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COMMENTARY

CLINICAL ASSESSMENT OF SCAPULAR POSITIONING IN


PATIENTS WITH SHOULDER PAIN:
STATE OF THE ART
Jo Nijs, PhD, MSc, MT, PT,
a
Nathalie Roussel, PT, MT,
b
Filip Struyf, PT,
c
Sarah Mottram, MSc,
d
and Romain Meeusen, PhD, PT
e
I
t is widely recognized that the ability to position the
scapula at rest and during movements/tasks (scapular
positioning) is essential for optimal upper limb func-
tion.
1,2
Scapular positioning should be optimal in relation to
both the thorax and the humerus. In relation to the humerus,
optimal positioning is essential for appropriate positioning
of the glenoid, which in turn guarantees mobility and
stability of the glenohumeral joint.
The simultaneous movement of the scapula and the
glenohumeral joint is referred to as the scapulohumeral
rhythm. A natural kinematic rhythm exists between gleno-
humeral abduction and scapular upward rotation. According
to de Groot,
3
the mean glenohumeral-to-scapular rotation
ratio varied between 2.3 and 3.6 across different studies.
The first phase of shoulder abduction (b608 and the final
408 of adduction) is characterized by a large glenohumeral-
to-scapular ratio
4
; the scapula makes small movements to
position the glenoid adequately in relation to the humerus.
The first phase is called the dsetting phase,T during which the
scapula contributes very little to the range of motion.
5
During the second phase of shoulder abduction/adduction,
the mean glenohumeral-to-scapular ratio in healthy should-
ers is 2.4.
4
Faulty positioning of the scapula during
movement is characterized by forward tilting and/or an
abnormal kinematic rhythm between glenohumeral abduc-
tion and scapular upward rotation.
The muscular system is the major contributor to
scapular positioning both at rest and during functional
tasks. In the case of altered activity (delayed firing,
inefficient recruitment, or increased tension and consequent
shortening) of scapular muscles, scapular positioning is
likely to become abnormal. Inappropriate control of
scapular positioning has frequently been linked to shoulder
and neck disorders.
6-9
Moreover, scientific evidence
supporting abnormal scapular positioning in patients with
shoulder impingement syndrome,
2
symptoms of shoulder
impingement,
10,11
atraumatic shoulder instability,
12
multi-
directional shoulder joint instability,
13
and shoulder pain
after neck dissection in patients with cancer
14,15
is
accumulating. One study has shown that physiotherapy
(primarily exercise therapy targeting the scapulothoracic
muscles) was superior over no treatment in patients with
subacromial impingement syndrome.
16
Many strategies for the assessment of scapular position-
ing are described in the scientific literature. However, most
of these strategies apply expensive and specialized equip-
ment (laboratory methods), making their applicability in
clinical practice nearly impossible. From a clinical
perspective, guidelines for a reliable and valid assessment
of faulty scapular positioning in patients with shoulder
pain are essentially lacking. There is a need to develop
simple clinical indicators to allow clinicians to assess
scapular kinematic behavior accurately.
2,5
These tests
69
a
Assistant Professor, Division of Musculoskeletal Physiother-
apy, Department of Health Sciences, University College Antwerp,
Belgium; Assistant Professor, Department of Human Physiology
and Sports Medicine, Faculty of Physical Education and Physi-
otherapy, Vrije Universiteit Brussel, Belgium.
b
Teacher, Division of Musculoskeletal Physiotherapy, Depart-
ment of Health Sciences, University College Antwerp, Belgium.
c
Teacher, Division of Musculoskeletal Physiotherapy, Depart-
ment of Health Sciences, University College Antwerp, Belgium;
Research Fellow, Department of Human Physiology and Sports
Medicine, Faculty of Physical Education and Physiotherapy, Vrije
Universiteit Brussel, Belgium.
d
Founding Director, Kinetic Control, Ludlow, Shropshire,
United Kingdom.
e
Professor and department head, Department of Human
Physiology and Sports Medicine, Faculty of Physical Education
and Physiotherapy, Vrije Universiteit Brussel, Belgium.
