The effect of scapular protraction on isometric shoulder rotation strength in normal subjects

Jay Smith, MD,a Christopher T. Dietrich, MD,a Brian R. Kotajarvi, MS, PT,b and Kenton R. Kaufman, PhD,b Rochester, MN

To measure the effect of scapular protraction on isometric shoulder rotation strength, 20 normal subjects completed 2 maximal isometric internal and external rotation contractions in 2 scapular positions (scapula neutral [SN] and scapula protracted [SP]) from 3 arm positions (90 internal rotation [IR], 45 internal rotation [MR], and 90 external rotation [ER]). Scapular protraction reduced shoulder rotation strength in 5 of 6 test positions (P .0004), with signicant interactions between scapular position and arm position (P .001) and between scapular position and contraction type (P .0001). Protraction signicantly reduced IR strength by 13% to 24% relative to SN. The effect of SP on ER strength was more position-dependent, increasing strength by 6% in the IR position and decreasing it by 7% in the MR position and 20% in the ER position. In conclusion, acute changes in scapular position affect shoulder isometric IR and ER strength. The potential adverse effects of scapular protraction on shoulder rotation strength should be considered during the evaluation and treatment of shoulder pain. (J Shoulder Elbow Surg 2006;15:339-343.)

houlder pain and dysfunction are common complaints among individuals seeking care from physical medicine and rehabilitation, primary care, sports medicine, and occupational medicine physicians.7,21 New shoulder complaints account for up to 5% of general practice visits and up to 13% of all disabling athletic injuries.7 Although some shoulder complaints are related to acute trauma, such as dislocation or contusion, most shoulder disorders result from cumulative, microtraumatic overuse injuries to the rotator cuff and shoulder soft tissues.6 Consequently, traditional diagnostic and therapeutic efforts have emphaFrom the aCollege of Medicine and bMotion Analysis Laboratory, Mayo Clinic. Reprint requests: Jay Smith, MD, 200 First St SW, Rochester, MN 55905. Copyright 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2005.08.023

sized the role of rotator cuff dysfunction in the pathogenesis of shoulder pain.16-18 Recently, clinicians and investigators have focused increased attention on the role of the scapula in the pathogenesis of shoulder pain in general and rotator cuff dysfunction specically.5,9,11 The scapula must fulll several important roles for normal, pain-free shoulder function, including the provision of a stable base of support from which the rotator cuff muscles function.8,11,15,19,25 Optimal function of the scapula is predicated on precise control of its position on the thoracic cage and coordination of its motions with those of the glenohumeral joint. An increasing number of studies have correlated abnormalities in scapular position or motion (dyskinesis) with rotator cuff disorders and instability.1,2,20,23,24 In particular, the position of scapular protraction, or the inability to retract the scapula, appears to impart several negative biomechanical effects on the shoulder, including a narrow subacromial space, increased strain on the anterior-inferior glenohumeral ligament, reduced impingement-free arc of upper limb elevation, reduced isometric abduction strength, and reduced isometric elevation strength tested in the sagittal plane.1,8,22,23 Surprisingly, no prior study has investigated the effect of scapular protraction on rotator cuff function as measured by rotational force generation capabilities. Clarication of this relationship would advance our understanding of shoulder biomechanics and provide important information to assist in the evaluation and treatment of rotator cuff disorders. The purpose of this study is to measure the effects of scapular protraction on isometric shoulder rotation strength in normal subjects. MATERIALS AND METHODS
The study design consisted of each subject performing 2 maximal isometric internal and external rotation contractions in 3 different arm positionsfull internal rotation (IR), midrange internal rotation (MR), and external rotation (ER)and 2 different scapular positionsscapula neutral (SN) and scapula protracted (SP). The investigation was approved by the institutional review board at our institution. We recruited 20 subjects, 10 men and 10 women, aged 18 to 35 years, from a volunteer population consisting of Mayo Health System employees,

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Figure 1 Photograph of test apparatus and setup. The subjects arm is in the scapula-protracted, externally rotated test position. A load cell is attached to wrist at a 90 angle.

residents, and students. The health status of each subject was evaluated on the basis of a medical review and objective examination performed by one of the investigators. Inclusion criteria included symmetric, pain-free shoulder range of motion and the absence of any exclusion criteria. Exclusion criteria included current or past history of neck or upper limb pain; history of trauma, surgery, or major deformity to the thoracic spine, rib cage, neck, or shoulder girdle; known neuromuscular or cardiovascular disease; and currently pregnant or lactating. All subjects completed an appropriate written informed consent from before participation. The testing apparatus consisted of an aluminum cage frame, an adjustable strap attached to a load cell, and movable rings to anchor the strap (Figure 1). The load cell was interfaced with a computer data acquisition system and was attached to the subjects wrist by a strap applied just proximal to the ulnar and radial styloid processes of the test arm. The anchor rings were adjusted so that the line of tension could be redirected for each of the 6 different upper limb test positions. This was adjusted so that the angle between the subjects arm and the strap was 90 during all rotation strength testing. Subjects eligible for the study were asked to refrain from upper-body weight-training activities in the 48 hours before testing. On the test day, subjects completed a 5-minute warm-up on an upper body ergometer, followed by passive range of motion into exion, abduction, and 90 of abduction with internal rotation. They were then positioned sitting on a rigid-backed chair with the trunk immobilized with a nonrestrictive Velcro strap. All testing was performed with the arm in 90 of elevation in the sagittal plane and with the elbow exed at 90. Clinically, normal values for protraction have only been published for the position of 90 elevation in the sagittal plane.4 Consequently, this testing position allowed us to ensure that our subjects achieved normal amounts of protraction and reproduced the position used in our earlier investigation.4,22 Once established, the basic test position was conrmed with a goniometer. The order of shoulder position (IR, MR, and ER) and scapular position (SN and SP) was determined by a randomized

