Scapular Muscle Performance in

1 Scapular Muscle Performance in Individuals with Lateral Epicondylalgia
3 Joseph M. Day, PT, PhD, OCS, CIMT

4 Department of Physical Therapy, University of South Alabama, Mobile, AL
5
6 Heather Bush, PhD
7 Department of Biostatistics, University of Kentucky, Lexington, KY
Downloaded from www.jospt.org at Lock Haven University on January 20, 2015. For personal use only. No other uses without permission.
8
9 Arthur J. Nitz, PT, PhD, ECS, OCS
10 Division of Physical Therapy, University of Kentucky, Lexington, KY
11
12 Tim L. Uhl, ATC, PT, PhD, FNATA
13 Division of Athletic Training, University of Kentucky, Lexington, KY
Copyright ${year} Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
14
15 The study protocol was approved by the University of Kentuckys Institutional Review Board.
16
17 The authors certify that they have no affiliations with or financial involvement in any
18 organization or entity with a direct financial interest in the subject matter or materials discussed
Journal of Orthopaedic & Sports Physical Therapy
19 in the article.
20
21 Corresponding Author: Joseph M. Day, PhD, MSPT, OCS, CIMT
22 Assistant Professor
23 University of South Alabama
24 Pat Capps Covey College of Allied Health Professions
25 Department of Physical Therapy
26 HAHN 2011
27 5721 USA Drive N.
28 Mobile, AL 36688-0002
29 Phone: (251) 445-9330
30 Fax: (251) 445-9238
31 josephday@southalabama.edu
32
33
34 Study Design: Descriptive, laboratory based, cross sectional study.
35 Objectives: To describe scapular musculature strength, endurance, and change in thickness in
36 individuals with unilateral lateral epicondylalgia (LE) compared to their uninvolved limb and the
37 corresponding limb of a matched comparison group.
38 Background: Reported poor long term outcomes for the non-surgical management of
39 individuals with LE suggests a less than optimal rehabilitation process. Knowledge of scapular
40 muscle function in a working population of individuals with LE may help further refine
41 conservative management of this condition.
42 Methods: Twenty eight patients with symptomatic LE and 28 controls matched by age and gender were
43 recruited to participate in the study. Strength of the middle trapezius (MT), lower trapezius (LT), and
44 serratus anterior (SA) was measured with a hand held dynamometer. A scapular isometric muscle
45 endurance task was performed in prone. Changes in muscle thickness of the SA and LT were measured
46 with ultrasound imaging (USI). ANOVA models were used to determine within and between group
47 differences.
48 Results: The involved side of the group with LE had significantly lower values for MT strength
49 (P=.031), SA strength (P<.001), LT strength (P= .006), endurance (P = .003), and change in SA
50 thickness (P = .028) when compared to the corresponding limb of the control group. The
51 involved side of the group with LE had significantly lower strength of the LT (P = .023) and SA
52 (P = .016) when compared to their uninvolved limb, however these differences were small and of
53 potentially limited clinical significance.
54 Conclusion: When compared to a matched comparison group, there were impairments of
55 scapular musculature strength and endurance in patients with LE, suggesting that the scapular
56 musculature should be assessed and potentially treated in this population. Cause and effect
57 cannot be established as the weakness of the scapular musculature could be a result of LE.
60
59
58
Key Words: serratus anterior, strength, trapezius, ultrasound imaging
61 Lateral epicondylalgia (LE), originally described as lawn tennis elbow,36 is characterized
62 by pain in the region of the lateral epicondyle of the humerus.29 While a high percentage of
63 recreational tennis players develop the pathology,20 LE is also a common condition with
64 significant negative consequence in the general population. The prevalence of LE has been
65 reported to be as high as 12.2% in occupational settings.46 In addition, 27% of patients with LE

66 report severe limitations with activities of daily living,52 such as lifting bags or boxes.53
67 The effectiveness of conservative treatment approaches remains less than optimal
68 secondary to high recurrence rates. Cortisone injections are effective in pain management but
69 only up to 8 weeks from the time of the injection.11, 22, 40, 41 A recent study reported between a
70 29% to 38% recurrence rate in individuals receiving conservative treatment.10 In the only study
71 with a 2 year follow after physiotherapy intervention, more than half the patients reported
72 ongoing pain and functional lost, secondary to return of LE symptoms.38
73 It has been suggested that assessing scapular muscle impairments should be an important
74 component of in the evaluation of individuals with LE. Lucado et al30 recently reported
75 diminished lower trapezius (LT) muscle strength in a group of female tennis players with LE
76 compared to a matched group of asymptomatic female tennis players.30 In a healthy population
77 of throwing athletes, fatigue of the scapular stabilizers has been shown to produce alterations of
78 elbow kinematics,25, 29 implying that scapular muscle fatigue could predispose individuals to
79 throwing injuries at the elbow region. Another investigator reported that induced pain at the
80 upper trapezius (UT) produces an increase in wrist extensor electromyographic (EMG) signal
81 intensity in healthy individuals,45 which could potentially lead to an overuse injury, such as LE,
82 at the elbow. Anecdotally, our clinical experience suggest that overuse of the UT and underuse
83 of the LT, may result in UT pain.

