Scand J Med Sci Sports 2011: 21: 809818

doi: 10.1111/j.1600-0838.2010.01115.x

& 2010 John Wiley & Sons A/S

Scapular positioning in overhead athletes with and without shoulder

pain: a casecontrol study
F. Struyf1,2, J. Nijs1,2, J. De Graeve1, S. Mottram3, R. Meeusen2
1

Division of Musculoskeletal Physiotherapy, Department of Health Sciences, Artesis University College Antwerp, Antwerp, Belgium,
Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium,
3
Kinetic Control International, Ludlow, UK
2

Corresponding author: Filip Struyf, PT, Campus HIKE, Dept G, Artesis University College Antwerp, Van Aertselaerstraat 31,
2170 Merksem, Belgium. Tel: 132 36 418 265, E-mail: lip.struyf@artesis.be
Accepted for publication 27 January 2010

Abnormalities of scapular positioning are considered important risk factors for developing shoulder disorders. This
study analyses the scapular positioning pattern in a group of
overhead athletes with and without shoulder pain. In a multicenter blinded casecontrol study, 36 shoulder pain athletes
(19 men, 17 women), were compared with 36 unimpaired
athletes free of shoulder pain, matched for gender, age, hand
dominance and body mass index. The blinded assessor
performed visual observation, the measurement of the dis-

tance between the acromion and the table, inclinometry and

the kinetic medial rotation test for dynamic scapular control
in random order. Athletes with shoulder pain demonstrate
scapular asymmetry in the sagittal plane, observed visually
as anterior tilting on the painful side. Athletes with shoulder
pain show a lack of scapular motor control on their painful
side in contrast to their pain-free side. No scapular positioning or motor control dierences were found in athletes with
or without shoulder pain.

Narrowing of the subacromial space might increase

the risk for developing shoulder pain, and be a factor
in shoulder impingement syndrome. Abnormal scapular positioning has previously been related to this
excessive narrowing of the acromiohumeral distance
(Brossmann et al., 1996; Hebert et al., 2002).
Changes in scapular positioning are considered important risk factors for developing shoulder disorders such as shoulder impingement syndrome,
shoulder instability as well as post-operative
shoulder complaints, neck pain and cervicogenic
headache (Host, 1995; Paletta et al., 1997; Schmitt
& Snyder-Mackler, 1999; Ludewig & Cook, 2000;
Hebert et al., 2002; Lewis et al., 2002; Van Wilgen
et al., 2003; Endo et al., 2004; Van Wilgen, 2004;
Cools et al., 2005; Von Eisenhart-Rothe et al., 2005;
McClure et al., 2006). In addition, a recent study
suggests that reducing the scapular mobility (nonspecic) directly reduces the acromiohumeral distance and therefore increases the risk for subacromial
impingement (Atalar et al., 2009).
Normally, humeral elevation is accompanied by
scapular upward rotation and posterior tilting, glenohumeral external rotation, clavicular retraction,
elevation and posterior axial rotation (Ludewig &
Cook, 2000; McClure et al., 2001; Borsa et al., 2003;
Ebaugh et al., 2006; Ludewig et al., 2009). Controversy exists on the pattern of internal or external

scapular rotation during humeral elevation (McClure

et al., 2001; Ebaugh et al., 2006; Ludewig et al.,
2009). In addition, scapular upward rotation appears
to be greater in the scapular plane than in the sagittal
plane (Borsa et al., 2003). In contrast to pain-free
shoulders, patients with various shoulder disorders
demonstrate altered scapular positioning patterns
(Lukasiewicz et al., 1999; Ludewig & Cook, 2000;
Hebert et al., 2002; Borstad & Ludewig, 2005;
McClure et al., 2006; Ludewig et al., 2009). Excessive
scapular internal rotation, a decrease in scapular
upward rotation and a decrease of posterior scapular
tilting are closely associated with shoulder impingement syndrome (Solem-Bertoft et al., 1993; Ludewig
& Cook, 2000; Hebert et al., 2002; Endo et al., 2004;
Lukasiewicz et al., 2009). However, some studies
mention more upward rotation in patients with
shoulder pain (Von Eisenhart-Rothe et al., 2005;
McClure et al., 2006).
While the complex kinematic behavior of the
scapula and shoulder has been studied extensively
(McKenna et al., 2004), these full three-dimensional
motion tracking systems are costly and not readily
available for clinical practice. Additionally, the question remains whether there are clinical tools that are
able to demonstrate the same ndings. Therefore
there is a need for valid and reliable measures that
have strong clinical utility. A literature review con-