drawing. The upper limb and scapula were positioned in the rst test position ensuring that the humerus remained at 90 sagittal-plane elevation by use of the goniometer. Standard verbal instructions were given to the subject regarding testing. These included instructions to avoid holding their breath or bearing down into a Valsalva maneuver. The rest periods (30 seconds between repetitions) used were in agreement with previous strength studies and were sufcient to avoid the effects of fatigue.3,14,15 Pilot testing was performed on 2 subjects, 1 man and 1 woman, by use of an identical testing method. On the basis of the results, we determined that 0.5 kg was a realistic level of expected change that would be potentially clinically meaningful. Power analysis indicated that 20 subjects would be needed to detect a 0.5-kg difference based on test position with 80% power (ie, error of .20) and P .05. Final testing consisted of a warm-up of 1 submaximal isometric contraction lasting 5 seconds, followed by 30 seconds of rest, after which subjects performed 2 maximal voluntary isometric contractions in the direction of internal rotation and 2 in the direction of external rotation. For each position, the rst 2 repetitions were reviewed. If the results were consistent with each other with no signicant increase in torque from repetition 1 to 2, data were saved and testing at that position was stopped. When there was a discrepancy, a third repetition was performed to ensure that the peak torque value had been obtained. The procedure was repeated for the next randomly determined shoulder position. When all 3 shoulder positions had been completed, subjects rested for 5 minutes and then repeated the procedure for the other scapular position. Scapular protraction was conrmed with measurements from the patients olecranon process to the rigid chair back. The process of obtaining scapular protraction was identical to the method used in our previous work. A measurement of greater than 3 cm was considered acceptable to conrm protraction.4,22 This process resulted in a total of 6 test positions, or 2 scapular positions (SP and SN) per arm position (IR, MR, and ER) tested. Each subject performed 2 isometric internal rotation and 2 isometric external rotation contractions in each upper limb position, performing approximately 24 contractions to complete the study. The order of positions tested was randomized and included complete internal rotationscapula neutral (IR-SN), complete internal rotationscapula protracted (IR-SP), midrangescapula neutral (MR-SN), midrangescapula protracted (MR-SP), complete external rotationscapula neutral (ER-SN), and complete external rotationscapula protracted (ER-SP). The primary variable of interest was the difference between the mean isometric external strength values for the SN position when compared with the SP position. These variables were compared by use of a 3-factor repeated-measures analysis of variance (ANOVA). This statistical measure was used to evaluate the effects of arm position (IR, MR, and ER), scapular position (SN and SP), and muscles activated (external or internal rotators) on isometric shoulder strength.

RESULTS Scapular protraction signicantly reduced shoulder rotation strength (main effect, SN vs SP; P .0004). However, ANOVA indicated signicant in-

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Table I External and internal rotation strength

SN (kg) External rotation strength IR start MR start ER start* Internal rotation strength IR start* MR start* ER start* SP (kg) % Change (SN vs SP) P value

7.25 7.87 7.08 11.38 13.37 12.79

7.71 7.32 5.89 10.05 10.78 10.40

6% 7% 20% 13% 24% 23%

.13 .07 .0003 .0001 .0001 .0001

Abbreviations: IR - Internal rotation; ER - External rotation; MR - Mid range; SN - Scapula neutral; SP - Scapula protracted. *Statistically signicant.

teractions between scapular position and starting arm position (P .0001) and between scapular position and contraction type (P .0001). As shown in Table I and Figure 2, scapular protraction resulted in a signicant reduction in internal rotation strength regardless of arm position. (Table I and Figure 2). Internal rotation strength was on average 20% greater in the SN versus SP test posture. The greatest internal rotation strength difference was noted in the MR position, where SP resulted in a 24% strength reduction. The ability to generate ER strength varied inversely with the starting position during SP, showing a maximal decrement of 20% in the ER starting position. In the IR starting position, ER strength in the SP position was 7.7 kg, decreasing to 7.3 kg at MR and 5.9 kg at ER. DISCUSSION This study is the rst to demonstrate that scapular position affects shoulder rotation force generation capabilities. Scapular protraction signicantly reduced isometric internal rotation strength, regardless of arm test position (Table I and Figure 2). In comparison, the effect of protraction on isometric external rotation strength was more position-dependent. External rotation strength was signicantly reduced when