84 Although it appears that scapular musculature strength and endurance has a potential
85 influence on patients with LE, data are limited to a population of female tennis players30 and a
86 case report.5 Because there is a high prevalence of LE in the working population,46 and most
87 studies report that males will develop the condition just as frequently as females,21 there is a need
88 to investigate scapular muscle strength in a more inclusive group of patients. In addition,

89 although the study by Hidetomo et al,25 implies that fatigued scapular muscles may contribute to
90 elbow pathology, no studies have directly investigated scapular muscle endurance on patients
91 with LE.
92 The primary purpose of this study was to compare scapular musculature strength,
93 endurance, and change in thickness from resting to contraction, as measured by RUSI, of patients
94 with unilateral LE with the corresponding limb of a matched comparison group. The secondary
95 purpose was to compare the same variables between the involved and uninvolved limb of the
96 group with unilateral LE.
97
98 METHODS
99 Participants
100 A sample of convenience of 28 patients with unilateral LE (15 females, 13 males) and 28
101 age and gender matched controls agreed to participate in the study (FIGURE 1). Patients were
102 recruited from 1 of 5 outpatient rehabilitation clinics in central Kentucky and controls were
103 recruited from the central Kentucky region.
104 Patients were recruited to participate in this study if they: were seeking medical attention
105 from a therapist at 1 of 5 outpatient clinics, reported a primary symptom of unilateral lateral
106 elbow pain, were between the ages of 18 and 65, and if they presented with at least 2 positive
107 clinical tests for LE. The clinical tests performed for symptoms of LE were: palpation of the
108 lateral epicondyle and the associated common wrist extensor unit, passive stretching of the wrist
109 extensors (Mills sign), strength assessment with a hand grip dynamometer, manual resistance
110 against maximal volitional contraction (MVIC) of the wrist extensors (Cozens sign), and
111 manual resistance applied to extension of the middle digit (Maudsleys test).8, 18 The clinical tests
112 were considered positive if there was reproduction of pain at the lateral epicondyle.
113 Patients were excluded from the study if they reported any of the following as part of
114 their medical history: peripheral neuropathy secondary to diabetes, progressive neurological
115 disorder, cancer, infection in spine or upper extremity, upper motor neurological disorder (eg,
116 stroke, traumatic brain injury), or fibromyalgia. Patients were also excluded if they had surgery
117 on the upper quadrant within the previous 6 months or if they had a score of less than 10% on the
118 quick version of the disabilities of the arm, shoulder, and hand questionnaire (QuickDASH). This
119 last exclusion was based on a previous study indicating that DASH scores typically range from 0
120 to 10.1% in the general population.26
121 For those in the comparison group, the tests for LE were performed and the disability
122 score was also recorded during the initial intake. Potentials participants for the control group
123 were excluded from the study if they reported: any current or history of upper quadrant
124 musculoskeletal conditions within the past 6 months, had trunk or upper quadrant surgery in the
125 previous 6 months, tested positive for any of the tests for LE, or had a disability score of greater
126 than 10% as measured by the QuickDASH.26
127 To be included in the study, all potential participants had to demonstrate the ability to
128 tolerate and maintain the instructed test positions. All participants gave their written, informed
129 consent to take part in the study and the study protocol was approved by the University of
130 Kentuckys Institutional Review Board. Participants rights were protected.