809

Struyf et al.
cluded that clinical assessment strategies for scapular
positioning are available but require further study of
their clinimetric properties (Nijs et al., 2007).
Researchers have suggested that shortening of the
pectoralis minor, a decrease in activity of the serratus
anterior muscle and an increase of activity of the
upper trapezius muscle may aect scapular positioning in terms of winging, anteriorly tilting and a
reduced scapular upward rotation. (Ludewig &
Cook, 2000; Borstad & Ludewig, 2005; Cools et al.,
2003) It has also been shown that subjects with short
pectoralis minor muscle length demonstrate similar
scapular kinematics as subjects with shoulder impingement syndrome (Lukasiewicz et al., 1999; Ludewig
& Cook, 2000; Borstad & Ludewig, 2005; Smith
et al., 2006).
Likewise, muscle imbalance results in an abnormal
force contribution around the shoulder, which could
lead to pain and pathology (Comerford & Mottram,
2001). It is noted clinically that patients presenting
with upper extremity dysfunction, frequently demonstrate poor scapular control (Mottram, 1997; Morrissey et al., 2008). Consequently, abnormal scapular
movement and muscle function has been shown to be
related to shoulder impingement syndrome (Lukasiewicz et al., 1999; Ludewig & Cook, 2000). No
previous study examined the ability of a muscular
motor control test in discriminating people with or
without shoulder pain. In addition, the kinetic medial rotation test (KMRT) aims at observing movement faults at the scapula and glenohumeral joint
associated with glenohumeral medial rotation
(Comerford & Mottram, 2001; Mottram, 2003).
This test has been developed by observation of
patients together with research results relating
shoulder girdle movement (Comerford & Mottram,
2001; Morrissey et al., 2008).
The specic purpose for this study was to analyze
the scapular positioning pattern: scapular upward
rotation, forward shoulder posture, tilting, winging
and scapular motor control in a group of athletes
with shoulder pain relative to a group of athletes
without symptoms. Second, inter-individual dierences are subject to this research.

Materials and methods

Study design
Scapular positioning and dynamic scapular control were
assessed in a casecontrol study in 153 voluntary overhead
athletes (Fig. 1). Before assessment, a variety of sports
associations agreed to participate in the study. Subsequently,
athletes that were present at training, were asked to participate
in the study. All athletes agreed to participate and lled in a
written informed consent. The assessor was blinded for the
presence of shoulder disorders among the participants. After
measuring the athletes weight and height, the clinical assessment was performed in random order: observation of forward

810

153 athletes voluntary

rectruited
Blinded clinical
assessment

YES

Shoulder pain?

NO

117 athletes without

shoulder pain

36 athletes with shoulder

pain

36 athletes matched for

age, gender, hand
dominance and Body
Mass Index.

Fig. 1. Flow chart of the study design; case vs control.

tilt and winging, measurement of forward shoulder posture

(the acromial distance), the measurement of scapular upward
rotation (inclinometry) and the assessment of scapular
dynamic control (the KMRT). Scapular positioning of both
shoulders was assessed. After the assessment protocol, the
study participants with shoulder pain were asked to ll in
the shoulder disability questionnaire (SDQ). Finally, they
were interviewed to collect relevant demographic information
(age, gender and hand dominance). Height and weight were
measured using a measurement tape and a digital scale
(Exacta, Nassau, Germany). The study protocol was reviewed
and approved by the local medical ethics committee.
Before the study, the assessor (holder of a bachelor degree
in physiotherapy) underwent a 4-h training session. The
training session was used to instruct the assessor in performing
an accurate measurement of scapular positioning and scapular
dynamic control including pilot testing on healthy athletes.
The assessor was trained by two highly experienced physiotherapists. All participants received an information leaet
and provided written informed consent. The male athletes
were tested with their trunk bare. Female athletes wore a
sports bra or a halter-top so that the scapula remained visible
and shoulder movements were not hampered by clothing.
Previous study concluded that palpation was a valid method
to nd the location of the scapula, so all reference points used
during the inclinometry and acromial distance were palpated
(Karduna et al., 2001; Lewis et al., 2002).

Athlete recruitment
Seventy-two athletes (38 men, 34 women), 1860 years of age
[mean  standard deviation (SD), 33  11 years] were
included in this study. Thirty-six shoulder pain athletes (19
men, 17 women) were compared with 36 unimpaired athletes
free of shoulder pain, matched for gender, age, hand dominance and body mass index. Among the 36 athletes with
shoulder pain, 35 painful shoulders were on the dominant side.
The mean shoulder disability score (SDQ) was 35.8  13.5.
No signicant dierences were noted in height, age, weight,
hand dominance or duration of overhead activities between
both groups. Table 1 shows the descriptive characteristics of
the athletes.

Scapular positioning in overhead athletes

Table 1. Descriptive characteristics of the athletes

Athletes with shoulder

pain (n 5 36)

Athletes without shoulder

pain (n 5 36)

Age (years)
Mean
33.4
33.1
SD
11.3
10.9
Range
1860
1856
Gender
Male
19 (52.8%)
19 (52.8%)
Female 17 (47.2%)
17 (47.2%)
Height (cm)
Mean
176.9
178.2
SD
10.5
9.8
Range
156194
158195
Duration of contiguous overhead activities (years)
Mean
12.8
11.9
SD
8.8
9.5
Range
135
137
Type of sport
Tennis
9 (25%)
9 (25%)
Volleyball 16 (44%)
12 (33%)
Baseball
2 (6%)
1 (3%)
Badminton 7 (19%)
10 (28%)
Handball 2 (6%)
4 (11%)

A total number of 306 shoulders were examined from 153

overhead athletes who were recruited from a variety of sports
associations.
Because of possible dierences in scapular positioning
between adults and children, study participants had to be at
least 18 years of age to be included in the study (Dayanidhi
et al., 2005; Struyf F, Nijs J, Horsten S, Mottram S, Meeusen R,
unpublished observation). In addition, athletes had to participate in an overhead sport at least once a week and had to be
able to perform at least 1401 of humeral abduction in the
coronal plane. This range of shoulder abduction was measured
by use of an inclinometer, using a standardized and reliable
protocol (Green et al., 1998). Sucient reliability of the
measurement of scapular upward rotation (by means of two
inclinometers) was only attained for subjects performing 1401
of humeral abduction or more (Watson et al., 2005). The
exclusion criteria for all athletes were a history of injury or
surgery to the shoulder complex, upper thorax, upper back
and humerus in the past year.

