Use of vertebral levels to measure presumed internal rotation at the shoulder: A radiographic analysis

Internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patientʹs thumb, but it is not at all certain that this maneuver is strictly measuring internal rotation. We analyzed this maneuver with computed tomographic scans of the shoulder in differing positions. We also analyzed extension of the glenohumeral joint and scapulothoracic articulation with scapular lateral radiographs. Finally, we used posteroanterior radiographs to analyze elbow flexion at the limits of internal rotation behind the back. We found that maximal internal rotation behind the back occurs in approximately a 2:1 ratio between the glenohumeral joint and the scapulothoracic articulation. However, the scapulothoracic articulation was more significant in placing the arm behind the back, whereas the glenohumeral joint performed most of the internal rotation in front of the body. The scapulothoracic articulation assists in this motion by both extension and internal rotation of the scapula on the thorax. The limits of internal rotation behind the back are reached with a significant contribution from elbow flexion. We conclude that measuring shoulder internal rotation by the maximal vertebral level reached by the patientʹs thumb greatly oversimplifies the concept of internal rotation and that limitations in this motion may not be strictly due to a loss of internal rotation at the glenohumeral joint.