131 Procedures
132 All measures of scapular muscle strength were performed by the primary investigator
133 who was not blinded to the participants group assignment or to the knowledge of the involved
134 limb for the patients with LE. Before the first dependent variable was measured, a baseline
135 resting heart rate was obtained. For the purpose of this study, heart rate was assessed to examine
136 the arousal factors related to the muscle performance tests. A 5 minute rest period was given to
137 the participant after each group of dependent variables was measured to allow time for
138 recovery.42, 48 Heart rate was measured immediately after data collection of each group of
139 dependent variables and then after the allotted 5 minute rest to ensure the participant had
140 recovered to baseline values. Extra rest was given if the participant did not return to baseline
141 values.
142 Microsoft Excel 2007 was used to generate a random list of numbers to determine the
143 order for scapular muscle testing (thickness measures with USI, hand held dynamometer (HHD)
144 testing, and endurance testing). The order of each outcome measure within each scapular test and
145 the first limb tested (dominant versus non-dominant) was also determined from a random list of
146 numbers.
147 Strength Testing Prior to the study, a Nicholas manual muscle HHD (model 01160, Lafayette
148 Instrument Co.) was calibrated by placing weights of 15lbs (6.8kg), 25lbs (11.3kg), and 50lbs
149 (22.7kg) on the dynamometer and then calculating the absolute difference between the expected
150 value of the weight and observed value on the dynamometer. The largest difference between
151 measures was .14kgs.
152 Previously established methods for measuring strength of scapular muscles using a HHD
153 report good between day intrarater reliability (ICC = .75 to .97),7, 33 however, no validity data
154 have been established for measuring MT or SA strength. MVICs for both the left and right upper
155 extremities were assessed. Each patient performed a practice trial on the affected upper extremity
156 for each test before data were recorded. The investigator instructed the participant to slowly push
157 into the dynamometer and increase force production to the maximum force by the end of the 5
158 seconds used for testing. The MVIC was recorded by the assessor. The following muscles were
159 tested: MT, LT, and SA.33 Three trials were performed for each muscle and the average value of
160 the 3 trials was used for statistical analysis.
161 The SA was tested by positioning the participant supine with the shoulder and elbow
162 flexed to 90. The dynamometer was placed on the olecranon of the elbow. The patient was
163 asked to protract the scapula and resistance was given along the humeral axis (FIGURE 2). For
164 the MT, the participant was positioned prone with the elbow flexed and shoulder held to 90
165 abduction. The dynamometer was placed on the spine of the scapula, in between the acromion
166 and the medial superior border of the scapula. The participant was instructed to lift the arm
167 upward, while resistance with the dynamometer was being applied in the lateral direction
168 (FIGURE 2). Finally, the LT was tested by positioning the participant prone with arm extended
169 and shoulder held to 135 of abduction. The dynamometer was placed in the middle of the
170 scapula, in between the acromion and the medial superior border. While the participant lifted
171 his/her arm upward, resistance with the dynamometer was applied in the lateral and superior
172 direction (FIGURE 2). For both the MT and LT, the investigator was positioned on the opposite
173 side of the limb to be tested.16, 33
174 Scapular Muscle Endurance Lying prone, the participant was asked to place their forehead on
175 the contralateral limb. The limb to be tested was passively positioned to 135 of shoulder
176 abduction. The test position was chosen because EMG analysis demonstrates that the LT, MT,
177 UT, and SA, are active in this position.9, 15, 37 A cuff weight of 1% of the participants body
178 weight (to the nearest 0.23 kg) was strapped just proximal to the elbow. A level was positioned
179 at a height parallel to the trunk and at 135 of shoulder horizontal abduction. The participant was
180 then asked to elevate and hold their arm to the established level for as long possible (FIGURE
181 3). The test was terminated when the participant voluntarily lowered their upper extremity or if
182 the distal radius was no longer contacting the level.27, 49 A single trial was performed and its
183 value used for statistical analysis.
184 Muscle thickness The primary investigator received formal training through The Burwin Institute
185 of Diagnostic Medical Ultrasound. Data were collected on 18 of the 28 available patients and
186 controls. Participants were not preferentially chosen by the researchers but were instead based
187 on the participants time constraints or equipment availability.
188 Methods for positioning and landmark identification were based on a recently published
189 reliability study.12 Participants were seated comfortably on a chair without a back rest. A neutral
190 spine posture was established by instructing the participant to sit upright and then slump 3 times.
191 After the third movement, the researcher asked the participant to rest comfortably between the 2
192 motions.31 The participant was then asked to place their forearm on an adjustable table that was
193 adjusted to place the arm at 85 of shoulder elevation and 45shoulder horizontal adduction
194 (FIGURE 4). Horizontal adduction was maintained throughout testing by placing a mark for arm
195 position which was continuously monitored during testing. A felt tip pen was used to mark the
196 level of the thoracic spine that coincided with the inferior angle of the scapula so that the
197 ultrasound transducer could be placed in a consistent position for all measures.39 Additionally a
198 mark was placed on the lateral torso at the level of the inferior angle of the scapula between the
199 pectoralis major and the latissimus dorsi indicating the location of the serratus anterior.4
200 Computerized ultrasonography (General Electric LOGIQ e 2008) was used by the
201 primary investigator to produce a cross sectional image of the LT and SA at rest and during arm
202 lifting (FIGURE 4). In B mode, a 40 mm 8-MHz linear transducer was placed transversely over
203 the mark previously made to identify the LT and vertically along the mark used to identify the
204 SA. A 2.27 kg (5 lbs) weight was strapped around the arm of each participant, just proximal to
205 the elbow. This load was found to be equivalent to holding a 0.91 kg (2 lbs) weight in the hand.
206 In pilot work performed prior to this investigation, a load of 0.91kg held in the hand was
207 observed to produce a consistent visual increase in muscle thickness of the LT and SA, when
208 compared to their resting state.
209 Initially, an image was taken with the muscle in a resting state. Second, the participant
210 was asked to elevate their arm with the elbow extended to 0, shoulder horizontally adducted to
211 45 from the frontal plane, shoulder flexed at 90, and shoulder externally rotated (thumb up
212 position). This position is known to produce high SA and moderate LT activity15, 16, 37 and was
213 chosen over shoulder protraction because elevation of the arm in the scapular plane is a more
214 functional position. The arm was then held for approximately 2 seconds to allow an ultrasound
215 image to be taken. A second resting and lifting image was subsequently taken for the same arm
216 and muscle using the same procedure. The same procedure was then followed to test the same
217 muscle on the contralateral limb. The entire procedure was then repeated for testing of the other
218 muscle for both limbs.
219 Muscle thickness measurements were performed using procedures based on a previous
220 study.12 Two images were taken of each muscle for both the relaxed condition and contracted
221 condition.28 Linear measurements of LT thickness were made 2 cm from the spinous process
222 landmark.39 Linear measurements of SA thickness were made from the inside border of the rib
223 up to the inside edge of the muscle border. The rib served as the on-screen anatomical reference.
224 The average of 5 thickness measures, spanning the width of the rib, was recorded.12 Prior to
225 statistical analysis, the measures obtained from the 2 images of the same person, condition, and
226 muscle were averaged together for one data point.
227 Two patients were excluded from the SA USI analysis secondary to poor image quality
228 taken during data collection. Therefore, a total of 18 (11 female, 7 males) patients were included
229 for the LT USI data analysis and 16 (10 female, 6 male) for the SA USI data analysis. Eighteen
230 controls were matched by age and gender to the patient population. The average of 2 measures
231 of LT absolute thickness was the dependent measure in one model and the SA absolute thickness
232 was the other dependent measure examined.

