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Physical Therapy of the Shoulder
FIFTH EDITION
• Image Collection

• Reference lists linked to Medline

• Video clips
Physical Therapy of the Shoulder
FIFTH EDITION

Edited by

Robert A. Donatelli, PhD, PT, OCS

National Director of Sports Rehabilitation
Physiotherapy Associates
Las Vegas, Nevada
3251 Riverport Lane
St. Louis, Missouri 63043

PHYSICAL THERAPY OF THE SHOULDER, FIFTH EDITION ISBN: 978-1-4377-0740-3

Copyright # 2012, 2004, 1997, 1991, 1987 by Churchill Livingstone, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
permission in writing from the publisher.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Physical therapy of the shoulder / edited by Robert A. Donatelli. – 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0740-3 (hard copy)
1. Shoulder–Wounds and injuries. 2. Shoulder–Wounds and injuries–Treatment. 3. Shoulder–Wounds
and injuries–Physical therapy. I. Donatelli, Robert. II. Title.
[DNLM: 1. Shoulder–injuries. 2. Shoulder Joint–injuries. 3. Physical Therapy Modalities. WE 810]
RD557.5.P48 2011
617.5’72044–dc22
2011001297

Executive Editor: Kathy Falk

Developmental Editor: Megan Fennell
US/Chennai Publishing Services Managers: Julie Eddy and Rajendrababu Hemamalini
US/Chennai Project Managers: Celeste Clingan and Srikumar Narayanan
Designer: Jessica Williams

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Dedication

I would like to dedicate this book to my family—my wife Georgi Donatelli, my son,
Robby, and my daughters, Briana and Rachel. They have added a new meaning of love,
joy and happiness to my life.
 Contributors

RANDA A. BASCHARON, DO, AT XAVIER A. DURALDE, MD

Owner, President, Orthopedic and Sports Medicine Peachtree Orthopedics Clinic, Assistant Clinical Professor
Institute Of Las Vegas, Sports Performance Institute of of Orthopedic Surgery, Clinical Instructor, Emory University
Las Vegas, Las Vegas, Nevada School of Medicine, Atlanta, Georgia

MOLLIE BEYERS, DPT RICHARD A. EKSTROM, PT, DSC, MS

Physical Therapist, Biomax Rehabilitation, Effingham, Professor, Department of Physical Therapy, University of
Illinois South Dakota, Vermillion, South Dakota

PETER BONUTTI, MD, FACS, FAAOS, FAANA TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS
Founder and Director, Bonutti Clinic, Founder and Clinic Director, Physiotherapy Associates Scottsdale Sports
Director, Bonutti Technology, Effingham, Illinois, Assistant Clinic, National Director of Clinical Research, Physiotherapy
Clinical Professor, Department of Orthopedic Surgery, Associates, Director of Sports Medicine, ATP World Tour,
University of Arkansas, Fayetteville, Arkansas Scottsdale, Arizona

KENJI C. CARP, MPT, OCS, ATC ROBERT L. ELVEY, BAPPSC, GRAD. DIP. MANIP. THER.
Certified Vestibular Therapist, Director, Owner, Senior Lecturer, Curkin University, Physiotherapy
Cooperative Performance and Rehabilitation, Eugene, Consultant, Southcare Physiotherapy, Perth, Australia
Oregon
KATHLEEN GEIST, PT, DPT, OCS, COMT
JEFF COOPER, MS, ATC Assistant Professor, Division of Physical Therapy,
Athletic Training Solutions, Wilmington, Delaware, Department of Rehabilitation Medicine, Emory University
Consultant, Player Development, Philadelphia Phillies, School of Medicine, Atlanta, Georgia
Philadelphia, Pennsylvania
JOHN C. GRAY, DPT, OCS, FAAOMPT
DONN DIMOND, PT, OCS Lead Clinical Specialist, Department of Physical
Director of Clinical Operations, Owner, The KOR Physical Therapy, Sharp Rees-Stealy, Clinical Instructor, Ola
Therapy, Portland, Oregon Grimsby Institute, Credentialed Clinical Instructor,
American Physical Therapy Association, Associate Editor,
JAN DOMMERHOLT Journal of Manual and Manipulative Therapy, San Diego,
President and Physical Therapist, Bethesda Physiocare, California
Inc/Myopain Seminars, LLC, Bethesda, Maryland
BRUCE H. GREENFIELD, PT, PHD, OCS
PHILLIP B. DONLEY, PT ATC MS Assistant Professor, Department of Rehabilitation, Center
Optimum Physical Therapy, West Chester, Pennsylvania for Ethics, Emory University, Atlanta, Georgia
viii Contributors

OLA GRIMSBY, PT DOUGLAS M. MURRAY, MD

Chairman of the Board, Ola Grimsby Institute, San Diego, Surgeon, Peachtree Orthopedic Clinic, Consulting
California Physician, Shepherd Center, Atlanta, Georgia

TOBY M. HALL, PHD, MSC, POST GRAD DIP MANIP THER,

ROY W. OSBORN, PT, MS, OCS
ASSOC IN PHYSIOTHERAPY
Associate Professor, Physical Therapist, Physical Therapy
Director Manual Concepts, Perth, Australia, Adjunct
Department, Avera McKennan Hospital and University
Senior Teaching Fellow, School of Physiotherapy, Curtin
Health System, Sioux Falls, South Dakota
Innovation Health Research Institute, Curtin University of
Technology, Bentley, Australia, Senior Teaching Fellow, The
University of Western Australia, Perth, Australia, Director JAIME C. PAZ, PT, DPT, MS
Manual Concepts, Perth, Australia Clinical Associate Professor, Division of Physical Therapy,
Walsh University, North Canton, Ohio
SCOT IRWIN, DPT, CCS{
Formerly, Associate Professor, Department of Physical
SCOTT D. PENNINGTON, MD
Therapy, North Georgia College and State University,
Surgeon, Peachtree Orthopedic Clinic, Atlanta, Georgia
Dahlonega, Georgia

ROBERT C. MANSKE, PT, DPT, SCS, MED, ATC, CSCSC VIJAY B. VAD, MD
Associate Professor, Department of Physical Therapy, Assistant Professor of Rehabilitation Medicine, Hospital
Wichita State University, Wichita, Kansas for Special Surgery, New York, New York

JOHNSON MCEVOY, PT, BSC, MSC, DPT, MISCP, MCSP

JOSEPH S. WILKES, MD
Chartered Physiotherapist in Private Practice, United
Clinical Associate Professor, Orthopedics, Emory
Physiotherapy Clinic, Limerick, Ireland, Head
University, Active Staff Member, Piedmont Hospital,
Physiotherapist, Irish Boxing High Performance Team,
Specialty Consulting, Crawford Long Hospital, Atlanta,
Dublin, Ireland, External Lecturer, Sports Science, University
Georgia, Active Staff Member, Fayette Community Hospital,
of Limerick, Limerick, Ireland
Fayetteville, Georgia
CRAIG D. MORGAN, MD
Clinical Professor, University of Pennsylvania, Department MICHAEL S. ZAZZALI, DSC, PT, OCS
of Orthopaedics, Philadelphia, Pennsylvania, Morgan Kalman Co-Director and Partner, Physical Therapy Associates of
Clinic, Wilmington, Delaware New York, New York, New York

{
Deceased.
 Preface

The first edition of Physical Therapy of the Shoulder was pub- Part 2, Neurologic Considerations, has been updated with
lished in 1987, and now we are publishing the fifth edition new information and references. John C. Gray and Ola Grimsby’s
nearly 25 years later. I would like to thank my readers for chapter, Interrelationship of the Spine, Rib Cage, and Shoulder,
their support throughout the years that has made this book along with Neural Tension Testing by Tobby Hall and Bob
successful. The fifth edition has kept up with the tradition Elvy have been revised, and Bruce H. Greenfield and Kathleen
of Physical Therapy evidence-based practice. It is amazing Geist did a great job updating the chapter on Evaluation and
how the literature now has developed our profession from Treatment of Brachial Plexus Lesions. A new chapter, Sensory
and art to a science. Each chapter is a excellent example of Integration and Neuromuscular Control of the Shoulder by
how the science of Physical Therapy continues to grow. Kenji Carp has been added to the neurological section. I think
The shoulder joint is a complicated structure consisting of you will find that Kenji did an excellent job on defining
three synovial joints, the scapula thoracic articulation, and 17 neuromuscular control in the upper limb. The chapter is an
muscles. The shoulder complex hangs off the rib cage and is excellent representation of state of the art information that is
connected to the cervical and thoracic spine. The complexity of critical to the rehabilitation of shoulder patients.
the shoulder makes many rehabilitation students and clinicians Part 3, Special Considerations, was highlighted by the
uncertain in assessing shoulder pathomechanics and in establish- separation of Chapter 10 into two chapters, Impingement
ing treatment approaches for different shoulder pathologies. Syndrome and Shoulder Instabilities. Bruce Greenfield did
In keeping up to date with new and innovative treatment an excellent job on describing the mechanisms of impinge-
techniques, surgical procedures, and evaluation methods for ment and the new chapter, on shoulder instabilities, by
the shoulder, this fifth edition of Physical Therapy of the Shoulder Michael Zazzali, focused on the conservative approach to the
has been updated appropriately. There are 7 new chapters and evaluation and treatment of shoulder instabilities. The Frozen
8 new authors. The fifth edition is once again divided into five Shoulder chapter was update by Mollie Beyers and Peter
parts; Mechanics of Movement and Evaluation, Neurologic Bonutti. This chapter provides an excellent summary of the
Considerations, Special Considerations, Treatment Approaches, evidence-based research on treatment of frozen shoulder
and Surgical Considerations. pathology. John C. Gray’s chapter on Visceral Referred Pain
In honor of the memory of the late Scot Irwin, Jaime Paz to the Shoulder, was rewritten, along with important updates
helped to revise the Guide to Physical Therapist Practice. from Todd S. Ellenbecker on rotator cuff pathology.
The chapter is an overview of the Guide. Chapter 2 was In the Treatment Approaches Section, Richard A. Ekstrom
updated with new anatomic and biomechanical information and Roy W. Osborn did an excellent job on adding addition
on how the shoulder moves. Chapter 3 was rewritten by Jeff research on Muscle Length Testing and Electromyographic
Cooper with all the new information on the throwing injuries Evidence for Manual Strength Testing and Exercises for the
to the shoulder. Jeff has included new research data that he Shoulder. The Manual Therapy Techniques was updated with
has collected over the past several years on professional baseball additional illustrations of new manual procedures for the
pitchers. His approach to evaluation and treatment is state shoulder, with a section on evidence-based manual therapy
of the art. Chapter 4 is a new chapter by Donn Dimond treatment approaches. The treatment section was highlighted
that finishes the first section with updates on all the new- by one of two new chapters by Donn Dimond on strength
evidenced-based special tests for the shoulder. The special tests training in the shoulder. As previously noted the shoulder
on the shoulder greatly assist the clinician in the development has 17 muscle that allow it to move in multiple planes.
of a differential soft tissue diagnosis. In addition, manual Therefore this chapter is long awaited as the strength of
muscle testing to isolate the shoulder muscles is illustrated. the shoulder muscles is critical to the overall function. Finally,
x Preface

I am honored to have Johnson McEvoy and Jan Dommerholt I am pleased to include a companion Evolve site with the
in the fifth edition with a new chapter on Myofascial Trigger fifth edition of Physical Therapy of the Shoulder. The Evolve site
Points of the Shoulder. The chapter is very comprehensive compliments the text and enhances the clinical application with
covering evaluation and treatment of trigger points. The excerpts of an evaluation of a patient using manual therapy
treatment approaches described include, Myofascial release treatment techniques of the shoulder. A link to an electronic
techniques using manual therapy, massage techniques, dry image collection that features most of the illustrations contained
needling, spray and stretch, and the use of modalities. in the book are included on Evolve.
The Surgical Considerations Section includes the addition Any rehabilitation professional entrusted with the care and
of a chapter by Dr. Ronda Bascharon and Robert Manske on treatment of mechanical and pathologic shoulder dysfunction
the Surgical Approach to Shoulder Instabilities. The chapter will benefit from this book. I trust that the fifth edition will
includes state-of-the-art concepts in evaluation and treatment meet the reader’s expectation of comprehensive, clinically
of the Bankart lesion, S.L.A.P lesions, and rotator cuff interval relevant presentations and case studies that are well documen-
concepts. Dr. Joseph Wilkes and Dr. Xavier Duralde made ted, contemporary, and personally challenging to the student
important updates in their chapters on Rotator Cuff Repairs and the experienced specialist alike.
and Total Shoulder Replacements, respectively.
Robert A. Donatelli, PhD, PT, OCS
 C H A P T E R

1 Scot Irwin and Jaime C. Paz

The Guide to Practice

In this fifth edition of Donatelli’s Physical Therapy of the none alone. For most of the decade of the 1980s and early
Shoulder, the clinical cases continue to be written in the 1990s, the APTA debated the merits and even the existence
format of Guide to Physical Therapist Practice1 (the Guide) of of physical therapy diagnoses. The term diagnosis is so fraught
the American Physical Therapy Association (APTA). This with interpretations that, within the APTA, confusion and
format was developed and has been promoted by the APTA, debate have consumed an inordinate amount of the associa-
which is the largest professional representative for physical tion’s governance time. Finally, the APTA House of Delegates
therapists, physical therapy assistants, and physical therapy came to an agreement that physical therapists did diagnose
students in the United States. and that those diagnoses were directed at movement and
This chapter is designed to orient the reader to the origins, movement dysfunction.
purposes, content, and nature of the Guide. In this way, the The basic premise here is that human movement, like
intent of this chapter is to encourage clinicians and students digestion, is a system. The movement system has normal
who use this current book to incorporate the Guide’s language behaviors that can become dysfunctional, and a physical ther-
and philosophy into the examination, evaluation, diagnosis, apist can provide remedies for those dysfunctions. Eventually,
prognosis, intervention, and outcome provided for their because of a need to describe the scope of a physical therapist’s
patients with shoulder dysfunction. practice more clearly for many health care agencies and for the
physical therapy profession, the APTA undertook the develop-
ment of the Guide. From 1992 through the completion of the
ORIGINS current edition, a handful of physical therapists and staff
members of the APTA constructed this document. Those
To speak at any length about the origins of this document who have tried to produce anything by committee can imag-
would take most of this text. For the abbreviated yet complete ine the amount of time and effort required to write the Guide.
review, the reader is encouraged to read the Guide.1 Since The authors of the Guide are too numerous to list, but they are
Mary McMillan first constructed and presided over the acknowledged within the Guide itself, and they deserve the
Women’s Physiotherapy Association in the early 1920s—and respect and thanks of every physical therapist. All the authors
until the first edition of the Guide in 1997—the reconstruc- were chosen for their expertise and knowledge in a particular
tion aides, general practitioners, and certified clinical specia- practice pattern arena (musculoskeletal, neuromuscular, car-
lists all intuitively have known the value and importance of diovascular/pulmonary, and integumentary). Each of those
rehabilitation services. Throughout that short but illustrious authors is quick to point out that this document is not writ-
history, the association members have professed the unique- ten on a stone tablet. Its origins derive from the cataclysmic
ness and talent within the physical therapy profession to any changes that have occurred in health care delivery and reim-
who cared to listen. The scientific evidence of this effective- bursement in the United States. Those driving forces, along
ness, in contrast, remains to be presented. No defined body with the dynamic growth and development of the profession
of knowledge for physical therapists exists. The Guide pro- of physical therapy, created an environment that required this
vides a foundation for developing the evidence for the effec- document’s publication and demanded that the Guide be in
tiveness of physical therapist interventions. The body of constant evolution. Evidence of this evolution is electronic
knowledge will be defined from the evidence that proves the access to the revised second edition of the Guide in compact
value of these interventions. disk format, which includes a catalog of tests and measures
Physical therapy originated from many facets of health care employed by physical therapists. Furthermore, the APTA
and health sciences, nursing, physical education, medicine, has provided Internet access to the latest edition of the
pathology, and rehabilitation—yet physical therapists claim Guide.2
2 Physical Therapy of the Shoulder

The challenge for future physical therapists is to continue research. The current edition of the Guide was not written
to amend and edit the Guide by documenting errors and omis- to provide that level of information.
sions and by providing new practice patterns for impairments In this book, the case examples have been “Guideized,”
and functional limitations yet to be identified or discovered. including formatting and terminology. It is the intention that
A future edition of the Guide is likely to include the Interna- the reader should become familiar with this system of patient
tional Classification of Functioning, Disability, and Health evaluation and treatment and incorporate it into his or her
(ICF) developed by the World Health Organization (WHO) daily practice. It is also hoped that academic and clinical fac-
to promote human functioning with a standardized frame- ulty will use the Guide approach when instructing future gen-
work and language. The APTA House of Delegates endorsed erations of physical therapists and will thus fulfill the purpose
this model in 2008.3 of the Guide.

PURPOSES CONTENT

The list of purposes for the Guide can be found in the first The Guide was developed with three key concepts in mind:
section, “About the Guide,” of the revised second edition.1 (1) the Nagi model of disablement4 (Table 1-1); (2) the variety
Throughout the document, these purposes are reiterated. of work settings for physical therapists; and (3) the provision
Each of the diagnostic patterns described in the Guide uses of services by physical therapists through the continuum of
terminology found in the list of purposes. Although many health care.
readers find this constant redundancy a distracting feature To understand the Guide, a good understanding of the dis-
of the Guide, it is used to demonstrate the basic constructs ablement model is required. Articles by Guccione5 and Jette6
of a physical therapist’s approach to patient management. have provided the background for understanding disablement.
The authors of the Guide also used the combined term The reader can find these articles in the journal Physical Therapy
patient/client throughout the Guide. For this chapter, the from 1991 and 1994, respectively. The Nagi model4 was
term client is used. selected by the authors of the Guide because it provides the best
A summary of the purposes is as follows: The Guide was fit for the development of physical therapy practice patterns
developed to assist internal (physical therapists) and external and diagnoses. As Guccione’s diagram (Fig. 1-1) so aptly
(all others involved in health care delivery and reimburse- demonstrates, the Nagi model encompasses the entire spec-
ment) individuals in understanding the scope of a physical trum of health care. Pathology and pathophysiology lead to
therapist’s practice. As stated in the Guide, this list impairment, which can either cause more pathology or lead
includes—but is not limited to—practice settings, roles, ter- to functional limitations. These functional limitations may
minology, tests and measures, and interventions used by phys- revert back to impairments or progress to disability. The
ical therapists in the delivery of physical therapy. Perhaps domain of a physical therapist’s practice is outlined by the dot-
most important, the Guide establishes preferred practice pat- ted lines in Figure 1-1. The Guide was developed to address the
terns based on the Nagi model of disablement.4 Common delivery of health care services by physical therapists from
themes within the purposes listed in the Guide are the promo- pathology to impairment to functional limitation and to dis-
tion of health, wellness, and fitness along with prevention of ability with the greatest emphasis on identification and rectifi-
movement dysfunction and the appropriate use of physical cation of impairments and functional limitations. In effect, the
therapy services as provided by physical therapists. Guide is saying that physical therapists are the diagnosticians of
The authors of the Guide clearly describe what the Guide is movement impairments and provide interventions to prevent,
not. To quote the authors: “The Guide does not provide spe- improve, or eliminate functional limitations and disability.
cific protocols for treatments, nor are the practice patterns The Guide goes on to enhance and adapt the Nagi model
contained in the Guide intended to serve as clinical guide- by expanding it to include the larger arena of quality of life
lines.”1 The authors go on to state that the Guide is only an (Fig. 1-2). This enhancement requires that the Guide include
initial step in the development of clinical guidelines. Clinical psychological and social functions, as well as the constructs
guideline development requires evidence from peer-reviewed of the promotion of wellness, prevention, and fitness.

Table 1-1 Nagi Model of Disablement

Active Pathology Impairment Functional Limitation Disability

Interruption or interference with Anatomic, physiologic, Limitation in performance Limitation in performance of socially
normal processes, and efforts of the mental, or emotional at the level of the whole defined roles and tasks within a
organism to regain normal state abnormalities or loss organism or person sociocultural and physical environment
 Chapter 1 The Guide to Practice 3

Health care

Medical aspects Domain of physical therapist practice Social aspects

Pathology/ Functional
Impairment Disability
pathophysiology limitation

Figure 1-1 Scope of physical therapist practice within the continuum of health care services and the context of the disablement model. (Modified from
the American Therapist Association from Guccione AA: Physical therapy diagnosis and the relationship between impairments and function, Phys Ther
71:499–504, 1991.)

Pathology/ Functional
Impairment Disability
pathophysiology limitations

Physical function Physiologic function Social function

Non-health factors

• Economic status Health-related

quality of life
• Individual
expectations
and achievements Quality of life

• Personal
satisfaction with
choices and life

• Sense of
personal safety

Figure 1-2 Relationship of the disablement model, health-related quality of life, and quality of life.

The actual content of the Guide currently includes five become a physical therapist; the types of settings in which
major parts. The first part is a description of the Guide itself physical therapists practice; the roles of physical therapists
that provides insight into its development, purpose, scope, in primary, secondary, tertiary, and preventive care; the
and content overview. The second part of the Guide defines components of a physical therapist’s episode of care; and
who physical therapists are and describes their approaches to the criteria for termination of physical therapy services. In
the management of clients. The second part of the Guide also addition, this section describes in greater detail the six ele-
provides a description of the tests and measures used by phys- ments of patient management: (1) examination, (2) evalua-
ical therapists as a part of their examination process. In addi- tion, (3) diagnosis, (4) prognosis, (5) intervention, and
tion, the second part provides definitions and lists of physical (6) outcomes (Fig. 1-3). Finally, this section gives a broader
therapists’ interventions. The third and by far the longest por- description of the roles of physical therapists in manage-
tion of the Guide is made up of preferred practice patterns. ment, administration, communication, critical inquiry, and
The fourth part provides expanded access to the catalog of education.
tests and measures. The fifth part provides a document tem- The second part of the Guide provides the list of the tests
plate to facilitate the use of Guide terminology and the patient and measures used by physical therapists in their examination
management system in clinical practice. A glossary is of clients. If a test or measure is not listed in the Guide, this
included at the end of the Guide. does not preclude physical therapists from using that test or
The section that describes physical therapists provides measure. It is the intent of the Guide, however, that any test
information on the following: the prerequisites required to or measure used is valid and reliable and that each follows
4 Physical Therapy of the Shoulder

DIAGNOSIS
Both the process and the end
result of evaluating examination
data, which the physical therapist
organizes into defined clusters,
syndromes or categories to help
determine the prognosis (including
the plan of care), and the most
appropriate intervention strategies.

PROGNOSIS
(Including plan of care)
Determination of the level of
EVALUATION optimal improvement that may be
A dynamic process in which the attained through intervention and
physical therapist makes clinical the amount of time required to
judgments based on data gathered reach that level. The plan of care
during the examination. This specifies the interventions to be
process may also identify possible used and their timing and
problems that require consultation frequency.
with or referral to another provider.

INTERVENTION
Purposeful and skilled interaction
of the physical therapist with the
patient/client and, if appropriate,
with other individuals involved in
EXAMINATION care of the patient/client, using
The process of obtaining a history, various physical therapy methods
performing a systems review, and and techniques to produce
selecting and administering tests changes in the condition that are
and measures to gather data about consistent with the diagnosis and
the patient/client. The initial prognosis. The physical therapist
examination is a comprehensive conducts a re-examination to
screening and specific testing determine changes in patient/client
process that leads to a diagnostic status and to modify or redirect
classification. The examination intervention. The decision to
process also may identify possible re-examine may be based on new
problems that require consultation clinical findings or on lack of
with or referral to another provider. patient/client progress. The
process of re-examination also
may identify the need for
consultation with or referral to
another provider.

OUTCOMES
Results of patient/client
management, which include the
impact of physical therapy
interventions in the following
domains: pathology/
pathophysiology (disease,
disorder, or condition);
impairments, functional limitations,
and disabilities; risk reduction/
prevention; health, wellness, and
fitness; societal resources; and
patient/client satisfaction.

