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Clinical Assessment of Scapular Positioning in Patients with Shoulder Pain: State of the Art

  • Jo Nijs
    Correspondence
    Submit requests for reprints to: Jo Nijs, PhD, MSc, MT, PT, Campus HIKE, Departement G, Hogeschool Antwerpen, Van Aertselaerstraat 31, B-2170 Merksem, Belgium.
    Affiliations
    Assistant Professor, Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Belgium; Assistant Professor, Department of Human Physiology and Sports Medicine, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Belgium

    Teacher, Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Belgium
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  • Nathalie Roussel
    Affiliations
    Teacher, Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Belgium
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  • Filip Struyf
    Affiliations
    Teacher, Division of Musculoskeletal Physiotherapy, Department 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
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  • Sarah Mottram
    Affiliations
    Founding Director, Kinetic Control, Ludlow, Shropshire, United Kingdom
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  • Romain Meeusen
    Affiliations
    Professor and department head, Department of Human Physiology and Sports Medicine, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Belgium
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      It is widely recognized that the ability to position the scapula at rest and during movements/tasks (scapular positioning) is essential for optimal upper limb function.
      • Mottram SL
      Dynamic stability of the scapula.
      • Hébert LJ
      • Moffet H
      • McFadyen BJ
      • Dionne CE
      Scapular behavior in shoulder impingement syndrome.
      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 glenohumeral abduction and scapular upward rotation. According to de Groot,
      • de Groot J
      The scapulo-humeral rhythm: effects of 2-D roentgen projection.
      the mean glenohumeral-to-scapular rotation ratio varied between 2.3 and 3.6 across different studies. The first phase of shoulder abduction (<60° and the final 40° of adduction) is characterized by a large glenohumeral-to-scapular ratio
      • Sugamoto K
      • Harada T
      • Machida A
      • Inui H
      • Miyamoto T
      • Takeuchi E
      • et al.
      Scapulohumeral rhythm: relationship between motion velocity and rhythm.
      ; the scapula makes small movements to position the glenoid adequately in relation to the humerus. The first phase is called the ‘setting phase,’ during which the scapula contributes very little to the range of motion.
      • Borsa PA
      • Timmons MK
      • Sauers EL
      Scapular positioning patterns during humeral elevation in unimpaired shoulders.
      During the second phase of shoulder abduction/adduction, the mean glenohumeral-to-scapular ratio in healthy shoulders is 2.4.
      • Sugamoto K
      • Harada T
      • Machida A
      • Inui H
      • Miyamoto T
      • Takeuchi E
      • et al.
      Scapulohumeral rhythm: relationship between motion velocity and rhythm.
      Faulty positioning of the scapula during movement is characterized by forward tilting and/or an abnormal kinematic rhythm between glenohumeral abduction 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.
      • Host HH
      Scapular taping in the treatment of anterior shoulder impingement.
      • Schmitt L
      • Snyder-Mackler L
      Role of scapular stabilizers in etiology and treatment of impingement syndrome.
      • Lewis JS
      • Green AS
      • Dekel S
      The aetiology of subacromial impingement syndrome.
      • Ackermann B
      • Adams R
      • Marshall E
      The effect of scapula taping on electromyographic activity and musical performance in professional violinists.
      Moreover, scientific evidence supporting abnormal scapular positioning in patients with shoulder impingement syndrome,
      • Hébert LJ
      • Moffet H
      • McFadyen BJ
      • Dionne CE
      Scapular behavior in shoulder impingement syndrome.
      symptoms of shoulder impingement,
      • Ludewig PM
      • Cook TM
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      • Cools AM
      • Witvrouw EE
      • Declercq GA
      • Danneels LA
      • Cambier DC
      Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms.
      atraumatic shoulder instability,
      • von Eisenhart-Rothe R
      • Matsen FA
      • Eckstein F
      • Vogl T
      • Graichen H
      Pathomechanics in atraumatic shoulder instability: scapula positioning correlates with humeral head centering.
      multidirectional shoulder joint instability,
      • Illyés A
      • Kiss RM
      Kinematic and muscle activity characteristics of multidirectional shoulder joint instability during elevation.
      and shoulder pain after neck dissection in patients with cancer
      • van Wilgen CP
      • Dijkstra PU
      • van der Laan BFAM
      • Plukker JTh
      • Roodenburg JLN
      Shoulder complaints after neck dissection; is the spinal accessory nerve involved?.
      • van Wilgen CP
      Morbidity after neck dissection in head and neck cancer patients. A study describing shoulder and neck complaints, and quality of life. Doctoral dissertation.