233 Statistical Analyses
234 An a priori power analysis was completed based on previous measures of scapular
235 muscle strength which indicated that a minimal detectable change (MDC) of 3.6 kg can identify
236 true difference between tests for the SA. An effect size of .60 was calculated by dividing the
237 MDC value of 3.6 kg by the reported standard deviation of 6.0 kg for the SA. The SA effect size
238 of .60 was chosen for the power analysis because this value was smaller than the effect sizes of
239 the LT and MT.33 Using an effect size of .60, a sample size of 28 participants in each group
240 provided a true power of 86% conducted at alpha = .05.
241 Statistical Analysis was performed using SPSS version 20 for windows (SPSS Inc.
242 Chicago, IL). Descriptive data for mechanism of injury and duration of symptoms was
243 calculated for patients with LE. In addition, descriptive data were calculated for the QuickDASH
244 and all dependent variables for both groups. To evaluate similarity between the control and
245 patient groups, paired t tests were used to compare age, body mass, height, and shoulder activity
246 levels.
247 Between group comparisons for Strength and Endurance variables For this comparison, the
248 involved limb of the patient group was compared to the matched limb, based on arm dominance
249 of the patient, of the control group. For each dependent measure (MT strength, LT strength, SA
250 strength, and endurance) separate linear mixed models were run using 1 within-group factor,
251 group (patient or control), and 1 between-group factor, dominance (whether the involved limb
252 from the patient group and matched limb from the control group was dominant or non-
253 dominant). Dominance of the analyzed limb had to be considered for both groups as statistical
254 difference due to limb dominance has previously been established for healthy individuals.
255 Finally, because our control participants were not matched according to height and weight, these
256 2 variables were used as covariates in each model. A P-value of .05 was set a priori. In the case
257 of an interaction, a least significant difference (LSD) post hoc analysis was performed. If no
258 significant interaction was present, the model was run again without the interaction so that the
259 other factors could be interpreted.
260
261 Between group comparisons for Muscle Thickness variables Similar to the above strength and
262 endurance analysis, only one limb was analyzed per group (the involved limb of the patient
263 group and the matched limb, based on arm dominance of the patient, of the control group). The
264 other element of the primary purpose was to investigate the differences in muscle thickness
265 (contracting thickness minus resting thickness) of the LT and SA between patients with LE and
266 controls. Separate linear mixed models were used using 2 within-group factors (1) condition (rest
267 and contraction) and (2) group (patient and control). Dominance (whether the involved limb
268 from the patient group and matched limb from the control group was dominant or non-dominant)
269 was used as a between-group factor. Height and weight were also used as covariates in each
270 model. A P-value of .05 was set a priori. In the case of an interaction, a LSD post hoc analysis
271 was performed. If no significant interaction was present, the model was run again without the
272 interaction so that the rest of the factors could be interpreted.

273
274 Within group comparisons (LE group) for Strength and Endurance variables For each
275 dependent measure (MT strength, LT strength, SA strength, and endurance) separate linear
276 mixed models were run using 1 within-group factor, limb (uninvolved or involved), and 1
277 between-group factor, dominance (dominant involved or non-dominant involved). A P-value of

278 .05 was set a priori. In the case of an interaction, a LSD post hoc analysis was performed. If no
279 significant interaction was present, the model was run again without the interaction so that the
280 other factors could be interpreted.
281
282 Within group comparisons (LE group) for muscle thickness variables The other element of the
283 secondary purpose was to investigate the differences in muscle thickness of the LT and SA
284 between involved and uninvolved limbs. Separate linear mixed models were used using 2 within-
285 group factors (1) condition (rest and contraction), and (2) limb (uninvolved and involved).
286 Dominance (dominant involved or non-dominant involved) was used as a between-group factor.
287 A P-value of .05 was set a priori. In the case of an interaction, a - LSD post hoc analysis was
288 performed. If no significant interaction was present, the model was run again without the
289 interaction so that the other factors could be interpreted.
290
291 RESULTS
292 Age, height, and shoulder activity levels were not statistically different between groups.
293 Those with LE were found to have higher QuickDASH scores (P<.001) than those in the control
294 group (TABLES 1 and 2). Among patients with LE, 79% reported an insidious onset, whereas
295 21% reported a specific event that caused the injury. In patients with LE the median
296 (interquartile range) duration of symptoms was 12 (8 to 22) weeks and 15 of 28 (53%)
297 participants reported the affected side as their dominant side. The descriptive (unadjusted) data
298 for strength, endurance, and USI measures are provided in TABLES 3, 4, and 5.
299
300 Comparisons between groups

301 Strength There was no significant interactions between group and dominance when accounting
302 for the participants height and weight (P>.503). There were no differences in limb dominance
303 regardless of group (P>.535). However, the control group was stronger than the LE group for the
304 LT (P=.006), MT (P=.031), and SA (P <.001; FIGURE 5).

305 Endurance Similar to strength, there was no significant interactions between group and
306 dominance when accounting for participants height and weight (P = .775) and there were no
307 differences in limb dominance regardless of group (P = .740). The control group had greater
308 endurance than the LE group (P=.003; FIGURE 6)
309 Muscle Thickness For SA, there was no significant 3 way interaction between muscle type,
310 group, and dominance (P = .11). There was a significant 2 way interaction (P=.028) between SA
311 thickness condition and group when accounting for the participants height and weight. The
312 marginal means indicate that those in the control group had a greater change in SA thickness (1.4
313 mm) relative to patients with LE (0.7 mm; TABLE 6). Post hoc analysis revealed a significant
314 increase in thickness from rest to a contracted condition for the LE (P<.001) and control
315 (P=.015) groups. No significant differences were found between patients with LE and control
316 group for resting SA thickness (P = .919) or contracting thicknesses (P= .248). The statistical
317 analysis for the LT muscle indicates no 3 way (P=.155) or 2 way interaction for group and type
318 (P = .580). There was a significant increase in thickness from rest to a contracted condition
319 regardless of groups (P<.001, TABLE 6).
320
321 LE Involved to Uninvolved Comparison
322 Strength There were no significant interactions between limb and dominance (P >.381). There
323 were no differences in dominance regardless of group (P>.524). In addition, there was no
324 significant difference in involved versus uninvolved muscle strength for the MT (P=.26).
325 However, the involved limb was weaker than the uninvolved limb when measuring SA strength
326 (P =.016) and LT strength (P = .023, FIGURE 7)
327 Endurance Similar to our within group results for strength, there was no interaction between
328 limb and dominance (P = .178) and no differences in dominance regardless of whether the limb
329 was involved or uninvolved (P = .587). There were no differences in endurance times when
330 comparing the uninvolved and involved limbs (Noninvolved = 64 +/- 34 s, Involved = 53 +/- 41
331 s; P=.096).
332 Muscle Thickness For both the SA and LT, there were no significant 3 way interactions between
333 muscle type, limb, and dominance (P >.071) or 2 way interactions between type and limb (P
334 >.444). There was a significant increase in thickness from rest to a contracted condition
335 regardless of group (P<.001) for both muscles (TABLE 7).