Figure 1-3 The elements of patient management leading to optimal outcomes. (From American Physical Therapy Association: Guide to Physical
Therapist Practice, ed 2. Baltimore, APTA, 2003.)

the Standards for Tests and Measurements in Physical Therapy required to perform when intervening on behalf of a client.
Practice as presented in the journal Physical Therapy in 1991.7 This list includes coordination, communication, administra-
The interventions section is provided primarily for external tion, client education, and the entire spectrum of the physical
groups. This section contains definitions and descriptions of therapists’ interventions from therapeutic exercise to physical
all the activities in which physical therapists are trained and agents and modalities.
 Chapter 1 The Guide to Practice 5

The bulk of the Guide is dedicated to the practice patterns. projection of the frequency and duration of treatment required
The patterns are broken up into four broad classifications: and plans for discharge from therapy.
(1) musculoskeletal, (2) neuromuscular, (3) cardiovascular/ Perhaps the most important contribution of the Guide to
pulmonary, and (4) integumentary. All the client cases the clinician is in the intervention segments of each practice
described in this edition of Physical Therapy of the Shoulder pattern. These suggested interventions are not cookbooks for
can be found in the musculoskeletal and neuromuscular prac- care, but rather are listed specifically as possible physical thera-
tice patterns. Although the physical therapists’ evaluations pist approaches to achievement of the desired outcomes for
direct them initially to a specific pattern, this does not the client. In all cases, education of the client or of supportive
preclude therapists from changing to an alternative pattern personnel is included as part of the interventions listed
if the examination information leads them to another conclu- regardless of the selected practice pattern. Alternative inter-
sion. It is also possible for a client to fit into more than one ventions listed under a particular pattern should not be inter-
pattern. In this case, the professional opinion of the therapist preted by the therapist as an indication to try one or two
directs the allocation of resources and time to the pattern of interventions and then move on to the next practice pattern
highest priority. if the interventions do not work. Each intervention should
The practice patterns were developed using the Nagi be applied as appropriate to the client’s responses, goals,
model4 and the patient management system previously needs, and projected outcomes. Nowhere in the Guide is it
described.1 This system includes six components. Each com- suggested that the interventions listed are the only ones
ponent in the patient management system is found in every appropriate to a particular practice pattern. As the reader will
practice pattern. The purpose of this format is to create a con- learn later in this book, however, application of the correct
sistent, uniform methodology for patient examination and intervention to the client with shoulder dysfunction has been
treatment. As depicted in Figure 1-3, each component of this found to improve the client’s functional level and to reduce
system has specific supportive parts. Examination includes his or her overall impairment.
obtaining a history, review of systems (cardiopulmonary, mus- In few, if any, cases are the interventions of the physical
culoskeletal, neuromuscular, and integumentary), choice and therapist directed solely toward the pathologic or pathophysi-
administration of tests, measurements of appropriate values, ologic features of the client’s medical condition. The Guide is
and identification of any need for referral to another a textbook for providing direction for physical therapists to
practitioner. intervene at the level of impairment and functional limitation
Figure 1-4 provides an in-depth summary of the data that without the use of medication for the most part or surgical
can be gathered during client history taking. The evaluation interventions. Intervention also includes the need for the ther-
is the process of using the information obtained during the apist to interact with the rest of the medical community
examination to determine a diagnosis or need for referral. This involved in the client’s care. This interaction requires coordi-
process continues throughout the client’s contact with the nation and communication with, and documentation of, all
therapist and requires clinical judgment on a regular and rou- the physical therapist’s clients.
tine basis. The diagnosis is a determination of which practice Inherent in the system of patient management is that at
pattern is a “best fit” for the previously gathered examination any point during the client’s treatment, the therapist is man-
and evaluation information. This physical therapist diagnosis dated to provide re-examination. The re-examination should
relates directly to an impairment classification in the Nagi be performed periodically during an episode of care, to ensure
model4 and should lead the therapist to determine the relative that the client is progressing according to his or her prognosis
level of functional loss the client is experiencing. This infor- and that short- and long-term goals are being achieved. Dur-
mation, in turn, directs the therapist to the appropriate inter- ing re-examination, the patient management system steps are
vention to obtain the optimal outcome for the client. repeated as in the original examination process.
The next component is the prognosis. This component also
includes the plan of care. The prognosis is a natural extension SUMMARY
of the diagnosis. Once the diagnosis has been made, the ther- Why is the Guide entitled Guide to Physical Therapist Practice
apist should begin to formulate a realistic prognosis and esti- and not Guide to Physical Therapy Practice? That is the nature
mate how much improvement in function can be achieved of the document. It is intended to describe the scope, role,
given the amount of impairment suffered as a result of the and spectrum of the physical therapist’s activity. Why not
disease. The logical progression of these interwoven formula- physical therapy? Because many other practitioners who are
tions between the Nagi model and the patient management not physical therapists are legally allowed to provide and be
system has been included in the Guide to create a continuum reimbursed for physical therapy. The APTA believes that
of care that leads to improved function or appropriate referral. physical therapy per se is well described within the Guide,
The plan of care is the culmination of all the steps previ- but physical therapy is really performed only by physical
ously listed and includes the client’s goals, the short- and therapists. Therefore, the Guide correctly describes the physi-
long-term goals of the therapist, specific interventions, and cal therapists’ diagnoses (practice patterns), tests and mea-
the projected outcomes of those interventions. Included sures, interventions, and responsibilities within the context
within the interventions and outcomes should be some of the Nagi model.4
6 Physical Therapy of the Shoulder

General Demographics Medical/Surgical History Current Condition(s)/

• Age • Cardiovascular Chief Complaint(s)
• Gender • Endocrine/metabolic • Concerns that led the
• Race/ethnicity • Gastrointestinal patient/client to seek the services
• Primary language • Genitourinary of a physical therapist
• Education • Gynecological • Concerns or needs of
• Integumentary patient/client who requires the
Social History • Musculoskeletal services of a physical therapist
• Cultural beliefs and behaviors • Neuromuscular • Current therapeutic
• Family and caregiver resources • Obstetrical interventions
• Social interactions, social • Prior hospitalizations, surgeries, • Mechanisms of injury or disease,
activities, and support systems and preexisting medical and including date of onset and
other health-related conditions course of events
Employment/Work • Psychological • Onset and pattern of symptoms
(Job/School/Play) • Pulmonary • Patient/client, family, significant
• Current and prior work other, and caregiver expecta-
(job/school/play), community, tions and goals for the therapeu-
and leisure actions, tasks, or tic intervention
activities • Patient/client, family, significant
other, and caregiver perceptions
Growth and Development of patient’s/client’s emotional
• Developmental history response to the current clinical
• Hand dominance situation
• Previous occurrence of chief
Living Environment complaint(s)
• Devices and equipment (eg, • Prior therapeutic interventions
assistive, adaptive, orthotic, pro-
tective, supportive, prosthetic) Functional Status and
• Living environment and Activity Level
community characteristics • Current and prior functional
• Projected discharge destinations status in self-care and home
management, including activities
General Health Status of daily living (ADL) and instru-
(Self-Report, Family Report, mental activities of daily living
Caregiver Report) (IADL)
• General health perception • Current and prior functional
• Physical function (eg, mobility, status in work (job/school/play),
sleep patterns, restricted bed community, and leisure actions,
days) tasks, or activities
• Psychological function
(eg, memory, reasoning ability, Medications
depression, anxiety) • Medications for current
• Role function (eg, community, condition
leisure, social, work) • Medications previously taken for
• Social function (eg, social current condition
activity, social interaction, • Medications for other conditions
social support)
Other Clinical Tests
Social/Health Habits • Laboratory and diagnostic tests
(Past and Current) • Review of available records (eg,
• Behavioral health risks medical, education, surgical)
(eg, smoking, drug abuse) • Review of other clinical findings
• Level of physical fitness (eg, nutrition and hydration)

Family History
• Familial health risks

Figure 1-4 Types of data that may be generated from a client history. (From American Physical Therapy Association: Guide to Physical Therapist
Practice, ed 2. Baltimore, 2003, APTA.)

The template for defining the body of knowledge of phys-

REFERENCES
ical therapy has been produced in the Guide. The physical
therapist community has been challenged to provide the evi- 1. American Physical Therapy Association: Guide to physical thera-
dence to prove or disprove the usefulness of the interventions pist practice, ed 2 rev, Alexandria, Va, 2003, American Physical
Therapy Association.
provided within each practice pattern. The Guide has provided
2. American Physical Therapy Association: Guide to physical thera-
all physical therapists with a common language, a patient pist practice (website). http://guidetoptpractice.apta.org/. Accessed
management system, and an opportunity to develop definitive May 17, 2010.
and reproducible methods of optimally improving impair- 3. American Physical Therapy Association: House of Delegates Policies
ments and functional limitations of a physical therapist’s cli- 2009, Page 32, line 8. http://www.apta.org/AM/Template.cfm?
ents. The Guide to Physical Therapist Practice is indeed a truly Section¼Policies_and_Bylaws1&TEMPLATE¼/CM/Content
epic document. Display.cfm&CONTENTID¼67833. Accessed October 28, 2010.
 Chapter 1 The Guide to Practice 7

4. Nagi S: Disability and rehabilitation, Columbus, Ohio, 1969, 6. Jette AM: Physical disablement concepts for physical therapy
Ohio State University Press. research and practice, Phys Ther 74:381, 1994.
5. Guccione AA: Physical therapy diagnosis and the relationship 7. American Physical Therapy Association: Standards for tests
between impairments and function, Phys Ther 71:499–504, and measurements in physical therapy practice, Phys Ther
1991. 71:589–622, 1991.
 PART 1
MECHANICS OF MOVEMENT AND EVALUATION

C H A P T E R

2 Robert A. Donatelli

Functional Anatomy and Mechanics

One of the most common peripheral joints to be treated in a the sagittal plane (flexion), and the plane of the scapula (POS;
physical therapy clinic is the shoulder joint. The physical scaption).8,9 Movement of the long bones of the arm into ele-
therapist must have an in-depth understanding of the anat- vation is referred to as osteokinematics. The term arthrokine-
omy and mechanics of this joint to evaluate and design a matics describes the intricate movement of joint surfaces:
treatment program most effectively for the patient with rolling, spinning, and sliding.10
shoulder dysfunction. This chapter describes the pertinent
functional anatomy of the shoulder complex and relates this
Osteokinematic Movement
anatomy to functional movements, stability, muscle activity,
and clinical application.
Scaption-Abduction: Plane of the Scapula
The shoulder joint is better called the shoulder complex,
because a series of articulations are necessary to position the Abduction of the shoulder in the frontal or coronal plane has
humerus in space (Fig. 2-1). Most authors, when describing been extensively researched.4,8,11-17 Poppen and Walker15 and
the shoulder joint, discuss the acromioclavicular (AC) joint, Johnston8 suggested that the true plane of movement in the
the sternoclavicular joint (SC), the scapulothoracic articula- shoulder joint occurs in the POS. The term plane of the scapula
tion, and the glenohumeral joint.1-4 Dempster5 related all is defined as elevation of the shoulder in a range between 30
these areas by using a concept of links. The integrated and and 45 anterior to the frontal plane (Figs. 2-2 and 2-3).15
harmonious roles of all the links are necessary for full normal Kondo et al18 devised a method for taking radiographs to
mobility.5 define scaption during elevation. The medial tilting angle
The glenohumeral joint sacrifices stability for mobility. This was used to describe scaption. The medial tilting angle refers
joint is characterized by its large range of motion. The shoulder to the tilting of the scapula toward the sagittal plane. As
is capable of moving in more than 16,000 positions, which can the medial tilting angle increases, movement of the scapula
be differentiated by 1 in a normal person.6 The mobility of around the thoracic cage occurs. Kondo et al18 demonstrated
the shoulder relies on the congruent articulating surfaces and that the medial tilting angle was constant at 40 anterior to
the surrounding soft tissue envelope for static and dynamic sta- the frontal plane throughout a range of 150 of elevation.
bility. The position of the humerus and scapula must change Several authors believe that the POS is clinically significant
throughout each movement to maintain stability.6 because the length-tension relationship of the shoulder abduc-
tors and rotators is optimum in this plane of elevation.8,15
Research has demonstrated that the length of the muscle deter-
OSTEOKINEMATIC AND ARTHROKINEMATIC mines the amount of stretch applied to the individual sarco-
MOVEMENT meres, thus enabling them to exert maximum tension.19 The
length-tension curves obtained from normal muscles show that
Analysis of shoulder movement emphasizes the synchronized maximum tension develops when the muscle length is approx-
movement of four joints: the glenohumeral, scapulothoracic, imately 90% of its maximum length.19 Conversely, when the
SC, and AC joints.2,4,7,8 As the humerus moves into elevation, muscle is fully shortened, the tension developed is mini-
movement must occur at all four joints. Elevation of the arm mal.20,21 Therefore, the optimal lengthened position of the
can be observed in three planes: the frontal plane (abduction), muscle tendon facilitates optimal muscle contraction.22
10 Physical Therapy of the Shoulder

3
5
2 6

Figure 2-1 The components of the shoulder joint complex: 1,

glenohumeral joint; 2, subdeltoid joint; 3, acromioclavicular joint; 4,
scapulothoracic joint; 5, sternoclavicular joint; 6, first costosternal joint;
7, first costovertebral joint.

Several studies have compared the torque production of

different shoulder muscle groups when tested in scaption ver-
sus other body planes.23-27 Soderberg and Blaschak23 and
Hellwig and Perrin24 demonstrated no significant differences Figure 2-2 Elevation in the plane of the scapula.
in the peak torque of the glenohumeral rotators between scap-
tion and other body planes. These studies used 45 and 40 torque in the scaption plane 30 anterior to the frontal plane.
anterior to the frontal plane, respectively, for the scaption test The pectoralis major and the latissimus muscle groups are not
position. Greenfield et al25 reported greater torque in the attached to the scapula. Therefore, it would seem reasonable
external rotators when tested in scaption versus the coronal that when the torque output of the internal rotators is com-
plane. Furthermore, Tata et al26 reported higher ratios of pared, the change in position of the scapula should not influ-
abduction to adduction and external to internal torque when ence the optimal length-tension relationship. The internal
tested in the scapular plane at 30 and 35 anterior to the rotators exhibit no change in torque when they are tested in
frontal plane, respectively. Whitcomb et al27 found no signif- different planes of movement.
icant difference in torque produced by the shoulder abductors In addition to optimal muscle length-tension relationship in
in the coronal and scapular planes when a scaption position the POS, the capsular fibers of the glenohumeral joint are
35 anterior to the frontal plane was used. relaxed.8 Because the capsule is untwisted in the POS, mobiliza-
The studies cited indicate that the external rotators are the tion and stretching in this plane may be tolerated better than in
only muscle group that demonstrate a significant increase in other planes, where the capsule is starting in a twisted position.

Plane of the scapula

Abduction

Figure 2-3 Abduction in the plane of the scapula.

 Chapter 2 Functional Anatomy and Mechanics 11

Poppen and Walker14 demonstrated that an increase in joint the contact area between the head of the humerus and the gle-
congruity occurs in scaption that allows for greater joint sta- noid with abduction in the POS and found that the contact
bility. Therefore, for reasons of glenohumeral stability, mini- area on the head of the humerus shifted upward and forward,
mal scapular torsion, avoidance of impingement, and balance whereas the contact area on the glenoid remained relatively
of muscle action, scaption may be the plane in which shoulder constant, a finding indicating a rotation movement. Poppen
trauma is minimal and may thus be the most advantageous and Walker15 measured the instant centers of rotation for
plane for mobilization, stretching, testing, and strengthening the same movement. These investigators found in the first
of the glenohumeral rotators. 30 , and often between 30 and 60 , that the head of the
humerus moved superiorly in the glenoid by 3 mm, a finding
indicating rolling or gliding. At more than 60 , movement of
Flexion
the humerus was minimal, a sign of almost pure rotation.15
The movement of flexion has been investigated less thor- Effective arthrokinematic movements are achieved by com-
oughly. Flexion is movement in the sagittal plane. Full flexion plex interaction between the various articular and soft tissue
from 162 to 180 is possible only with synchronous motion restraints in addition to the dynamic action of the rotator cuff
in the glenohumeral, AC, SC, and scapulothoracic joints.14 muscles. For example, the rotator cuff muscles center the
The movement is similar to that of abduction. humeral head in the congruent glenoid fossa during the mid-
range of motion when the capsuloligamentous structures are
lax.28 Dysfunction of this complex mechanism occurs with
Arthrokinematic Movement
tightening of the capsule anteriorly, a situation that results
The motion occurring at joint surfaces is arthrokinematic in anterior restriction and causes an associated posterior shift
motion, the three types of which are rolling, gliding, and rota- in contact of the humerus on the glenoid. The posterior
tion (Fig. 2-4). Rolling occurs when various points on a migration of the humeral head center and glenohumeral con-
moving surface contact various points on a stationary surface. tact are pronounced in shoulder joints with poor congru-
Gliding occurs when one point on a moving surface contacts ence.28 To re-establish harmonious movement within the
multiple points on a stationary surface. During rolling or shoulder complex, the therapist must rehabilitate the connec-
gliding, a significant change occurs in the contact area tive tissue by restoring its extensibility and the normal bal-
between the two joint surfaces. The third type of arthrokine- ance of muscles.
matic movement, rotation, occurs when one or more points on
a moving surface contact one point on a stationary surface.
Displacement between the two joint surfaces in rotation is ROTATIONS OF THE HUMERUS
minimal.
All three arthrokinematic movements can occur at the gle- Rotations of the humerus are important for elevation. Con-
nohumeral joint, but not in equal proportions. These motions comitant external rotation of the humerus is necessary for
are necessary for the large humeral head to take advantage of abduction in the coronal plane.4,8,10,14,17 Some investigators
the small glenoid articulating surface.16 Saha16 investigated have postulated that this motion is necessary for the greater

Rolling

Glenohumeral Jt. Rotation

Gliding

Figure 2-4 Arthrokinematic motion occurring at the glenohumeral joint: rolling, rotation, and gliding.
12 Physical Therapy of the Shoulder

tuberosity to clear the acromion and the coracoacromial liga- rotation, measured in the adducted position, and active
ment.1,2,17 Saha16 reported sufficient room between the abduction in the POS.
greater tuberosity and the acromion to prevent bone impinge- When treating patients with limited active elevation, the
ment. External rotation also remains necessary for full coronal practitioner should avoid pushing the joint into painful eleva-
abduction even after surgical removal of the acromion and the tion activities. Restoring passive external rotation in the
coracoacromial ligament. Saha16 reasoned that external rota- adducted position is a safe and effective way of restoring
tion is necessary to prevent the humeral head from impinging extensibility to the capsule and enhancing active abduction
on the glenoid rim. in the POS.
Using cadaveric glenohumeral joints, Rajendran29 demon-
strated that automatic external rotation of the humerus is an
essential component of active and passive elevation of the STATIC STABILIZERS OF THE
arm through abduction. Even in the absence of extra-articular GLENOHUMERAL JOINT
influences, such as the coracoacromial arch and glenohumeral
muscles, external rotation of the humerus was spontaneous. The stability of the glenohumeral joint depends on the integ-
An et al30 used a magnetic tracking system to monitor the rity of soft tissue and bony structures such as the labrum,
three-dimensional orientation of the humerus with respect glenohumeral ligaments, capsular ligaments, and bony gle-
to the scapula. Appropriate coordinate transformations were noid.39 The glenohumeral joint contributes the greatest
then performed for the calculation of glenohumeral joint amount of motion to the shoulder because of its ball and
rotation. Maximum elevation in all planes anterior to the socket configuration. Saha40 confirmed the ball and socket
scapular plane required external axial rotation of the humerus. joint of the glenohumeral articulation in 70% of his subjects.
Browne et al,31 using three-dimensional magnetic field track- In the remaining 30%, the radius of curvature of the humeral
ing, demonstrated that elevation in any plane anterior to the head was greater than the radius of curvature of the glenoid.
scapula required external humeral rotation. Furthermore, Thus, the joint was not a true enarthrosis.16 Saha16 further
maximum elevation was associated with approximately 35 described the joint surfaces, especially on the head of the
of external humeral rotation. Conversely, internal rotation humerus, to be very irregular and to demonstrate a great
was necessary for increased elevation posterior to the POS. amount of individual variation.
Otis et al32 demonstrated that external rotation of the The head of the humerus is a hemispherical convex articu-
humerus allows the insertion of the subscapularis tendon to lar surface that faces superiorly, medially, and posteriorly. This
move laterally, with a resulting increase in the distance from articular surface is inclined 130 to 150 to the shaft of the
the axis of elevation in the scapular plane. An increase in the humerus and is retroverted 20 to 30 .3 The retroversion
moment arm enhances the ability of the superior fibers of the and the posterior tilt of the head of the humerus and the gle-
subscapularis to participate in scaption. Conversely, internal noid cultivate joint stability (Fig. 2-5). This retroversion of
rotation of the humerus increases the moment arm of the supe- the head of the humerus corresponds to the forward inclina-
rior fibers of the infraspinatus and increases the ability of the tion of the scapula, so that free pendulum movements of the
muscle to participate in scaption. Flatow et al33 reported that arm do not occur in a straight sagittal plane but at an angle
acromial undersurface and rotator cuff tendons are in closest of 30 across the body.41 Retroversion of the humeral head
proximity between 60 and 120 of elevation. corresponds to the natural arm swing evident in ambulation.
Conditions limiting external rotation or elevation may The head of the humerus is large in relation to the glenoid
increase rotator cuff compression. Rajendran and Kwek34 fossa. Therefore, only one third of the humeral head can contact
described how the course of the long head of the biceps the glenoid fossa at a given time.1,41 The glenoid fossa is a shal-
(LHB) would influence external rotation of the humerus, low structure deepened by the glenoid labrum. The labrum is
which, in turn, prevents tendon impingement between the wedge shaped when the glenohumeral joint is in a resting posi-
greater tuberosity and the glenoid labrum and allows gleno- tion and changes shape with various movements.42 The glenoid
humeral elevation to move to completion. Brems35 reported and the labrum combine to form a socket with a depth up to
that external rotation is possibly the most important func- 9 mm in the superior-inferior direction and 5 mm in the ante-
tional motion that the shoulder complex allows. Loss of exter- rior-posterior direction.43 The functional significance of the
nal rotation can result in significant functional disability. labrum is questionable. Most authors agree that the labrum is
Walker36 described external rotation of the humerus as neces- a weak supporting structure.42,44 The function of the labrum
sary for the greater tuberosity to clear the glenoid, thus has also been described as a “chock block” preventing humeral
providing more articular cartilage motion to produce eleva- head translation.45 Moseley and Overgaard42 considered the
tion of the arm. Abboud and Soslowsky37 reported that loss labrum a redundant fold of the capsule composed of dense
of rotational range of motion is deleterious because of its fibrous connective tissue but generally devoid of cartilage
effect on activities of daily living and sports and its likely except in a small zone near its osseous attachment.
relation to the development of osteoarthritis. The glenohumeral joint was described by Matsen et al46 as
External rotation is an important component for active a suction cup because of the seal of the labrum and glenoid to
abduction in POS elevation. In a pilot study, Donatelli38 the humeral head. This phenomenon is caused by the
demonstrated a direct correlation between passive external graduated flexibility of the glenoid surface, which permits
 Chapter 2 Functional Anatomy and Mechanics 13

and function. The central location of the humeral head is

maintained by a balance of muscle forces and connective tissue
extensibility. Off-center joint force has more potential for sub-
luxation and dislocation.49
If the head of the humerus is not in a central position, it
will reduce the compressive forces of the rotator cuff muscles,
thereby decreasing dynamic stability by altering the length
tension of the rotator cuff muscles. A reduction in rotator cuff
strength promotes destabilizing forces and poor joint
arthrokinematics.