Submit requests for reprints to: Jo Nijs, PhD, MSc, MT, PT,
Campus HIKE, Departement G, Hogeschool Antwerpen, Van
Aertselaerstraat 31, B-2170 Merksem, Belgium
(e-mail: j.nijs@ha.be).
Paper submitted May 22, 2006; in revised form August 8, 2006;
accepted August 24, 2006.
0161-4754/$32.00
Copyright D 2007 by National University of Health Sciences.
doi:10.1016/j.jmpt.2006.11.012
should be affordable, easy to perform, reliable, valid, and
responsive to change.
The present article provides an overview of the clinical
examination of scapular positioning in patients with
shoulder pain. First, an overview of the observation of
scapular positioning is provided. The outline should enable
clinicians to identify faulty scapular positioning at rest and
during movement. Second, an overview of the literature on
clinical tests for the assessment of scapular positioning at
rest and during movement is provided. The published data
addressing the clinimetric properties of the tests is pre-
sented, and suggestions for future research are provided.
OVERVIEW OF SCAPULAR POSITIONING
Observation of Static and Dynamic Scapular Positioning
Observation of resting scapular position should be
performed in the frontal and sagittal view, with the patient
positioning both arms relaxed beside their body. At present,
there is no consensus about the optimum resting scapular
position; further study is warranted.
1
From the available
literature, it can be concluded that the scapula (or the
scapular plane) makes an angle of 308 in respect to the
frontal plane,
3
the medial border of the scapula is positioned
parallel to the spine (ie, the spinous processes of the thoracal
spine),
17
the upper edge of the scapula should be located
at the second or third thoracic vertebra (Th), the inferior
angle at Th7-9, and the scapula of the dominant side is
positioned lower and further away from the spine in com-
parison to the nondominant side.
17
In addition, the inferior
angle and medial border of the scapula should be flat against
the chest wall,
1
the scapula should be positioned midway
between medial and lateral rotation and midway between
elevation and depression, and clinicians should be aware
of potential asymmetric scapular positioning patterns
(although minor differences are considered normal in
respect to hand dominance).
dScapular wingingT is often seen in patients with shoulder
dysfunctions. It is important to make a distinction between
dtrue wingingT and dpseudowinging.T True winging (medial
border winging) is characteristic by an inefficient serratus
anterior muscle (in some cases related to long thoracic nerve
palsy) or spinal accessory nerve involvement. The latter
might be a mononeuritis of the spinal accessory nerve or a
consequence of neck dissection in head and neck cancer
patients. In either case, it is characterized by a painless
weakness of the trapezius muscle that results in slight
limitation of active arm elevation and lateral gliding
with concomitant lateral rotation of the scapula.
15
Pseudo-
winging is characterized by a prominent inferior angle
and indicates forward tilting of the scapula. It is often
associated with downward rotation (ie, the scapula adopts a
protracted and downwardly rotated position). Scapular
winging (pseudowinging) is likely to increase anterior
tipping of the scapula during humeral elevation in the
scapular plane. Patients with (symptoms of) shoulder
impingement syndrome, on average, have been shown to
move the scapula toward a more anteriorly tipped position
during humeral elevation in the scapular plane in comparison
with asymptomatic subjects.
10,18
This pattern of faulty
scapular dynamics may be related to a decreased action
of the serratus anterior and lower trapezius muscle and
would place the anterior acromion in closer proximity to the
rotator cuff tendons and increase the potential for subacro-
mial impingement.
10
Scapular winging might be related to and/or be more
pronounced by poor posture characterized by anterior
positioning of the head and shoulders. Indeed, evidence
supportive of a relationship between posture, pectoralis
minor muscle length, and scapular malpositioning has been
provided.
19
A short pectoralis minor muscle length was
related to increased scapular internal rotation and decreased
scapular posterior tilting during arm elevation. Thoracic
hyperkyphosis in sitting alters dynamic scapular position-
ing: the acromion will be positioned lower, leading to
diminished subacromial space
8
and consequent increased
impingement risks.
20
The observation that a slouched sitting
posture decreases posterior tipping and lateral rotation of the
scapula during humeral elevation
20
supports this view.