336
337 DISCUSSION
338 To our knowledge, this is the first study to investigate scapular muscle characteristics in a
339 general population of patients with LE. Consistent with our primary hypothesis, SA strength, LT
340 strength, MT strength, scapular muscle endurance, and change in SA muscle thickness in patients
341 with LE were significantly less than for the matched comparison group. The findings suggest
342 that therapists should consider factors that impact scapular muscle performance (strength and
343 endurance) in patients with LE.
344 While our results indicated that scapular muscle strength and endurance was impaired in
345 patients with LE compared to matched controls, when comparing the patients involved limb to
346 their uninvolved limb, the differences, although statistically significant and only for SA and LT
347 strength, do not exceed measurement error using a HHD. These 2 findings are consistent with
348 previous cross sectional studies on patients with LE.1, 30 Most closely related to our study,
349 Lucado et al30 found significantly lower LT strength in female tennis players with LE compared
350 to healthy female tennis players. In a second study, Alizadehkhaiyat et al1 assessed isometric
351 strength for select shoulder muscles in patients with LE comparing the results to matched
352 controls and also to the patients uninvolved side. Similar to our study, the authors found that
353 there were deficits in strength when comparing patients with LE to matched controls but no
354 meaningful differences in shoulder strength between the uninvolved and involved limbs.1
355 The current study also demonstrates diminished scapular muscle endurance in patients
356 with LE. There has been very little literature published with which to compare our endurance
357 results. Alizadehkhaiyat et al3 found no significant differences in rotator cuff muscle endurance
358 compared to a control group. The differences in findings between studies may be attributed to the
359 type of endurance task performed. Alizadehkhaiyat et al1 investigated repetitive isotonic
360 shoulder contractions compared to the current study in which sustained isometric contraction was
361 used to measure fatigue. The 2 types of endurance tests physiologically differ. Intramuscular
362 tissue pressure (MTP) increases during sustained isometric contractions and MTP is known to
363 interfere with muscular blood flow.14, 44 The impeded blood flow could result in muscle ischemia
364 thus altering muscle performance.32, 47 Diminished oxygen delivery will accelerate muscle
365 fatigue compared to the isotonic test where the muscle acts as a natural pump for blood flow.
366 Thus, the differences observed in isometric endurance times in the current study, may be a
367 difference in muscle perfusion efficiency between patients with LE and controls.
368 The position of this endurance test, prone shoulder abduction at 135, was chosen by the
369 investigators because it is known to produce a high amount of LT activity.15, 16, 37 However, it
370 could be argued that because other posterior shoulder muscles are also active in this position, the
371 described test may not be a true measure of LT endurance. Therefore, future research is needed
372 to better determine which of the posterior shoulder muscles are most affected by this test
373 position. Previous studies have compared rate of median frequency shifts between muscles to
374 show which muscle is fatigued at a greater rate. 35 Although factors like muscle strength and the
375 contribution of synergistic muscles would have to be considered, comparing rates of median
376 frequency shifts could be used to determine which of the several posterior shoulder muscles are
377 fatiguing the fastest.
378 Our findings have implications to clinical practice. The differences in LT strength (25 N)
379 and SA strength (72 N) between patients with LE and controls meet or exceed the MDC values
380 from previously published data.33 The mean values indicate that the differences are beyond
381 measurement error of the device used. Although MDC values for the described scapular muscle
382 endurance test have never been published, the mean difference between patients with LE and
383 controls are large (31 seconds) and statistically significant. As a result, addressing LT strength,
384 SA strength, as well as scapular muscle endurance should be considered in patients with LE.
385 In contrast to the above finding, there were no measureable differences between patients
386 involved and uninvolved limbs. Because a limb to limb comparison in the clinical setting is often
387 the most convenient approach to assess patients, scapular muscle impairments may be missed.
388 Therefore, to determine the presence of deficits, clinicians should compare strength and
389 endurance findings in patients with LE to normative data, yet to be established.
390 The assessment of scapular muscle strength and endurance is potentially important in
391 patients with LE to provide clinicians with objective information to make a clinical decision as to
392 whether treatment is indicated. Based on this study design, we are unable to definitively
393 determine if treating scapular muscle strength and endurance deficits will improve outcomes in
394 patients with LE. However, Bhatt et al5 reported successful treatment of a 54 year old female
395 with only strengthening exercises targeting the middle and lower trapezius muscles. It has also
396 been reported that after successful remission of pain symptoms, patients previously diagnosed
397 with LE continue to present with shoulder weakness.2 During functional arm motions, kinetic
398 energy is transferred from proximal to more distal segments of the arm. With an impaired ability
399 to stabilize the scapula, increased energy demands are theoretically required of tissues in the
400 distal upper extremity when performing a functional activity.17, 43 Theoretically, the
401 scapulothoracic muscle impairments found in this study could perpetuate the LE or predispose
402 patients to re-injury if left unaddressed.
403 Notwithstanding, the design of this study does not allow for definitive conclusions that
404 scapular muscle weakness is a causative factor for the development of LE. One other possible
405 theory is that lateral epicondyle pain triggers a centrally mediated mechanism resulting in the
406 observed scapular muscle weakness. To that end, muscle inhibition from a regional source of
407 pain has been reported for the quadriceps,19, 51 hamstrings,24 and masseter34 muscles. In addition,
408 pain of the common wrist extensors may cause the patient to use the upper extremity less and in
409 a more guarded range of motion. Over time, disuse would result in decrease in shoulder active
410 range of motion and weakness of the shoulder musculature.
411 Future studies are needed to more completely define the clinical significance of scapular
412 muscle deficits in patients with LE. Because it could be argued that the differences in muscle
413 strength could be a difference solely of scapular and thoracic posture. Future studies should
414 assess the spinal curvature and position of the scapula in both populations and then see if the
415 testing position equally impacts both groups. In addition, it would be interesting to determine if
416 treating scapular muscle deficits will improve both short and long term outcomes in patients with
417 LE. Prospective studies are also warranted to determine if scapular muscle weakness is present
418 prior to the development of LE and if scapular muscle weakness is a potential risk factor for LE.
419 The results of our study highlight that the change in SA thickness from rest to contraction
420 was significantly different between patients with LE and controls, but no differences were found
421 comparing the involved SA with the uninvolved SA. In addition, using this methodology, the
422 change in LT does not appear to behave differently in patients with LE compared to normal
423 controls or when comparing a patients involved LT with the uninvolved LT. Preliminarily, the
424 differences observed between patients with LE and controls for the change scores from rest to
425 contraction is encouraging and warrants further investigation, but there is a number of limitations
426 to the interpretation of USI of muscle actions. 55