Clinical Evaluation of Humeral Head Central

Position
• Evaluation of scapula posture
• Assessment of glenohumeral capsular extensibility by tests
of external and internal rotation in various positions
• Assessment of strength of the rotator cuff muscles
• Assessment of strength of the scapula rotators
A centrally located humeral head on the glenoid enhances
A the dynamic stability of the glenohumeral joint. Joint forces
associated with the rotator cuff muscles are stabilizing to
the glenohumeral joint, whereas the forces produced by the
deltoid muscles deviate from the surface of the glenoid joint
during elevation of the arm. At 60 of glenohumeral abduc-
B tion the shearing force is the greatest. The line of pull of
the deltoid is oriented superiorly and parallel to the glenoid
surface; this can be described as a shearing force. This parallel
Figure 2-5 A, Humerus with marker through the head-neck and a
second marker through the epicondyles. B, Retroversion of the
and superior action of the deltoid muscle may therefore result
humerus as seen from above. in a more off-center joint reaction force at the glenoid surface.
This off-centered joint force could be the cause of several
mechanic dysfunctions of the shoulder, including impinge-
the glenoid to conform and seal to the humeral head. Com- ment and rotator cuff tears. Ideally, the best strategy for a
pression of the head into the socket expels the synovial glenohumeral elevation would be the combination of a strong
fluid to create suction that resists distraction. Negative intra- deltoid muscle and the rotator cuff muscles to stabilize the
articular joint pressure is produced by the limited joint vol- joint by directing the joint force toward the a stable compres-
ume.47 Matsen et al46 illustrated the importance of an intact sive force that is the center of the joint surface.
glenoid labrum in establishing concavity compression stabiliza-
tion. The compressive load is provided by dynamic muscle con-
Anatomy of the Glenohumeral Ligaments
traction. In addition, Matsen et al46 discussed the importance
of the central position of the humerus on the glenoid, to opti- The coracohumeral ligament is the strongest supporting liga-
mize the mechanical advantage of the rotator cuff muscles. ment of the glenohumeral joint. Fibers of the capsule and cor-
The glenoid fossa faces laterally. Freedman and Munro48 acohumeral ligament blend together and insert into the
found that the glenoid faced downward in 80.8% of the borders of the supraspinatus and subscapularis.50 Portions of
shoulders they studied radiographically. Saha40 found a 7.4 the coracohumeral ligament form a tunnel for the biceps ten-
retrotilt of the glenoid in 73.5% of normal subjects. The retro- don on the anterior side of the joint. The rotator cuff interval,
tilt is a stabilizing factor in the glenohumeral joint. Both the the region of the capsule between the anterior border of the
humeral and glenoid articular surfaces are lined with articular supraspinatus and the superior border of the subscapularis
cartilage. The cartilage is the thickest at the periphery on the muscle, is reinforced by the coracohumeral ligament.45 The
glenoid fossa and at the center of the humeral head.16 superior glenohumeral ligament and the coracohumeral liga-
ment limit external rotation and abduction of the humerus
and are important stabilizers in the inferior direction from
Central Position of the Humerus on the
0 to 50 of abduction.45,51
Glenoid
The superior glenohumeral ligament forms an anterior
Because the shoulder is not inherently stable, the orientation cover around the LHB tendon and is also part of the rotator
and location of the joint reaction force with respect to the gle- cuff interval.45 The coracohumeral ligament blends with the
noid surface are important considerations in joint stability superior glenohumeral ligament. The anatomy of the middle
14 Physical Therapy of the Shoulder

glenohumeral ligament is similar to that of the superior gle- glenohumeral ligament attaches to the glenoid labrum. Turkel
nohumeral ligament. The middle glenohumeral ligament et al54 determined the relative contribution to anterior stability
blends with portions of the subscapularis tendon medial to by testing external rotation in different positions. The subscapu-
its insertion on the lesser tuberosity. The middle glenohum- laris resisted passive external rotation in the adducted position
eral ligament has been shown to become taut at 45 of abduc- more than any other anterior structure (Fig. 2-6A). In patients
tion, and at 10 of extension and external rotation, and it with internal rotation contracture and pain after anterior repair
provides anterior stability between 45 and 60 of abduction. for recurrent dislocation of the shoulder, surgical release of the
The inferior glenohumeral ligament complex is a subscapularis increased the external rotation range of motion
hammock-like structure with attachments on the anterior and an average of 27 .55 Turkel et al54 demonstrated that, at 45 of
posterior sides of the glenoid. The anterior band of the inferior abduction, external rotation was resisted by the subscapularis,
glenohumeral ligament is attached to the anterior labrum. At middle glenohumeral ligament, and superior fibers of the infe-
the neutral position (0 of abduction and 30 of horizontal rior ligament (Fig. 2-6B). At 90 of abduction, the inferior gle-
extension), the anterior band of the inferior glenohumeral liga- nohumeral ligament (Fig. 2-6C) restricted external rotation.
ment becomes the primary stabilizer. The inferior glenohum- Itoi et al56 concluded that the LHB and short head of the
eral ligament complex was found to be the most important biceps (SHB) have similar functions as anterior stabilizers of
stabilizer against anterior-inferior shoulder dislocation.45,52 the glenohumeral joint with the arm in abduction and external
The capsule and ligaments reinforce the glenohumeral joint. rotation. Furthermore, the role of the LHB and SHB increased
The capsule attaches around the glenoid rim and forms a sleeve with shoulder instability. Warner et al57 studied the capsuloliga-
around the head of the humerus, by attaching on the anatomic mentous restraints to superior and inferior translation of the gle-
neck. A functional interplay or interdependence exists between nohumeral joint. The primary restraint to inferior translation of
the anterior and posterior and superior and inferior capsuloliga- the adducted shoulder was the superior glenohumeral ligament.
mentous system. This concept is referred to as the circle theory, a Abduction to 45 and 90 demonstrated the anterior and poste-
term implying that excessive translation in one direction may rior portions, respectively, of the glenohumeral ligament to be
damage the capsule on the same and opposite sides of the the main static stabilizers resisting inferior translation.
joint.37 The capsule is a lax structure. The head of the humerus Guanche et al58 studied the synergistic action of the cap-
can be distracted one-half inch when the shoulder is in a sule and the shoulder muscles. A reflex arch was identified
relaxed position.51 The anterior capsule is reinforced by the gle- from mechanoreceptors within the glenohumeral capsule to
nohumeral ligaments noted earlier. The support these liga- muscles crossing the joint. Stimulation of the anterior and
ments lend to the capsule is insignificant.53 inferior axillary articular nerves elicited electromyographic
Turkel et al54 described the inferior glenohumeral ligament (EMG) activity in the biceps, subscapularis, supraspinatus,
as the thickest and most consistent structure. The inferior and infraspinatus muscles. Stimulation of the posterior

A B C

Figure 2-6 External rotation of the humerus. A, In the adducted position. The most stabilizing structure to this movement is the subscapularis muscle.
B, At 45 of abduction. The most stabilizing structures for this movement are the middle and inferior ligaments and the subscapularis muscle. C, At 90 of
abduction. The most stabilizing structure for this movement is the inferior ligament.
 Chapter 2 Functional Anatomy and Mechanics 15

axillary articular nerve elicited EMG activity in the acromio- depressors of the humeral head. Translation of the humeral
deltoid muscle. head is of clinical interest in most shoulder disorders. At the
Between the supporting ligaments and muscles lie synovial glenohumeral joint, the amount and direction of translation
bursae or recesses. Anteriorly, three distinct recesses are pres- define the type of instability. Wuelker et al62 demonstrated
ent.59 The superior recess is the subscapular bursa, which nor- that translation of the humeral head during elevation of the
mally communicates with the shoulder joint. The inferior glenohumeral joint between 20 and 90 averaged 9 mm
recess is referred to as the axillary pouch, and the middle superiorly and 4.4 mm anteriorly. Translation of the humeral
synovial recess lies posterior to the subscapularis tendon. head during active elevation may be diminished by the coor-
Arthrograms of frozen shoulders in relatively early stages, dinated activity of the rotator cuff muscles. This active con-
before glenohumeral abduction is completely restricted, show trol of translation forces provides dynamic stability to the
obliteration of the anterior glenoid bursa.60 glenohumeral joint. Perry63 described 17 muscle groups that
provide dynamic interactive stabilization of the composite
movement of the thoracoscapular humeral articulation.
DYNAMIC STABILIZERS OF THE The deltoid muscle makes up 41% of the scapulohumeral
GLENOHUMERAL JOINT muscle mass.4 This muscle, in addition to its proximal attach-
ment on the acromion process and the spine of the scapula,
The major muscles that act on the glenohumeral and scapu- also stems from the clavicle. The distal insertion is on the
lothoracic joints may be grouped into the scapulohumeral, shaft of the humerus at the deltoid tubercle. The mechanical
axiohumeral, and axioscapular muscles. The muscles of the advantage of the deltoid is enhanced by the distal insertion
scapulohumeral group, which include the rotator cuff mus- and the evolution of a larger acromion process.4 The deltoid
cles, originate on the scapula and insert on the humerus. is a multipennate and fatigue-resistant muscle. These charac-
The rotator cuff muscles insert on the tuberosities and along teristics may explain the rare involvement of this muscle in
the upper two thirds of the humeral anatomic neck.10 The pathologic shoulder conditions.64 The deltoid and the clavic-
contribution of the shoulder musculature to joint stability ular head of the pectoralis major muscles have been described
may be caused by the following mechanisms: muscle bulk act- as prime movers of the glenohumeral joint because of their
ing as a passive muscle tension, contraction of the rotator cuff large mechanical advantage.4 Michiels and Bodem65 demon-
muscles primarily causing compression of the articular sur- strated that deltoid muscle action is not restricted to the gen-
faces, joint motion that secondarily tightens the ligamentous eration of abduction in the shoulder joint.
constraints, barrier or restraint effects of the contracted mus- The deltoid provides dynamic stability with the arm in the
cle, and redirection of the joint force to the center of the gle- scapular plane and decreases stability with the arm in the cor-
noid surface by coordination of muscle forces.37 onal plane. The middle and posterior heads of the deltoid pro-
The infraspinatus and teres minor control external rotation vide more stability by generating more compressive forces and
of the humerus and reduce anterior-inferior capsuloligamen- lower shearing forces than the anterior head. Therefore, the
tous strain. The subscapularis muscle is the strongest stabi- middle and posterior heads of the deltoid should strengthen
lizer of the rotator cuff muscles. It has the largest amount of vigorously in anterior shoulder instability.66
muscle mass of the four rotator cuff muscles.4 Combined con- Itoi et al56 reported that the biceps muscle group becomes
traction of the subscapularis and the infraspinatus forms a more important than the rotator cuff muscles as stability from
force couple, providing stability throughout the midrange of the capsuloligamentous structure decreases. The anterior dis-
elevation, which is from 60 to 150 of abduction.52 placement of the humeral head under a 1.5-kg force was signif-
Researchers showed that during late cocking by baseball icantly decreased by both LHB and SHB loading in all capsular
pitchers, the glenohumeral joint reaches extreme external conditions when the arm was in 60 or 90 of external rotation
rotation. The subscapularis is the strongest activity stabilizer, and abduction. Abboud and Soslowsky37 demonstrated that the
followed by the infraspinatus and teres minor. The supraspi- LHB in the shoulder neutral position is anterior to the joint.
natus has the least stabilizing activity.37 In addition, the sub- Internal rotation of the humerus positions the tendon of the
scapularis of a professional baseball pitcher is more active in biceps further anterior to the joint, and external rotation posi-
the propulsive phase than any other internal rotator.37 tions the biceps tendon posterior to the joint. The forces gener-
Travell and Simons60 believed that a trigger point within ated by the LHB help to stabilize the glenohumeral joint and
the subscapularis may spur the other shoulder girdle muscula- assist in restricting the translations of the humeral head. The
ture into developing secondary and satellite trigger points. restrictions in translation of the humeral head result from inter-
These points would lead to major restrictions in glenohumeral nal and external rotation of the humerus that allow the forces
joint motion and cause adhesive capsulitis. generated by the tendon to change to compressive with a pos-
The rotator cuff muscles have been described as steering terior-directed force and compressive with an anterior-directed
mechanisms for the head of the humerus on the glenoid.16 force, respectively (Fig. 2-7).
The subscapularis, latissimus dorsi, teres major, and teres The deltoid and the rotator cuff muscles produce shearing
minor act as humeral depressors.16,61 The arthrokinematics and compressive forces in the glenohumeral joint. These forces
(rolling, spinning, and sliding) of the glenohumeral joint vary as the alignment of the muscles changes.67 The compres-
result from the action of the steering mechanisms and the sive forces produced by those muscles acting parallel to the
16 Physical Therapy of the Shoulder

deltoid force required to abduct the arm increased by 17%.

ER
N
According to the study by Payne et al,67 the action of the deltoid
muscle increased the pressures under the acromion by 1240%.
IR One study described the lines of action of 18 major muscles
spanning the shoulder joint during abduction and flexion and
their potential contributions to glenohumeral joint stability.68
The superior pectoralis major and inferior latissimus dorsi were
the chief scapular plane destabilizers, with a demonstrated abil-
ity to provide superior and inferior shear to the glenohumeral
joint, respectively. Evaluation of the middle and anterior del-
A toid during flexion and abduction demonstrated a potential
contribution to superior shear, by opposing the combined
destabilizing inferior shear potential of the latissimus dorsi
and inferior subscapularis. The rotator cuff muscles were more
aligned to stabilize the glenohumeral joint in the transverse
plane than in the scapular plane. Overall, the anterior supraspi-
natus was most favorably oriented to apply glenohumeral joint
compression. The study identified the posterior deltoid and
subscapularis as potential stabilizers because they had posteri-
orly directed muscle lines of action, whereas the teres minor
and infraspinatus had anteriorly directed lines of action.
The foregoing study helps the clinician identify the
dynamic action of muscles surrounding the shoulder. A coor-
dinated activation of the destabilizers and stabilizer muscles
results in movement patterns that are not destructive to the
shoulder. However, muscle imbalances around the shoulder
may be the underlying cause of abnormal movement patterns
and the resultant pathologic process. Knowledge of the stabi-
lizing potential of shoulder musculature may assist clinicians
B C
in identifying muscle-related instabilities and may aid in
Figure 2-7 Forces produced by the long head of the biceps tendon in the development of rehabilitation programs to improve joint
conjunction with internal rotation (IR) and external rotation (ER) of the stability and prevention programs.
humerus. A, Tendon position neutral and anterior to joint, ER posterior
to joint, IR anterior to joint. B, Forces are compressive and posterior
with IR. C, Forces are compressive and anterior with ER. (Modified STERNOCLAVICULAR JOINT
from Pagnani MJ, Xiang-Hua D, Warren RF, et al: Role of the long head
of the biceps brachii in glenohumeral stability: a biomechanical study in The SC joint is the only articulation that binds the shoulder
cadavers, J Shoulder Elbow Surg 5:225–262, 1996.) girdle to the axial skeleton (Fig. 2-8). This is a sellar joint,
with the sternal articulating surface greater than the clavicular
glenoid fossa stabilize the humeral head. Muscles acting more surface, thus providing stability to the joint.10 The joint is
perpendicular to the glenoid produce a translational shear. also stabilized by its articular disk, joint capsule, ligaments,
A larger superior shear produces impingement, whereas a and reinforcing muscles.5,69 The disk binds the joint together
larger compressive force centers the humeral head in the
glenoid and reduces impingement of the rotator cuff under
the acromion.67 The central position of the humeral head on
the glenoid helps to stabilize the glenohumeral joint.
Payne et al67 simulated rotator cuff, deltoid, and biceps mus-
cle forces on 10 human cadaver shoulders using transducers
within the acromial arch. The muscle forces that reduced acro-
mial pressure included the biceps, which decreased acromial
pressure by 10% in all the shoulders and 34% in 6 of the
shoulders. Rotator cuff muscle force, without simulating supra-
spinatus, was very effective in reducing the acromial pressure.
With simulation of the subscapularis, infraspinatus, and teres
minor, these investigators noted a 52% decrease in the ante-
rior-lateral acromion pressure in neutral shoulders with type Figure 2-8 The upper and lower attachments of the meniscus and the
III acromion. Without the rotator cuff force, the amount of upper and lower ligaments of the sternoclavicular joint.
 Chapter 2 Functional Anatomy and Mechanics 17

and divides the joint into two cavities. The capsule surrounds with a convex girdle.1,63 The scapula is without bony or liga-
the joint and is thickest on the anterior and posterior aspects. mentous connections to the thorax, except for its attachments
The section of the capsule from the disk to the clavicle is more at the AC joint and coracoacromial ligament. The scapula is
lax and allows more mobility than among the disk, sternum, primarily stabilized by muscles. The importance of the scap-
and first rib.10 The interclavicular ligament anteriorly and ula rotators has been established as an essential ingredient of
inferiorly reinforces the capsule. The costoclavicular ligament glenohumeral mobility and stability (Fig. 2-10). The stable
connects the clavicle to the first rib.10 The SC joint gains base and therefore the mobility of the glenohumeral joint
increased stability from muscles, especially the sternocleido- largely depend on the relationship of the scapula and the
mastoid, sternohyoid, and sternothyroid.69 humerus. The scapula and humerus must accommodate to
ever-changing positions during shoulder movement to main-
tain stability.6 Figure 2-11 demonstrates the force couple of
ACROMIOCLAVICULAR JOINT the scapula rotators.
Scapulothoracic kinematics involve combined SC and AC
At the other end of the clavicle is the AC joint. This articula- joint motions.71,72 Three-dimensional motion occurs at both
tion is characterized by variability in size and shape of the cla- the SC and AC joints during arm elevation in healthy sub-
vicular facets and the presence of an intra-articular jects.71,72 The clavicle demonstrates a pattern of slight eleva-
meniscus.66 The AC joint capsule is more lax than the SC tion and increasing retraction as arm elevation progresses
joint, and thus a greater degree of movement occurs at the overhead.72
AC joint that contributes to the increased incidence of dislo- Teece et al71 described that the scapula is simultaneously
cations.69 The AC joint has three major supporting ligaments. upwardly rotating, internally rotating, and posteriorly tilting
The conoid and trapezoid ligaments are collectively called the relative to the clavicle at the AC joint (Fig. 2-12). In addi-
coracoclavicular ligament and the AC ligament. It is through the tion, scapulothoracic “translations” of elevation and depres-
conoid and trapezoid ligaments that scapula motion is trans- sion and abduction and adduction were observed by the
lated to the clavicle.5 Teece et al.71 These scapula movements actually derive from
Rotation of the clavicle is the major movement at the AC clavicular motions at the SC joint. Scapulothoracic elevation
joint. Steindler70 described AC joint rotation occurring is a result of SC elevation, and abduction and adduction result
around three axes. Longitudinal axial rotation, vertical axis from SC protraction and retraction.72,73
for protraction and retraction, and horizontal axis for elevation
and depression are all controlled and facilitated by the conoid,
trapezoid, and AC ligaments (Fig. 2-9). FUNCTIONAL BIOMECHANICS

As previously noted, shoulder elevation is defined as the move-

Scapulothoracic Joint
ment of the humerus away from the side. It can occur in a
The scapulothoracic joint is not an anatomic joint, but it is an seemingly infinite number of body planes.47
important physiologic joint that adds considerably to motion Shoulder elevation can be divided into three phases. The
of the shoulder girdle. The scapula is concave, articulating initial phase of elevation is 0 to 60 . The middle or “critical”
phase is 60 to 140 . The final phase of elevation is 140 to
180 . Specific to each phase of movement, precise muscle
B function and joint kinematics allow normal, pain-free motion.
Analysis of the precise components critical for each phase of
shoulder elevation determines the success of clinical manage-
C ment of shoulder dysfunction.

Initial Phase of Elevation: 0 to 60

All three arthrokinematic movements occur at the glenohum-
eral joint, but they do not occur in equal proportions. These
movements—roll, spin, and glide—are necessary for the large
humeral head to take advantage of the small glenoid articulat-
A ing surface.16 Saha74 and Sharkey and Marder75 investigated
the contact area between the head of the humerus and the gle-
Figure 2-9 Axes of motion of the clavicle. A, Longitudinal axis of
rotation. B, Vertical axis for protraction and retraction. C, Horizontal axis
noid with elevation in abduction and in scaption. The studies
for elevation and depression. The sternal end of the scapula is on the found that the contact area on the head of the humerus was
left. (From Schenkman M, Rugo de Cartaya V: Kinesiology of the centered at 30 and was superiorly shifted 1.5 mm by 120 .
shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with Poppen and Walker14 also studied the instant centers of rota-
permission of the Orthopaedic and Sports Physical Therapy Sections of tion for abduction. These investigators reported that in the
the American Physical Therapy Association). first 30 and often between 30 and 60 of abduction, the
18 Physical Therapy of the Shoulder

FUT
FUT

FSA
FSA

FLT

A B

Figure 2-10 Force couple of muscles acting at scapula. A, Axis of scapular rotation from 0 to 30 . B, Axis of scapular rotation from 30 to 60 . FLT, force
of lower trapezius; FSA, force of serratus anterior; FUT, Force of upper trapezius. (Modified from Schenkman M, Rugo de Cartaya V: Kinesiology of the
shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with permission of the Orthopaedic and Sports Physical Therapy Sections of the American
Physical Therapy Association.)

humerus in the initial phase of elevation.3 Kadaba et al61

Upper reported EMG activity of the upper and lower portions of
trapezius Levator
scapulae the subscapularis muscle recorded by intramuscular wire elec-
trodes. During the initial phase of elevation, EMG activity of
the upper subscapularis was greater at the beginning of the
range, whereas the lower subscapularis increased as the eleva-
Rhomboideus tion reached 90 .54 A significant amount of force is generated
minor at the glenohumeral joint during abduction.4,15 In the early
Middle stages of abduction, the loading vector is beyond the upper
trapezius edge of the glenoid.76
Rhomboideus During the initial stage of elevation, the pull of the deltoid
major muscle produces an upward shear of the humeral head.3 This
shearing peaks at 60 of abduction and is counteracted by the
transverse compressive forces of the rotator cuff muscles.3,15
The primary function of the subscapularis muscle is to depress
Serratus the humeral head, thus counteracting the superior migrating
anterior force of the deltoid.61 At 60 (abduction), the downward
(short rotator) force is maximal at 9.6 times the limb weight
Lower
trapezius or 0.42 times the body weight.2,15 The subscapularis, infra-
spinatus, and latissimus dorsi muscle have small lever arms
that form 90 angles to the glenoid face, thereby producing
compressive forces to the joint.
Figure 2-11 Force couple of the scapula rotators.
Movement of the AC and SC joints permits movement of
the scapula. Shoulder abduction is accompanied by clavicular
elevation. SC elevation is most evident during the initial
head of the humerus moved superiorly in the glenoid by phase of arm elevation. A 4 SC movement occurs for each
3 mm, a finding that indicates the occurrence of rolling or 10 of shoulder abduction.4 The AC joint moves primarily
gliding of the head. The EMG activity of the supraspinatus before 30 and after 135 .4
muscle indicates an early rise in tension that produces a com- The instantaneous center of rotation (ICR) of the scapula
pressive force on the glenohumeral joint surface. during the initial phase of elevation is located at or near the
The deltoid muscle also demonstrates EMG activity in the root of the scapula spine in line with the SC joint.77 The
initial phase of elevation. The subscapularis, infraspinatus, initial phase of arm elevation was referred to by Poppen
and teres minor muscles are important stabilizers of the and Walker15 as the setting phase; scapula rotation occurs
 Chapter 2 Functional Anatomy and Mechanics 19

A B

D E
C

Figure 2-12 It is important to understand the various motions of the scapula relative to the thorax: A, upward and downward rotation; B, protraction and
retraction; C, elevation and depression; D, tilting about a frontal axis; and E, tilting about a vertical axis. (Porterfield, James A. Mechanical Shoulder
Disorders: Perspectives in Functional Anatomy. W.B. Saunders Company, 102003.)

about the lower midportion. The relative contribution from

scapular rotation during the initial phase of elevation is
D
considerably less than from glenohumeral motion. Bagg S
and Forest77 estimated a 3.29:1 ratio of glenohumeral to R
scapulothoracic mobility during the initial phase of elevation. D
The upper trapezius and lower serratus anterior muscles pro-
vide the necessary rotatory force couple to produce upward I SⴙI
scapular rotation during the early phase of arm abduction.78

Middle or Critical Phase of Elevation:

60 to 100
The middle or critical phase of elevation is initiated by exces-
sive force at the glenohumeral joint. As previously noted, the
shearing of the deltoid muscle is maximal at 60 elevation
(Fig. 2-13). Wuelker et al62 simulated muscle forces under Figure 2-13 In the early stages of glenohumeral abduction, the deltoid
the coracoacromial vault. The forces at the glenohumeral joint reactive force (D) is located outside the glenoid fossa. The transverse
were recorded and applied to the shoulder muscles at a con- compressive forces of the supraspinatus (S) and infraspinatus (I)
stant ratio approximating physiologic conditions of shoulder muscles are counteracted by this force. The resultant reactive force (R)
elevation: deltoid, 43%; supraspinatus, 9%; subscapularis, is therefore more favorably placed within the glenoid fossa for joint
26%; and infraspinatus/teres minor, 22% (Fig. 2-14). Peak stability.
forces under the coracoacromial vault occurred between 51
and 82 of glenohumeral joint elevation. These force values The resultant acting forces, which help to stabilize the
may represent the pathomechanics of shoulder impingement. joint, are maximal at 90 of elevation,3 with shear and com-
Figure 2-15 demonstrates the compressive and depressive pressive forces equal.78 As the arm reaches the end of the crit-
forces generated by the muscles that provide a parallel force ical phase, the resultant and shearing forces of the deltoid are
to the glenohumeral joint to counteract the shearing of the almost zero.3,15
deltoid muscle group, which is perpendicular to the gleno- The balance of shearing and compressive force establishes
humeral joint. dynamic stability of the glenohumeral joint. In the early part
20 Physical Therapy of the Shoulder

110 of abduction and maintains a plateau level of activity.3

Supraspinatus EMG activity peaks at 100 of elevation and
rapidly diminishes thereafter.3 The subscapularis activity
FTD
decreases substantially after 130 of elevation, a finding sup-
porting the concept that anterior ligament stability is critical

FDeltoid
beyond 130 of elevation.3
The head of the humerus demonstrates an excursion of 1 to
2 mm of a superior and inferior glide on the glenoid surface.14
FRR The movement of the humeral head in a superior and inferior
FTR
FRD
direction after 60 of elevation indicates that roll and glide
uff

are occurring in opposite directions, resulting in a spin of

rc
o
tat

the bone. As previously noted, external rotation of the

Ro
F

humerus is critical for elevation (abduction) of the arm.

