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Humeral Head to Greater Tuberosity Angle Study

Completed Research
The greater tuberosity angle: a new predictor for rotator cuff tear
(Humeral Head to Greater Tuberosity Angle Study)


We have often observed that a lateral or high-riding greater tuberosity was associated more with rotator cuff lesions, and have therefore developed an angle that could take into account both first parameters that we have called the humeral head to greater tuberosity angle (HGTA).

Several studies have demonstrated a link between scapula morphology (acromion shape and lateralization, glenoid version) and rotator cuff tears. However, influence of humeral anatomy on such lesions has as yet been poorly investigated. Our hypothesis is that a lateral or high-riding greater tuberosity position relative to the humeral head significantly predisposes to impingement and rotator cuff tear. This position can be determined by a single angle calculated on a plain AP radiograph and has been named the humeral head to greater tuberosity angle (HGTA); a higher angle is associated with a higher occurrence of rotator cuff tear. This angle may be a simple and valuable tool enabling to screen patients and predict those prone to a rotator cuff tear. It could help refine the diagnostic presumption and guide adequate choice of complementary workup and treatment. Moreover, demonstrating this correlation may underline the importance of performing tuberoplasty (correcting the tuberosity protuberance) during surgery in order to correct the angle. Finally, measuring HGTA on postoperative radiographs could also offer a quality control for surgeons, not only after rotator cuff surgery, but also in other situations such as quality of greater tuberosity reduction in trauma surgery.

The humeral head to greater tuberosity angle is calculated on a plain x-ray.


The primary objective of this study is to determine the correlation between HGTA and rotator cuff tears, and determine a threshold value above which such lesions are more prevalent.

Secondary objectives of the study are:

  • To determine whether patient characteristics, (such as age, gender, time since onset of symptoms, rotator cuff tear size and pattern) correlate with this angle.
  • To determine the inter- and intra-observer reliability of the measurement.


This is a prospective observational comparative study.

Study Procedure

All participants meeting inclusion criteria will undergo a standard AP shoulder radiograph with the arm in neutral rotation, which is usually part of the initial workup. They will undergo the same assessment, and the rest of the consultation and treatment decision will not be influenced by their enrolment in the study. There will be no patient participation required beyond the initial workup. All patients will be studied in the same way; any deviation from the assigned treatment will be reported as a deviation from Protocol. There will be two groups: the “Cuff Tear” group (patients) regrouping patients with non-traumatic rotator cuff tear and the “Control” group (any other shoulder condition).

Inclusion Criteria

“Cuff Tear” Group

  • Any patient presenting with a non-traumatic rotator cuff tear
  • Patients who present with a recent x-ray of their shoulder
  • Patients who are capable of and have given informed consent participate

“Control” Group

  • Patients presenting with any other shoulder condition and with no rotator cuff tear (instability, early to moderate primary osteoarthritis)
  • Patients who present with a recent x-ray of their shoulder
  • Patients who are capable of and have given informed consent to their participation in the Study

Exclusion Criteria

“Cuff Tear” Group

  • Patients with a traumatic rotator cuff tear
  • Any previous history of shoulder surgery or trauma
  • Patients with shoulder instability or hyperlaxity
  • Patients with systemic inflammatory diseases which may predispose to rotator cuff tear
  • Patients who present without a recent x-ray of their shoulder

“Control” Group

  • Any previous history of rotator cuff tendinitis or tear
  • Any condition that may significantly alter the shape of the proximal humerus, (post-traumatic, advanced osteoarthritis, congenital deformity)
  • Patients who present without a recent x-ray of their shoulder

Ethics and Governance

Approved by Northern Sydney Local Health District Human Research Ethics Committee to be undertaken at Royal North Shore Hospital.
HREC reference LNR/15/HAWKE/112 and SSA reference LNRSSA/15/HAWKE/123.


Our study recruited 71 patients (33 patients, 38 controls). Mean GTA value was 72.5° (range, 67.6°-79.2°) in patients and 65.2° (range, 55.8°-70.5°) for controls (P < .001). A value above 70° resulted in 93-fold higher odds of detecting a rotator cuff tear (P < .001). Interobserver and intraobserver reliability were high. Based on these results, we conclude that GT morphology is implicated in rotator cuff tears. The GTA can be thought of as a reliable radiographic marker, with more than 70° being highly predictive in detecting such lesions.


  • Bigliani L U, Morrison D S, April E W. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:228.
  • Nyffeler R W, Werner C M, Sukthankar A, Schmid M R, Gerber C. Association of a large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg (Am) 2006; 88 (4): 800-5.
  • Moor BK, Bouaicha S, Rothenfluh DA, Sukthankar A, Gerber C. Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint?: A radiological study of the critical shoulder angle. Bone Joint J.2013 Jul;95-B(7):935-41.
  • Tétreault P, Krueger A, Zurakowski D, Gerber C. Glenoid version and rotator cuff tears. J Orthop Res. 2004 Jan;22(1):202-7.


Lead Investigator:

Dr Greg Cunningham
SSRI 2015 Fellow


August 2015


August 2016


Cunningham G, Nicodème-Paulin E, Smith MM, Holzer N, Cass B and Young AA. The greater tuberosity angle: a new predictor for rotator cuff tear. Journal of Shoulder and Elbow Surgery 2018 – Volume 27 –p 1415-1421


18th EFFORT Congress, Vienna, AUSTRIA, June 2017


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