427 In the EMG literature, it has been consistently reported that individuals with cervical
428 pain, shoulder pain, and postural deficits demonstrate diminished SA activity compared to
429 controls, while results for LT activity have been inconsistent.13, 23, 50, 54 Overall, the findings in
430 our study and in previous studies may indicate that individuals with upper quarter pain or
431 postural deficits often present with diminished SA function. Future research should examine
432 whether the observed SA deficits are a result of a specific pathology or are a predetermining
433 factor in the development of conditions like cervical, shoulder, and lateral elbow pain.
434 Limitations
435 Despite efforts made to eliminate extraneous factors influencing the results of our study,
436 there are several limitations that should be considered. First, all measures of scapular muscle
437 strength were performed by the primary investigator and the investigator was not blinded to
438 neither group assignment nor the involved limb in patients with LE, thus introducing potential
439 investigator bias. In addition, it has been demonstrated by EMG analysis that the SA strength test
440 used in this study does not isolate SA function, and therefore the test may be better regarded as a
441 indicating scapulothoracic protraction weakness.33 Second, a submaximal endurance task as
442 completed in this study is thought to be influenced by an individuals ability to self-regulate.
443 Self-regulation can cause an individual to override a feeling of fatigue, through the central
444 nervous system, to sustain an endurance task.6 Therefore, it is possible that individuals with LE
445 have a diminished ability to self-regulate, thus reducing the endurance times. Third, because the
446 patients have pain and no systematic differences were detected between limbs, it is possible that
447 pain is a central drive factor for MVIC, endurance, and muscle thickness measures. Fourth, the
448 power analysis suggested that 28 participants be recruited for this study but only 18 were
449 available for the USI assessment. Finally, it is difficult to ascertain the exact meaning of change
450 in muscle thickness using USI because of the inconsistent findings reported by previous authors
451 looking at the correlations between change in muscle thickness and muscle activity.55
452
453 CONCLUSION
454 Patients with LE demonstrated significant weakness of the LT and SA as well as a

455 significant decline in scapular muscle endurance when compared to an asymptomatic control
456 group. Assessment of SA strength, LT strength, and posterior shoulder muscle endurance is
457 recommended in patients with LE. Future studies should seek to investigate the short and long
458 term efficacy of treating scapular muscle deficits as part of a comprehensive treatment program
459 for individuals with LE.

460
461 KEY POINTS
462
463 Findings: Patients with LE demonstrated significant weakness of the LT and SA as well as a
464 significant decline in scapular muscle endurance when compared to an asymptomatic control
465 group. The differences between a patients uninvolved and involved limb were not clinically
466 meaningful.
467 Implications: Scapular muscle strength and endurance deficits should be considered in the
468 management of patients with lateral elbow pain.
469 Caution: This was a cross-sectional study of a small group of patients with LE; therefore, the
470 data do not indicate a causal relationship between LE and scapular muscle weakness.
471
472 Acknowledgements: We thank the therapist and staff at Kentucky Hand and Physical Therapy
473 for their participation in patient recruitment and Dr. Joe Stemple for his editorial comments on
474 the manuscript.

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623
624
625
626
Variables Patients with LE Controls

(n=28) (n=28)
Age, y 46.8 +/- 8.8 46.1 +/- 9.2
Body mass, kg* 83.8 +/- 15.9 73.3 +/- 13.3
Height, m 1.70 +/- 0.10 1.71 +/- 0.09

Shoulder Activity Level (0-20) 10.3 +/- 4.1 10.8 +/- 4.2
QuickDASH, %* 40.6 +/- 16.3 2.6 +/- 3.5
627 TABLE 1: Characteristics of participants with Strength and Endurance data.