Bagg and Forrest77 examined 20 subjects and found three
distinctive patterns of scapulohumeral movement. Each pat-
tern had three phases with varying ratios of humeral to scap-
ular movement. The most common pattern had 3.29 of
humeral motion to every degree of scapular motion from
20.8 to 81.8 of scaption. The humeral component decreased
to 0.71 for scaption between 81.8 and 139.1 . Therefore,
Figure 2-14 Force couple of deltoid and rotator cuff muscles. Rotatory the greatest relative amount of scapular rotation occurs between
forces, acting on opposite sides of the axis of motion, combine to 80 and 140 of arm abduction.77 The ratio of glenohumeral to
produce upward rotation. Translatory forces cancel each other out. FRD, scapulothoracic motion has been calculated to be 0.71:1 during
rotatory force of deltoid; FRR, Rotatory force of rotator cuff; FTD, the middle phase of elevation.78 Doody et al,12 along with
translatory force of deltoid; FTR, translatory force of rotator Freedman and Munro,48 proposed that the significant role of
cuff. (Modified from Schenkman M, Rugo de Cartaya V: Kinesiology of the scapular rotators during the critical phase of elevation is
the shoulder complex, J Orthop Sports Phys Ther 8:438, 1987, with
secondary to the relatively long moment arms of the upper tra-
permission of the Orthopaedic and Sports Physical Therapy Sections of
pezius, lower trapezius, and lower serratus anterior muscles.
the American Physical Therapy Association.)
Therefore, during the middle phase of elevation, the scapular
rotators provide an important contribution to elevation of the
Acromion Supraspinatus humerus in the POS.
Deltoid
Movement of the AC and SC joints permits movement of
the scapula. The relative contribution of these two joints
changes throughout the range of motion, depending on where
the ICR lies.77 During the middle phase of abduction, the
ICR of the scapula begins to migrate toward the AC joint.
Subscapularis Clavicular elevation about the SC joint, coupled with scapular
Lat rotation about the AC joint, facilitates normal scapula mobil-
iss Infraspinatus
imu
sd and Teres minor ity. Motion can occur at the AC joint, with less movement
ors occurring at the SC joint because of the clavicular rotation
i
around its long axis.4 The double-curved clavicle acts like a
crankshaft, to permit elevation and rotation at the AC end.
The rotation of the scapula about the AC joint is initiated
between 60 and 90 of elevation.78 Clavicular elevation is
completed between 120 and 150 of humeral abduction.77
Biceps Clavicular elevation at the AC joint permits maximum scapu-
lar rotation. At approximately 150 of elevation, the ICR of
Figure 2-15 Forces provided to the muscles that are parallel to the
the scapula is in line with the AC joint.77
glenohumeral joint. These muscles produce compressive and
depressive forces to help stabilize the glenohumeral joint. The deltoid
muscle is perpendicular to the glenohumeral joint. Final Phase of Elevation: 140 to 180
During the final phase of elevation, the ratio of glenohumeral
of the critical phase, dynamic stability must be initiated to scapulothoracic motion is 3.49:1, a finding indicating rel-
before further progression of pain-free movement can occur. atively more glenohumeral motion.77 The ICR of the scapula
As previously noted, the lower fibers of the subscapularis has relocated upward and laterally. The rotatory force arm of
muscle showed more activity at 90 of abduction.61 The del- the upper trapezius muscle has reduced in length, and the role
toid muscle reaches maximum EMG activity at approximately of this muscle is now supportive of the scapula.78 The new
 Chapter 2 Functional Anatomy and Mechanics 21

location of the ICR of the scapula allows the middle trapezius SUMMARY
to become a prime mover for downward scapular rotation.78 Patients with shoulder dysfunction are routinely treated in the
The lower trapezius and the serratus anterior muscles continue physical therapy clinic. An understanding of the anatomy and
to increase in activity during the final phase of elevation, and biomechanics of this joint can help to provide the physical
they act as an upward rotator and oppose the forces of the therapist with a rationale for evaluation and treatment. Most
upper and middle trapezius.77 studies involving shoulder anatomy and biomechanics reveal
As the humerus elevates toward the end of the elevation a common pattern, along with a wide variation among sub-
range of motion, it must disengage itself from the scapula. jects. The physical therapist should keep this variation in
As previously noted, the ratio of glenohumeral to scapulothor- mind when treating an individual patient.
acic motion is 3.49:1. Good extensibility of the teres major and Treatment may be directed toward restoring mobility,
the subscapularis muscles is important, to allow the humerus to providing stability, or a combination of the two. The shoulder
disassociate itself from the scapula. Often, with passive humeral is an inherently mobile complex, with various joint surfaces
elevation, a bulge of the scapula is noted laterally. The bulge is adding to the freedom of movement. The shallow glenoid,
usually the inferior angle that is secondary to increased protrac- with its flexible labrum and large humeral head, provides
tion of the scapula. Lack of elongation of these muscles prevents mobility. At times, this vast mobility occurs at the expense
the normally dominant movement of the humerus at the end of of stability. The shoulder relies on various stabilizing mechan-
the elevation range. Tightness of the subscapularis muscle, teres isms, including shapes of joint surfaces, ligaments, and mus-
major muscle, or both, is often observed. cles to prevent excessive motion. Almost 20 muscles act on
Furthermore, observation of limited passive humeral eleva- this joint complex in some manner, and at different times
tion may exhibit elevation of the chest cavity. If muscles con- these muscles can be both prime movers and stabilizers. Har-
necting the humerus and rib cage are not flexible enough, monious actions of these muscles are necessary for the full
movement will occur at both ends. The latissimus and pector- function of this joint.
alis major muscles connect the humerus to the rib cage. Lack
of dissociation of the rib cage from the humerus results in
excessive rib cage mobility in passive terminal elevation.
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Summary of Shoulder Phases of 2. Lucas D: Biomechanics of the shoulder joint, Arch Surg
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3. Sarrafian SK: Gross and functional anatomy of the shoulder,
The initial phase of elevation occurs predominantly at the gle-
Clin Orthop Relat Res 173:11, 1983.
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has been observed in the initial phase of elevation. The activ- tion of the shoulder joint, J Bone Joint Surg Am 26:1, 1944.
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The early phase of scapula movement is described as the
“plane of the scapula” as plane of reference for movements
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63. Perry J: Muscle control of the shoulder. In Rowe CR, editor: 72. Ludewig PM, Behrens SA, Meyer SM, et al: Three-dimensional
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 C H A P T E R

3 Jeff Cooper, Phillip B. Donley

and Craig D. Morgan

Throwing Injuries

To throw a baseball with high velocity and with great accuracy Pitchers sustained 69% of the reported shoulder injuries.24
is a skill that escapes the majority of the population. Those who Collegiate players, like high school players, are more likely to
have accomplished this skill often demonstrate a heightened be injured during games than practices. A study conducted over
neuromuscular system and have invested thousands of hours 16 years calculated the injury rate to be 5.78 versus 1.85 per
of sport-specific training. This unique athletic act has produced 100 athlete exposures, competition versus practice. The chance
a wide array of disabilities that have been reported in the liter- of an athlete’s sustaining a shoulder strain was twice as high in
ature. These disabilities include neurologic entrapments, a game as in practice (0.37 versus 0.18 per athlete exposures).
arterial and venous thrombosis, acromioclavicular joint degen- Shoulder injuries accounted for 23.4% of all game injuries
eration, primary impingement, secondary impingement, gleno- and for 16% of all practice injuries. Throwing accounted for
humeral instabilities, labral lesions, subdeltoid bursitis, biceps 59.5% shoulder injuries, and pitching accounted for 73%.25
tendinitis, subluxing bicipital tendon, undersurface tears of In an attempt to identify causal factors in injury in youth
the rotator cuff, full-thickness tears of the rotator cuff, lesions baseball, a prospective injury study was conducted of 298
of the humeral head, fracture of the humerus, fracture of the youth pitchers over the course of two seasons. The reported fre-
lateral border of the scapula, fracture of the coracoid, rib frac- quency of shoulder pain was 32%, and that of elbow pain was
tures, posterior capsular syndrome, and muscle imbalances, 26%. The following were identified as risk factors related to
among others.1-19 shoulder pain: decreased self-satisfaction, arm fatigue during
During the years 1995 to 2006, an estimated 1,595,000 one game pitched, throwing more than 75 pitches in one game,
baseball-related injuries were treated in US hospital emergency and throwing fewer than 300 pitches in a season. Risk factors
facilities. Upper extremity injuries were second (32.4%) only to for reported elbow pain were increased age, increased weight,
injuries of the face (33.5%).20 An estimated 131,555 high decreased height, lifting weights during the season, playing
school baseball injuries occurred during the school years 2005 baseball outside the league, decreased self-satisfaction, throwing
to 2007. The shoulder was involved in 17.6% of the reported more than 75 pitches in one game, and throwing fewer than
injuries.21 Nationally, the estimated number of injuries in high 300 pitches or more than 600 pitches during the season.26
school baseball players during the 2007 to 2008 school year A follow-up study by the same authors reported an
was 44,760, occurring at a rate of 0.93 per exposure. The injury increased injury risk associated with youth baseball pitchers
rate during competition (1.37) was twice as high as reported who threw breaking balls. Of the 476 youth baseball pitchers
during practices (0.68). The number of injuries increased from participating in the study, half of the players reported either
the freshman player (16.6%) to the senior players (33.0%). shoulder pain or elbow pain during the competitive season.
Shoulder injuries were reported to be 16% of all injuries, sec- The investigators determined that the throwing of a curve
ond only to reported hand and wrist injuries (17.9%). Eighteen ball was associated with an increased the risk of shoulder pain
percent of all injuries occurred in the pitcher, and 15.7% of by 52%, and the throwing of a slider was associated with an
these injuries were specific to pitching. An additional 7.4% increased the risk of elbow pain by 86%. Whether the pri-
of all injuries were related to nonpitching throwing.22 From mary offender is the specific mechanics of the breaking pitch
2005 to 2007, an estimated 19,988 baseball injuries in high or the increased load placed on the youth baseball pitcher
school athletes were considered severe, defined as causing a loss trying to learn a new pitch, it is prudent to develop the break-
of more than 21 days. Severe shoulder injuries accounted for ing ball as an older teenager.27
21.5% of the total.23 In a retrospective cohort study of adolescent pitchers 14 to
A study of collegiate baseball injuries over a 3-year period 20 years old, 95 injured pitchers who required either shoulder
revealed that upper extremity injuries accounted for 58% of or elbow surgery were matched with 45 uninjured pitchers.
the total, and those injuries accounted for 75% of time loss. The 29 injured pitchers who required shoulder surgery were
26 Physical Therapy of the Shoulder

more frequently used as starting pitchers. They threw at higher The hand can be placed in an infinite number of localities,
velocities and pitched significantly more months of the and it is essential that the scapula humeral rhythm place it
year, more innings per game, and thus more pitches per game. in an optimum setting for the task of propulsion. The draw-
These pitchers reported using more warm-up pitches before ing of the humerus into the moment center of the glenoid
their starts, pitching when fatigued, and using more anti- fossa is accomplished during the first 30
of elevation as the
inflammatory medication. Almost 60% of these injured pitch- arm is brought upward by the deltoid and supraspinatus.
ers reported playing another position when not pitching.28 Because of these many individual styles, no consistent pattern
An examination of the 3282 disabled players in Major of muscle activity occurs during the windup phase.
League Baseball between 1989 and 1999 showed revealed that
48.4% of all injuries occurred in pitchers. A team’s pitching
Early Cocking
staff comprises 40% to 46% of the club roster; however, not
all pitchers are active on a game-to-game basis. In the 5-year Early cocking is the period when the dominant hand is sepa-
period from 1995 to 1999, 27.8% of all disabled Major League rated from the gloved hand, and it ends when the forward foot
players had shoulder injuries. Elbow injuries accounted for an makes contact with the mound. The scapula is retracted and
additional 22% of the disablement days. Thus, upper extremity maintained against the chest wall by the serratus anterior.
injuries in this period constituted half of all the Major League The humerus is brought into 90
of abduction and horizontal
Baseball injuries that required removal of an athlete from the extension, with a minimal external rotation of approximately
active roster for a minimum of 15 days. In days lost, this figure 50
. This position is accomplished by activation of the
converts to an average loss to Major League Baseball of 5619 anterior, middle, and posterior deltoid. The external rotators
days per year for shoulder injuries and an additional 4452 days of the cuff are activated toward the end of early cocking, with
per year for elbow injuries. On average, each club lost 336 days the supraspinatus more active than the infraspinatus and the
or 1.84 years of service time (182 days constitutes a service year) teres minor as it steers the humeral head in the glenoid.
to upper extremity injuries.29 The biceps brachii and brachialis act on the forearm to
Injury to the shoulder complex precipitated by overhand develop the necessary angle of the elbow.
throwing is most often the result of a failure in the kinetic As the body moves forward, the humerus is supported by
chain manifesting itself in the weakest link. This weakest link the anterior and middle deltoid as the posterior deltoid pulls
is usually the glenohumeral joint. Macrotrauma injuries, such the arm into approximately 30
of horizontal extension. At
as a fracture of the humerus, can often be related to this prox- this time, the static stability of the humeral head becomes
imal kinetic chain failure, which imposes higher demands on dependent on the anterior margin of the glenoid, notably
distal structures. Injury to the elbow is often precipitated by a the inferior glenohumeral ligament and the inferior portion
dysfunction of the shoulder complex.30,31 This chapter focuses of the glenoid labrum.
on the underlying causes of most shoulder injuries and a pre-
ventive conditioning program that can be applied to the treat-
Late Cocking
ment of these injuries in the overhand throwing athlete.
Late cocking is the interval in the throwing motion when the
lead foot makes contact with the mound, and it ends when
OVERHAND THROWING the humerus begins internal rotation. The lead foot applies an
anterior shear force to slow the lower extremity and to transfer
The biomechanical and electromyographic activity of overhand energy. The foot serves as an anchor; the forward and vertical
throwing has been investigated to give a relative model of func- momentum is transformed into rotational components. During
tion in a controlled environment.32-40 Electromyographic this time, the humerus is moved into a position more forward
sequence activity appears fairly consistent regardless of generated in relation to the trunk and begins to come into alignment
velocities and is discussed here. Whiteley41 presented an excel- with the upper body. The extreme of external rotation, an addi-
lent review of biomechanical investigations on this topic. tional 125
, is achieved to provide positioning for the power
The overhand throw as it relates to pitching has been phase or acceleration. This is the first of two critical instants.40
divided, depending on the investigator, into three, four, five, The supraspinatus, infraspinatus, and teres minor are active
or six phases. This discussion explores a five-phase model con- in this phase but become quiet once external rotation is
sisting of (1) windup, (2) early cocking, (3) late cocking, achieved. Deceleration of the externally rotating humerus is
(4) acceleration, and (5) follow-through. accomplished by the contraction of the subscapularis. It
remains active until the completion of late cocking. The serra-
tus anterior and the clavicular head of the pectoralis major
Windup
have their greatest activity during deceleration. The biceps
The windup is an activity that is highly individualized. Its brachii aids in maintaining the humerus in the glenoid by
purpose is to organize the body beneath the arm to form a sta- producing compressive axial load. At the end of this phase,
ble platform. As with all overarm activities, it is vital that the the triceps begins activity by providing compressive axial
body perform in sequential links to enable the hand to be in loading to replace the force of the biceps. The capsule
the correct position in space to complete the assigned task. becomes wound tight in preparation for acceleration.
 Chapter 3 Throwing Injuries 27

Acceleration Professional versus Amateur Pitchers

Acceleration is a ballistic action lasting less than one tenth of a Gowan et al36 conducted a study to determine whether the
second. The ball is accelerated from 4 miles per hour to a muscle firing sequence of professional pitchers was signifi-
speed of more than 90 miles per hour.39 The scapula is pro- cantly different from that of amateur pitchers. No significant
tracted and rotated downward and held to the chest wall by differences were noted in the first three phases of the pitch:
the serratus anterior. The arm continues into forward flexion the windup and early and late cocking. No significant differ-
and is marked by a maximum internal rotation of the ences were noted in the follow-through, in which muscle
humerus. The humerus travels forward in 100
of abduction activity was described as general.
but adducts approximately 5
just before release. The latissi- During the acceleration phase, professional pitchers
mus dorsi and pectoralis major provide power to the forward recorded increased activity of the pectoralis major and latissi-
moving shoulder. Subscapularis activity is at maximum levels mus dorsi. They also had increased activity in the serratus
as the humerus travels into medial rotation. The triceps devel- anterior muscle. The professional pitchers had decreased activ-
ops strong action in accelerating the extension of the elbow. ity in the supraspinatus, infraspinatus, and teres minor during
The forces developed in this instant reflect the body’s acceleration. The professional pitchers used the subscapularis
amazing ability to develop power and encase itself in a protec- predominantly during acceleration and internal rotation.
tive mechanism. This acceleration produces angular velocities Activity in the biceps brachii was also lower in the profes-
that have been reported in excess of 10,000
/second.41 Gainor sional than in the amateur pitchers.
et al1 reported 14,000 inch pounds of rotatory torque pro-
duced at the shoulder. This torque develops 27,000 inch
Electromyographic Activity in the Injured
pounds of kinetic energy in the humerus. Control of the ball
Thrower
is lost approximately midway through the acceleration phase,
when the humerus is positioned slightly behind the forward- Athletes who were diagnosed as having subacromial impinge-
flexing trunk and at an angle of approximately 110
of exter- ment demonstrated differences in their electromyographic
nal rotation. The hand follows the ball after release and is studies compared with uninjured throwers.37 During the sec-
unable to apply further force. ond phase of throwing, early cocking, the injured athletes had
continued deltoid activity, whereas the healthy athletes had
decreased deltoid activity. A lower level of supraspinatus
Follow-through
activity was also noted during this period. During early cock-
Follow-through begins with the release of the ball. Within the ing and late cocking, the internal rotators, subscapularis, pec-
first tenth of a second, the humerus travels across the midline toralis major, and latissimus dorsi had decreased activity. The
of the body and develops a slight external rotation before fin- serratus anterior followed this pattern and was less effective.
ishing in internal rotation. The second critical instant occurs Investigators theorized that the combination of these differ-
during this segment.18 This is a very active phase for all gle- ences may lead to increased external rotation, superior
nohumeral muscles as the arm is decelerated. The deltoid and humeral migration, and impaired scapular rotation. All or
upper trapezius have strong activity, as does the latissimus some of these factors may be the underlying cause of the ini-
dorsi. The infraspinatus, teres minor, supraspinatus, and sub- tial problem or a factor in the continuum of the syndrome.
scapularis are all active as eccentric loads are produced. The Throwing athletes who have been hampered by glenohum-
biceps develops peak activity in decelerating the forearm eral instabilities were compared with healthy athletes in a
and imposes a traction force within the glenohumeral joint. similar fashion.38 This series tested the activity of the biceps,
The task of documenting the sequence of muscle activity middle deltoid, supraspinatus, infraspinatus, pectoralis major,
during the act of pitching has allowed the musculature acting subscapularis, latissimus dorsi, and serratus anterior. Noted
on the glenohumeral joint to be divided into two groups.19 were differences in every muscle except the middle deltoid.
The first group of muscles contains those that are most active These investigators suggested that the mildly increased activ-
during the second and third phases of throwing: early and late ity of the biceps and supraspinatus may be compensatory for
cocking. These muscles are least active during the acceleration the laxity present in the anterior capsule. The infraspinatus
phase. The deltoid, trapezius, external rotators, supraspinatus, developed a pattern of activity during early cocking, reduced
infraspinatus, teres minor, and biceps brachii comprise this activity during late cocking, and again increased activity in
first group. follow-through. As noted with the impingement group, the
The second group of muscles contains those used primarily internal rotators, consisting of the subscapularis, pectoralis
for the fourth phase of throwing: acceleration. These muscles major, and latissimus dorsi, had decreased activity, which
are necessary to protract the scapula, horizontally forward flex was marked in the early cocking phase. The serratus anterior
and internally rotate the humerus, and extend the elbow. This showed decreased activity as well.
group consists of the subscapularis, serratus anterior, pectora- These investigators concluded that these changes in muscle
lis major, latissimus dorsi, and triceps brachii. The first phase activity allowed decreased internal rotation force needed in
of throwing is not included in either group because of the both late cocking and acceleration.38 Reduced activity
nonspecific generalized activity. demonstrated in controlling the scapula by the serratus
28 Physical Therapy of the Shoulder

anterior allowed the glenoid to be placed in a compromising investigated. Measurements were made at intervals of 20
of
position during late cocking and increased the stress on the internal and external rotation. The investigations concluded
labrum and capsule. Microtraumas can be associated with with an intact capsuloligamentous complex with the humerus
deficiencies in a muscle or muscle group that fails to aid in translated maximally in the glenoid when the humerus was
stabilizing the glenohumeral joint or fails to become active between 40
and 100
of external rotation. When the gleno-
in the proper sequence during the distinct phases of throwing. humeral capsuloligamentous complex was increased in length,
Lack of flexibility can be a factor leading to disability, partic- translation increased. During internal rotation, the length of
ularly in the deceleration phase, when tremendous eccentric the posterior capsule had a greater influence on anterior-poste-
forces develop. rior translation, and the anterior capsule length had a greater
effect on external rotation.
Anterior translation and inferior glenohumeral ligament
CAPSULE strain in simulated scapular protraction were investigated by
Weiser et al.46 This cadaver study was conducted with the
A more detailed description of the function of the capsule of specimens placed in the position of apprehension and
the glenohumeral joint and its ligaments can be found in simulated protraction. With anteriorly directed loads, the
Chapter 2. Here, it is necessary to describe some works in investigators reported increasing strain in the anterior band
regard to the capsule in the cocked position in the over- of the inferior glenohumeral ligament with increased scapular
hand-throwing athlete. Harryman et al42 indicated that protraction.
oblique glenohumeral translations are not the result of liga- Novotny et al47 used an analytical model to predict gleno-
ment insufficiency or laxity, but rather translation results humeral kinematics and to view the way in which the gleno-
when the capsule is asymmetrically tight. He surgically tight- humeral capsule and bony contact stabilize the joint. The
ened fresh cadaver posterior capsules and found increased simulation was conducted in the cocking phase of throwing
anterior humeral head translation during cross-body move- with an abducted extended external rotated humerus. In this
ment, flexion, and internal rotation and increased superior position, the center of the humeral head translated posteriorly
translation with flexion. and superiorly during external rotation. The anterior band of
O’Brien et al43 demonstrated that the posterior band of the the inferior glenohumeral ligament increased in tension with
inferior glenohumeral ligament complex, which is a thickening external rotation. The axillary pouch and posterior band
of the posterior capsule, is the primary restraint to any posterior decreased in tension. The contact area, stress, and force
force when the arm is positioned at 90
of abduction and is increased with external rotation. The contact area moved pos-
internally rotated. Tightening of the posterior or posterior- teriorly and inferiorly on the area of the glenoid.
inferior capsule causes a posterior-superior shift of the gleno- In a cadaver study by Kuhn et al,48 the ligamentous
humeral fulcrum, which allows contact of the labrum in the restraints of the glenoid capsuloligamentous complex were
posterior-superior glenoid. investigated in the late cocking phase of throwing. This study
Collagen fiber bundle patterns of the capsule were reported involved cutting selected structures and measuring the
by Gohlke et al.44 These investigators described both the increase in external rotation. The release of the entire inferior
radial and circular components of this structure. The nature glenohumeral ligament allowed the greatest increase in exter-
of these patterns predisposes the capsule to dual action during nal rotation. Isolating the loss of the anterior band of the infe-
glenohumeral rotation. During rotation, the capsule becomes rior glenohumeral produced the greatest external rotation
shortened and produces both a compressive force and a center- when compared with the loss of either the superior or middle
ing of the humerus on the glenoid. The role of the glenohum- glenohumeral ligaments.
eral ligaments depends on humeral position. When the Pollock et al49 examined the mechanical response of the
humerus is abducted to 90
and the motion of external rota- inferior glenohumeral ligament of cadaver shoulders that were
tion is introduced, the anterior band of the inferior gleno- exposed to different levels of subfatigue cycle strains. Three
humeral ligament becomes the supporting structure to resist groups of specimens received increased loads and frequency
anterior displacement of the humeral head. The posterior of subfatigue strains. The repeated loading of the inferior gle-
band of the glenohumeral ligament is now positioned under nohumeral ligament induced laxity. The mechanical response
the humeral head and resists inferior displacement. As the reflected the magnitude of the cycles, strain, and frequency
humerus is rotated medially into internal rotation with the of the loading. A ligament length increase noted in all speci-
elevated humerus, the posterior band of the inferior gleno- mens led the investigators to believe that this could be a
humeral ligament becomes the structure to prevent posterior mechanism for acquired glenohumeral instability.
translation and the anterior portion of the ligament then has A three-dimensional kinematic study was designed by
the inferior position. Baeyens et al50 to determine the rotation and shift of the
Branch et al45 investigated the function of the capsule in humeral head in the glenoid cavity and the migration of
its relation to anterior and posterior translation of the contact of the articular surfaces. Helical axis parameters of
humerus during internal and external rotation. An artificially rotation, shift, and direction were compared between the gle-
constructed lengthening of the capsule tissue and its relation noid and the articulation surface of the humerus. Calculations
to the changes in anterior-posterior translation were also were made from the beginning position of 90
of abduction
 Chapter 3 Throwing Injuries 29