      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.
      • Dickens VA
      • Williams JL
      • Bhamra MS
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      Many strategies for the assessment of scapular positioning are described in the scientific literature. However, most of these strategies apply expensive and specialized equipment (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.
      • Hébert LJ
      • Moffet H
      • McFadyen BJ
      • Dionne CE
      Scapular behavior in shoulder impingement syndrome.
      • Borsa PA
      • Timmons MK
      • Sauers EL
      Scapular positioning patterns during humeral elevation in unimpaired shoulders.
      These tests 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 presented, 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.
      • Mottram SL
      Dynamic stability of the scapula.
      From the available literature, it can be concluded that the scapula (or the scapular plane) makes an angle of 30° in respect to the frontal plane,
      • de Groot J
      The scapulo-humeral rhythm: effects of 2-D roentgen projection.
      the medial border of the scapula is positioned parallel to the spine (ie, the spinous processes of the thoracal spine),
      • Sobush DC
      • Simoneau GG
      • Dietz KE
      • Levene JA
      • Grossman RE
      • Smith WB
      The Lennie test for measuring scapula position in healthy young adult females: a reliability and validity study.
      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 comparison to the nondominant side.
      • Sobush DC
      • Simoneau GG
      • Dietz KE
      • Levene JA
      • Grossman RE
      • Smith WB
      The Lennie test for measuring scapula position in healthy young adult females: a reliability and validity study.
      In addition, the inferior angle and medial border of the scapula should be flat against the chest wall,
      • Mottram SL
      Dynamic stability of the scapula.
      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).
      ‘Scapular winging’ is often seen in patients with shoulder dysfunctions. It is important to make a distinction between ‘true winging’ and ‘pseudowinging.’ 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.
      • van Wilgen CP
      Morbidity after neck dissection in head and neck cancer patients. A study describing shoulder and neck complaints, and quality of life. Doctoral dissertation.
      Pseudowinging 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.
      • Ludewig PM
      • Cook TM
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      • Lukasiewicz AC
      • McClure P
      • Michener L
      • et al.
      Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement.
      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 subacromial impingement.
      • Ludewig PM
      • Cook TM
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      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.
      • Borstad JD
      Resting position variables at the shoulder: evidence to support a posture-impairment association.
      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 positioning: the acromion will be positioned lower, leading to diminished subacromial space
      • Lewis JS
      • Green AS
      • Dekel S
      The aetiology of subacromial impingement syndrome.
      and consequent increased impingement risks.
      • Finley MA
      • Lee RY
      Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors.
      The observation that a slouched sitting posture decreases posterior tipping and lateral rotation of the scapula during humeral elevation
      • Finley MA
      • Lee RY
      Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors.
      supports this view. Contrary to this, other researchers were unable to find conclusive evidence supportive of interactions between scapular posture and subacromial impingement syndrome
      • Lewis JS
      • Green A
      • Wright C
      Subacromial impingement syndrome: the role of posture and muscle imbalance.
      and shoulder overuse injuries.
      • Greenfield B
      • Catlin PA
      • Coats PA
      • Green E
      • McDonald JJ
      • North C
      Posture in patients with shoulder overuse injuries and healthy individuals.
      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, 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.
      • Sugamoto K
      • Harada T
      • Machida A
      • Inui H
      • Miyamoto T
      • Takeuchi E
      • et al.
      Scapulohumeral rhythm: relationship between motion velocity and rhythm.
      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.
      • Borsa PA
      • Timmons MK
      • Sauers EL
      Scapular positioning patterns during humeral elevation in unimpaired shoulders.
      • Gibson MH
      • Goebel GV
      • Jordan TM
      • Kegerries S
      • Worrell TW
      A reliability study of measurement techniques to determine static scapular position.
      The addition of weights during shoulder movements has been suggested as a method to increase or reveal faulty scapular positioning patterns.
      • Schmitt L
      • Snyder-Mackler L
      Role of scapular stabilizers in etiology and treatment of impingement syndrome.