Outcome measures

Visual observation for tilting and winging

Firstly, the scapular was observed to identify the resting
position. Secondly, observation of scapular positioning during
humeral movement was noted to assess the kinematical
rhythm between glenohumeral abduction and scapular upward rotation.
The observations were performed with the athlete standing
and instructed to stay relaxed. Because high-heeled shoes can
inuence posture and consequently scapular positioning, we
asked the athletes to stand barefoot. Only articial lighting
from above was used, in order to reduce the altering eect of
natural light on the body. The scapula was observed in resting
posture and during active unloaded movement. The athlete
was observed from dorsal (frontal plane) and lateral (sagittal
plane). During scapular observation at rest, we observed all
participants bilaterally in three positions: static with both
arms relaxed (thumbs facing forward), hands placed on

Fig. 2. Measurement of forward shoulder posture (acromial

distance).

ipsilateral hips (thumbs facing backward) and arms in 901 of

humeral abduction in the frontal plane (thumbs facing up).
Scapular positioning was deemed impaired when (1) the
inferior angle of the scapula becomes prominent dorsally
(the axis of rotation is in the horizontal plane tilting);
(2) the entire medial border of the scapula becomes prominent
dorsally (the axis of rotation is vertically and in the frontal
plane winging). If one (or more) of the criteria listed positive,
we judged scapular positioning as impaired (score 5 1), if none
of the criteria satisfy, we judged scapular positioning as
normal (score 5 0). Next, the athlete performed active movement (unloaded) in standing posture. We asked them to
perform bilateral shoulder abduction (01801) in the frontal
plane. The same criteria as above were used.

Forward shoulder posture (acromial distance)

The acromial distance is the measurement of the acromion to
the table in supine, intended to measure forward shoulder
posture.
The measurement of the distance between the posterior
border of the acromion and the table was performed in supine.
In this position, the assessor measured the distance between
the most posterior aspect of the posterior border of the
acromion and the table bilaterally [measured vertically with
a sliding calliper Manutant (Manutan nv, Brussels,
Belgium), accuracy 0.03 mm]. Next, the assessor repeated
this procedure with the athlete actively retracting both
shoulders while keeping the thorax xed against the table.
The data collected during this measurement were adjusted by
dividing by the body length, which resulted in a score entered
as cm/cm. Each position was measured once (Fig. 2).

Scapular upward rotation (Inclinometry)

One gravity referenced inclinometer (Plurimeter-V, La Conversion, Switzerland; accuracy to 11) (Green et al., 1998) was
used to measure humeral elevation, and a second inclinometer
was used to measure upward rotation of the scapula. The
gravity-referenced inclinometer is calibrated on the basis of

811

Struyf et al.
gravity. The starting position of the movement to be measured
is therefore xed, minimizing placement error. All athletes
were assessed in a relaxed, standing (barefoot) position.
Scapular upward rotation was measured during total shoulder
abduction using a standardized reliable protocol as described
by Green et al. (1998).
Athletes were asked to perform full extension at the elbow,
neutral wrist position and with the thumb leading. The
inclinometer is attached perpendicular to the humerus, just
under the deltoid insertion using a Velcro tape. Athletes were
then asked to move both arms into abduction and to stop at
451, 901, 1351 and at full range of humeral abduction (Fig. 3).
At each of these positions, the degree of upward rotation of
the scapula was measured using the second inclinometer. This
was achieved by manually aligning the base of the inclinometer along the spine of the scapula. Additionally, we
created four phases of humeral elevation: phase I (resting
position to 451), phase II (45901), phase III (901351) and
phase IV (1351 to end range). Only positions that can be
measured reliably with the Plurimeter-V inclinometer were
included in this study. For standardization, each athlete gets
one test-rehearsal before the test was performed.

tion, fatigue, the need of external feedback and external

support are also scored (score 5 1 if present B-list) (Comerford & Mottram, 2001). Finally, this gives rise to a total score
on a 117-points scale (Table 2). We state the scapula to have a
lack of motor control when the score is 1 on the A-list, 43 on
the B-list or both. For standardization, each athlete gets one
test-rehearsal before the test was performed.

Scapular motor control (KMRT)

Reliability of outcome measures

The athlete is supine with the humerus abducted to 901, the

elbow exed 901 and the humerus in 301 of horizontal
abduction (hand to the ceiling with the humerus in the plane
of the scapula). All angles were measured by using an
inclinometer. The athlete is taught to perform medial rotation
at the glenohumeral joint while keeping the scapula still in its
neutral position. This test is scored positive when scapular
forward tilt, downward rotation or elevation occurs (Fig. 4).
The KMRT is performed until 601. Normative research data
suggest that during medial rotation to 601, in non-painful
shoulders the glenoid does not anterior translate 44 mm, and
the scapula does not translate 46 mm (Morrissey et al., 2008).
Accuracy of palpation is critical to the test. Recent study
concluded that this manual landmark identication can be
tracked accurately by palpation (Morrissey et al., 2008).
For this experiment, test scoring was twofold: rst, this test
is scored positive (score 5 1) when the assessor feels that the
scapula forward tilts or elevation occurs (A-list). Second,
diculties in breathing, performing diculties, unable to
perform 601 medial rotation, glenohumeral anterior transla-