Contrary to this, other researchers were unable to find
conclusive evidence supportive of interactions between
scapular posture and subacromial impingement syndrome
21
and shoulder overuse injuries.
22
We conclude that clinicians
should be aware of the potential influence of (scapular)
posture on shoulder and scapula kinematics.
This brings us to the observation of dynamic scapular
positioning. To assess the kinematic rhythm between
glenohumeral abduction and scapular upward rotation,
Fig 1. The measurement of the distance between the posterior
border of the acromion and the table surface with the patient
relaxed.
70
Journal of Manipulative and Physiological Therapeutics Nijs et al
January 2007 Scapular Positioning in Shoulder Pain
clinicians observe scapular positioning during movement of
the shoulder girdle (eg, shoulder abduction in the coronal
plane). However, studies examining the reliability or
validity of the observation of dynamic scapular positioning
are essentially lacking. In absence of guidelines supported
by research data of direct relevance to clinical practice,
clinicians might consider the following issues. For a single
shoulder girdle and for a constant movement velocity, the
kinematic rhythm between glenohumeral abduction and
scapular upward rotation does not appear to vary from
1 testing session to another, but left-right differences are
considered normal.
4
Thus, clinicians should try to make sure
that their patients perform shoulder abductions at the same
velocity when observations of the dynamic scapular
positioning pattern are performed. For interpretation of the
scapular rhythm, clinicians can apply the movement pattern
as described in the introduction section. Shoulder patients
with a capsular pattern (capsular restrictions of joint
mobility) typically present with the scapula contributing a
great deal to the range of motion in the first part of shoulder
abduction.
5,23
The addition of weights during shoulder
movements has been suggested as a method to increase or
reveal faulty scapular positioning patterns.
7
MEASUREMENT OF STATIC SCAPULAR POSITIONING
The measurement of the distance between the posterior
border of the acromion and the table was first described by
Host.
6
The patient is positioned supine and instructed to
relax. In this position, the assessor measures the distance
between the posterior border of the acromion and the table
bilaterally (measured vertically with a tape measure as
displayed in Fig 1). Afterward, this procedure can be
repeated with the patient actively retracting both shoulders.
To achieve active bilateral shoulder retraction, the patient is
instructed to actively move both shoulders toward the table
surface. This measurement might reflect pectoralis muscle
length or even forward tilting.
The measurement of the distance between the posterior
border of the acromion and the table displayed excellent
interobserver reliability in patients with shoulder pain: the
intraclass coefficients (ICCs) varied between 0.88 and 0.94
(relaxed) and between 0.91 and 0.92 for the measurement
with active shoulder retraction.
24
When comparing the
mean values between the symptomatic and the asympto-
matic side, nearly identical results were obtained (F72 mm
for the relaxed position and F48 mm for the retracted
position).
24
This finding is in accordance with the observa-
tions of Hebert et al,
2
who found that in patients with
primary shoulder impingement syndrome, the 3-dimen-
sional scapular behavior does not differ between the
symptomatic and the asymptomatic side, but, in fact, both
shoulders differ in respect to scapular behavior when
compared with healthy subjects. If the measurement of
the distance between the posterior border of the acromion
and the table generates clinically important data, then the
test should be able to differentiate between patients with
primary shoulder impingement syndrome and healthy
controls. However, recently published data question the
validity of the measurement: it correlated poorly with the
pectoralis minor muscle length measured using a Flock
of Birds electromagnetic capture system.
19
The measure-
ment performed with the patient in supine position may be
biased because of the influence of the table on scapular
position (the table is likely to dsetT the scapula in a correct
position) and the alteration on the effect of gravity.
19
Therefore, it is suggested to perform the same measurement
with the patient in standing position (ie, measure the
horizontal distance between the posterior border of the
acromion and the wall). This measurement has been found
to display fair to good interobserver agreement (unpublished
data) in a mixed sample of symptomatic and asymptomatic
subjects, but validity data are currently unavailable. Further
study is warranted.
The measurement of the distance from the medial
scapular border to the fourth thoracic spinous process was
also first described by Host.
6
The test is performed in
standing position with the patient instructed to stay relaxed.
