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Clinical Assessment of Scapular Positioning in Patients With Shoulder Pain, State of The Art
Clinical Assessment of Scapular Positioning in Patients With Shoulder Pain, State of The Art
IN
Jo Nijs, PhD, MSc, MT, PT,a Nathalie Roussel, PT, MT,b Filip Struyf, PT,c
Sarah Mottram, MSc,d and Romain Meeusen, PhD, PT e
a
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.
b
Teacher, Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Belgium.
c
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.
d
Founding Director, Kinetic Control, Ludlow, Shropshire,
United Kingdom.
e
Professor and department head, Department of Human
Physiology and Sports Medicine, Faculty of Physical Education
and Physiotherapy, Vrije Universiteit Brussel, Belgium.
Submit requests for reprints to: Jo Nijs, PhD, MSc, MT, PT,
Campus HIKE, Departement G, Hogeschool Antwerpen, Van
Aertselaerstraat 31, B-2170 Merksem, Belgium
(e-mail: j.nijs@ha.be).
Paper submitted May 22, 2006; in revised form August 8, 2006;
accepted August 24, 2006.
0161-4754/$32.00
Copyright D 2007 by National University of Health Sciences.
doi:10.1016/j.jmpt.2006.11.012
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Table 1. Overview of the reliability data of clinical tests for the assessment of scapular positioning
Test
Posterior acromion,
table relaxed
Posterior acromion,
table retraction
Medial scapular border,
T4 relaxed
Medial scapular border,
T4 retraction
Medial scapular
border, T3
LSST position 1
LSST position 2
LSST position 3
Scapular distance
Scapula upward
rotation
Peterson
et al26
DiVeta
et al27
Gibson
et al23
Nijs
et al24
Odom
et al29
McKenna
et al31
0.79
0.45
0.57
0.65-0.74
0.79-0.82
0.20-0.57
Watson
et al32
Johnson
et al33
0.81-0.94a
0.89-0.96a
0.88-0.94
0.92-0.91
0.50-0.79
0.70-0.80
.91a
0.82-0.96
0.85-0.95
0.70-0.85
0.94a
0.91-0.92
Unless indicated (superscript baQ), intraclass correlation coefficients are provided to indicate the interobserver reliability.
DISCUSSION
There is evidence suggesting that scapular positioning is
abnormal in patients with shoulder impingement syndrome,2
symptoms of impingement,10,11 atraumatic shoulder instability,12 multidirectional shoulder joint instability,13 and
shoulder pain after neck dissection in cancer patients.14,15
As no longitudinal study has yet been reported, it is not
known if abnormal scapular positioning is a cause or
consequence of shoulder pain or a secondary phenomenon
caused by shoulder pain. In addition to the evidence from
case-control studies, physiotherapy targeting the scapulothoracic muscles was found effective in patients with
subacromial impingement syndrome,16 and conservative
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Scapular Positioning in Shoulder Pain
treatments consisting of stretching and strengthening exercises targeting scapulothoracic muscles were able to
improve scapular positioning in asymptomatic subjects.35,36
Although it seems plausible, there is currently no evidence
to show that assessing scapular positioning helps with the
diagnosis or treatment of patients with shoulder pain. Future
studies should address this issue.
Clinicians are able to incorporate the available research
data in their daily practice by interpreting the observation of
static and dynamic scapular positioning pattern, including
scapular rhythm, in relation to the relevant research data.
From the literature overview presented here, it can be
concluded that clinicians can use reliable tests for the
assessment of both static and dynamic scapular positioning
in patients with shoulder disorders. For the measurement of
static scapular positioning, the measurement of the distance
between the posterior border of the acromion and the table,
the measurement of the distance from the medial scapular
border to the third thoracic spinous process, and the assessment of the dscapular distanceT 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 patients shoulders in
active shoulder retraction, has been shown to have sufficient
interobserver reliability. Apart from the study supporting the
criterion validity of the assessment of the distance from the
medial scapular border to the third thoracic spinous process,26
the authors of the present article are unaware of studies
addressing the validity of clinical tests for the assessment of
static scapular positioning in patients with shoulder disorders.
A clinical test should be both reliable and valid. If a test is not
valid, then it is useless, regardless of whether it is reliable. For
the measurement of dynamic scapular positioning, studies
examining the reliability of the LSST were inconclusive, but
the test was shown to have criterion validity. The 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
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CONCLUSION
Scientific evidence supporting a role for faulty scapular
positioning in patients with various shoulder disorders are
accumulating. From a clinical point of view, it seems
essential to have the skills to assess static and dynamic
scapular positioning. Based on biometric and kinematic
studies, an overview of the observation of static and
dynamic scapular positioning pattern in patients with
shoulder pain was provided. At this point, clinicians can
use reliable clinical tests for the assessment of both static
and dynamic scapular positioning in patients with shoulder
pain, and some data supportive of the validity of the tests
have been provided.
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 (bA study examining static and
dynamic preventive factors for injuries in dancersQ) 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.
REFERENCES
1. Mottram SL. Dynamic stability of the scapula. Man Ther 1997;
2:123-31.
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