Previous study on the inter-tester reliability of scapular

observation conclude that the observation at rest and during
movement is a clinically applicable tool for assessing patterns
of scapular positioning and movement (McClure et al., 2009;
Struyf et al., 2009). The k values for the observation of tilting
and winging at rest were 0.48 and 0.42, during unloaded
movement 0.52 and 0.78 (Struyf et al., 2009). Validity of the
scapular dyskinesis test was demonstrated (Tate et al., 2009).
The measurement of the acromial distance was found reliable
(both relaxed and during retraction, ICCs40.88) (Nijs et al.,
2005) and is suggested to be indicative for pectoralis minor
muscle length (Borstad & Ludewig, 2005). Overall, measurement of upward rotation by means of analogue inclinometers
reached very good intrarater reliability (ICC 5 0.88) (Watson
et al., 2005). The KMRT has been validated against dynamic
ultrasound (Morrissey, 2005). However, reliability data for the
KMRT are currently lacking. Cross-sectional comparison
showed similar overall validity and patient acceptability as
the UK version (Paul et al., 2004). Participants of that crosssectional comparison rated the Dutch version of the SDQ as

Fig. 3. Measurement of scapular upward rotation with two

inclinometers.

Fig. 4. Measurement of scapular motor control using the

KMRT.

812

SDQ
The SDQ covers 16 items to evaluate functional status
disability in athletes with shoulder disorders and is suggested
to be responsive and ready for use in clinical trials and
longitudinal studies (Van der Windt et al., 1998; Van der
Heijden et al., 2000). All 16 items describe a possible painprovocation during the last 24 h of the athletes daily activities.
The questionnaire is completed with yes, no or not applicable.
It is scored by the summation of all yes-answers, divided by all
answered questions (yes or no) and subsequently multiplied by
100. This results in a score between 0 (no disabilities) to 100
(very disabled). In this study, the Dutch version of the SDQ
was used.

Scapular positioning in overhead athletes

analysis, data were analyzed using SPSS version 12.0, for
Windows (SPSS Inc.).

best for the relevance to their shoulder problem (Paul et al.,

2004).

Statistical analysis

Results
Visual observation for tilting and winging

Means, standard deviations and ranges were calculated for all

measured and normalized data. A one-sample Kolmogorov
Smirnov goodness-of-t test was used to identify normal
distribution. The athletes painful shoulder is always compared with the same side in the pain-free group. An independent-samples t-test was used when analyzing the dierence
between the athletes with and without shoulder disorders for
the inclinometry and acromiontable (AT) distance. For
comparisons between the painful and pain-free shoulder
within the athletes with shoulder pain group, the paired
sample t-test and the chi-square test were used for the
parametric and non-parametric data, respectively. The chisquare test was used to identify dierences for the outcome of
the KMRT and observation protocol. The Pearson and
Spearman correlations were computed for examining associations between the scores of the SDQ, demographic features
and the clinical measures and between the clinical measures
mutually. Because the body length correlated with the measurement of the distance between the posterior border of the
acromion and the table, the data were adjusted for the body
length, creating an acromial distance index (i.e. the outcome of
the measurement of the distance between the posterior border
of the acromion and the table was divided by the body length
in cm and multiplied by 100). The scapulohumeral rhythm was
calculated by dividing the total humeral elevation by the
scapular upward rotation. Groups were matched for age,
gender and BMI without the knowledge of other outcome
measures. Data were analyzed using SPSS version 12.0, for
Windows (SPSS Inc., Chicago, Illinois, USA). The power
analysis was performed using SigmaStat 3.1 (Systat Software
Inc., San Jose, California, USA). Except for the power

The observation protocol for scapular tilting and

winging did not show signicant dierences between
the athletes with and without shoulder pain. Table 3
shows all observations for present or absent tilting
and winging. Within the group of athletes with
shoulder pain, tilting was found to be more present
on the painful side (12/36; 33%) then on the pain-free
side (8/36; 22%) (Po0.01). Winging was found to
more present on the pain-free side (5/36; 14%) than
on the painful side (4/36; 11%) (Po0.01). No dierences were seen between men and women.

Forward shoulder posture (acromial distance)

The athletes with shoulder pain presented with a
mean AT-distance of 83.6  28 mm at rest and
53.8  22 mm during bilateral retraction. The athletes without shoulder pain presented with a mean
AT-distance of 84.9  25 mm at rest and
54.6  22 mm during bilateral retraction. Table 4
shows the results of the AT distance index [corrected
for BL (cm)  100] between athletes with and without shoulder pain. No signicant dierences were
found between groups or between men and women.
Within subgroup analysis did not show any signicant dierences in the AT-distance index.

Table 2. 117-point scale for scoring the kinetic medial rotation test

Correct pattern

Score
A-list
(0 or 1)

Compensation
scapular

Efficiency

Score
B-list
(0 or 1)

Scapular upward rotation (inclinometry)

When comparing scapular upward rotation between
the two groups using two inclinometers, no signicant dierences were found. Table 5 shows the results
of the upward scapular rotation during humeral
elevation in both groups. No signicant dierences
were found between men and women. However,
when analyzing the women only, the athletes with
shoulder pain did show a signicant loss of upward
rotation (351) compared with the pain-free women
(421) (P 5 0.049).

