 2
could change the balance of the joint in such a way that
instability appears, or if the compressing component is
large enough to compensate for this.
500 C.M.L. Werner et al. / Clinical Biomechanics 22 (2007) 495–501
Although the line of action of the muscle segments devi-
ates from this reference position when dislocation starts,
we believe that the anatomy of the muscle is such that
the subscapularis alone should maintain a stabilizing func-
tion. Therefore, it seems that the dislocation effect of the
subscapularis muscle observed in the ‘unstable’ cadaver
specimens might not have been provoked by this muscle
alone but in concert with other passive structures.
An interesting analogy can be found between the find-
ings of this study, and the Latarjet procedure (Latarjet,
1958) – an operation commonly performed for anterior
shoulder instability where the tip of coracoids bone is
transposed through the subscapularis muscle onto the ante-
rior aspect of the glenoid: Although the enlarged bony sup-
port, the hinge provided by the transposed conjoined
tendon, and the redirected line of action of the conjoined
tendon (Werner et al., 2004a) all lead to more stability of
the shoulder – the procedure also addresses glenohumeral
instability by preventing extensive upward migration of
the subscapularis tendon due to its transsection by the con-
joined tendon. This – along with the other stabilizing mech-
anisms – could explain the rare reports on recurrent
dislocations after this procedure, independent of the preop-
erative capsular properties or the absence of bony defects
(Latarjet, 1958; Delaunay et al., 1985; Kerboul et al.,
1985; Benammar et al., 1986; Van der Maren et al., 1993;
Fontanesi et al., 1996; Huguet et al., 1996; Allain et al.,
1998) and potentially confirms the findings of this investi-
gation.
The main limitation of this study is the low number of
cadavers so that the trends shown in this study should be
confirmed with a larger series. The role of the other rotator
cuff muscles and gravity has not been taken into account,
even though they all play a role in shoulder joint stability
and might compensate for an incidentally destabilizing
subscapularis muscle. The horizontal mounting of the
glenoid allowed keeping the humeral head centered without
other artificial forces, and thereby, influence of the sub-
scapularis muscle alone could be investigated. The initial
dislocation force was chosen to logically induce the wanted
translation of the humeral head, but it is currently not
known what external force usually leads to antero-inferior
dislocation of the shoulder. For this reason, only the cen-
tered position of the humerus was examined in the epoxy
model. Also, patients with antero-inferior shoulder insta-
bility show a distension of the anterior capsule-ligamentous
structures. In our model, however, the antero-inferior cap-
sules had no obvious signs of laxity and can therefore not
fully represent an instable situation. Experimental dissec-
tion of this capsular area would have injured the closely
related tendon of the subscapularis.
5. Conclusions
Our results suggest that conservative treatment by
strengthening of the subscapularis for anterior glenohu-
meral instability is not a guarantee of success. Operative
techniques in treatment of antero-inferior glenohumeral
instability – provided that there is no bony or labral lesion
– might therefore have to focus on the capsulo-ligamentous
structures, or on inhibition of postero-superior displace-
ment of the subscapularis tendon like provided by the
Latarjet procedure. In cases where conservative treatment
is considered, passive motion patterns of the humeral head
with respect to the glenoid might serve as an indication for
an adequate decision: If the humeral head moves antero-
inferiorly when an antero-inferiorly directed force is
applied, strengthening exercises seem to be indicated. If,
however, displacement of the humeral head is antero-supe-
riorly, strengthening exercises could increase the instability.
This category of patients might more likely benefit from
surgical procedures. Further investigations will have to
provide a clinical validation of these laboratory findings,
and the eventual development of a clinical test based on
kinematical patterns during passive examination (anterosu-
perior versus antero-inferior subluxation of the humeral
head caused by antero-inferior traction in the abducted/
externally rotated position). The findings therefore might
help to differentiate the non-operative from operative can-
didates among patients presenting with anterior instability
of the shoulder.
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