      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.
      • Host HH
      Scapular taping in the treatment of anterior shoulder impingement.
      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.
      Figure thumbnail gr1
      Fig 1The measurement of the distance between the posterior border of the acromion and the table surface with the patient relaxed.
      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.
      • Nijs J
      • Roussel N
      • Vermeulen K
      • Souvereyns G
      Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.
      When comparing the mean values between the symptomatic and the asymptomatic side, nearly identical results were obtained (±72 mm for the relaxed position and ±48 mm for the retracted position).
      • Nijs J
      • Roussel N
      • Vermeulen K
      • Souvereyns G
      Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.
      This finding is in accordance with the observations of Hébert et al,
      • Hébert LJ
      • Moffet H
      • McFadyen BJ
      • Dionne CE
      Scapular behavior in shoulder impingement syndrome.
      who found that in patients with primary shoulder impingement syndrome, the 3-dimensional 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.
      • Borstad JD
      Resting position variables at the shoulder: evidence to support a posture-impairment association.
      The measurement 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 ‘set’ the scapula in a correct position) and the alteration on the effect of gravity.
      • Borstad JD
      Resting position variables at the shoulder: evidence to support a posture-impairment association.
      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.
      • Host HH
      Scapular taping in the treatment of anterior shoulder impingement.
      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.
      • Lewis J
      • Green A
      • Reichard Z
      • Wright C
      Scapular position: the validity of skin surface palpation.
      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 shoulder retraction, the patient is instructed to actively move both shoulders backward.
      Figure thumbnail gr2
      Fig 2The measurement of the distance from the medial scapular border to the fourth thoracic spinous with active bilateral shoulder retraction.
      Together with the initial description of the test, Host
      • Host HH
      Scapular taping in the treatment of anterior shoulder impingement.
      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).
      • Nijs J
      • Roussel N
      • Vermeulen K
      • Souvereyns G
      Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.
      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 supportive 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.
      • Peterson DE
      • Blankenship KR
      • Robb JB
      • Walker MJ
      • Bryan JM
      • Stetts DM
      • et al.
      Investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture.
      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 normalized by dividing it by the scapular length (ie, the distance between spina scapula, localized at the margo medialis, and the angulus acromion).
      • DiVeta J
      • Walker ML
      • Skibinski B
      Relationship between performance of selected scapular muscles and scapular abduction in standing subjects.
      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.
      • DiVeta J
      • Walker ML
      • Skibinski B
      Relationship between performance of selected scapular muscles and scapular abduction in standing subjects.
      Likewise, the interobserver reliability in asymptomatic subjects was excellent (ICC between 0.91 and 0.92).
      • Gibson MH
      • Goebel GV
      • Jordan TM
      • Kegerries S
      • Worrell TW
      A reliability study of measurement techniques to determine static scapular position.
      The scapular distance was not related to muscle strength of the pectoralis minor or trapezius muscle.
      • DiVeta J
      • Walker ML
      • Skibinski B
      Relationship between performance of selected scapular muscles and scapular abduction in standing subjects.
      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.
      • Sobush DC
      • Simoneau GG
      • Dietz KE
      • Levene JA
      • Grossman RE
      • Smith WB
      The Lennie test for measuring scapula position in healthy young adult females: a reliability and validity study.
      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
      • Kibler WB
      The role of the scapula in athletic shoulder function.
      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.
      • Kibler WB
      The role of the scapula in athletic shoulder function.
      • Odom CJ
      • Taylor AB
      • Hurd CE
      • Denegar CR
      Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: a reliability and validity study.
      • Koslow PA
      • Prosser LA
      • Strony GA
      • Suchecki SL
      • Mattingly GE
      Specificity of the lateral scapular slide test in asymptomatic competitive athletes.
      For interpreting the LSST, a side-to-side difference of 1.5 cm was originally suggested for the diagnosis of shoulder dysfunction.
      • Kibler WB
      The role of the scapula in athletic shoulder function.
      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.