Difficulty breathing
Difficult to perform
No movement
possible (601)
Fatigue
Extra feedback needed
External support needed
Glenohumeral
compensation

Sum

/1

/7

Table 3. Observation of winging and tilting of the scapula between case and control

Observation

Winging
Tilting

Present
Absent
Present
Absent

Athletes with shoulder pain

Painful side (A)

Pain-free side (B)

A-matched side

B-matched side

4
32
12
24

5
31
8
28

5
31
10
26

5
31
6
30

(11%)
(89%)
(33%)
(67%)

(14%)
(86%)
(22%)
(78%)

(14%)
(86%)
(27%)
(72%)

(14%)
(86%)
(17%)
(83%)

813

Struyf et al.
Scapular motor control (KMRT)

Visual observation for tilting and winging

Table 6 shows the positive KMRT scores in both

athletes with and without shoulder pain.
No signicant dierence was found between
groups. Within the shoulder pain group, 77%
(n 5 10) of the positive MRT scores were on the
painful side, in contrast to 23% (n 5 3) on the painfree side (P 5 0.017). No signicant dierences were
noted between the left or right shoulder within the
pain-free subgroup (data not shown). No signicant
dierences were observed between men and women.

First, tilting appears to be more present on the

painful side and winging on the asymptomatic side.
This nding reinforces earlier research in which it has
been shown that subjects with a protracted scapula
(or short pectoralis minor muscle length) demonstrate similar scapular positioning as subjects with
shoulder impingement syndrome (Solem-Bertoft
et al., 1993; Lukasiewicz et al., 1999; Ludewig &
Cook, 2000; Borstad & Ludewig, 2005). In addition,
both tilting and AT-distance are suggested to be
indicative for pectoralis minor muscle length (Borsa
et al., 2003; Nijs et al., 2005). Scapular asymmetry in
the sagittal plane (increased scapular tilting) was
previously seen in patients with the shoulder impingement syndrome between their asymptomatic and
symptomatic shoulders (Lukasiewicz et al., 1999).
However, when comparing dominant vs non-dominant shoulder, these dierences signicantly reoccur.
This reinforces the results from a recent study in
healthy overhead athletes, which concluded that the
dominant-side scapula was more anteriorly tilted
than the non-dominant-side scapula (Oyama et al.,
2008). We need to recognize that scapular asymmetry

Discussion
This casecontrol study highlights several interesting
aspects of the clinical evaluation of scapular positioning and scapular motor control. Although the
clinical assessment protocol was not able to identify
statistically signicant dierences in scapular positioning or motor control between athletes with or
without shoulder pain, there appear to be some
signicant dierences between the athletes symptomatic and asymptomatic shoulder.

Table 4. Measurement of forward shoulder posture (acromial distance index) corrected with body length

AT distance (relaxed)
AT distance (retracted)

Case vs control

Mean [(cm/BL)  100]

SD [(cm/BL)  100]

Power

Pain-free athletes
Athletes with shoulder pain
Pain-free athletes
Athletes with shoulder pain

36
35
36
35

4.77
4.70
3.07
3.04

1.45
1.54
1.20
1.26

0.863
0.913

SD, standard deviation; AT, acromiontable.

Table 5. Scapular upward rotation (inclinometry) during humeral elevation between the different groups

Case vs control
Scapular upward rotation at rest
Scapular upward rotation at 451 humeral abduction
Scapular upward rotation at 901 humeral abduction
Scapular upward rotation at 1351 humeral abduction
Maximal scapular upward rotation
Ratio phase 1
Ratio phase 2
Ratio phase 3
Ratio phase 4
Overall gh/st ratio

SD, standard deviation.

814

Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder
Pain-free athletes
Athletes with shoulder

pain
pain
pain
pain
pain
pain
pain
pain
pain
pain

Mean (1)

SD (1)

Power

36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36

7.72
8.53
3.08
3.75
9.08
8.94
24.64
23.61
39.44
37.22
16.13
16.15
5.35
5.55
3.41
4.29
4.96
3.78
3.66
3.81

6.68
7.00
7.39
7.27
7.37
9.15
8.90
9.25
10.46
9.68
15.19
1.83
5.51
8.37
1.57
3.77
8.56
4.91
0.82
0.99

0.662
0.721
0.94
0.67
0.53
0.99
0.91
0.51
0.58
0.59

Scapular positioning in overhead athletes

The AT-distance measurements are put into perspective with the body length. Our results are in line with
the normative data presented in a previous study on
the AT-distances relative to the body length in 105
healthy subjects (Struyf F, Nijs J, Horsten S, Mottram S, Meeusen R, unpublished observation).
Adults presented with a mean AT-distance (corrected
to BL) of 4.12 cm/cm and 2.67 cm/cm for the relaxed
and retracted position, respectively, while the present
study showed a mean AT-distance of 4.77 cm/cm and
3.07 cm/cm. When we address non-relative distances,
our results are slightly higher than a previous study
in patients with shoulder pain. Nijs et al., (2005)
reported a mean (relaxed) AT-distance of 7.2 vs
4.6 cm during retraction. Our results are approximately 1.0 cm larger, which could be due to the study
population. More specic, Nijs and colleagues implemented a sample of convenience of 29 patients,
mainly recruited in private practices for physical
therapy, while our study included overhead athletes.
The repetitive movements performed by overhead
athletes may increase the AT-distance and hence
trigger forward shoulder posture. This might increase
the risk for developing shoulder disorders among
overhead athletes.