and 90
of external rotation to full cocking (full external rota- most evident at 15
to terminal internal rotation. These
tion and horizontal extension). The humeral head in normal changes were considered significant.
shoulders did not externally or internally rotate on the gle- This study52 suggested that posterior-inferior capsule con-
noid. In shoulders deemed clinically as having minor anterior tracture not only changes the humeral head apex in extremes
glenohumeral instability, a larger external rotational compo- of external rotation but also significantly alters the course of
nent was found. Thus, the humeral head of the normal shoul- the articulation at the end ranges of internal rotation. The
der translated into the posterior portion of the glenoid, and investigators suggested that this occurrence may be more rel-
the shoulder with minor anterior instability translated cen- evant to traction injury than to internal impingement.
trally in the glenoid. When the anterior part of the inferior
glenohumeral ligament limits anterior translation and exter-
nal rotation, minor anterior instability is the result of dys- BICEPS TENDON–SUPERIOR LABRAL
function of the anterior part of the inferior glenohumeral COMPLEX: SLAP LESIONS
ligament.
Grossman et al51 conducted a cadaveric study in which the The role of the long head of the biceps tendon within the gleno-
anterior capsule was stretched and the posterior capsule was humeral mechanism has long been overlooked. Often dismissed
tightened. Stretching the anterior capsule alone produced a sig- as only a minor player at the shoulder as a humeral head depres-
nificant increase in total range of motion, with the primary sor, long head of the biceps tendon was recognized for its role as
gains in external rotation. When the posterior capsule was an elbow stabilizer and decelerator. Since the advent of shoulder
tightened, a significant decrease in total motion was noted investigation by arthroscopy, the role of this structure has been
when compared with the stretched anterior capsule. When both better appreciated. The data of Snyder et al53 suggested that
alterations were applied, the stretched anterior capsule and the the superior labrum anterior to posterior (SLAP) lesion occurs
contracted posterior capsule, a significant increase in external in a very limited number of cases among the general population,
rotation and a significant decrease in internal rotation occurred. and the mechanism of trauma is varied. Maffet et al,54 in a
This study also examined the position of the humeral head review of 712 surgical shoulders with significant biceps tendon
on the glenoid with each capsule alteration. Normally, the and superior labral abnormalities, suggested that these separa-
humeral head settles in a posterior-inferior position during tions are indeed caused by various events. In the general popula-
maximum external rotation. When the anterior capsule was tion, injury to the biceps tendon–labral complex is mostly a
stretched, the externally rotation humeral head settled into a traumatic event. Two injury mechanisms for a disabling injury
position that was more inferior but less posterior. When the to this structure in the overhand-throwing athlete have been
condition of a posterior capsule contracture was added, the put forth: maximum forces occurring at deceleration and the
externally rotating humeral head settled more posteriorly peel back mechanism during terminal external rotation.
and less inferiorly. Although these humeral head positional Andrews et al2 examined a population of 73 throwing ath-
changes on the glenoid were not significant, the investigators letes and observed that 60% of this group had tears in the
suggested that posterior capsular tightness, as opposed to anterior-superior labrum, and another 23% had tears in both
anterior capsular laxity, may be a causative factor in poste- the anterior-superior and posterior-superior portion. In a sub-
rior-superior glenoid internal impingement. group of baseball pitchers, this lesion was associated with a
In yet another cadaveric study,52 with similarly simulated partial tear of the supraspinatus in 73% of the athletes.
conditions of a stretched anterior capsule and a contracted A smaller group of 7% demonstrated a partial tear of the long
posterior-inferior capsule, an attempt was made to measure head of the biceps. The investigators hypothesized that the
the glenohumeral articulation throughout the rotational range incident of injury to this region of the glenoid labrum was
of motion, not just maximum external rotation. This study the result of the tremendous eccentric stresses placed on the
incorporated twice the compression forces (44 N) and equal biceps in an attempt to decelerate the arm during the fol-
translation forces (20 N) and incorporated a three-dimensional low-through phase of the overhand throw.
digitized system to record the apex of the humeral head A correlation with patient history revealed that 95% of the
throughout the test range of motion. Measurements were patients reported pain during the overhand throw, and 45% of
recorded at 15
intervals. When the range of motion measure- the population reported a popping or catching sensation. On
ments of the altered specimens were compared with their pre- physical examination, the popping was evident in the position
vious state, the investigators noted a significant increase in of full abduction and full flexion as the upper arm was aligned
external rotation. The changes in internal rotation were with the ear in 79% of the athletes. None of the population
deemed not statistically significant. In maximum external demonstrated a significant weakness of either the rotator cuff
rotation, the humeral head apex was posteriorly displaced an or biceps tendon. This lesion gave the athlete a sensation of
average 7.5 mm with the combined condition. No significant instability.
difference was noted between the individual conditions. This In a retrospective totaling 2375 arthroscopically evaluated
shift began occurring at 120
of external rotation to the shoulders, Snyder et al53 reported 140 cases with superior gle-
maximum at the tested end range of 150
. Maximum internal noid labrum injuries. These cases represented only 6% of the
rotation of the humeral head apex had an anterior shift of sample population. The involvement of the dominant shoul-
3.5 mm and an inferior shift of 2.8 mm. The changes were der versus the nondominant shoulder was greater than 2 to 1.
30 Physical Therapy of the Shoulder

No radiographic findings could be correlated with the dis- and middle glenohumeral ligament may allow overhand-
order. At the time, no clinical examination was considered throwing athletes to continue to function in the absence of
specific for the superior labrum. Approximately half of the mechanical symptoms or pain.59 However, once the integrity
patients described a painful catching or popping, a finding of the glenohumeral joint is reduced by superior labrum dis-
consistent with the previous study. Only approximately one sociation, the shoulder sacrifices stability. Shoulder instability
third demonstrated a positive biceps tension test. Fifty-five clearly coexists with a SLAP lesion.37 A SLAP lesion must be
percent of these shoulders were categorized as having a type among the suspected diagnoses in the overhand-throwing ath-
II SLAP lesion consisting of detachment of the superior lete who complains of instability or a sense of instability of
labrum and biceps tendon from the glenoid rim. Of these the shoulder.
shoulders, only 28% were isolated from a rotator cuff injury Morgan et al60 suggested that the mechanism of injury
or other labral problems. extending or potentially producing a type II SLAP lesion is a
Rodosky et al55 investigated the role of the long head of torsional force that “peels back” the biceps and posterior
the biceps and its attachment to the superior labrum in a lab- labrum from the neck of the glenoid. The investigators sug-
oratory model of the glenohumeral joint positioned in abduc- gested that when the shoulder is placed in extreme abduction
tion and external rotation as experienced by the overhand and external rotation, torsion is applied to the biceps tendon.
thrower. The investigators hypothesized that the presence of Placing the upper extremity in this position of cocking the
the long head of the biceps acted to help limit the external biceps creates a more vertical and posterior angle. When a force
rotating shoulder. The biceps compressed the humeral head is applied, a twist is produced at the base of the biceps, and this
against the glenoid resisting the rotation. The long head of transmits a torsional force to the posterior-superior labrum.
the biceps withstood higher external rotational forces without Morgan et al60 reviewed a group of 102 patients with type
the inferior glenohumeral ligament’s experiencing a greater II SLAP lesions. Of this group, 53 were overhand-throwing
strain. This finding suggested that the biceps has a role in the athletes, 44 of whom were baseball pitchers. A common his-
provision of anterior stability. The glenohumeral joint demon- tory for these individuals included the development of pain
strated heightened torsional stiffness as force was increased in the cocking phase of throwing, pain arising either ante-
through the long head of the biceps. riorly or posteriorly, and decreased performance or decreased
When a surgical SLAP lesion was created, torsional rigid- velocity. These symptoms were often described as a “dead
ity decreased 26%, and the strain on the inferior glenohum- arm.” The clinical examination included the following tests:
eral ligament was increased by 33%. This model suggested (1) bicipital groove tenderness, (2) Speed’s test, (3) O’Brien’s
that the shoulder thus depends on the long head of the biceps cross-arm test (active compression test),61 and (4) Jobe’s
to provide dynamic stability to the glenohumeral joint in the relocation test62 in which pain and apprehension posteriorly
cocking, acceleration, and follow-through phases. This and superiorly are relieved by a force directed posteriorly to
dynamic stability ensures a consistent stress on the inferior the humeral head. These clinical findings were then correlated
glenohumeral ligament. The long head of the biceps acts as to a further classification of type II SLAP lesion. In the over-
a continuum provider of axial tension as a protective mecha- hand throwing athletes, 19% had anterior-superior lesions,
nism for the humerus and the inferior glenohumeral ligament. 47% had posterior-superior lesions, and 34% had a combined
A cadaveric study measuring strain to the superior labrum anterior-posterior lesion. Thus, 81% of the SLAP lesions in
and biceps anchor through the phases of throwing reported the throwing group had a posterior component.
increased labral strain during the late cocking phase of When compared with the entire group of 102 patients, the
throwing.56 In another cadaveric study that compared the late posterior type II SLAP lesion was three times more common in
cocking and a simulated deceleration phase of throwing (in-line the overhead-throwing athletes, and the anterior type II SLAP
loading), the biceps anchor was loaded to failure.57 Anchor fail- was three times more common in the nonthrowing group who
ure in the late cocking position resulted in a type II SLAP had sustained trauma. When the clinical examination was corre-
lesion. Most deceleration failures resulted in midsubstance tears lated with the arthroscopic findings, the investigators generally
of the tendon itself. This study reported significantly higher determined that Speed’s test and O’Brien’s test were useful in
structure strength with the in-line loading–deceleration phase. predicting anterior-superior lesions, and Jobe’s relocation test
In a study incorporating a three-dimensional finite ele- was useful in predicting posterior-superior lesions.60
ment model, the superior labrum was stressed through the Of the 53 overhand-throwing athletes, 10 presented with a
long head of the biceps tendon in four phases of throwing.58 partial-thickness undersurface tear of the rotator cuff, and 1
In addition to the throwing phases, three types of insertions presented with a complete tear. Eighty-seven percent of the
were analyzed: a mostly posterior origin, an equal anterior overhand throwers reported an excellent result with internal
and posterior origin, and a mostly anterior origin. The decel- fixation of their SLAP lesion. The other 13% reported a good
eration phase provided the highest labrum stress in all orien- result. Eighty-four percent returned to their preinjury level of
tation types, and the highest stress orientation was in the sports participation. Sixteen percent reported decreased veloc-
mostly anterior model. ity and control. Those 7 athletes all had associated rotator cuff
Investigators have suggested that lesions that produce disorders.60
small increases in external rotation and glenohumeral transla- All overhead-throwing athletes in this study were measured
tion and lack involvement of superior glenohumeral ligament for internal and external rotation at 90
of abduction in the
 Chapter 3 Throwing Injuries 31

plane of the scapula. A noted lack of internal rotation in the • Elevation of the acromion
surgical shoulder was present. On average, a loss of 45
of inter- • Being a base for muscle attachment
nal rotation (range, –35
to –60
) occurred. External rotation • Serving as a link in the proximal to distal sequence energy
in the plane of the scapula had an average gain of 40
(range, delivery
þ20
to þ45
).60 A dysfunction in one role or a combination of dysfunctions
The final observation in this investigation is the relation- in other scapular roles puts the throwing athlete at risk.
ship of the posterior-superior SLAP and rotator cuff disease. Normal scapular kinematics is necessary for optimum
Thirty-one percent of those patients with chronic SLAP had upper extremity motion. The glenoid must be continually
associated undersurface rotator cuff involvement. The investi- repositioned to correlate with the moving humerus to main-
gators postulated that the humeral head acquired the ability tain the stable glenohumeral joint. A malpositioned scapula
to translate superiorly or to sublux because of the lack of a has been demonstrated to place greater demands on the ante-
fixed biceps labrum. This combination of superior translation rior capsule.46 The ability of the scapula to retract places the
and repetitive twisting of the rotator cuff in the cocking phase upper extremity in the “full tank of energy” position for
of throwing results in fiber fatigue and failure of the cuff.60 throwing, and the ability to protract through the delivery is
The foregoing group of investigators63 reinforced their necessary for the scapula to follow the moving humerus while
position on the mechanism of injury of the biceps tendon– providing a stable platform. Elevation of the acromion
superior labral complex in the overhead throwing athlete. increases the subacromial space to prevent impingement of
Their model encompassed the following: the rotator cuff. Certain muscular force couples are necessary
1. A type II posterior-superior glenoid labrum tear. This tear to move the scapula through its three axes of motion. In the
causes anterior pseudolaxity and a positive arthroscopic active scapular plane, upward rotation has been reported to
drive-through sign. be 50
(–SD 4.8
), posterior tilting on a medial to lateral axes
2. The upper extremity positioned in abduction and external is 30
(–SD 13
), and external rotation around a vertical axis
rotation with a type II posterior-superior glenoid labrum is 24
(–SD 12.8
).65 Scapular positioning has also been
tear and unstable biceps anchor will cause the biceps– reported in nondominant movement patterns of abduction
superior labral complex to “peel back” over the posterior- and horizontal adduction, as well as in the tasks of reaching
superior corner of the labrum. and hand-behind-the-back maneuvering.66
3. A contracted posterior-inferior capsule resulted in a An adaptive change of greater upward rotation of the scap-
reduction of internal rotation in abduction. This clinical ula in the overhand-throwing athlete has been recognized at
finding is present in all overhand-throwing athletes who an early age and can be a consistent finding in the professional
develop posterior-superior SLAP lesions. athlete.67,68 Myers et al69 investigated this adaptation in
The mechanism is as follows: When an overhand-throwing throwing athletes as compared with a control group. The
athlete with an acquired tight posterior capsule places the motion of humeral elevation in the scapular plane demon-
shoulder in the cocking position of abduction and external strated significant increased upward rotation at 0
to 30
,
rotation, the posterior capsule inhibits normal full external 60
to 90
, and 120
. In addition, the throwing athlete
rotation. This situation causes a posterior-superior shift of demonstrated significant increases of retraction at both
the moment center of the glenohumeral joint. This new center 90
and 120
of humeral elevation in the scapular plane. No
of rotation places the humeral head in increased contact with significant differences were in anterior and posterior scapular
the internal impingement zone and thus causes increased tipping or in scapular elevation and depression. However,
forces to the biceps tendon–superior labrum complex through increased scapular internal rotation in the throwing group
external rotation. This mechanism produces the SLAP lesion, was present in all test positions.
and the creation of the SLAP lesion contributes to a posterior- In a study comparing scapular upward rotation in high
superior shift and instability. school and collegiate baseball players, a significant decrease
Given that deceleration produces the greatest force of motion was determined in the older group at both 90

through the phases of overhand throwing, the biceps-labrum and 120
in abduction. Collegiate players also demonstrated
complex also exhibits its greatest strength in this in-line posi- more scapular protraction when they were assessed in the
tion. Deceleration does play a role in the creation of a SLAP hands-on-hips and 90
abduction with internal rotation posi-
lesion, probably by being the force that generates the adaption tions.70 A comparison of upward scapular rotation during
of the posterior capsule. A restricted posterior capsule intensi- humeral elevation in the plane of the scapula of dominant
fies the superior shear force in terminal external rotation and shoulders of professional position players and professional
becomes a component of this disabling injury. pitchers revealed decreased motion at the four static test posi-
tions: rest, 60
, 90
, and 120
. A significant difference was
seen between the groups at both 60
and 90
.71
ASYMMETRICAL SCAPULAR MALPOSITION Oyama et al,72 in a three-dimensional study, investigated
the scapular resting position bilaterally in three male over-
Five roles of the scapula have been described64: hand athlete groups: baseball pitchers, volleyball players,
• Being a stable part of the glenohumeral articulation and tennis players. The dominant scapula in all groups was
• Retraction and protraction along the thoracic wall more internally rotated and anteriorly tilted. Tennis players
32 Physical Therapy of the Shoulder

had a more protracted scapula. The investigators suggested

that these changes in scapular position could be defined as
normal for these populations because all subjects were asymp-
tomatic. Decreased scapular upward rotation was not present
in these subjects, and this finding could suggest that this
component may be associated with the injured athlete.
More often than not, the disabled overhand-throwing ath-
lete clinically presents with a markedly asymmetrical, malposi-
tioned scapula. This malpositioned scapula is referred to by the
acronym SICK scapula73: (1) scapula, (2) infera, (3) coracoid,
and (4) dyskinesis. A SICK scapula is a muscular overuse
fatigue syndrome that manifests clinically with three major
components. First, the scapula drops or is lower when com-
Figure 3-1 SICK scapula: right scapula is lower, protracted, and abducted.
pared with the nondominant scapula. Second, the scapula
is protracted or lies farther laterally from the spine when com-
pared with the nondominant scapula. Third, the scapula has
increased abduction or a greater angle from the spine to the these symptoms also increases the athlete’s ability to forward
medial scapula border when compared with the nondominant flex, which is often restricted and painful.
scapula. One, any combination, or all of these components The acromioclavicular joint becomes symptomatic as a
can be present at the time of examination. result of the altered kinematics of the malpositioned scapula.
An athlete often presents with one or more of the follow- Because the clavicle is more rigidly secured at the sternum,
ing symptoms in association with a SICK scapula: stresses from the infera and from protraction and abduction
1. Pain located on the medial aspect of the coracoid of the scapula are imposed on the distal clavicle articulation.
2. Pain located at the superior-medial aspect of the scapula Thoracic outlet symptoms are present in a few athletes
3. Painful subacromial space because of the pressure on the neurovascular structures by
4. Painful acromioclavicular joint the unsupported scapula and clavicle.
5. Thoracic outlet symptoms or radicular pain The challenge for the clinician is to recognize the subtle
The onset of these symptoms is usually insidious and changes in the position of the scapula and the way in which
occurs when the athlete passes a pathologic threshold. A care- those subtle changes put the glenohumeral joint at risk. The
ful medical history does not reveal a single event or rapid pro- task of repositioning the scapula by stretching the contracted
gression to disability. structures and strengthening the supporting musculature in
Because of the components of a malpositioned scapula, the corrected position is paramount in the sequence of reha-
which is located inferiorly, protected, and abducted, increased bilitation of the overhand-throwing athlete.
tension is placed on the coracoid by virtue of a shortened pec-
toralis minor tendon and conjoined tendon. With repetitive
overhand motions, the restrictive nature of these shortened POSTERIOR SHOULDER TIGHTNESS:
tendon structures encourages tendinopathy that results in a GLENOHUMERAL INTERNAL ROTATION
painful medial coracoid. DEFICIT
Pain located at the superior-medial aspect of the scapula is
present in the malpositioned scapula at the insertion of the Adaptive range-of-motion changes in overhand-throwing ath-
levator scapulae, upper rhomboids, and upper trapezius. letes have been observed for some time.76,77 Common adapta-
Because these scapular control muscles originate from the tions occur in horizontal adduction and in external and
essentially fixed spine, they are required to function in an internal rotation of the glenohumeral joint at 90
of abduc-
overtensioned pattern of pain referral into the muscle belly. tion. Asymptomatic pitchers have been reported to manifest
Most often, the key indicator in this sequence is posterior an increase of up to 30
of glenohumeral external rotation
neck pain on the dominant side. Dyskinesis of the scapula is in both the frontal and scapular plane when compared with
the primary offender, and a treatment protocol should be their nondominant shoulders.1 Glenohumeral internal rota-
designed to rectify the malposition of the scapula to resolve tion deficits of 15
to 20
have also been associated with
the posterior neck symptoms. Any attempt to stretch the asymptomatic pitchers,46,48-51 whereas symptomatic pitchers
offended musculature will add insult to the present injury. have reported deficits as high as 45
.38 These changes have
Subacromial pain often results from the infera component been attributed to numerous factors including a posterior-
of the SICK scapula, which reduces the subacromial space inferior capsular restriction, muscular inflexibility of the
by essentially lowering the acromion (Fig. 3-1). This reduc- external rotators, eccentric loading of the external rotators,
tion of space hinders the function of the rotator cuff in all and osseous adaptations of humeral head or glenoid.52-54,78
phases of the overhand throw. The coinciding lack of posterior Since the late 1990s, numerous studies have determined
tilting of the scapula with elevation increases the impinge- the passive range of motion of the overhand-throwing
ment symptoms.74,75 A scapular relocation test that relieves athlete.78-94 Some of these studies have addressed the issue
 Chapter 3 Throwing Injuries 33

of humeral retroversion.83,87 The study of humeral retrover- Uninjured athletes, whether pitchers or position players, aver-
sion may be relatively new in the sports medicine world; how- aged an internal rotation deficit of only 24%.
ever, it was described as far back as 1881 in the anthropology Warner et al104 demonstrated a significant limitation of
literature.95 The relationship of the distal humerus with the internal rotation range of motion and posterior shoulder
proximal humerus changes through the skeletal maturation tightness, as measured in horizontal abduction, in a group
process. Adults have humeral retroversion in the range of of patients with impingement compared with patients with
25
and 35
. Fetal skeletons (N ¼ 50) have been measured shoulder instability and control patients. Kugler et al105
with a mean retroversion angle of 78
.96 By the age of 8 years, attempted to identify features that could correlate with shoul-
most of the derotation occurs, and in the following 8 years, der injuries in highly skilled volleyball attackers, an overhand
the process is complete.97 activity. To measure posterior shoulder tightness, the research-
During overhand throwing, humeral torque is developed as ers measured the distance from the lateral epicondyle to the
the distal portion of the humerus is externally rotated at a rate acromion of the opposite shoulder during maximal horizontal
greater than the proximal end, in an attempt to achieve maxi- adduction. The researchers did not report whether the scapula
mum glenohumeral rotation. Humeral peak torque peaks was stabilized. They found that the dominant posterior shoul-
immediately before maximum external rotation.98 It appears der was significantly tighter in attackers with shoulder pain
that the stress endured by the maturing proximal humerus compared with attackers without shoulder pain or compared
during the overhand throw slows the derotation in the domi- with a control group. Attackers without shoulder pain had
nant arm.99,100 significantly tighter shoulders than did the control group.
In a cross-sectional study of 294 Little League and adoles- Both groups of volleyball players had an increase in tightness
cent baseball players between 8 and 16 years old, peak changes in their dominant shoulder compared with their nondominant
in elevation, external rotation, and internal rotation occurred shoulder.
between the ages of 11 and 13 years. Significant changes in Bigliani et al79 examined upper extremity range of motion
internal rotation of the dominant shoulder occurred between and glenohumeral joint laxity in a study of 148 healthy pro-
the 12- and 13-year-old groups. Changes in internal rotation fessional baseball players, 72 pitchers and 76 position players.
of the nondominant shoulder was seen between the 14- and Glenohumeral internal rotation was recorded as the highest
15-year-old groups. vertebral level reached by the thumb up the spine.106 This
When the youngest group of baseball players was compared recording was converted to a number value according to the
with the oldest group, the differences in internal rotation, American Shoulder and Elbow Surgeons’ standards, to permit
external rotation, and total range of motion were significant. statistical comparisons. Shoulder external rotation with the
Internal rotation in the dominant shoulder decreased by an humerus at 90
of abduction in the frontal plane and internal
average of 17.7
, and it decreased by 9.1
in the nondominant rotation, measured as previously described, both demonstrated
shoulder. External rotation in the dominant shoulder decreased statistically significant differences between dominant and
by an average of 20.5
, and this value decreased by 23.5
in the nondominant shoulders.
nondominant shoulder. Thus, the total range of motion For pitchers, the dominant glenohumeral external rotation
decreased by 38.2
in the dominant shoulder as compared with range of motion averaged 118
(range, 95
to 145
), and the
32.5
in the nondominant shoulder.101 nondominant glenohumeral external rotation range of motion
Pappas et al102 reported a significant limitation of gleno- averaged 102
(range, 85
to 130
). The difference was 15.2

humeral internal rotation range of motion and posterior or a 13% increase in external rotation in the dominant
shoulder tightness as measured by horizontal abduction with extremity. Pitchers’ dominant glenohumeral internal rotation
scapula stabilization in patients diagnosed as having subacro- range of motion averaged 15.5
(T6-7) (range, L3-T2); the
mial impingement. Brown et al80 recorded the range of nondominant glenohumeral internal rotation range of motion
motion for multiple upper extremity movements in two sep- averaged 17.6
(T4-5) (range, T8-T2) or a loss of 14%. Posi-
arate groups consisting of professional pitchers and position tional players measured in similar fashion had an average
players. The pitchers had significant increases of 9
of external dominant glenohumeral external rotation range of 109.3