Both the fourth thoracic spinous process and the medial
scapular border are identified through palpation. Previous
research provided evidence supportive of the use of scapular
skin surface palpation as a component of clinical tests:
surface palpation of scapular position has been shown to be
a valid method for determining the actual location of the
scapula.
25
The distance between both anatomical landmarks
is measured in the horizontal plane using a tape measure.
Again, this procedure is repeated with the patient actively
retracting both shoulders (Fig 2). To achieve active bilateral
Fig 2. The measurement of the distance from the medial scapular
border to the fourth thoracic spinous with active bilateral shoulder
retraction.
Nijs et al Journal of Manipulative and Physiological Therapeutics
Scapular Positioning in Shoulder Pain Volume 30, Number 1
71
shoulder retraction, the patient is instructed to actively move
both shoulders backward.
Together with the initial description of the test, Host
6
provided a guideline for the interpretation of the test
outcome: in normal subjects, the distance from the medial
scapular border to the fourth thoracic spinous process
should be 5.08 cm. However, the guideline was based on
clinical observations rather than on experimental data. In
our study, we found mean values of 6.15 cm (symptomatic
side) and 6.00 cm (asymptomatic side).
24
The interobserver
reliability for the test was too low (the ICCs varied between
0.50 and 0.79) when performed with the patient relaxed. A
fair interobserver reliability was found (ICCs between 0.70
and 0.80) when the distance from the medial scapular
border to the fourth thoracic spinous process with active
bilateral shoulder retraction was measured. Others measured
the distance from the medial scapular border to the third
(not the fourth) thoracic spinous process. Evidence suppor-
tive of intraobserver reliability (ICC = 0.91) and criterion
validity (the clinical test outcome correlated with the
measurement performed on a radiography; r = 0.57) has
been provided.
26
The scapular distance is another test for the assessment of
resting scapular position. The distance between the angulus
acromion and the third thoracic spinous process is measured
to determine the scapular distance. The distance is normal-
ized by dividing it by the scapular length (ie, the distance
between spina scapula, localized at the margo medialis, and
the angulus acromion).
27
The measurement of both the
scapular distance (ICC = 0.94) and the scapular length
(ICC = 0.85) has been shown to have good to excellent
intraobserver reliability in asymptomatic subjects.
27
Like-
wise, the interobserver reliability in asymptomatic subjects
was excellent (ICC between 0.91 and 0.92).
23
The scapular
distance was not related to muscle strength of the pectoralis
minor or trapezius muscle.
27
Finally, the Lennie test has been postulated to measure
scapular resting position and has been found to have fair
intertester reliability and criterion validity in relation to
radiographic measurements.
17
Despite its undoubted value
for biometric research, the Lennie test is time-consuming
and complex, limiting its applicability in clinical practice.
For these reasons, the interested reader is referred to the
original manuscript.
Measurement of Dynamic Scapular Positioning
The lateral scapular slide test (LSST) was designed by
Kibler
28
to assess scapular asymmetry under varying loads.
The test performance has been repeatedly presented in the
scientific literature. The interested readers are therefore
referred to the relevant literature.
28-30
For interpreting the
LSST, a side-to-side difference of 1.5 cm was originally
suggested for the diagnosis of shoulder dysfunction.
28
Experimental data, however, indicated that a side-to-side
difference of 1.5 cm is frequently observed in asymptomatic
subjects, and that the threshold value of 1.5 cm has a low
specificity in diagnosing shoulder dysfunctions.
29,30
In
addition, the outcome of the LSSTwas unable to differentiate
between the symptomatic and asymptomatic side.