[mean (SD) 5 37.21 (9.71) vs 501 (4.81) in the

McClures study]. Although overhead athletes constantly perform activities which require sucient
upward scapular rotation, they demonstrate less
upward rotation. Although the athletes without
shoulder pain did not report any pain, these results
might indicate that they are at increased risk for
developing shoulder problems.
Controversy still exists about the overall ratio of
glenohumeral to scapulothoracic (gh/st) movement
(Freedman & Munro, 1966; Poppen & Walker, 1976;
McQuade & Smidt, 1998; Johnson et al., 2001). First,
most studies assume a 01 starting position of the
humerus, whereas others actually measure the resting
position. Second, dierences in measurement techniques and methodology can create a wide range of
reported ratios. Finally, the comparison across different studies is dicult due to inter-individual
variability. The mean ratio of glenohumeral to scapulothoracic motion in the athletes with shoulder
pain was 3.8:1 in our study vs 1.7:1 (McClure et al.,
2001) and 2.1:1 (Graichen et al., 2001) in other
studies. The study of McClure implemented healthy
subjects, whereas Graichen also examined patients
with shoulder impingement syndrome. Previous research in patients with atraumatic shoulder instability demonstrate similar results with an increased
ratio in the patient group (Von Eisenhart-Rothe
et al., 2005). The implementation of subjects with
shoulder pain appears to increase the gh/st ratio.
No signicant dierences were noted between men
and women. Surprisingly, when analyzing women
only, the athletes with shoulder pain showed a
signicant loss of upward rotation in comparison
to pain-free women. In contrast, earlier research of
160 healthy men and women did not nd any
signicant dierences between men and women on
shoulder posture variations (Raine & Twomey,
1997). One explanation for this discrepancy could
be the inuence of shoulder pain. Based on these
observations, it is postulated that shoulder pain
manifests dierently in men and women. Further
study is required to examine this issue.

Scapular upward rotation (inclinometry)

Scapular motor control (KMRT)

Third, inclinometry for measuring scapular upward

rotation did not reveal any signicant dierences
between both groups or between the symptomatic
and asymptomatic shoulder. These observations are
in line with previous studies (Lukasiewicz et al., 1999;
Graichen et al., 2001; Hebert et al., 2002). As
suggested by Lukasiewicz et al. (1999), this could
be caused by the faulty use of neuromuscular strategies in both shoulders. Compared with the study of
McClure et al. (2001), our athletes with shoulder pain
attained lower degrees of scapular upward rotation

Finally, this study also addressed scapular motor

control. The KMRT did not show signicant dierences between both groups, but there were some strong
signicant dierences between the painful shoulder
and the pain-free shoulder within the athletes with
shoulder pain subgroup. More than three-quarters of
the impaired subgroup demonstrated with positive
scores on their symptomatic side. However, poor
scapular motor control was prevalent among the
athletes without shoulder disorders as well, possible
explaining the lack of signicant dierences in motor

Table 6. Positive KMRT scores

Pain-free athletes

Athletes with
shoulder pain

10/36 (28%)

13/36 (26%)
On painful side: 10/36
On pain-free side: 3/36

P 5 0.017

in healthy overhead athletes often occurs. However,

as tilting is related to shoulder impingement syndrome, we suggest assessing the scapula for this
asymmetry is needed in order to create a baseline
evaluation of the athlete.
Forward shoulder posture (acromial distance)

815

Struyf et al.
control between the two groups. The athletes without
shoulder disorders are all performing overhead activities and have therefore an increased risk for developing shoulder disorders. In addition, the KMRT was
validated in a sample of convenience of normal subjects (Morrissey et al., 2008). However, baseball pitchers, tennis and handball players have been repeatedly
found to have an increased range of external rotation
with a corresponding decreased range of internal
rotation in their throwing shoulder compared with
the contralateral shoulder when assessed at 901 of
abduction (Borsa et al., 2008). This could have caused
extra positive scores on the KMRT in both case and
control group. Likewise, this could have increased the
side-to-side dierences.
Except for the KMRT and the visual observation
during humeral elevation, an important limitation of
this study is that in the main outcome measures only
statically held positions were used rather than dynamic motion. Statically held positions may not
represent functional movement patterns. Secondly,
no identication of the type of shoulder disorder was
performed in this study. Pain, as the only inclusion
criteria, may neglect relevant dierences between the
various shoulder disorders. More specically, the
most frequently seen shoulder pathologies are accompanied with dierent scapular motion patterns
(Ludewig et al., 2009). While patients with shoulder
impingement syndrome, rotator cu diseases or
glenohumeral joint instability are accompanied with
a reduced scapular upward rotation, patients with
adhesive capsulitis show an increase in upward rotation. Additionally, patients with shoulder impingement syndrome or rotator cu diseases can show less
posterior tilting, while no evidence for this alteration
is found in patients with other shoulder pathologies.
Future study should include dierentiation of
shoulder pathologies.
As the athletes age ranged from 18 to 60 years, it is
possible that age dierences alter scapular positioning and motor control. Although no dierences in
scapular positioning were noted between unimpaired
adults, clinicians should be aware of the decreasing
muscular system during aging. Since the scapular
muscular system is the major contributor to scapular
positioning, dierences in scapular positioning and

motor control in adults may exist (Dayanidhi et al.,

2005; Nijs et al., 2005).
The majority of researchers in the eld apply
expensive and specialized equipment for assessing
scapular positioning. In contrast, the results obtained
in this study were all gathered with clinical tests.
Although three-dimensional electromagnetic tracking systems allow us to increase scapular assessment
accuracy, the use of these measurement tools in the
clinic are limited. However, our methods of measuring scapular motion should be validated against
accurate motion analysis. Finally, the ndings from
this study can only be generalized to inter-individual
dierences in athletes who compete in overhead
sports.
Perspectives
This study puts extra emphasis on the clinical evaluation of overhead athletes with various shoulder
disorders. Scapular asymmetry in the sagittal plane,
observed visually as tilting and a lack of scapular
motor control are highly related to the athletes
shoulder pain. Both observation of tilting and the
KMRT are therefore suggested to be discriminative
in distinguishing symptomatic and asymptomatic
shoulders. Future research needs to be directed to
unravelling the basic mechanisms that control the
scapular motion and study the eects of various
treatment methods in patients with a variety of
shoulder pathologies.
Key words: scapula, athletes, clinical, assessment,
pain.