rotation in 90
abduction. The pitchers had significant (range, 80
to 150
) and a nondominant glenohumeral exter-
decreases of 5
shoulder flexion and 15
internal rotation in nal rotation range of motion averaging 97.1
(range, 80
to
90
of abduction when compared with their nondominant 120
). Positional players recorded a loss of two levels of ver-
side. Position players had a significant increase of 8
external tebrae calculated to 12.2
or 11% of their internal rotation
rotation in 90
of abduction. in their dominant shoulder.
Verna et al103 measured 137 professional baseball players In a similar study,107 152 right-handed professional base-
bilaterally for internal rotation by fixing the scapula and medi- ball pitchers were measured for glenohumeral internal rota-
ally rotating the humerus while in 90
of abduction in the tion with three different protocols: vertebrae level/thumb up
supine position. Correlating the internal rotation deficits of spine, glenohumeral internal rotation in the frontal plane at
the dominant shoulder with injury history revealed that those 90
of abduction with a stabilized scapula, and glenohumeral
pitchers who reported a shoulder or an elbow problem averaged internal rotation in the scapular plane at 90
of abduction
an internal rotation deficit of 41%. Position players reporting a with a stabilized scapula. Correlation between the vertebrae
shoulder or an elbow problem averaged a deficit of 43%. level/thumb up spine (average loss of 7.8  4.8 cm in the
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Thos H elk Dept of Bldgs h 300 Linnsmore cres n (EY) --Thos W elect
Conti Can h 9 Frankdale av (EY) Lambi Ivo studt r 298 Indian gr
Lambie Alex A asst foremn Edwd Hawes & Co r 399 Lansdowne av
— Alex W shpr Aluminum Co of Can h 28 Wooding ton av --David r
i9 Fairmar av (Etob) —David suprvsr P O h 81 Stewartsmith dr (Nth
Y) — Donald W supt America Fore Ins Group h 19 Fairmar av (Etob)
--Douglas J h 342 Springdale blvd (EY) --Eva Mrs elk Pilot Ins r 16
Harris Park dr (Scar) — Elizth emp Edwd Hawes & Co r 449 Brock av
--Geo pntr’s hlpr B A Oil r 33 Appleton av (York Twp) --Howard
grinder Massey-Harris r 1386 Danforth avenue --J Kenneth chief acct
Reform Institutions Dept h 16 Kingsmere rd --Jas r 449 Brock av --
Jas elect h 82 Fermanagh av --Jared drvr slsmn Valleyview Dairy h
1386 Danforth av --Jean (wid Jas) h 255 Sterling rd --John A insp
Inti Eus Mach h 76 Durie (Swan) --John P with Tor Hydro h 600E
Bloor w --Jos T watchmn Grand & Toy h 78 Eicknell av --Laura (wid
Albt) h 375 Greenwood av --Margt (wid Guy) h 22 Corby av (York
Twp) --Margt M Mrs IBM opr Ont Hosp Assn Blu< r 285 Caledonia rd
(York Twp) --Robt B mill hand Ault & Wiborg h 681 Mer --Russell elk
Natl Emp Serv r 90 Miranda a Twp) — Sydney R suprvsr P O h 278
Boon av (Yorl — Wm emp Can Laundry r 679 Crawford Lambis Co
(Sami Shapiro) whol mfg furrier Avenue rd Lambkin Arthur emp
Heintzman’s h 22 Pelh — Doris fnshr Aladdin Hand Laundry res Hie
Creek --Douglas J shpr Winter Seal Co r 22 Felha: —Edwd night
watchmn Simpsons h 44 McDor (Scar) --Geo emp Mobile Radio
Service Ltd r 175 —Thos S wtr Todmorden House h 1044 Loea (EY)
— Wm tuber opr Viceroy Mfg r 7 The Wishb (Nth Y) --Wm P wtr
Wembley Hotel h 181 Lawlor a^ Lambie Charlotte h 11 Pell (Scar) —
Dorothy sec-treas Dearnley Cartage Ltd ] (Scar) --Frank slsmn
Electro -Service Co h 488 Du avenue — Horace emp A V Roe r 614
Huron — Jos F elk CGE r 488 Duplex av — Lottie Mrs h 653 Bloor w
—Norman pres Dearnley Cartage Ltd h 11 I (Scar) --R H Bruce die
mkr Wm E Coutts h 191 G1 cres (EY) Lambo Louis emp CPR h
l63Sackville Lamboum May dom Upper Can Coll r same Lamboume
Elizth C (wid Edwd) r 22 Greemj — Robt stkpr W J Bell F aper h 89
Newmark Lambrech M J h 307, 355 Westmount av Lambrick Elizth
Mrs r 718 Dufferin Lambro Dimitry (Greenwood Cafe) r 1686 W i
Pleasant rd Lambroff Benny emp Dunland Open Kitchen Weston rd
— Foto (Dunland Open Kitchen) h 532 Old W< road — Frances wtrs
Rest r 532 Old Weston rd --Jas (Cole Porter’s Rest) r 447A Queen w -
-Jas elk John’s Restaurant r 35 Heintzman — Kuzo (Dunland Open
Kitchen) h 1745 Dund Lambros G A Duncan slsmn Ofrex (Can) h 1
Indian Road cres Lambrov Nick h 204 DeGrassi Lambshead Esther R
mach opr Reed Shaw £ Naught r 716 Dover court rd Lambton Coffee
Bar (Jos & Gladys Hendric! Dundas w (Etob) — Fire Hall 59
Government rd (Etob) --Fish & Chips (Wm Brown) 86 Lambton av
Twp) --Food Market (F H Savage) gro 201 Lambt (York Twp) — Golf
& Country Club Ltd Jas Cochrane He Yor d ngr w av h 11 Par lfor in
av dew £ A C Ashforth pres Stephen G Norru sec WEN Eell vice -pres
W S Scar] (York Twp) --Kathleen Mrs r 67 Clendenan av — Kingsway
Pub Schl Donald A Me Lay prii Prince Edward dr n (Etob) --Lumber
Ltd John L McGregor pres Audn McGregor vice -pres S R Bennett se
4210 Dundas w (Etob) --Motors (J McIntyre & J Murphy) auto rep
service 82 Lambton av (York Twp) — Park after 4010 Dundas w
(York Twp) --Park' Schl Jack W Norman prin w s Berni (York Twp) --
Park Service Stn (David Pivato) 4005 Dun (York Twp) --Tavern (J
Stuart & G Leslie Adam) hotel Dundas w (York Twp) Lambur Eric
drftsmn Ont Hydro r 6 Castle Lamburn Matthew dept mgr Dun & Bra
dstr Galley av Lamby Alex h 399 Lansdowne av — Gerald emp Valley
View Dairy h 47 Mona avenue LaMeaux John emp A V Roe r 18
Keystone Lamen Helen r 12, 50 Gerrard e Lam end Jacob h 70 East
Lynn av Lamendolla Steve r 128 Concord av Lamentia Agostino r
283A Danforth av — Florence Mrs r 283A Danforth av — Richd emp
Lanson Celery Hearts r 283A avenue Lamers F&ulus H emp
Rowntree Co r 20 Ch Lamerton Alfred F claims agt CNR h 16 Bii rd
(Scar) —Kenneth F sr elk CNR h 12 Cree av (Scar — Wallace law
studt r 16 Birchmount rd (Sc Lamey Albt firemn CPR h 255 Evelyn av
— Barbara typist Baker Adv Agency r 111 R — Chas A pntr Ont
Hydro hill Roslin av —Danl A opr O’Keefes Brewery h 45 Eallac --
Harry tire winder Goodyear Tire r 36 La --Marian barr h 357 Eglinton
av e — Martin F dentist 214A Greenwood ay h sa --Martin P techn
Ont Hydro r 383 Rimilton Laminated Building Materials Co Ltd Robt ,
Thompson pres Alex W Smith sec-U genl distributors & bldrs supplies
8 Osier --Structures (1952) Ltd (br) Arthur J Petch pre fab houses
4l4, 57 Bloor w Laming Hugh S W journalist CBC h 206, 451
Laminsky Joe h 48, 98-100 Lippincott Lamintino Laurie emp Don &
Tony h 8 Ferr (EY) Lamiot Alex genl hlpr Browns' Bread r 252 av (EY)
— Gerald mach opr Eatons r 252 Gowan av ( . Lamirand David
foremn pntr Natl Fainters • lecc h 15 Boulton av --Pauline cash Dept
Transp A ir Services E, 37* Soudan av Lamirande Jean wtrs Holiday
Tavern h 410 mington av Lamiskie Walter r 267 Havelock Lamkin H C
h 211, 51 Grosvenor --J Chi, 1384 King w --Margt stenog Radio -
Television Mfrs Assn Can r 60 Laughton av — Norma sis elk Eatons r
60 Laughton av --Norman cartage 60 Laughton av h same --Thos wtr
Todmorden House Lammalzo Ants h 700 Eeresford av (York ? •
Lammens Karla Mrs typist Upton Bradeen \ r 36 Edgar av --Raymond
E elk Upton Eradeen & James r avenue Lammers Hardy r 264 Rcxton
rd —Henk pekr Candn Tire r 90 Lansdowne av Larnmerse Comelis A
elk Fruehauf Trailer r 143 Geoffrey --Jack suprvsr of production
Radio Valve h Edgecroft rd (Etob) Lammiman Nancy slsldy Simpsons
r E14, 9 crescent (Etc! mgr Edgar
 [MING mine Leonard (Bulien & Lamming) r 92 Brown’s Line
(Etob) mle Louise C h 1022 Spadina rd n (Fst H) arta wtrs Murrays r
97 Spadina rd ode (Mrs Minnie Tobias) ladies wear 563 Mt Pleasant
rd oine Melvin Derm force r 120 Jones av jos stablemn Blantyre
Dairy h 120 Jones av okros Geo cook Grosvenor Hotel h 185 Seaton
non see also Leamon, Leamen, Lehman, Leman and Lemon >ien M
with Tor Hydro r 12, 50 Gerrard e ;,rd barr h 283 St Clair av e onbv
Wm emp Moffats r 17 Sunnybrae cres ond Arthur emp Firestone Co
h 2, 1980A Davenport rd itherine bkpr Dom Auto Accessories r 4, 12
Ulster trl J slsmn r 467-9 Jarvis •nest h 2, 828 S haw inneth h 550
Front w irgt h 810 Loeran av arie Mrs r 46 Spruce Hill rd Drris h 810
Logan av nde Gladys order filler Stedman Bros r 399 Summon av
(EY) onis Brants mech Halliday’s Garage r 10 Suffolk onski Stanley r
104 Pembroke mson Joe emp Dept of Highways r 1 Alcina av ont
AGW metallurgical engnr Gunnar Gold Mines Ltd r 56 Glen Davis
sheet metal wkr A V Roe h 60 Deloraine av ex welder r 101 Dewson
stair emp John Inglis h 75 Northridge av (EY) he store suprvsr Star
Service Store h 36, 684 Danforth av nie (wid Wm) r 23 Jerome thony
adjustor Eatons h 9 Finsbury cres (Etob) chd J master mech Massey
-Harris h 35 Cavendish '_ce M asst mgr business develop dept Royal
Bank h 15 Dromore cres (Willowdale) tharine elk Geo Hardy Ltd r 60
Deloraine av therine studt r 453 Briar Hill av arity r 219 Main s
(Wstn) as J tel appraiser Northern Electric h 1161 Dover court rd '/id
paint mixer Aulcraft Paints r 71 Isabella vid W pressmn Southam
Press h 83 Bartlett av nald millwright Stand Sanitary r 973 Ossington
avenue nald studt r 821 Shaw nald H L (Lamont & Lamont) h 4
Alexandra Wood (Nth Y) ith Mrs h 216 Symington av zth (wid Jas) h
810A St Clair av w ^rence (wid Wm J) h 347 Runnymede rd Drence
L (wid Wm H) (Lamont & Co) h 3n Cluny dr ed ins agt 4th fir, 12
Wellingtoneh 113 Chaplin cres o D E dir Howell Forwarding Co Ltd
res Bolton o R space buyer Young & Rubicam h 45 Strath av (Etob) ?
nn slsmn Goodrich Rubber h 31 Charleswood dr (Nth Y) aham r 81
Banff rd nry N engnr Dept of Highways (Prov) h 210, 15 Bedford
Park av rbt J insulator U of T h 311 Indian rd gh traffic rep Candn
Overseas Communications Corp res Agincourt gh vehiclemn C P Exp
h 8 Mills rd (Mim) ?h A trav United Co-Operatives of Ont h 12
Tumpane (Nth Y) gh L elk Candn Crittall Metal Window r 41E Huntley
neon tube bender Neon Signs h 249 Fulton av (EY) :k r 10 Dartford
rd » bkr Mascott Bakery h 75 Don Valley dr (EY) s plmbr r 51 Heath
w nine elk C P R r 19 Ardagh in M typist Grand & Toy r 722 Crawford
in emp Face Elle Co r 24 Rutherford av (York Twp) in emp Safety
Supply res West Hill in security guard CCM h 21 Church (Wstn) in D
yardmn CPR h 19 Ardagh > elk Elias Rogers r 16 Peterborough av ith
R slsmn Gypsum Lime & Alabastine h 8, 3488 Yonge wrence G mail
elk Dom Securities Corp r 101 Salem av me D slsmn Beatty Bros h
453 Eriar Hill av le stkpr Eatons r 2, 1081 Avenue rd n rgt emp
Rolpn-Clark -Stone r 117 Cambridge avenue rgt mach opr Frigidaire
h 72 Simpson av ry elk St Joseph’s Hosp r 3 Humber Trail (York Twp)
tthew J opr TTC r 198 Fern av ■ud bkpr Moffats r 170 Main s (Wstn)
‘la A stenog Fenteman & Son r 101 Salem av riel G stenog DVA r 847
Runnymede rd rray bkpr TTC h 28, 892 Eglinton av e (Leas) m(EY)
kpr Ea^er ^dv Agency h 15 Denvale rd ra Mrs r 28, 892 Eglinton av
e (Leas) rene E Mrs elev opr Bank ofCom r 622 Euclid avenue ’’man
emp Telegram h 8, 2453 Queen e a (wid Jas A) h23 Meadowvale dr
(Etob) ■ricia editorial assts MacLean Hunter r 45 Strath av (Etob)
/ilis B r 32 Cornish rd gd W slsmn Ault & Wiborg res Burlington r
810A St Clair av w *’ emP Simpsons h 134 Soudan av " se opr r 722
Crawford ^ Mrs h. 9 Finsbnrv cres (Etob) nl R stkpr Ont Hydro h 101
Salem av T^Lsec"*-reas Candn Dressed Meats Ltd h 38 Fulham dr
(Etob) os sismn Browns’ Bread h 2355 Dundas w ierie elk Dept of
Highways h 79 Kendal av Cosby (Lamont & Co) h 178 Dunvegan rd
(Fst H) o M r 8 Lankin blvd (EY) l T litho Ashton -Potter r 347
Runnymede rd o (Mrs F L & W C Lamont) investment dlrs 718, 68
Yonge •am ont (Donaid H L & Mrs Mary Lamont) barrs j H02-1103,
62-76 Richmond w Ont s Bakery (Geo Smith) 826 Danforth av
bntagne Aibt G mgr Sorel Steel Foundries Ltd . h 104, 2400 Bathurst
(Fst H) ns housemaid Royal York Hotel r 1525 Queen west r°thy lab
techn Sick Children’s Hosp r 104, 2480 Bathurst (Fst H) mette
stewardess TCA r 42 Gothic av n latex dipper Viceroy Mfg r 787
Oxford (Etob) 1 r dining car steward CNR h 251 Bingham av 0 A H
Strong rep ribbons, laces, & infants ■ roods 304, 23 Scott — ; 148
Glebeholme blvd LAMONTE LAMPORT Lamonte Albt E shpr &
receiver Bennett & Wright h (basement) 183-189 Huron --Dorothea
Mrs h 62 Barker av (EY) — Geo policemn Tor Pol Dept r 73 Davisville
av — Geo & Son Ltd Wm P Batchelor mgr safety paper 319 Car law
av --Valerie Mrs elk Dept of Highways (Prov) r 79 Kendal av
Lamoreaux Chas S emp Barret Roofing Co h 81 Hamilton — Howard
emp Hunts Ltd r 81 Hamilton Lamoreux S emp Eastern Auto
Wreckers r 271 Ontario Lamothe John slsmn Martell h 110 Kingsway
cres (Etob) --Lionel bkr Kempley Bakery r 105 Munro --Paul press
opr Toronto Specialties Mfg Co r 203 Sherboume Lamotte Geo h 4
Denison sq Lamou Stanley r 160 Rose av Lamour Jean r 9 Kereven
(Nth Y) —Jean r 102 Robina av (York Twp) — John barber John
Grobb h 46 Muriel av — Rene E maint man h 207, 214 Wellesley e
Lamourea Jos emp Ramsey Contracting Co h 17 Olive av —Jos
wrehsemn Woolworths r 181 Avenue rd Lamoureaux Cena diecast
set-up Pressure Castings r 40 Dynevor rd (York Twp) --Eva emp J D
Carrier Shoe r 33 Prospect av Lamoureux Edgar O lab Dept St Clng r
175 Sherbourne — Edwd ctr Reliance Shoe h 215 Dewhurst blvd n
4EY) — Eugene plmbr h 157 Harvie av — Florence T pekr Christie
Brown r 214 Parliament — Geo J lab h 96| Lippincott — Guy maint
Woman’s Bakery h 159 Dupont — John acct Bank of Toronto r 172
Rushton rd — Laurence florist Morrow Florist r 14 Evans av --Leo sr
chkr B A Oil r 199 Woodmount av (EY) — Theresa Mrs sis elk Eatons
r 16 Avoca av — W’ilfrid mach opr Goodyear Tire h 8 Minto Lamouri
Carpet Layers (Norman Lamouri) 37 DeGrassi — Norman (Lamouri
Carpet Layers) h 168 Merton Lamouroux Louis G elk Prudential of
America r 222 Lawrence av w --Louis M chief French translation
Confed Life Assn h 222 Lawrence av w Lamovic Seladin h 48
Boustead av Lamp Shop The (G Robt Reeds) antique gifts 65 Gerrard
w Lampadius Jos bkr Guest Bakery h 35 Allanbrook dr (Etob)
Lampard Arthur r 513 Naim av (York Twp) --Arthur J gasmn Gas Co
h 56 Cloverdale av — Harry shpr CIL r 690 Old Weston rd (York Twp)
— Islwyn struct assmblr A V Roe h 95 Northland av (York Twp) --
Jack r 41 Macdonell av — Margt Mrs drill press opr Pressure Castings
h 513 Nairn av (York Twp) — Percival S purch agt Unique Crest &
Athletic Supplies h 310, 230 Heath w (York Twp) — R Stuart pres
International Show Services Ltd h 70 Walmer rd Lampchuk Jas r 98
Portland Lampe John W millhand Bush -Federal r 5, 51 Stanley
(Mim) — Robt wrehsemn Howell Warehouses r 22 Dundonald Lam
pel Cecil dentist 1474 Bathurst h 185 Millwood road — Clare studt r
2 College View av — Helen Mrs h 209, 1654 Bathurst (York Twp) —
Joan librarian U of T h 2 College View av --Jonas r 2 College View av
♦Lampert see also Lamport --Aaron ctr Hollywood Children’s Wear h
283 Westmoreland av --Aaron studt r 1112 Bloor w — Benj h 38
Spadina av —Benj foremn James Bros h 2 Croydon rd (York Twp) —
Elizth (wid Alex) h 2, 833 College — Gerald (Auto Body Supply Co) h
21 Prince Charles dr (Nth Y) — Gerald slsmn Motor Coach
Advertising Ltd r 180 Ossington av --Jos (Lampert & Wilder) r 2
Croydon rd (York Twp) — Jos plmbr r 93 Kenwood av (York Twp) —
Leopold jwlr Regent Jewellery r 155 Ontario — Phillip A sis mgr
Automotive Hdwre h 218 Hillhurst blvd (Nth Y) --Rose (wid S) r 553
Briar Hill av (Fst H) --Sami (Quality Dry Goods) h 1112 Bloor w —
Saul prsr Candn Cleaners h 218 Melita av — & Wilder (Jos Lampert &
Max Wilder & Max Ehrenwort) pant makers 553 Queen w Lamphen J
M public acct 1251 Lake Shore rd (Long Branch) h same --John P M
elk Bank of Com h 1251 Lake Shore rd (Long B) Lamphier Anastasia
Mrs h 102 Simpson av (Etob) — Chas emp Cassmans Machinery r
102 Simpson av (Etob) --Frank emp G E Baird & Sons h 118 Seventh
(New Toronto) --Helen r 40, 150 Fermanagh av — Joyce stenog r 80
Yorkville av --Loretto r 102 Simpson av (Etob) --Mary E seed analyst
United Co-operatives r 30 Lake Shore blvd — Patk emp Labatts h 46
Rainsford rd — Patk J h 30 Lake Shore blvd — Theresa switchbd opr
St Joseph’s Hosp r 102 Simpson av (Etob) Lampila Pentti T emp
English & Mould r 86 McGill — Vilho mech Borden Co h 68 Soudan
av Lamping Jack bkr A & P h 100 Aldwych av (EY) — Patk emp CNR
h 97 Russett av — Stanley h 838 Ossington av Lampkin Chas A
slsmn Simpson r 8, 2526 Bloor w (Swan) --Earl chem engnr
Sangamo Elect h 19 Farnsworth dr (Nth Y) --Jas C stkpr Hinde &
Dauch h 29 Courcelette rd (Scar) --Marjorie Mrs emp Murphy Paints
h 75 Burlingame rd (Etob) --Raymond elk Maple Leaf Milling h 118
Brookside av (York Twp) --Rebecca Mrs r 54 Maher av -rStanley emp
Smith’s Dry Cleaners r 196 Chatham avenue Lampl Caroline (wid
Alex) h 121 Admiral rd --Ed mech Art Wire & Iron r 162 Geoffrey
Lampman Elsie mlnr Holt Renfrew r 32 Albany av --Ethelh 89 Quebec
av --Gertrude emp Drug Trading r 174 Bartlett av —Helen W artist h
30, 338 Bloor e — Robt J slsmn Simpsons h 136 Edna av --Wm emp
Moffats h 146 Empress cres ♦Lamport see also Lampert —A A & Co
(Allan A Lamport) ins brokers 2, 981-983 Bay —Abraham foremn Tip
Top Tailors h 207 Avenue rd _ Alphabetical, White Page 727
LAMPORT ALLAN A, Mayor City of Toronto City Hall, h 84 Harper
Avenue Phone MOhawk 8626 --Arthur W chief agt Ont Hydro r 975
Warden av (Scar) --B A Miss elk Confed Life Assn res Highland Creek
— Bide 981-983 Bav v „ n --Ferguson Co (Wm A Lamport ) barrs 1,
98b Bay — Henry A film librarian Shell Oil res Highland Creek — Jack
mach h 101 Natal av (Scar) --John elk Lever Bros h 48 Columbine av
— John mach Can Arsenals h 1139 Woodbine av (EY) --Ora V Mrs
tchr h 310, 83 St Clair av w --Wm a (Lamport Ferguson & Co) h 600
Milverton blvd Lamprey Glyn barr Tilley, Carson, Morlock &
McCrimmon h 207 Sheldrake blvd — Marian priv sec Harry Price Ins
Agencies h 19, 2867 Yonge Lampsa Henry drvr Candn Breweries
Transp h 335 Grace Lamro Nane r 330 King e Lamrock Geo milk insp
Walnut Dairy r 7 Bernice (York Twp) — Howard lab Candn Gypsum
— LeRoy Mach remover Colville Cartage h 1, 488 Montrose av --
Norman H asst bkpr Toronto Jail h 7 Bernice cres (York Twp) Lams
Annie (wid Morris) (Belgium Dry Goods) r 106 Bowie av (York Twp) -
-Bert H (Belgium Dry Goods) h 85 Avard (York Twp) — Edgar attdt
Ont Hosp r 91 Ninth (New T) --Jacob lab Lambert Const h 91 Ninth
(New T) Lamsa Aame r 30 Willcocks --Thos h 30 Willcocks Lams on
Bessie lunch room Elizabeth Arden r 51 Howland rd. --Edna Mrs opr