the arm was tested in the ER position, nonsignicantly reduced in the MR position, and essentially unchanged in the IR position. The primary purpose of this investigation was to elucidate any potential inter-relationship between scapular position and shoulder rotational force generating capabilities, not to determine the source of such changes if they occurred. Nonetheless, it is interesting to hypothesize what factor or factors may account for our observations. The ability of the scapula to provide a stable base of support may have been compromised by scapular protraction, as the scapular stabilizer muscles would be placed in disadvantageous positions on their length-tension curves. If this were true, then one might expect equally detrimental effects on ER and IR strength measures. However, this was clearly not the case (Table I). A second, and perhaps more likely, explanation for our ndings is that scapular protraction altered the length-tension relationships of the IR and ER muscles differentially. The internal rotators would include not only the subscapularis, but also the teres major, pectoralis major, and latissimus dorsi. Scapular protraction would lengthen the latissimus dorsi and reduce the internal rotatory moment of the pectoralis major. Thus, the two most powerful internal rotators would be expected to

Figure 2 External (A) and internal (B) rotation strength. SP results in signicant reduction in internal rotation strength regardless of arm position. The external rotation strength change was only signicant in the ER arm position. Asterisk, Statistically signicant.

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have reduced force-generation capabilities in SP relative to SN. The external rotator muscles are more limited in number and diversity and include the supraspinatus, infraspinatus, teres minor, and posterior deltoid. Protraction would shorten all of these muscles, thus placing them on a shortened, disadvantageous position on their length-tension curves. Externally rotating the arm, as in the SP-ER position, would accentuate this shortening effect for all muscles. On the contrary, as the arm is moved to MR and then IR, these muscles would be lengthened, thus partially counteracting the shortening induced by scapular protraction. Thus, the effect of protraction would be expected to be greatest in the ER position and least in the IR position, which is exactly what was observed. A third explanation is that the altered scapular position affected neuromuscular activation patterns about the shoulder girdle differentially, regardless of lengthtension relationships.2 The relative roles of lengthtension changes versus altered neuromuscular activation patterns in producing our results are indeterminate at this time and are a topic for future investigation. Several study limitations are noteworthy. First, we investigated normal subjects to examine the relationship between scapular position and shoulder rotation strength in the absence of confounding clinical factors such as symptom etiology, duration, and severity, in addition to variable reex inhibition due to pain. Although we believe our results provide sufcient evidence that normal scapular position should be re-established in symptomatic individuals, further study is required to elucidate the inter-relationship of scapular position and shoulder muscle function in symptomatic populations.2 Second, the number of subjects in this investigation may have been insufcient to detect statistically signicant changes with regard to ER strength in the IR and MR positions. Our power calculations, for which standard equations and assumptions were used, predicted that we would have an 80% chance of detecting a 0.5-kg strength change. In other words, we had a 20% chance of missing a true difference of 0.5 kg. Because the quantitative ER strength change in protraction starting from the MR and IR positions was 0.5 kg, it is possible that a larger number of subjects would have resulted in the change reaching statistical signicance. However, we emphasize that this recognition of potential underpowering would not change the pattern of observed results or the fundamental conclusions of the study. Third, we chose to measure isometric shoulder strength to extend our previous investigation.22 Although these isometric strength measurements may not correlate with more dynamic measurements, we recognize that, during many daily and occupational activities (eg, assembly-line work, painting, and washing windows), the shoulder girdle works rela-

tively isometrically to maintain upper-limb position, whereas movement predominately occurs at the elbow, wrist, and hand. Thus, we feel that isometric shoulder strength measurements are clinically relevant. Regardless of the potential source(s) of our ndings, we have clearly established that the ability of the shoulder to generate isometric rotation strength is dependent on scapular position. Specically, the position of scapular protraction may have detrimental effects on force-generating capabilities for the shoulder internal and external rotators. These ndings extend our previous research documenting a 23% reduction in isometric force generation during sagittalplane elevation22 and the report of Kebaetse et al8 showing a 16% reduction in isometric scapular-plane abduction in a slouched posture (this latter investigation did not specically measure scapular protraction). Thus, there is an emerging body of literature documenting the adverse effects of scapular protraction on shoulder muscle function.2,8,22 These ndings have signicant implications for clinicians evaluating and treating shoulder disorders. Clinicians need to be aware of the impact of scapular protraction on shoulder muscle function and consider both scapular position and motion when evaluating muscle function about the shoulder or rehabilitating shoulder disorders.1,9-13,19 More specically, as reected in the current study results, the ability to restore shoulder rotation strength successfully may be jeopardized if the scapula is abnormally positioned. Specic methods by which to evaluate and rehabilitate scapulothoracic disorders are beyond the scope of this article and have been discussed in several excellent recent articles.1,9-13,19,20
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