Acknowledgements
This study was nancially supported by a research grant
(G826) provided by the Department of Health Sciences,
Artesis University College Antwerp, Antwerp, Belgium.
We certify that no party having a direct interest in the
results of the research supporting this article has or will confer
a benet on us or on any organization with which we are
associated.
The study protocol was reviewed and approved by the
medical ethics committee of the University Hospital Brussels
(2006/137).

References
Atalar H, Yilmaz C, Polat O, Selek H,
Uras I, Yanik B. Restricted scapular
mobility during arm abduction:
implications for impingement
syndrome. Acta Orthop Belgica 2009:
75: 1924.

816

Borsa PA, Laudner KG, Sauers EL.

Mobility and stability adaptations in
the shoulder of the overhead athlete: a
theoretical and evidence-based
perspective. Sports Med 2008: 38: 17
36.

Borsa PA, Timmons MK, Sauers EL.

Scapular-positioning patterns during
humeral elevation in unimpaired
shoulders. J Athl Train 2003: 38: 1217.
Borstad JD, Ludewig PM. The eect
of long versus short pectoralis

Scapular positioning in overhead athletes

minor resting length on scapular
kinematics in healthy individuals.
J Orthop Sports Phys Ther 2005: 35:
227238.
Brossmann J, Preidler KW, Pedowitz RA,
White LM, Trudell D, Resnick D.
Shoulder impingement syndrome:
inuence of shoulder position
on rotator cu impingement
an anatomic study. Am Roentgen
Ray Soc 1996: 167: 15111515.
Comerford MJ, Mottram SL. Movement
and stability dysfunction
contemporary developments. Man
Ther 2001: 6: 1526.
Cools AM, Witvrouw EE, Declercq GA,
Danneels LA, Cambier DC. Scapular
muscle recruitment patterns: trapezius
muscle latency with and without
impingement symptoms. Am J Sports
Med 2003: 31: 542549.
Cools AM, Witvrouw EE, Declercq GA,
Vanderstraeten GG, Cambier DC.
Evaluation of isokinetic force
production and associated muscle
activity in the scapular rotators during
a protractionretraction movement in
overhead athletes with impingement
symptoms. Br J Sports Med 2005: 38:
6468.
Dayanidhi S, Orlin M, Kozin S, Du S,
Karduna A. Scapular kinematics
during humeral elevation in adults and
children. Clin Biomech 2005: 20:
600606.
Ebaugh DD, McClure PW, Karduna AR.
Eects of shoulder muscle fatigue
caused by repetitive overhead activities
on scapulothoracic and glenohumeral
kinematics. J Electromyo Kinesiol
2006: 16: 224235.
Endo K, Yukata K, Yasui N. Inuence of
age on scapulo-thoracic orientation.
Clin Biomech 2004: 19: 10091013.
Freedman L, Munro RR. Abduction of
the arm in the scapular plane: scapular
and glenohumeral movements. J Bone
Joint Surg 1966: 48: 15031510.
Graichen H, Stammberger T, Bonel H,
Wiedemann E, Englmeier K-H, Reiser
M, Eckstein F. Three-dimensional
analysis of shoulder girdle and
supraspinatus motion patterns in
patients with impingement syndrome. J
Orthop Res 2001: 19: 11921198.
Green S, Buchbinder R, Forbes A,
Bellamy N. Standardized protocol for
measurement of range of movement
of the shoulder using the Plurimeter-V
inclinometer and assessment
of its intrarater and interrater
reliability. Arthr Care Res 1998: 11:
4352.
Hebert LJ, Moet H, McFadyen BJ,
Dionne CE. Scapular behaviour
shoulder impingement syndrome.
Arch Phys Med Rehabil 2002: 83:
6069.

Host HH. Scapular taping in the

treatment of anterior shoulder
impingement. Phys Ther 1995: 75:
803812.
Johnson MP, McClure PW, Karduna
AR. New method to assess scapular
upward rotation in subjects with
shoulder pathology. J Orthop Sports
Phys Ther 2001: 31: 8189.
Karduna RA, McClure PW, Michener
LA, Sennet B. Dynamic measurement
of three-dimensional scapular
kinematics, a validation study. J
Biomech Eng 2001: 123: 184190.
Lewis J, Green A, Reichard Z, Wright C.
Scapular position: the validity of skin
surface palpation. Man Ther 2002: 7:
2630.
Ludewig PM, Cook TM. Alterations in
shoulder kinematics and associated
muscle activity in people with
symptoms of shoulder impingement.
Phys Ther 2000: 80: 276291.
Ludewig PM, Phadke V, Braman JP,
Hassett DR, Cieminski CJ, LaPrade
RF. Motion of the shoulder complex
during multiplanar humeral elevation.
J Bone Joint Surg Am 2009: 91: 378
389, doi: 10.2106/JBJS.G.01483.
Lukasiewicz AC, McClure P, Michener L,
Pratt N, Sennet B. Comparison of
3-dimensional scapular position and
orientation between subjects with and
without shoulder impingement. J
Orthop Sports Phys Ther 1999: 29:
574586.
McClure P, Tate AR, Kareha S, Irwin D,
Zlupko E. A clinical method for
identifying scapular dyskinesis, part 1:
reliability. J Athl Training 2009: 44:
160164.
McClure PW, Michener LA, Karduna
AR. Shoulder function and 3dimensional scapular kinematics in
people with and without shoulder
impingement syndrome. Phys Ther
2006: 86: 10751090.
McClure PW, Michener LA, Sennett BJ,
Karduna AR. Direct 3-dimensional
measurement of scapular kinematics
during dynamic movements in vivo.
J Shoulder Elbow Surg 2001: 10:
269277.
McKenna L, Cunningham J, Straker L.
Inter-tester reliability of scapular
position in junior elite swimmers. Phys
Ther Sports 2004: 5: 146155.
McQuade KJ, Smidt GL. Dynamic
scapulohumeral rhythm: the eect of
external resistance during elevation of
the arm in the scapular plane. J Orthop
Sports Phys Ther 1998: 27: 125133.
Morrissey D. 2005. The development of
the kinetic medial rotation test of the
shoulder. PhD Thesis, University of
London.
Morrissey D, Morrissey MC, Driver W,
King JB, Woledge RC. Manual