Currie's r 110 Balmoral av — Garnet H supt Adella Apts h 53
Howland rd — Harvey emp’ Dunlop Tire h 38 Albermarle av — Munro
Ltd Mrs Maude Bloodsworth pres Jas L Fell vice -pres F Pauline Fell
treas pneumatic tubes & conveyors 2803 Bathurst (Nth Y) --Real
Estate (Wm T Lamson) 6, 2498 Yonge — Wm F F studt r 301 Oriole
Parkway — Wm T (Lamson Real Esate) h 301 Oriole Pkwy Lamster
Morris metal caster Lipman Bros Silverware h 77 Montrose av —Yetta
Mrs opr Morris Dress h 6, 156 Huron Lamthier Harvey mach Imp
Optical h 256 Howland avenue --Rose Mrs h 256 Howland av Lamus
Ernest mech Lake Simcoe Ice h 42 August av (Scar) Lamy Roy h 60
Elm Grove av Lanaamae Edith dietitian Central Mort & Housing Corp
r 40 Pinewood av (York Twp) Lanack Clarence (Lawrence Salvage) r
1563 Lawrence av w (Nth Y) Lanaigan Herbt R insp Massey -Harris h
241 Woodbine av La-Napoletana Italian Pastry Shop (Achim
Dalaoker, Jos Licastro & Ronald Barbara) 680 Bloor w Lanark
Furniture Co (C Caplan & M Goldhar) 3rd fir, 2971 Dundas w Lanasa
Jos mach Lucas & Rotex h 1021 Logan av Lancake Chas mach A V
Roe h 410 Durie Lancashire Arthur carp h 104 Coxwell av — Harold
S h 8 Dault rd (Scar) --Kenneth audit elk Norman Sheppard Elliott &
Co h 608 Milverton blvd Lancaster Alan slsmn Goodyear Tire r 43
Royal York rd n (Etob) --Anna emp Aluminum Goods h 1 Thornhill av
(York Twp) ■--Arthur G Jr slsmn Dennison Mfg Co of Can Ltd res
Oakville --Arthur G sis mgr Dennison Mfg Co of Can Ltd h 43 Royal
York rd n (Etob) --Benj emp Goodyear Tire h 30 Arcadian Circle
(Long B) — Bert asst pressmn Automatic Paper Box r 81 Jones av —
Building 767 Yonge — C Edwd pressmn Miln -Bingham Print -Craft h
1065 Greenwood av (EY) --C Ford sec-treas Underwood Ltd h 313W,
118 Montgomery av — Chas E h 446 Milverton blvd —Clifton M asst
acct Bank of N S h 308, 15 Anglesey blvd (Etob) --Donald E
customer engnr Inti Bus Mach r 137 Gough av --Doreen emp
McMurrich Ins r 124 Mortimer av (EY) — Douglas G inst rep Thomas
Pocklington Ltd h 107 Cliffcrest dr (Scar) --E W Co Ltd (Toronto Br) E
W Lancaster (Windsor) pres Roy G Lancaster (Windsor) vice -ores
Eric E Lancaster (br mgr) Mrs A J Lancaster (Windsor) sec-treas
cartage moving storage 4022 Dundas w (York Twp) --Earl R suprvsr
London & Lancashire Las h 137 Gough av --Edwd A research fellow
Ont Research Foundation res Ajax — Ellen (wid Jos J) h 179 Wolfrey
av — Elsie mgr Eatons h 29 Lankin blvd (EY) --Eric E br mgr E W
Lancaster Co Ltd h 21 Ashbourne dr (Etob) — Ernest J export elk
CNR r 179 Wolfrev av --Florence Mrs emp Baker Platinum r lyb
Hamilton — Fredk caretkr Lamonts h 34 Lewis --Fredk G vice -pres
Whyte -Hooke Papers Ltd h 118 Baby Point rd (York Twp) --Fredk H
work leader Imp Varnish h 213 Rhodes avenue — Fredk J elk PO h
124 Mortimer av (EY) — Geo wire chief CPR Communications h 46
Northbrook rd (EY) --Gloria with Tor Genl Trusts r 935 First
(Lakeview) --Harold plmbr Candn Comstock Co h 85 Burnham thorpe
rd (Etob) — Harriet B priv sec Aluminum Rolling Mills r 23
Edgecombe av (Nth Y) --Harry mach E S & A Robinson h 84 Forman
av — Harry M h 84 Weyboume cres --Henry &ork leader Imp Varnish
h 257 Rhodes av — Jas emp Murphy Paints h 1314A Lake Shore rd
(Long_B) — John maintmn Mimic o High Schl h 112 George (Mim) --
John D mach opr Elvedge Paper Box Co Ltd h 2 Willowbrook rd
(Etob) --John W foremn construction Imp Oil h 182 Chatham avenue
--Jos S Income Tax h 85 Norton av (Nth Y) --Kathryn Mrs elk
Simpsons r 34 Webb av — Leonard dec h 45 Glengarry av —Lionel
emp Simpson Sears r 63 Parkwood av — Mae office elk Eatons r 79
Eaton av LAN LANDAU LANCASTER --Margt elk Dom Flow Meter Co r
321 Willard av --Margt W with Dom Flow Meter r 420 Beresford
avenue --Martha R editorial elk Can Law Book r 46 Milverton blvd --
Mary (wid Harry) r 84 Forman av --Mary Mrs elk Eatons r 38
Woodington av --Nelson W acct Dom Stores h 89 Glenvale blvd
(Leas) --Nina N playground suprvsr Parks & Recreation Dept r 58
Sparkhall av — Oscar M h 1, 1346 Avenue rd n --Robt instrument
assembler Taylor Instrument h 28 Landseer rd (Scar) --Rose M
stenog Can Law Book Co r 446 Milverton blvd — Shirley Mrs stenog
Chas H Sanders & Co r 817B Lake Shore rd (New T) --Thos caretkr
Gledhill Schl r 846 Broadview av --Thos S alteration room mgr John
Northway h 49 Kenilworth av --Victor H elk Royal Bank h 16
Dalecrest dr (EY) — W Douglas tchr Weston Coll& Vocational Schl h
9 9 John (Wstn) — Wm foremn Minneapolis -Honeywell h 434 Old
Orchard gr (Nh Y) --Wm A h 45 Poucher --Wm stillmn B A Oil r 268
Cedarvale av (EY) Lancbargar Otto r 449 Concord av Lance Alex h 15
Clinton pi — Clemance emp Kirkland Roofing h 140 Walmer rd --
Egan blasting contr r 710 Dovei*court rd — Elizth mach opr Natl
Carbon r 15 Clinton ol --Frank druggist Murray's Drugs h 267 Old
Weston road — Jos pntr r 65 Yorkville av --Jos P rfr h 136 Cameron
av (York Twp) --Lena h 45, 1638 Queen e --Raymond firemn CNR h
426 Strathmore blvd —Thos emji Kirkland Roofing h 3 Watt av (York
— Wallace engnr Trinity Coll h 114 Hazelton av --Wm trk drvr
Johnston Haulage r 627 Spadina av Lancefield C res prop Erne st
Ridout Real Est r 305, 2525 Eathurst (Nth Y) — Douglas P techn
Dunlop Tire & Rubber r 305, 2525 Bathurst (Nth Y) --H A field engnr
Goodyear Tire h 89 Haliburton av (Etob) Lanceley Clara Mrs h 112-|
McGill --Edna M tchr Allenby Schl r 16 Braemar av --Esther E Mrs h
1L. 80-84 St Clair av w — Harry r 112f McGill --Jessie W h 16
Braemar av Lancelot Robt structural drftsmn Genl Engineering r 245
Lauder av (York Twp) Lancewicka Bella Mrs r 12 Dalton rd Lan chalk
Pete metal plshr John Inglis r 24-26 Gloucester LanchDury Florence r
94 Hillside av (Mim) --Horace h 14 Warden (Mim) — Mary (wid
Percy) h 94 Hillside av (Mim) — Mervyn emp Anaconda Amer Brass h
59A Station rd (Mim) — Wm H trav agt CNR h 59 Humbervale av
(Etob) Lanci Demazio cement fnshr h 1155 Dupont Lancia Domenico
factory wkr Liberty Co r 342 Bartlett av — Felice lab Benney Forletta
h 28 Beaver av --Mary r 28 Beaver av — Patk emp Ornamental Iron
h 84 Beaver av — Phyllis elk C P Tel r 84 Beaver av --Vincent emp
Gilbert & Barker r 28 Beaver av Lanciault Violet Mrs elk Edwd
Callaghan Ltd r 640 Ontario Lanco Ltd Kenneth Lane pres Herbt J
Coles Sr vice -pres Herbt J Coles Jr sec-creas games 1654 O’Connor
dr (EY) Lancos Jos emp Anaconda Amer Erass h 35 Fourteenth (New
T) — Stephen lab Swifts h 138 Belgravia av (York Twp) Lancy A W h
8, 9 Humewood dr (York Twp) Land Ada F Mrs drug fnshr Rexall
Drug h 118B Eastwood rd --Alan trk drvr Parisian Laundry h 1068
Shaw — Alan R elk P O h 464 A Danforth av --Allan R h 102
Roselawn av — B Joan elk Bulova Watch r 102 Roselawn av --Betty r
262 Concord av --Chas H h 358 Milverton blvd — Denis M with Natl
Trust res Oakville — Donald lab Dom Gasket r 272 Evelyn av —
Geoffrey sismn C AleA Jones r ss Uiaver av (Nth York) --Gordon W
vice-pres The British Metal Corp (Can) Ltd h N, 723 Bloor w — Harry
W placement officer Candn Nat] Tnst for The Blind h 48 Finch av w
(Nth Y) --Jas H ins adj Inter -Prov Ins Claims r 744 Duplex avenue --
John emp Aristocrat Mfg h 106 DeGrassi —Louisa (wid A) h 744
Duplex av --Molly Mrs assembler Allcock, Laight & Westwood r 33
Claver av (Nth Y) — Nancy A studt r 744 Duplex av --Norman carp
Massey -Harris r 14 Runnymede rd (Swan) --R Brian librarian Toronto
Public Library h 105, 1 Harbord — Robt D group dept Crown Life Ins
Co r 102 Roselawn av LAND TITLES OFFICE (See York Government)
--Wm D acct Clarkson & Gordon r 19 Strathearn blvd (Fst H) Landa
Bohumil pekr Eatons h 88 Main — Fred B office mgr Sunnibuilt
Prefab Prod h 7, 2550 Bathurst (Fst H) — Gerald E elk Royal York
Hotel r 24 Nanton av Landale Jas h 24 McDonald (Mim) Lanaary
Dara emp Natl Sewer Pipe h 52 Lake cres (Mim) Landau Allan chart
acct Wm Eisenberg & Co r 20, 1597-99 Bathurst (Fst H) — BarbaraL
stenog Cohen & Dicker r 20, 1599 Bathurst (Fst H) --Carolyn S Mrs
elk Mnfrs Life r 170 Grace — Credit Jewellers (Pinkus & Sami I
Landau) 1507 Gerrard e — David (Landau’s) h 54 Hillcrest dr —
Esther slsldy Landau’s r 54 Hillcrest dr --Harvey pinty Moore’s Open
Kitchen) h 20, 1599 Bathurst (Fst H) --Herman with Swiss Rose Co h
123 Spadina rd --Irma elk Eatons r 163 Parkside dr — Jack r 75
Whitmore av (Fst H) —Julius dentist 212, 455 Spadina av h 204
Glenayr rd (Fst H) — Louis emp Superior Pants h 371 Crawford --
Pinkus (Landau Credit Jewellers) h 29 Menin rd (York Twp) — Sami
bldg constr h 110 Dewboume av (York Twp)
 LAN LANDAU LANDAU —Sami I (Landau Credit Jewellers) r
29 Menin rd (York Twp) --Shirley r 37 Arlington av Landau's (Mrs M
& David Landau) ladies ready to wear grnd fir. 667 Yonge Landauer
Walter pres Giftcraft Ltd h 116 Elm Ridge dr (Fst H) Landawitch Joe
btchr G & S Meat Supply Ltd r 606 Huron Landeau A1 h 170 Grace
Landel Frank r 130 Crawford Landell Duncan A mgr Eastman
Photographic Stores h 38 Sparkhall av — Harold W slsmn Genl Films
h 32 Shangarry dr (Scar) — Stanley B sis mgr Spudnuts Ltd h 233
Hillsdale av east Landels Marion Mrs slsldy Fay’s Dress & Coat
Shoppe h 68 Lamb av *Lander, see also Lauder — Albt emp CNR r
295 Jarvis --Alfred asst off mgr Heinz Co r 30 Morningside av (Swan)
— Brokerage (J B Lander (British Columbia) brkrs fruits & veg 24
Mirket — Co (Canada) Ltd, The J F Hagan pres, C B Hopgood sec-
treas & mgr toilet preparations 1207 King w — Credit Jewellers (Lou
& Bob Friedlander) 1211 St Clair av w — Etnelwyn (wid Wm J) h 32
Alexandra blvd — Evelyn r 32 Alexandra blvd —Henry D h 429 Main
(E Y) — Ida Mrs r 15 Cameron pi — Jack musician Embassy Hotel h
107 Bloor w — Kenneth N slsmn Hutchison & Son h 112, 707
Eglinton av w (Fst H) — Louis diamond ring expert Lander’s Credit
Jewellers h 103 Viewmount av (Nth Y) — Newton J pres Continental
Life Insurance Co h 2, 61 Elm av --Pauline stenog Eatons r 159
Evelyn av Lander’s Credit Jewellers (Louis H & Ann Friedlander) 1163
Bloor w Landerkin Jas G bldg servicemn Bell Tel h 562 Crawford —
Jas H r 146 Divadale dr (Leas) Landers Arnold emp Campbell Soups
h 16C, 445 Lakeshore rd (Mim) — J Edwd vice-pres in charge of
sales Mitchell Mfg Co Ltd h 8 Alder rd (E Y) --John cigars & lending
library 3305 Yonge h 316 Douglas av (Nth Y) — Thos P carp LaLonde
h 71 Woodmount av Landeryou John C elk Can Life r 460
Roncesvalles avenue Landfelt Tage tool crib Accurate Machine & Tool
r 728 Shaw Landi Elga M Mrs bkpr McLeod, Young, Weir & Co r 605
Huron Landis Ben taxi drvr h 4 Killarney rd — Boris pdlr h 6, 387
Spadina av — Henry studt r 62 Bellevue av — Herbt studt r 387
Dundas w — Maurice (Hammersmith Drugs) h 53 Latimer av —
Noah phy 391 Dundas w h 387 same --Sami furrier Levitt’s h 62
Bellevue av Landiuk Wm shpr United Ch Pub House h 147 Grange av
Landler Stanley B h 4, 6 Drexel rd (Nth Y) Landles Archd r 72
Wellesley e — F Guy asst head Construction & Repair Div Imp Oil
Marine Dept h 117 Sandringham dr (Nth Y ork) — Jas typist Tor Pol
Commn h 67 Sandown av (Scar) --Jemima r 67 Sandown av (Scar)
Landless Walter D carp h 481 Cosburn av (E Y) Landman Edith dress
opr r 582 Palmerston av — Harry r 816 College Landmann Martin
prod mgr E W Reynolds Ltd r T204, 50 Upper Canada dr (Nth Y) --
Wm h 65 Lawrence av e Lando Albt studt r 101 Major — Clover
Foods Co (Edwd Hallam) chocolate beverage 1675 St Clair av w —
Jack prsr Tip Top Tailors h 126 Lennox — Sollie prsr Sunshine
Cleaners r 825 St Clarens av — Thos ctr h 154 Winnett av (York
Twp) Landon Carl r 229 Gerrard e --Celina Mrs mach opr Eatons r
194 Oakwood av — Donald M studt r 13 Verbena av (Swan) --
Dorothy Customs & Excise r 15 Whitewood rd — Eliza h 305 Chaplin
cres (Fst H) — Emmett pipe ftr Bennett & Wright h 87 Ravina cres —
Flora winder York Men ding Wool r 1011 Bathurst --Floyd foremn
mach CNR h 41 Hadley rd --Frank mach Sangamo Elect h 24
Stanhope av (EY) — Helen P timekpr Can Illinois Tools r 215 Pearson
av --Jas E teller Gas Co r 137 Johnston av (Nth Y) --Norman r 260
Waverley rd --Norman E sec Swift Canadian Co Ltd h 13 Verbena av
(Swan) --Ralph needle sharpener Candn Red Cross Soc r 100
Caroline av — Richd r 1229 Bathurst — Stephen r 159 Pacific av —
W Harry optometrist h 1 Glenwood terr (E Y) — Wm r 3 Glenvalley
dr (Y ork Twp) --Wm H (Chas Potter) h 4, 303 Bayview av (Leas)
Landovitch Joseph btchr r 606 Huron Landow Jess slsmn Wm P
Landow h 5, 584 Lawrence av w (Nth Y) — Louis slsmn Wm P
Landow r 4, 481 Palmerston blvd --Wm P oriental rug importers 1st
fir, 66-8 Dundas w h 4, 481 Palmerston blvd Landr Maria emp CGE h
367 Markham — Stanley legal elk T Edgar Reilly h 367 Markham
Landra Harry r 286 High Pk av — Linda Mrs h 2422 Danforth av
Landray Doris A stenog Cook Clothing r 186 Hamilton Landre Ralph
lab r 30 Kenwood av (York Twp) — Ralph sawyer Candn Wirebound
Boxes r 645 Gerrard e L.andrean Harold J trk drvr Shell Oil h 40
Tiverton avenue Landree Victor h 537 Jones av Landreth Jessie S
stenog Natl Lumber h 77 Dearbourne av Landreville Doris N Mrs elk
Fruehauf Trailer Co r 5, 18 Wadsworth blvd (Wstn) — Fredette
receptionist S Fremes & Co r 1711 Dufferin --Thos E h 3, 10
Boustead av Landrey Albt r 359 Dovercourt rd — Albertina r 359
Dovercourt rd — Edna r 359 Dovercourt rd LANDREY — Merveille
chkr Simpsons r 119 Humewood dr (Y ork Twp) — Philip mech
Stark’s Motors h 119 Humewood dr (York Twp) Landriau C Julie
social wkr Catholic Children's Aid Soc r 451 Parkside dr --Frank A
barr DVA h 451 Parkside dr --Lawrence A QC (Landriau & Dean) h
113 Highbourne rd --Nora M studt r 451 Parkside dr — & Dean
(Lawrence A Landriau QC & E G Percy Dean QC) barrs 214, 68
Yonge Landriault Armos sandblasting Can Illinois Tools r 109
Jameson av --J carp r 1243 Lake Shore rd (Long B) — Mildred
(Andria Shop) r 2, 125 Twenty-Seventh (Long B) — Oliver emp CPR
h 18 King Edward av (E Y) — Oliver E off mgr Hugh Williams & Co h
303 Scarborough rd --Theadore wldr Reliable Toy r 142 Lawlor av
Landridge Clifford G field man Bell Tel h A3, 231 Vaughan rd (York
Twp) --Ronald emp John Woods h 4 , 546 Indian gr --Ronald E
stkmn’s hlpr Bell Tel r 4 , 546 Indian gr Landrigan Arield hrdrsr Gay
Paree Beauty Salon h 551A Bloor w --Francis r 161 Concord av —
Lome bacteriologist Dept of Health h 478 Atlas av (York Twp) —
Mabelle h 246 Greenwood av — Ronald r 142 Lindsey av --Ruth elk
Federal Grocery r 312 Gladstone av Landrigon Jas lab r 386
Parliament Landry Abdon r 68 Wood --Adelard barber Rosehill Barber
Shop r 7 Constance — Adelor emp DeHavilland Aircraft h 625
Christie — Adorice Mrs h 4, 219 Wellesley e --Albt A traffic mgr
Nestle (Canada) h 138 Berry rd (Etob) --Albt J prod consultant
Anaconda Amer Brass h 35 Bedford Pk av --Albt M band bldr
Goodyear Tire h 1218 College --Albt W (Landry & Weeks) h 50
Dorset rd (Scar) — Albertina emp Candn Wallpaper-Reg N Boxer Div
r 212 Sixth (New T) — Alphee r 79 Springhurst av — Ann nurse Link-
Belt r 464 Spadina rd --Anna brushmkr Boeckh Co r 7 Constance —
Anne nurse h 16, 464 Spadina rd (Fst H) --Annie Mrs r 202
Parliament — Arthur wrehsemn Natl Gro r 113 Sixth (New T) —
Aurel emp Campbells Soup r 7 Constance — Benj tnsmth Toronto Air
Conditioning r 21 Grenadier rd --Bert mgr Regent Motor Sales r 54
Victor av — Blair J lab Stand Sanitary r 112 Westmoreland av — Carl
r 69 Walmer rd — Chas r 133 Fourth (New T) — Chas colour-mkr
Dom Colour Corp r 128 Seventh (New T) — Claire elk Rogers
Majestic h 16, 464 Spadina rd (Fst H) — Clement hlpr Candn Ice
Mach r 69 Walmer rd — Clovis carp Ryan Constn h 112 Harvie av —
Dara lab h 89 Tenth (New T) --Edgar r 267 Broadview av --Edgar
carp h 149 Hastings av — Edwd emp Brown Constn h 31 Thirtieth
(Long B) — Edwd supt Edland Constn Co h 7, 470 Summerhill
avenue — Edwd R dept asst Natl Carbon r 35 Bedford Pk av --Edwd
W lab Stand Sanitary h 212 Sixth (New T) --Edwin carp r 40 Leopold
--Eileen emp Rowntree Co r 80 Grenadier rd --Elda hlpr Wm Wrigley
Jr r 44 Garnock av — Eliza M hrdrssr Dahlia Beauty Salon r 172
Hampton av --Emile handymn Ont Hydro res Long Branch --Ernest
constn wkr r 199 Seaton — Eugene asst-acct Natl Candn Bank r 2,
294 Broadview av — Fern Mrs typist Nerlich & Co h 585 Brookdale av
(Nth Y) --Geo messr Noranda Mines r 1531 Queen w — Gerald emp
Frigidaire Products r 46 Leopold --Germaine emp Christie Brown Co r
214 Parliament --Henrietta wtrs Royal York Hotel h 16, 172 Vaughan
rd (York Twp) — Henry carp h .18 McMaster av --Howard emp
Eatons h 504, 5 Lakeside Camp — Ivan lab Henry Disston & Sons r
636 Huron — J Edwd chkr Candn Wirebound Boxes h 17 Melbourne
av — Jas r 351 Sherbourne --Jean P emp Goodyear Tire h 60 Tenth
(New T) — Jerome apprentice McCorquodale & Blades r 20
Montague --Joseph cartage h 351 Sherbourne — Joseph lab
Christie’s Bread h 123 Corbett av (York Twp) — Joseph revr Phoenix
Engineering Products h 45, 194 Dowling av --Joseph wldr Fruehauf
Trailer r 9 Ottawa — Joseph C h 4 Fort Rouille --Joseph W stk
controller DeHavilland Aircraft h 360 Jones av — Joyce stenog r 63
Lowther av — Lawrence mach Can Steamship Lines h 32 Carlyle --
Leo elect Candn Arsenals r 153 Leyton av (Scar) --Leo emp Can
Packers r 7 Constance --Leo mech Frigidaire Products r 636 Huron —
Leonard emp Becks Lumber Co r 202 Parliament — Leslie foremn
Cross-Town Motor Sales Ltd h 585 Brookdale av (Nth Y) — Lewis trk
drvr Hydraulic Metals r 185 Grange --Lillian r 83 Wellesley e --Liza r
1:72 Hampton av — Loias carp r 100 Lyndhurst av — M Rosalie
assmblr Natl Carbon r 12 Florence — Mabel (wid Louis) h 46 Edgeley
av s (Scar) — Margt Mrs r 17 Sumach — Melden mach suprvsr Acme
Carbon & Ribbon h 101 Linden av (Scar) --Narcis tnsmth r 21
Grenadier rd — Nettie Mrs lining opr Central Cloak r 360 Jones
avenue — Nicholas cook Eatons h 119 Alton av — Norman lab Candn
Steel h 38 Third (New T) — Odila opr Eatons r 278 Dundas e —
Omar slsmn Compact Ladder Co h 154A Dowling av --Patricia elk
Tuckett-Little & Firstbrook r 2138 Dundas w --Paul carp Day Sign Co
h 214 Parliament --Raymond emp CPR h 430 Markham — Rennie
emp Goodyear Tirer 25 Howland av --Rolande cook r 19 Rosedale rd
--Rose Mrs h 214 Parliament •-Roy emp Candn Wallpaper-Reg N
Boxer Div r 212 Sixth (New T) •-Russell W layout wkr Fruehauf
Trailer Co h 58 Alcorn av •-Stanley C tinsmith E L Ruddy h 231
Hallmark av (Etob) _ —7 28LANDRY — Thos emp TTC h 80