628 Abbreviations: LE, lateral epicondylalgia; QuickDASH, quick version of the disability of the arm, shoulder, and
629 hand questionnaire. Values are means +/- standard deviations. Shoulder Activity Level is based on a scale from 0
630 (no shoulder activity) to 20 (highest shoulder activity). * Indicates a significant difference between groups (P<.05)
631
632
633
Variables Patients with LE Controls

(n=18) (n=18)
Age, y 48.2 +/- 9.8 48.0 +/- 10.2
Body mass, kg* 83.9 +/- 17.3 69.9 +/- 13.0

Height, m 1.67 +/- 0.11 1.71 +/- 0.08
Shoulder Activity Level (0-10) 10.5 +/- 3.9 11.5 +/- 4.0
QuickDASH, %* 38.4 +/- 16.8 2.0 +/- 3.1
634 TABLE 2: Characteristics of participants with Muscle Thickness data.

635 Abbreviation: LE, lateral epicondylalgia; QuickDASH, quick version of the disability of the arm, shoulder, and hand
636 questionnaire. Values are means +/- standard deviations. Shoulder Activity Level is based on a scale from 0 (no
637 shoulder activity) to 20 (highest shoulder activity). *Indicates a significant difference between groups (P<.05)
638
639
640
641
Measure Patients with LE (n=28) Controls (n=28)
Uninvolved Involved Matched limb
LT Strength (N) 123 +/- 25 109 +/- 37 125 +/- 29
MT Strength (N) 146 +/- 27 139 +/- 38 149 +/- 25
SA Strength (N) 205 +/- 51 185 +/- 66 244 +/- 49

Endurance (s) 64 +/- 41 54 +/- 34 85 +/- 34
642 TABLE 3: Scapular muscle strength and endurance. Data are unadjusted means +/- standard deviations.
643 Unadjusted means are raw data and do not consider arm dominance, weight, and height.
644 Abbreviations: LE, lateral epicondylalgia; LT, lower trapezius; MT, middle trapezius; SA, serratus anterior. Values
645 displayed for the control group represents a matched limb to a patient with LE. Matching was based on arm
646 dominance.
647
648
Muscle
Patients with LE Control
Relaxed Contracted Difference Relaxed Contracted Difference
Serratus Anterior 5.9 +/-2.4 6.6 +/- 2.3 0.7 4.9 +/- 1.6 6.3 +/- 1.6 1.4
Lower Trapezius 5.1 +/- 2.0 6.5 +/- 2.1 1.4 4.3 +/- 2.0 5.6 +/- 2.0 1.3
649 TABLE 4: Scapular Muscle Thickness. Data are unadjusted means +/- standard deviations in mm. Unadjusted
650 means are raw data and do not consider arm dominance, weight, and height. Abbreviation: LE, lateral
651 epicondylalgia. Values displayed for the control group represents a matched limb to a patient with LE. Matching
652 was based on arm dominance. N=16 for the serratus anterior, N=18 for the lower trapezius.
653
654
Muscle
Uninvolved Limb Involved Limb
Serratus Anterior 5.9 +/- 2.3 6.6 +/- 2.5 0.7 5.9 +/- 2.4 6.6 +/- 2.3 0.7
Lower Trapezius 5.3 +/- 2.0 6.4 +/- 2.3 1.1 5.1 +/- 2.0 6.5 +/- 2.1 1.4
655 TABLE 5: Within Group Comparison of Scapular Muscle Thickness for the group with lateral
656 epicondylalgia. Data are unadjusted means +/- SD in mm. Unadjusted means are raw data and do not consider arm
657 dominance. N=16 for the serratus anterior, N=18 for the lower trapezius.
658
659
Muscle
Patients with LE Controls
Serratus Anterior 5.4 +/1.6 6.1 +/- 2.0 0.7* 5.4 +/- 1.2 6.8 +/ 1.6 1.4*
Lower Trapezius 4.6 +/1.7 6.0 +/- 1.9 1.4* 4.8 +/- 1.4 6.1 +/-1.7 1.3*
660 TABLE 6: Between Group Comparison of Marginal Mean Values of Scapular Muscle Thickness.
661 Data are adjusted means +/- standard deviations values in mm when considering arm dominance, height, and weight.
662 Values displayed for the control group represents a matched limb to a patient with LE. Matching was based on arm
663 dominance. N=16 for the serratus anterior, N=18 for the lower trapezius.
664 Abbreviation: LE, lateral epicondylalgia.
665 * Indicates a significant increase from rest to contraction.
666 Indicates that there was a significant 2 way interaction (P=.028) between serratus anterior thickness condition and
667 group, showing that the controls had a greater change in thickness with contraction.
668
669
Muscle
Uninvolved Limb Involved Limb
SerratusAnterior 5.9 +/- 2.3 6.6 +/- 2.5 1.7* 5.9 +/- 2.5 6.8 +/- 2.9 0.9*
Lower Trapezius 5.1 +/- 2.1 6.5 +/- 2.3 1.4* 5.0 +/- 1.9 6.4 +/- 2.7 1.4*
670 TABLE 7: Within Group Comparison of Marginal Mean Values of Scapular Muscle Thickness for the group
671 with lateral epicondylalgia. Marginal Means +/- standard deviations in mm are the adjusted mean values when
672 also considering arm dominance. N=16 for the serratus anterior, N=18 for the lower trapezius. * Indicates a
673 significant increase from rest to contraction (P<.001).
674
675
676
677
678
679
680
681
682
683
684 Patients Controls