landmark identication and tracking

during the medial rotation test of the
shoulder: an accuracy study using
three-dimensional ultrasound and
motion analysis measures. Man Ther
2008: 13: 529535.
Mottram S. Dynamic stability of the
scapula. Man Ther 1997: 2: 123131.
Mottram S. Dynamic stability of the
scapula1postscript in Beeton. Man
Ther Masterclasses Periph Joints 2003:
Chapter 1: 317.
Nijs J, Roussel N, Struyf F, Mottram S,
Meeusen R. Clinical assessment of
scapular positioning in patients with
shoulder pain: state of the art. J Manip
Phys Ther 2007: 30: 6975.
Nijs J, Roussel N, Vermuelen K,
Souvereyns G. Scapular positioning in
patients with shoulder pain: a study
examining the reliability and clinical
importance of 3 clinical tests. Arch
Phys Med Rehabil 2005: 86: 13491355.
Oyama S, Myers JB, Wassinger CA, Ricci
RD, Lephart SM. Asymmetric resting
scapular posture in healthy overhead
athletes. J Athl Train 2008: 43:
565570.
Paletta GA, Warner JJP, Warren RF,
Deutsch A, Altchek DW. Shoulder
kinematics with two-plane x-ray
evaluation in patients in anterior
instability or rotator cu tearing.
J Shoulder Elbow Surg 1997: 6: 516527.
Paul A, Lewis M, Shadforth MF, Croft
PR, Van den Windt DAWM, Hay EM.
A comparison of four shoulder-specic
questionnaires in primary care. Ann
Rheum Dis 2004: 63: 12931299.
Poppen NK, Walker PS. Normal and
abnormal motion of the shoulder.
J Bone Joint Surg 1976: 58: 195201.
Raine S, Twomey LT. Head and
shoulder posture variations in 160
asymptomatic women and men. Arch
Phys Med Rehabil 1997: 78:
12151223.
Schmitt L, Snyder-Mackler L. Role of
scapular stabilizers in etiology and
treatment of impingement syndrome.
J Orthop Sports Phys Ther 1999: 29:
3138.
Smith J, Dietrich CT, Kotajarvi BR,
Kaufman KR. The eect of scapular
protraction on isometric shoulder
rotation strength in normal subjects.
J Shoulder Elbow Surg 2006: 15:
339343.
Solem-Bertoft E, Thuomas K,
Westenberg C. The inuence of
scapular retraction and protraction on
the width of the subacromial space.
Clin Orthop 1993: 296: 99103.
Struyf F, Nijs J, De Coninck K, Giunta
M, Mottram S, Meeusen R. Clinical
assessment of scapular positioning in
musicians: an inter-tester reliability
study. J Athl Train 2009: 44: 519526.

817

Struyf et al.
Tate AR, McClure P, Kareha S, Irwin D,
Barbe MF. A clinical method for
identifying scapular dyskinesis, part 2:
validity. J Athl Train 2009: 44: 165173.
Van der Heijden GJMG, Leers P,
Bouter LM. Shoulder disability
questionnaire design and responsiveness of a functional status measure.
J Clin Epidem 2000: 53: 2938.
Van der Windt DAWM, van der Heijden
GJMG, de Winter AF, Koes BW,
Deville W, Bouter LM. The
responsiveness of the shoulder

818

disability questionnaire. Ann Rheum

Dis 1998: 57: 8287.
van Wilgen CP. 2004. Morbidity
after neck dissection in head and
neck cancer patients. A study
describing shoulder and neck
complaints, and quality of life. PhD
thesis, Rijksuniversiteit Groningen,
1011.
van Wilgen CP, Dijkstra PU, van der
Laan BFAM, Plukker JT, Roodenburg
JLN. Shoulder complaints after neck
dissection; is the spinal accessory nerve

involved? Br J Oral Maxillofacial Surg

2003: 41: 711.
Von Eisenhart-Rothe R, Matsen FA,
Eckstein F, Graichen H.
Pathomechanics in atraumatic
shoulder instability: scapular
positioning correlates with humeral
head centering. Clin Orthop Relat Res
2005: 433: 8289.
Watson L, Balster SM, Finch C, Dalziel
R. Measurement of scapula upward
rotation: a reliable clinical procedure.
Br J Sports Med 2005: 39: 599603.