Bertmount av --Vincent burner Plate and Structural Steel r 127
Tyndall av --Walter body bldr Fruehauf Trailer Co r 35 Alcorn av --
Wilfred h 103 Twenty-Ninth (Long B) --Wilfrid G surface grinder Can
Illinois Tools r 164 Duchess --Wm emp Burndy of Can h 2138
Dundas w --Wm lab Swift’s h 330 Salem av --Wm H lab Dom Wire &
Cable h 125 Marlborough avenue --& Weeks (H W Landry & Guy
Weeks) electricians 2390 Kingston rd (Scar) Lands Wm paper
handler Star h 469 Glen Pk av (Nth Y) Landsberg Harry tnsmth J H
Terry h 1060 Shaw --Harry A (Landsberg & Garfield) h 75 Stormount
av (Nth Y) --Jacob stmftr h 201 Glenholme av (York Twp) --Martin H
chart acct J John Shulman & Co h 39 Lynn Haven rd (Nth Y) —
Maurice engineer M I Greisman Co h 477 Lytton blvd (Nth Y) —
Sadie fnshr Service Garment r 241 Delaware av — Sonya nursery
schl tchr Victoria Day Nursery r 477 Lytton blvd (Nth Y) — Wilfred
emp CNR r 1060 Shaw --& Garfield (Harry A Landsberg & Benj D
Garfield) dentists 1, 206 Bloor w Landsberger Otto fur fnshr Service
Garment r 449 Concord av Landsborough Frank staty firemn CPR h
10, 17 Jane --Herbt tire bldr Seiberling Rubber h 215 Indian gr --
Herbt E asst suprvsr Dept Pub Health h 286 Indian gr --Leonard bkpr
Lockhart’s Camera Exchange h 39 French av (York Twp) --Walter
mortician h 22 Constance Landsky Emma (wid Louis) h 92
Maplewood av (York Twp) Landsman Alfreda r 670 Shaw — Aubey O
(Taylor Pharmacy) r 307 Arlington av (York Twp) — Michael h 307
Arlington av (York Twp) Landstrom Alii (wid Karl) h 59 Boswell av —
Arvid p c Pol Dept r 59 Boswell av — Gustave h 20 Bernard av Landu
Sami emp Levy Auto Parts h 166 Howland av ♦Landy, see also Lundy
—Maude M pres Landy & Company Limited h 235 Briar Hill av —
Walter r 235 Briar Hill av — Wm r 39 Kensington av — & Co Ltd
Maude M Landy pres church supplies 16 Dundas w Landyga
Wasylina (wid Andrew) drsmkr h 146 Walmer rd Landymore Geo elk
CPR h 5, 520 Kingston rd Lane Albt E mill C B Parsons h 17 Harvie av
— Alfred J mach Dunham Heating Co h 380 Winnett ■ av (Y ork
Twp) --Alice r 122 Farnham av — Alice (wid Geo W) h 117
Sherbourne — Allan r 305 Mutual — Allen r 240 Parliament — Amy r
90 Albertus av — Arthur A (Arthur Lane Studio) h 1208 Broadview av
(E Y) --Arthur B suprvsr Imp Life h 31 De Vere gdns (Nth Y) --Arthur
O h 273 Leslie — Arthur R emp Arthur Lane Studio h 43 Cadorna av
(E Y) — Arthur Studio (Arthur A Lane) comml photo & silk screen
965 College --Arthur W mgr Nichols Chemical Co Ltd, The h 47
Armadale av (Swan) --Audrey M shpr’s asst Comml Fixture r 83
Holborne av (E Y) --Austin W p c East York Twp h 32 Donora dr (EY)
— Avis M sis elk Eatons r 201 Dunn av --Barbara E nurse Tor
Western Hosp r 677 A St Clair av w — Barbara J priv sec Ortho
Pharm Corp (Can) r 41 Methuen av (York Twp) --Basil dir of purch
Easy Washing Mach h 4 Farnsworth dr (Wstn) — Beatrice stenog J J
Gibbons r 35 Sheridan av —Bessie Mrs hsekpr r 229 Delta (Etob) —
Bessie sec United Church Training School r214 St George — Blake A
probation officer Tor Family Court h 78 Gates av — Byron G studt r
342 Oakwood av (York Twp) — Rita M Mrs stenog Imp Oil r 52A
Clonmore dr (Scar) — C with Tor Textile Mach r 52A Clonmore dr
(Scar) — Cecil assmblr Therm-O-Rite Products r 3275 Dundas w —
Cecil brakemn CNR h 80 Thirty-First (Long B) — Chas maint Hinde &
Dauch r 235 Broadview av — Chas E h 19 Armadale av (Swan) —
Chas J emp Telegram h 58, 82 Willow av — Chas O brklyr h 110
Ewart av (York Twp) --Chas W dec r 829 Gerrard e — Claire priv sec
Candn Hanson & Van Winkle r 21 Earlscourt av — Clifford H bus drvr
TTC h 160 Lyon av (York Twp) — Clifton H (Robertson, Lane, Perrett,
Frankish & Estey) h 88 Alexandra blvd — Della B wtrs Woolworths
res Port Credit --Dennis studt r 88 Alexandra blvd —Donia mach opr
Geo Hees r 386 Ossington av — Doreen Mrs sis elk Pennyworth’s
Dept Store — Edith (wid John) cafeteria asst East York Coll Inst h 83
Holborne av (E Y) --Edith priv sec L Everett Jaquith r 4A Oaklawn
gdns --Edith sec-treas Warwick Bros & Rutter Ltd h 90 Albertus av —
Edith nurse & sec r A, 4 Oaklawn gdns — Edna examiner R W
Matthewman & Son r 53 Indian Rd cres — Edwd G janitor Litho Print
h 171 Sellers av (York Twp) —Effie r 11 Charles e — Effie r 19
Glenora av (York Twp) — Elijah E emp CPR h 19 Wallace av --Ella E h
384 Berkeley --Eric R ftr TTC h 48 Schell av (York Twp) — Eric W
with Tor Genl Trusts h 32 Kirk Bradden rd w (Etob) — Ernest H elev
opr Eatons r 21 Baird av —Ethra hrdrssr Lane’s Beauty Salon r 29
Ellis av (Wstn) --Etta h 2, 281 Garden av — Eva L stenog-bkpr Geo
W Beecroft h 8 Millbrook cres — Florance J insp Simpsons h 28, 39
Metcalfe --Florence (wid Geo) h 26 Cordelia av (York Twp) --Frank J
mach Inti Bus Mach r 35 Sheridan av — Fred G D?pt of Highways
(Prov) r 41 Methuen av (York Twp) LANE --Fredk (Maple Leaf
Woodworking) h 87 W: (E Y) —Fredk E asst estates officer Royal
Trust Delisle av --Fredk M ambulance desk attdt Tor Weste h 82
Bertmount av — Garvey h 28 Tracy — Geo h 21 Baird av '—Geo
(Oakwood Cycle & Radio Supply) h 34 Oakwood av (York Twp) —
Geo asst steward Twentieth Battalion Clu George —Geo btchr Dom
Stores Ltd h 90 Spears (Y — Geo emp CNR h 61 Twenty-Seventh
(Lon£ —Geo lead hand Ferranti Elect h 28 Keith i (York Twp) --Geo E
emp Ford Motor Co h 20 Kenwortfc (Scar) —Gerald 1st vice-pres
Stanley Lane Ltd r Lanbrooke (Nth Y) —Gertrude typist D’Ambrosio
Tile Setter r Winnett av (York Twp) --Gertrude A Mrs elk Carswell Co
h 31 Ire av (Centre Island) --Gloria typist Bookman Ins Agency r 36
H —Gloria K elk Matthews & Co r 70 Wheele: — Gordon field techn
Dept of Highways (Prc Firstbrook rd --Gordon with Tor Hydro h 71
Strathcona a —Grace ironer Royal York Hotel r 330 Cec av (E Y) --
Grant emp A V Roe h 5 Handel (York Twi — Harold B h 471
Whitmore av (York Twp) — Harold F foremn Natl Cash Register h Y
Hillsview av --Harold J instrument man East York Twp Kings Pk blvd
(E Y) —Harold J mach Bawdon Mach Shop h 10 K Pk blvd (E Y) —
Harriet (wid Leon) h 20 Alhambra av — Harry comml artist Grip &
Batten h 44 Fernwood Pk av --Harry furn man Jas Sercombe & Sons
h : Thirtieth (Etob) —Harry H Customs & Excise r 46 Admiral --Helen
M prntr John Inglis h 84, 10 Kings --Henry M r 170 Wychwood av
(York Twp) — Herbt h 30 Butternut —Herbt G chemist’s hlpr Hinde &
Dauch h Aldercrest rd (Etob) — Herbt H elk Ont Hydro h 47 Hoyle av
— Howard wldr DeHavilland Aircraft h 50 C avenue — Howard B phy
714 Bloor w h same --Ida (wid Geo) r 29 Norlong blvd (E Y) — J
Edwin suprvsr P O h 73 King’s Pk blvd — J Wesley drvr Brighton
Laundry h 463 R mede rd --Jack h 260 Seaton --Jack firemn CPR r
33 Fisken av —Jack insp Albert Kerr Co Ltd res Richva --Jack N brkr h
3 Handel (York Twp) -^Jas h 201 Dunn av --Jas h 12 Orchard Green
(E Y) --Jas E shpr Farrington Mfg Co h 68B Bir — Jas W janitor Tor
Motor Car res Westhi --Jean Mrs h 185 Gladstone av — John (Lucky
Strike Sportswear) h 817 Br av (York Twp) -John chkr CPR h 498
Annette — John foremn Wicketts Salvage h 13 Mintc — John
prospector h 3, 102 Eleventh (New ' --John A asst buyer CNR h 59
Rosevear a\ — John E emp Natl Grocers h 5 Geoffrey --John G
(Lane’s Bdauty Salon) h 29 Ellis i — John H h 545 Windermere av —
John P h 29 Denison rd w (Wstn) --John T stkpr Trinidad Leaseholds
h 27 £ cres (Mim) — John The Bod.ley Head Ltd Thomas Nelsc Sons
(Can) Ltd agts publishers 3rd f Wellington w — John & Co (John
Lane) mfrs agt (noveltie fir, 32-36 Camden — Jose Mrs elk h 27
Appleton av (York Twj --Joseph cartage h 659 Bloor w — Kennecn
oeater man Gair Co res Maple — Kenneth pres Lanco Ltd r 199
Hastings a— Kenneth sis mgr Simpsons -Sears h 37 B< --Kenneth
tool & die mkr Diamond State F; Endean av •yLANE KENNETH E,
President - General Manager, Moto List Co. Ltd., h 35 White Pine
Aven (EY) Phone Oxford 9828 (Wsti 91im a 2 h 3 )0 ield --Kenneth G
studt r 73 Kings Pk blvd (E Y) --Kenneth T tree pruner Dept Property
h i i wood av (Scar) --Laura Mrs h 23 Hampstead av (E Y) — Leslie
photo Photo Engravers h 89 Squir : (E Y) — Lionel A shpr Don Valley
Paper Mills h Logan av (E Y) — Lois A typist Ont Hosp Assn Blue
Cross Summerhill av --Manly T (Lane Marine) h 3, 16 Humber b
(Etob) — Margt (wid Wm) rooming house 16 Beacc av h same —
Margt stenog r 714 Bloow w — Marian K ctr Honey-Chile Products r
6 < ar i avenue --Marie Mrs h 45 Badgerow av --Marine (Manly
Lane) marihe equip 1, 61 jarle west --Mary (wid Albt) r 33 Foxbar rd
--Mary Mrs r 258 Gainsborough rd — Mary (wid John W) emp Honey
Dew r 2, Ijl" Temple av — Mary Mrs pekr Foster-Dack Co Ltd h 12 ?a
: • av (Scar) --Mary tchr Bd of Educ h 50 Firstbrook rd — Mary A
typist Acme Windsor Directory i 0 Logan av (E Y) --Mary E r 37
Yorkville av --Maurice (Trinity Cartage) r 657 Bloor w --Milton press
feeder Gair Co h 226 Lee a\; --Muriel sis elk Eatons r 398 Old
Orchard d : York) — Nelson E securities mgr Excelsior Life ■ h
Highgate rd (Etob) --Nenette mach opr Geo Hees Ltd r 386
 t heavy equip opr Dept St Clng h 77 Squires av (E Y) t
maint dept Simpsons-Sears r 177 Collier ( A engineer Ont Hydro r
312 Fairlawn av t a rubber wkr Goodyear Tire res Port CC Coffee
Shop) h 710 Kingston rd U emp Goodyear Tire h 44 Hillside av (Mim)
S h 117 Eastwood av (Scar) Ud emp Arthur Lane Studio res Port
Credit , Mrs elk Musson Book r 384 Berkeley i (wid Philip) men’s
wear 582 Bloor w h 508, 7 80 Eglinton av w (Fst H) 1 (Lane’s Variety
Store) h 113 Lambton av (York Twp) I C E engineer Bell Tel h 57
Wineva av li Mrs r 420 Gladstone av ley tchr Rawlinson Pub Schl h
1431A Yonge II h 28 Third (New T) ley pres Stanley Lane Ltd r First
av (Nth Y) ley Limited Stanley Lane, pres, Gerald Lane 1st vice-pres,
Beryl Sellick 2nd vice-pres, Ken Kirby treas bicycles & sporting goods
2135 Danforth av ?n G A cable splicer Guest Co h 453 Scarborough
rd ey J bidg supt J E Hoare h 98 Summerhill av h 624 Glebeholme
blvd , metal plshr Comml Fixture r 26 Cordelia lv (York Twp) studt h
654 Huron .1 ! E h 37 Y orkville av 1 ■ j (Top’s Fish & Chips) h 1125
O’Connor dr ' (E Y) ..7 ; R auto serv stn 1586 Queen w h 3, 1399
[King w -Ti; W dec h 829 Gerrard e ..-I; W emp CNR h 229 Delta
(Etob) -vlrie A elk Royal Bank r 146 Garden av .7; A (wid Nelson)
clipper Candn Bag Co h i 94 Symington av ..y|5r lab Hinde & Dauch
Co r 33 Greenwood av .V|or R opr TTC h 70 Wheeler av „V a E h 11
Atkin av --i -edk prof engineer Ont Hydro h 8, 745 Bloor west »o
prsmn Ashton-P otter h 41 Methuen av (York Twp) r 4 Austin terr
Son (Wm & Wm Lane J:$ genl contrs 602 Lauder av (York Twp) sr F
porter r 104 Parliament sr G acct Long Bros h 72 Lyndhurst av sr J
acct Prudential Ins Co of Amer h 8 Fallsview \Etob) er J shipping elk
Robinson Cotton Mills h 375 Wellesley e sr M with Lever Bros h 108
Chestnut Hills Pkwy (Etob) ey C vehiclemn C P Exp r 16 Donlands av
ti 191 Madison av Old Orchard gr (Nth Y) (W Lane & Son) h 602
Lauder av (York Twp) jr (W Lane & Son) r 6 Penhale dr (Etob) (Wm
Lane & Son) h 386 Ossington av ;ar hlpr CNR h 40 Harvie av emp
Eauipment Mfg Co r 35 Glenbrook av (Nth Y) slsmn Tor Motor Car r
16 Kirkland blvd (Nth Y) b Son (Wm Lane) asphalt paving 386
Ossingon av ^ S suprvsr Candn Natl Inst for the Blind a 172 Booth
av -Vi ! h 34 Frankish av •Ifc R millwright Hinde & Dauch r 45
Badger ow -Vi iot W emp Belyea Bros h 4 Speers av (Wstn) -Y ne
emp J F Hartz Co r 10 Kings Pk blvd [(EY) Beauty Salon (John G
Lane) 3, 1695 Jane [Nth Y) 5ty Store (Sam Lane) 113 Lambton av
(York Twp) er John emp Barclay Hotel r 1853 Danforth avenue uray
Geo head gdnr Mt Pleasant Cemetery a 198 Merton .na r 65 Wolcott
av (Scar) new wtr uPR r 34 Gillespie av r Frances h (rear) 2642
Yonge stenog Macdonald & Macintosh r 31 Alameda av (York Twp)
Ted mach h 728 Shaw see aiso Laing, Leng & Long ham H
underwriter Mutual Life h 98 Braemore gdns i lab United Co-
Operatives of Ont h 1060 greenwood av (EY) lide (wid Alfred A) h 90
Dinnick cres J (wid Dr M W) r J, 350 St Clair av w s J Mrs asst supt
Hillcrest Convalescent Bosp r 47 Austin terr np Booth Brick h 5
Heslop dr (Etob) G slsmn Burns Bros &Denton h 78 Harper av emp
Stein-Hall Ltd r 130 River rose chef Bassils Rest h 132 Wychwood av
d h 567 Prince Edward dr n (Etob) i M p c Tor Pol Dept h 34
Greensides av ■ir r 6 Hornell (Etob) emp Moffats r 9 Elmlea av
(Etob) ■ir G h 11 Millbank av (Fst H) -ir K emp Laura Second r 11
Millbank av (Fst H) ^r S supt Cresswell- Pomeroy h 1300 Northmen
dr (Lakeview) er Shop (Wm Lang) 52 Mimico av (Mim) rice (wid J
oseph) h 27 Northview av (Scar) ■ ice dom r 615 Vesta dr (Fst H) 'ce
ins North American Ins r 6, 3792 Bathurst (Nth Y) "l bfklyr Hardy
Constn h 30 Eden pi W pres Broulan Reef Mines Ltd h 475 Lake -
hore rd (Mim) "S ,ia cash Simpsons r 53 Endean av :^e (wid JosePh)
h 310 Sackville ’b Frank Nagle mgr draperies 392 Spadina rd S
Specialty Co Ltd S G Lang pres, W G Lang n 3ef> treas lamps &
shades 69 Sherbourne ntney tchr Central Tech Schl h 200 Divadale ir
(Leas) -- W emp Stand Paving Ltd h 45 Rhydwen av Js™) 7,1, A Pres
Keystone Investments Ltd h 249 \Lyttpn blvd ' i (wid Wm J) h 144
Langley av ['-/t* r 198 Main n (Wstn) pfd G night mgr Granite Club r
90 Walmsley blvd (wid Chas) h 402 Wellesley t real est 110, 331 Bay
r 37 Lauder av •MLang, Michener & Cranston) h 9 Baker av , (Lang,
Michener & Cranston) h 414 1 icseU Hill rd (Fst H) \ \\ 14 5 Byng av
(Scar) y drftsmn Dept of Lands & Forests (Ont) - 1 1 Oneida av
(Algonquin Island) LANG --Donald elect Candn Comstock r 317
Whitmore av (York Twp) --Donna H elk Eatons r 604 Windermere av
—Dorothy compt opr Builders’ Flooring & Millwork r 124
Westmoreland av — - Douglas r 166 Beech av — E Margt research
asst Connaught Med Research Lab r 249 Lytton blvd --Edith (wid W
R) h 29 Oriole gdns --Edna E mgrss Woman’s Bakery (2062 Queen e)
h 47 Brentcliffe rd (Leas) — Edwd h 278 Major --Eleanor medical
research U of T h 9 Washington avenue — Elwood r 75 King (Wstn) -
-Emil hlpr Elco Ltd r 63 Gould --Emily Mrs h 28, 162 Huron --Emmy
Mrs hrdrssr Vincent & Tony’s Beauty Salon r 74 Watson av --Eric
foremn Metal Art res Scarboro Junction — Felix (Office & Shop
Equipment Co) h 17 Cranbrooke av --Felix L engineer h 602 Hillsdale
av e --Florence (wid Wm) r 44 Glendonwynne rd --Francis prntr
Maclean-Hunter Publishing h 4, 134 Midland av (Scar) --Frank
trucker Brisko Bros h 68 Dagmar av --Frank R emp Frigidaire
Products r 59^ Logan av — Fredk G elk Bd of Educ h 8, 197
Wellesley e — Fredk G sec-treas Lang & Jolley Co Ltd h 92 Hillcrest
av (Nth Y) --Fredk G vehiclemn C P Exp h 817 Coxwell av (E Y) — G
Ross traffic suprvsr Howell Forwarding h 416 Runnymede rd — Geo r
276 Crawford —Geo elk Imp Bank r 801 A St Clair av w — Geo
constn wkr Shell Oil Service Stn r 89 Avenue road --Geo mech Smith
Bros Auto Parts r 46 Raglan av (York Twp) --Geo A r 27 Tiverton av
— Geo W studt r 249 Lytton blvd — Georgia Mrs elk Dom Bank r 87
Scollard — Gerald r 52 Deloraine av --Gerald emp Ont Hydro h 129
Parliament --Gladwin emp Palmatier Service Stn r 557 Atlas av —
Gordon research Ferranti Electric h 46 Amsterdam av (E Y) —
Gordon trk drvr Weston Music & Radio Store res R R 3 Weston —
Gordon S elect engineer Cohn Chemicals h 92 Rykert cres (Leas) --H
Murray tchr Lawrence Park Coll Inst h 207 Haddington av (Nth Y) —
Harold limb mkr Sunnybrook Hosp h 485 Main (E Y) — Harold J elk
Ford Motor Co h 4 Caithness av --Harry (Victoria Fur Co) — Harry
furrier h 39 Rains av --Harry H asst engineer C N Tel h 604
Windermere avenue --Harvey lino opr Hunter Printing h 82 Bowie av
(York Twp) — Heather elk Dom of Can Genl Ins r 125 Woodrow blvd
s (Scar) —Herbt (Sample Shoes) h 355A Eglinton av e — Herbt N
sub foremn Westeel Products h 4. Hargrove Lane (Etob) — Hilda M
conveyancer Danl D Stokal r 291 Caledonia rd --Hilliard slsmn Harry
L McKee — Hulda r 657 Merton — Iain W slsmn Rootes Motors (Can)
h 302, 308 The Kingsway n (Etob) --Inga emp Bank of N S r 411
Roselawn av — Irving C engineer Silverwood’s r 122 Chester av —
Isabel (wid Norman)h 20 Scarboro Beach blvd --J Florence r 279
Lyttpn blvd — J Victor chem engineer W C Hardesty Co h 126
Queens av (Mim) — Jack (Maple Ridge Farms) res Newmarket —
Jack r 4 Rose av — Jack carp r 291 Caledonia rd (York Twp) --Jack
emp Frigidaire Products r 74 Westwood av (E Y) ‘--Jas r 55 Bleecker
—Jas jr r 53 Cambridge av —Jas r 76 Ivy av --Jas r 65^ Jarvis --Jas
chief estates mgr Tor Genl Trusts h 17 Hillhurst blvd — Jas sheet
metal man Prentice Heating & Appliances h 15 Brenton (E Y) --Jas B
stkpr Supreme Aluminum Industries h 1U1 Hasiam vsear) — Jas M h
2, ±716 Kingston rd (Scar) --Jas W trk drvr Scar Twp h 166 Byng av
(Scar) — Jean r 10, 153 Wellesley e — Jean E typist Meteorological
Serv r 42 Pinewood avenue — Jean M stenog United Co-operatives r
70 Tower dr (Scar) --John r 613 Logan av — John (El-Mocambo
Tavern) h 70 Gilgorm rd (Fst H) --John elect maint Tor Elevators res
Scar Bluffs --John emp Margaret’s Television r 21 Amroth av — John
emp Atlas Chem r 4 Rose av — John mach Pendrith Co h 16
Battenberg av --John mech r 1539 Dufferin --John plmbr h 251 Nairn
av (York Twp) --John radio techn Candn Arsenals h 16 Crestland av
(E Y) --John wtchmn Granite Club h 46 Raglan av (York Twp) — John
F mgr technical sis Nuodex Products h 108 Wolverleigh blvd --John F
R r 11 Millbank av (Fst H) — Joseph emp Smith Bros h 57
Beaconsfield av --Joseph rubber wkr Dunlop Tires h 1724A St Clair
av w --Joseph staff mgr Prudential Ins h Bldg 7, Apt 7, 281 Sheppard
av e (Nth Y) --Joseph H private office 400, 68 Yonge h 311, 755
Avenue rd n --Joseph J pres Lang & Jolley Co Ltd h 7 Hoyle av —
Josephine Mrs emp Dunlop Tire r 83 Dagmar av — Julia (wid John) h
233| Windermere av (Swan) — June stenog Henry Barber, Mapp &
Mapp r 1060 Greenwood av (E Y) --Karl solderer Roden Silversmiths
h 156 Windermere av (Swan) --Keith prntr h 214 Monarch Pk av —
Kenneth A emp O’Keefe’s Brewery h 11, 470 Roncesvalles av —Kong
r 103 Walton — Lawrence emp Stand Leather Coh 304 Fairlawn
avenue — Leila Mrs slsldy Darling Wear r 4 Caithness av — Lena r 16
Bain av — Leo pdlr h 36 Beatrice — Leona stenog r 17 Strathcona av
— Leonard h 97 Jones av --Leslie r 928 Dundas e --Leslie servicemn
Capital Television r 25 Glebe_ holme blvd _ Alphabetical, LANG —
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