      • Odom CJ
      • Taylor AB
      • Hurd CE
      • Denegar CR
      Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: a reliability and validity study.
      • Koslow PA
      • Prosser LA
      • Strony GA
      • Suchecki SL
      • Mattingly GE
      Specificity of the lateral scapular slide test in asymptomatic competitive athletes.
      In addition, the outcome of the LSST was unable to differentiate between the symptomatic and asymptomatic side.
      • Nijs J
      • Roussel N
      • Vermeulen K
      • Souvereyns G
      Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.
      For all 3 tests positions, we observed an acceptable to good interobserver reliability (ICC > 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
      • Odom CJ
      • Taylor AB
      • Hurd CE
      • Denegar CR
      Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: a reliability and validity study.
      and even lower ICC values for asymptomatic subjects (ranging between 0.18 and 0.69)
      • Gibson MH
      • Goebel GV
      • Jordan TM
      • Kegerries S
      • Worrell TW
      A reliability study of measurement techniques to determine static scapular position.
      and for junior elite swimmers (ranging between 0.20 and 0.82)
      • McKenna L
      • Cunningham J
      • Straker L
      Inter-tester reliability of scapular position in junior elite swimmers.
      (Table 1). It is difficult to explain the differences in findings among various studies. Addressing the validity, the LSST data correlated strongly with radiographic comparison (r > 0.90).
      • Kibler WB
      The role of the scapula in athletic shoulder function.
      Table 1Overview of the reliability data of clinical tests for the assessment of scapular positioning
      TestPeterson et al
      • Peterson DE
      • Blankenship KR
      • Robb JB
      • Walker MJ
      • Bryan JM
      • Stetts DM
      • et al.
      Investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture.
      DiVeta et al
      • DiVeta J
      • Walker ML
      • Skibinski B
      Relationship between performance of selected scapular muscles and scapular abduction in standing subjects.
      Gibson et al
      • Gibson MH
      • Goebel GV
      • Jordan TM
      • Kegerries S
      • Worrell TW
      A reliability study of measurement techniques to determine static scapular position.
      Nijs et al
      • Nijs J
      • Roussel N
      • Vermeulen K
      • Souvereyns G
      Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.
      Odom et al
      • Odom CJ
      • Taylor AB
      • Hurd CE
      • Denegar CR
      Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: a reliability and validity study.
      McKenna et al
      • McKenna L
      • Cunningham J
      • Straker L
      Inter-tester reliability of scapular position in junior elite swimmers.
      Watson et al
      • Watson L
      • Balster SM
      • Finch C
      • Dalziel R
      Measurement of scapula upward rotation: a reliable clinical procedure.
      Johnson et al
      • Johnson MP
      • McClure PW
      • Karduna AR
      New method to assess scapular upward rotation in subjects with shoulder pathology.
      Posterior acromion, table relaxed0.88-0.94
      Posterior acromion, table retraction0.92-0.91
      Medial scapular border, T4 relaxed0.50-0.79
      Medial scapular border, T4 retraction0.70-0.80
      Medial scapular border, T3.91
      Intraobserver reliability.
      LSST position 10.82-0.960.790.65-0.74
      LSST position 20.85-0.950.450.79-0.82
      LSST position 30.70-0.850.570.20-0.57
      Scapular distance0.94
      Intraobserver reliability.
      0.91-0.92
      Scapula upward rotation0.81-0.94
      Intraobserver reliability.
      0.89-0.96
      Intraobserver reliability.
      Unless indicated (superscript “a”), intraclass correlation coefficients are provided to indicate the interobserver reliability.
      a Intraobserver reliability.
      The measurement of scapula upward rotation is a clinical assessment procedure that uses 2 Plurimeter-V gravity references inclinometers.
      • Watson L
      • Balster SM
      • Finch C
      • Dalziel R
      Measurement of scapula upward rotation: a reliable clinical procedure.
      The patient is assessed in a relaxed, balanced standing position. The relative contribution 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 45°, 90°, 135°, and at their maximum achievable range. At each of the abduction positions, the scapula upward rotation is measured 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.
      • Watson L
      • Balster SM
      • Finch C
      • Dalziel R
      Measurement of scapula upward rotation: a reliable clinical procedure.
      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.
      • Johnson MP
      • McClure PW
      • Karduna AR
      New method to assess scapular upward rotation in subjects with shoulder pathology.
      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).
      • Johnson MP
      • McClure PW
      • Karduna AR
      New method to assess scapular upward rotation in subjects with shoulder pathology.
      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.
      • Michener LA
      • Boardman ND
      • Pidcoe PE
      • Frith AM
      Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity.