24
For all
3 tests positions, we observed an acceptable to good
interobserver reliability (ICC N 0.70). These results are
not in accordance with 2 previous studies that found ICC
values of 0.79, 0.45, and 0.57 for subjects with shoulder
impairments
29
and even lower ICC values for asymptomatic
subjects (ranging between 0.18 and 0.69)
23
and for
junior elite swimmers (ranging between 0.20 and 0.82)
31
(Table 1). It is difficult to explain the differences in
findings among various studies. Addressing the validity,
Table 1. Overview of the reliability data of clinical tests for the assessment of scapular positioning
Test
Peterson
et al
26
DiVeta
et al
27
Gibson
et al
23
Nijs
et al
24
Odom
et al
29
McKenna
et al
31
Watson
et al
32
Johnson
et al
33
Posterior acromion,
table relaxed
0.88-0.94
Posterior acromion,
table retraction
0.92-0.91
Medial scapular border,
T4 relaxed
0.50-0.79
Medial scapular border,
T4 retraction
0.70-0.80
Medial scapular
border, T3
.91
a
LSST position 1 0.82-0.96 0.79 0.65-0.74
LSST position 2 0.85-0.95 0.45 0.79-0.82
LSST position 3 0.70-0.85 0.57 0.20-0.57
Scapular distance 0.94
a
0.91-0.92
Scapula upward
rotation
0.81-0.94
a
0.89-0.96
a
Unless indicated (superscript baQ), intraclass correlation coefficients are provided to indicate the interobserver reliability.
72
Journal of Manipulative and Physiological Therapeutics Nijs et al
January 2007 Scapular Positioning in Shoulder Pain
the LSST data correlated strongly with radiographic com-
parison (r N 0.90).
28
The measurement of scapula upward rotation is a clinical
assessment procedure that uses 2 Plurimeter-V gravity
references inclinometers.
32
The patient is assessed in a
relaxed, balanced standing position. The relative contribu-
tion of the glenohumeral joint and the scapula to total
shoulder abduction within the coronal plane is assessed.
One inclinometer is Velcro-taped perpendicular to the
humeral shaft, just above the humeral epicondyle. The
resting position of the humerus is recorded. Next, the patient
is instructed to perform shoulder abduction with full
elbow extension, neutral wrist flexion/extension, and with
the thumb leading to ensure vertical alignment of the
inclinometer. The patient is asked to stop at 458, 908, 1358,
and at their maximum achievable range. At each of the
abduction positions, the scapula upward rotation is meas-
ured with a second inclinometer, manually aligned along the
scapular spine, and the patient is asked if any pain is present.
Twenty-six patients with a variety of shoulder pathology
were tested twice during a single testing session by a single
tester. The overall intrarater reliability was very good (ICC =
0.88) and ranged from 0.81 to 0.94 across different
testing positions.
32
A similar test using a Pro 360 digital protractor
inclinometer, modified using 2 wooden locator rods, has
been described previously for the clinical assessment of
scapula upward rotation in patients with shoulder pain.
33
The
2-dimensional measurements of scapula upward rotation
showed good to excellent intrarater reliability (ICCs varied
from 0.89 to 0.96) and good validity in comparison with a
magnetic tracking device (r varied from 0.59 to 0.92).
33
Given the fact that the muscular system is the major
contributor to scapular positioning, it should be noted that
clinicians should not assess scapular positioning without
assessing scapular muscle function by use of specific,
reliable, and valid manual muscle testing. This issue is
beyond the scope of the present review, and the readers are
consequently referred to the available scientific literature,
such as the article by Michener et al.
34
DISCUSSION
There is evidence suggesting that scapular positioning is
abnormal in patients with shoulder impingement syndrome,
2
symptoms of impingement,
10,11
atraumatic shoulder insta-
bility,
12
multidirectional shoulder joint instability,
13
and
shoulder pain after neck dissection in cancer patients.
14,15
As no longitudinal study has yet been reported, it is not
known if abnormal scapular positioning is a cause or
consequence of shoulder pain or a secondary phenomenon
caused by shoulder pain. In addition to the evidence from
case-control studies, physiotherapy targeting the scapulo-
thoracic muscles was found effective in patients with
subacromial impingement syndrome,
16
and conservative
treatments consisting of stretching and strengthening exer-
cises targeting scapulothoracic muscles were able to
improve scapular positioning in asymptomatic subjects.
35,36
Although it seems plausible, there is currently no evidence
to show that assessing scapular positioning helps with the
diagnosis or treatment of patients with shoulder pain. Future
studies should address this issue.
Clinicians are able to incorporate the available research
data in their daily practice by interpreting the observation of
static and dynamic scapular positioning pattern, including
scapular rhythm, in relation to the relevant research data.