685
686 FIGURE 1: Participant recruitment and testing flow diagram. Disability scores were based on the Quick
687 version of the Disability of the Arm, Shoulder and Hand questionnaire. Abbreviations: LT, lower trapezius; SA,
688 serratus anterior; USI, ultrasound imaging
689
698
697
696
695
694
693
692
691
690
C
B
A = Middle Trapezius, B= Lower Trapezius, C= Serratus Anterior

FIGURE 2: Positioning for strength testing using the hand held dynamometer.
FIGURE 3: Scapular Muscle Endurance Testing.
placement for ultrasound imaging of the lower trapezius12

FIGURE 4A: Resting position of the participant and probe
FIGURE 4B: Resting position of the participant and probe

placement for ultrasound imaging of the serratus anterior12
*
*
*
FIGURE 5: Scapular Muscle Strength. Data are marginal means +/- standard deviations (adjusted for height and
weight). Measures represent the involved limb of the patients with LE and a matched limb of the control group. The
matched limb of the control group was based on arm dominance. Abbreviations: LE, lateral epicondylalgia; LT,
lower trapezius; MT, middle trapezius; SA, serratus anterior. Data: LT Control = 130 +/- 29 N; LT Patient = 104 +/-
33 N; MT Control = 152 +/- 22 N; MT Patient = 135 +/- 33 N; SA Control = 250 +/- 50 N; SA Patient = 178 +/- 62
N. * Indicates a significant difference between groups (P<.01).
*
FIGURE 6: Scapular Muscle Endurance. Data are marginal means +/- standard deviations (adjusted for height
and weight). The comparison is between the involved limb of the patients with LE and a matched limb of the control
group. The matched limb of the control group was based on arm dominance. Control = 84 +/- 35 s, Involved = 53
+/- 37 s. * Indicates a significant difference between groups (P<.01).
*
*
FIGURE 7: Scapular Muscle Strength for Patients with LE. Data are means +/- standard deviations.
Abbreviations: LE, lateral epicondylalgia; LT, lower trapezius; MT, middle trapezius; SA, serratus anterior. Data:
LT Noninvolved = 122 +/- 25 N; LT Involved = 109 +/- 37 N; MT Noninvolved = 145 +/- 28 N; MT Involved = 138
+/- 38 N; SA Noninvolved = 204 +/- 51 N; SA Involved = 184 +/- 67 N * Indicates a significant difference between
groups (P<.01).

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1 Scapular Muscle Performance in Individuals with Lateral Epicondylalgia

3 Joseph M. Day, PT, PhD, OCS, CIMT

35 Objectives: To describe scapular musculature strength, endurance, and change in thickness in

37 corresponding limb of a matched comparison group.

41 conservative management of this condition.

53 potentially limited clinical significance.

54 Conclusion: When compared to a matched comparison group, there were impairments of

65 reported to be as high as 12.2% in occupational settings.46 In addition, 27% of patients with LE

67 The effectiveness of conservative treatment approaches remains less than optimal

72 ongoing pain and functional lost, secondary to return of LE symptoms.38

76 compared to a matched group of asymptomatic female tennis players.30 In a healthy population

83 of the LT, may result in UT pain.

88 to investigate scapular muscle strength in a more inclusive group of patients. In addition,

96 group with unilateral LE.

103 recruited from the central Kentucky region.

120 to 10.1% in the general population.26

126 than 10% as measured by the QuickDASH.26

130 Kentuckys Institutional Review Board. Participants rights were protected.

151 measures was .14kgs.

160 the 3 trials was used for statistical analysis.

173 side of the limb to be tested.16, 33

183 value used for statistical analysis.

187 on the participants time constraints or equipment availability.

208 compared to their resting state.

218 muscle for both limbs.

226 muscle were averaged together for one data point.

232 was the other dependent measure examined.

233 Statistical Analyses

240 provided a true power of 86% conducted at alpha = .05.

259 other factors could be interpreted.

272 interaction so that the rest of the factors could be interpreted.

277 between-group factor, dominance (dominant involved or non-dominant involved). A P-value of

280 other factors could be interpreted.

289 interaction so that the other factors could be interpreted.

300 Comparisons between groups

304 LT (P=.006), MT (P=.031), and SA (P <.001; FIGURE 5).

308 endurance than the LE group (P=.003; FIGURE 6)

319 regardless of groups (P<.001, TABLE 6).

321 LE Involved to Uninvolved Comparison

326 (P =.016) and LT strength (P = .023, FIGURE 7)

335 regardless of group (P<.001) for both muscles (TABLE 7).

343 endurance) in patients with LE.

377 fatiguing the fastest.

389 endurance findings in patients with LE to normative data, yet to be established.

402 patients to re-injury if left unaddressed.

410 range of motion and weakness of the shoulder musculature.

426 to the interpretation of USI of muscle actions. 55

441 indicating scapulothoracic protraction weakness.33 Second, a submaximal endurance task as

442 completed in this study is thought to be influenced by an individuals ability to self-regulate.

454 Patients with LE demonstrated significant weakness of the LT and SA as well as a

459 for individuals with LE.

468 management of patients with lateral elbow pain.

474 the manuscript.

493 and Scapular Muscles. J Sport Rehabil. 2012;Technical Notes 3:1-5.

530 R Coll Gen Pract. 1986;36:464-465.

620 Ther. 2010;14:367-374.

Variables Patients with LE Controls

Body mass, kg* 83.8 +/- 15.9 73.3 +/- 13.3

Height, m 1.70 +/- 0.10 1.71 +/- 0.09

QuickDASH, %* 40.6 +/- 16.3 2.6 +/- 3.5

627 TABLE 1: Characteristics of participants with Strength and Endurance data.

Variables Patients with LE Controls

Body mass, kg* 83.9 +/- 17.3 69.9 +/- 13.0