      Discussion

      There is evidence suggesting that scapular positioning is abnormal in patients with shoulder impingement syndrome,
      • Hébert LJ
      • Moffet H
      • McFadyen BJ
      • Dionne CE
      Scapular behavior in shoulder impingement syndrome.
      symptoms of impingement,
      • Ludewig PM
      • Cook TM
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      • Cools AM
      • Witvrouw EE
      • Declercq GA
      • Danneels LA
      • Cambier DC
      Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms.
      atraumatic shoulder instability,
      • von Eisenhart-Rothe R
      • Matsen FA
      • Eckstein F
      • Vogl T
      • Graichen H
      Pathomechanics in atraumatic shoulder instability: scapula positioning correlates with humeral head centering.
      multidirectional shoulder joint instability,
      • Illyés A
      • Kiss RM
      Kinematic and muscle activity characteristics of multidirectional shoulder joint instability during elevation.
      and shoulder pain after neck dissection in cancer patients.
      • van Wilgen CP
      • Dijkstra PU
      • van der Laan BFAM
      • Plukker JTh
      • Roodenburg JLN
      Shoulder complaints after neck dissection; is the spinal accessory nerve involved?.
      • van Wilgen CP
      Morbidity after neck dissection in head and neck cancer patients. A study describing shoulder and neck complaints, and quality of life. Doctoral dissertation.
      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 scapulothoracic muscles was found effective in patients with subacromial impingement syndrome,
      • Dickens VA
      • Williams JL
      • Bhamra MS
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      and conservative treatments consisting of stretching and strengthening exercises targeting scapulothoracic muscles were able to improve scapular positioning in asymptomatic subjects.
      • Roddey TS
      • Olson SL
      • Grant SE
      The effect of pectoralis muscle stretching on the resting position of the scapula in persons with varying degrees of forward head/rounded shoulder posture.
      • Wang C-H
      • McClure P
      • Pratt NE
      • Nobilini R
      Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics.
      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 assessment of the ‘scapular distance’ have been identified as reliable tests. In addition, the measurement of the distance from the medial scapular border to the fourth thoracic spinous process, when performed with the patient's 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,
      • Peterson DE
      • Blankenship KR
      • Robb JB
      • Walker MJ
      • Bryan JM
      • Stetts DM
      • et al.
      Investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture.
      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 measurement of scapula upward rotation was found reliable (intrarater) 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 importance of the tests, cross-sectional (examining the associations 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 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 impingement syndrome relative to controls.
      • Ludewig PM
      • Cook TM
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      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.
      • Michener LA
      • Boardman ND
      • Pidcoe PE
      • Frith AM
      Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity.

      Conclusions

      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.
      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.

      Acknowledgment

      Nathalie Roussel and Filip Struyf are financially supported by a research grant (“A study examining static and dynamic preventive factors for injuries in dancers”) from the Department of Health Sciences, University College Antwerp, 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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