From the literature overview presented here, it can be
concluded that clinicians can use reliable tests for the
assessment of both static and dynamic scapular positioning
in patients with shoulder disorders. For the measurement of
static scapular positioning, the measurement of the distance
between the posterior border of the acromion and the table,
the measurement of the distance from the medial scapular
border to the third thoracic spinous process, and the assess-
ment of the dscapular distanceT have been identified as
reliable tests. In addition, the measurement of the distance
fromthe medial scapular border to the fourth thoracic spinous
process, when performed with the patients shoulders in
active shoulder retraction, has been shown to have sufficient
interobserver reliability. Apart from the study supporting the
criterion validity of the assessment of the distance from the
medial scapular border to the third thoracic spinous process,
26
the authors of the present article are unaware of studies
addressing the validity of clinical tests for the assessment of
static scapular positioning in patients with shoulder disorders.
A clinical test should be both reliable and valid. If a test is not
valid, then it is useless, regardless of whether it is reliable. For
the measurement of dynamic scapular positioning, studies
examining the reliability of the LSST were inconclusive, but
the test was shown to have criterion validity. The measure-
ment of scapula upward rotation was found reliable (intra-
rater) and valid. The clinical relevance of the tests has yet to
be shown.
Further study of the clinimetric properties of the tests is
warranted, especially for establishing normative data, for
examining validity, responsiveness to change, and clinical
importance. Indeed, normative data are essential to enable
clinicians to interpret outcomes of tests for an individual
patient. Studies examining the validity of a combination of
tests, rather than a single test, for shoulder dysfunction or
pathology are warranted. For studying the clinical impor-
tance of the tests, cross-sectional (examining the associa-
tions between the tests and symptom severity or disability),
comparative (examining differences in scapular positioning
between patients with shoulder pain and asymptomatic
subjects), and prospective studies (examining whether the
tests outcome is of prognostic value for patients with
shoulder pain) are warranted.
It should be noted that assessment of scapular positioning
should be used in conjunction with objective measurements
Nijs et al Journal of Manipulative and Physiological Therapeutics
Scapular Positioning in Shoulder Pain Volume 30, Number 1
73
of scapular muscle performance. Indeed, the muscular
system is the major contributor to scapular positioning,
implicating that altered activity (delayed firing, decreased
strength, or increased tension and consequent shortening) of
scapular muscles prohibits normal scapular positioning.
This was evidenced by a study showing decreased serratus
anterior muscle activity in patients with shoulder impinge-
ment syndrome relative to controls.
10
Delayed timing and
inefficient recruitment are important because it may prohibit
generating enough tension to enhance normal scapular
positioning. Evaluation of scapular muscle (eg, serratus
anterior, lower trapezius) performance with a handheld
dynamometer has been found reliable.
34
CONCLUSION
Scientific evidence supporting a role for faulty scapular
positioning in patients with various shoulder disorders are
accumulating. From a clinical point of view, it seems
essential to have the skills to assess static and dynamic
scapular positioning. Based on biometric and kinematic
studies, an overview of the observation of static and
dynamic scapular positioning pattern in patients with
shoulder pain was provided. At this point, clinicians can
use reliable clinical tests for the assessment of both static
and dynamic scapular positioning in patients with shoulder
pain, and some data supportive of the validity of the tests
have been provided.
ACKNOWLEDGMENT
Nathalie Roussel and Filip Struyf are financially sup-
ported by a research grant (bA study examining static and
dynamic preventive factors for injuries in dancersQ) from the
Department of Health Sciences, University College Ant-
werp, Belgium. Filip Struyf is financially supported by a
PhD grant (G826) from the Department of Health Sciences,
University College Antwerp, Belgium.
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Practical Applications
! Evidence supporting abnormal scapular positioning
in shoulder impingement syndrome and shoulder
instability are cumulating.
! Clinicians should interpret the observation of static
and dynamic scapular positioning patterns in
relation to the relevant research data.
! Clinicians can use reliable tests for the assessment
of both static and dynamic scapular positioning in
patients with shoulder disorders.
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Journal of Manipulative and Physiological Therapeutics Nijs et al
January 2007 Scapular Positioning in Shoulder Pain
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