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An evidence-based review on the validity of the Kaltenborn rule as applied to

the glenohumeral joint

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 ARTICLE IN PRESS

Manual Therapy 12 (2007) 3–11

www.elsevier.com/locate/math

Review

An evidence-based review on the validity of the Kaltenborn rule as

applied to the glenohumeral joint
Corlia Brandta,, Gisela Soleb, Maria W. Krausea, Mariette Nelc
a
Department of Physiotherapy, Faculty of Health Sciences, University of the Free State, South Africa
b
Musculoskeletal and Sports Physiotherapy, School of Physiotherapy, University of Otago, New Zealand
c
Department of Biostatistics, Faculty of Health Sciences, University of the Free State, South Africa
Received 25 January 2005; received in revised form 26 January 2006; accepted 15 February 2006

Abstract

Kaltenborn’s convex–concave rule is a familiar concept in joint treatment techniques and arthrokinematics. Recent investigations
on the glenohumeral joint appear to question this rule and thus accepted practice guidelines. An evidence-based systematic review
was conducted to summarize and interpret the evidence on the direction of the accessory gliding movement of the head of the
humerus (HOH) on the glenoid during physiological shoulder movement. Five hundred and eighty-one citations were screened.
Data from 30 studies were summarized in five evidence tables with good inter-extracter agreement. The quality of the clinical trials
rated a mean score of 51.27% according to the Physiotherapy Evidence Database scale (inter-rater agreement: k ¼ 0:6111).
Heterogeneity among studies precluded a quantitative meta-analysis. Weighting of the evidence according to Elwood‘s classification
and the Agency for Health Care Policy and Research classification guidelines indicated that evidence was weak and limited. Poor
methodological quality, weak evidence, heterogeneity and inconsistent findings among the reviewed studies regarding the direction
of translation of the HOH on the glenoid, precluded the drawing of any firm conclusions from this review. Evidence, however,
indicated that not only the passive, but also the active and control subsystems of the shoulder may need to be considered when
determining the direction of the translational gliding of the HOH. The indirect method, using Kaltenborn’s convex–concave rule as
applied to the glenohumeral joint, may therefore need to be reconsidered.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Glenohumeral; Translational glide; Evidence-based; Kaltenborn

Contents

1. Introduction/background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2. Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2.1. The search strategy and data selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2.2. Quality assessment of the clinical trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.4. Weighting of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
3.2. Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
3.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
3.4. Level of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Corresponding author. P.O. Box 339 (G30), Bloemfontein 9300, South Africa. Tel: +51 4013297; fax: +51 4013290.
E-mail address: gnftcb.md@mail.uovs.ac.za (C. Brandt).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2006.02.011
 ARTICLE IN PRESS
4 C. Brandt et al. / Manual Therapy 12 (2007) 3–11

4. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
4.1. Methodological quality of the clinical trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
4.2. The evidence on the arthrokinematics of the glenohumeral joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
4.3. Relating the findings to Kaltenborn‘s rule and theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
4.4. Implications and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
4.5. Limitations of this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1. Introduction/background Kaltenborn and Evjenth (1989) thus based the clinical

Dysfunction of the shoulder girdle is one of the most
common musculoskeletal conditions to be treated in
primary care. Thirty-four per cent of the general
population may suffer from shoulder pain at least once
in their lifetime (Green et al., 2002). In addition to the
high incidence rate, shoulder dysfunction is often
persistent and recurrent (Winters et al., 1999).
Physiotherapy for shoulder dysfunction may include
manual therapy joint techniques to treat pain or stiffness.
Various approaches to treatment have been proposed,
such as the Maitland approach (Maitland, 1998), move-
ment with mobilization (Mulligan, 1999), and the
application of passive mobilization techniques following
the convex–concave rule (Kaltenborn and Evjenth, 1989).
The latter approach is based on direct and indirect
assessment of translational glides. Using the direct
method, the passive translational gliding movements
are performed by the therapist to the patient’s painful
and/or stiff joint to determine which direction may be
limited (Kaltenborn and Evjenth, 1989). Joint mobiliza-
tions would then be performed as a treatment method in
the decreased direction to restore normal movement.
The indirect method of determining the direction of
translational glide was termed the ‘‘Kaltenborn con-
vex–concave rule’’ (Kaltenborn and Evjenth, 1989). This
rule was first described by MacConaill (1953). Following
this method, the therapist examines active and passive
physiological movements such as flexion, extension,
abduction and lateral rotation (Kaltenborn and
Evjenth, 1989). The direction of the glide would then
be determined by considering the geometry of the
moving articular surfaces. In the glenohumeral joint,
the glenoid fossa (concave surface) was considered to be
stable (fixed) while the humeral head (convex surface)
would be moved (mobilized) during a physiological
shoulder movement. According to the convex–concave
rule, the convex surface (humeral head) would glide
in the opposite direction to the bone movement.
Thus, during abduction of the arm, the humeral head
would glide caudally. Kaltenborn and Evjenth (1989)
proposed that for restricted shoulder extension and
lateral rotation, the humeral head should be glided
ventrally (anteriorly), and for restricted flexion and
medial rotation, the humeral head should be glided
dorsally (posteriorly).
reasoning of appropriate direction of translational glide
mainly on the anatomy of the osseous articulating
surfaces. More recently it has been suggested that other
factors, such as the concept of functional stability
(Panjabi, 1992), may also need to be considered in the
assessment of the arthrokinematics of the glenohumeral
joint (Hess, 2000). The question thus arose whether the
convex–concave rule is valid in the clinical reasoning of the
most appropriate direction of translational glide applied in
the assessment and treatment of shoulder dysfunction.
The aim of this study was to investigate the evidence
on the arthrokinematics of the glenohumeral joint
supporting or negating the validity of the MacConaill
and Kaltenborn rule and theory.
2. Methodology
2.1. The search strategy and data selection
An academic, computerized search was conducted.
CINAHL, MEDLINE, The Cochrane Controlled trials
register of randomized controlled trials, Kovsiedex,
South African Studies and Sport Discussion were
searched from 1966 to October 2003. The search was
limited to English and human studies. Keywords such as
shoulder, glenohumeral, kinematics, arthrokinematics,
mechanics, translation(al), roll(-ing) and/or glide(-ing),
accessory movement, and Kaltenborn were optimally
combined. The search was continued over a period of
ten months (Hoepfl, 2002).
The titles and the abstracts of the retrieved citations
were screened for relevance by the primary investigator.
The reference lists of the relevant articles were checked
by one reviewer to identify additional publications. Five
clinical experts in the field of shoulder orthopaedics were
also contacted in order to retrieve data (Oxman et al.,
1994; Mays and Pope, 1999; Green et al., 2002; Tugwell
et al., 2003).
The second screening consisted of the blinded assess-
ment of the full papers’ Method and Results sections by
two independent reviewers. The reports were numbered at
random and the authors‘ names and affiliations, the name
of the journal, the date of publication, and the acknowl-
edgements were erased to ensure blinded assessment. All
types of study designs were included in the systematic
 ARTICLE IN PRESS
C. Brandt et al. / Manual Therapy 12 (2007) 3–11
review to increase its clinical value (Mays and Pope, 1999;
Elwood, 2002; Hoepfl, 2002; Fritz and Cleland, 2003). In
vivo and in vitro studies were assessed. The investigated
population had to be human (male and/or female), a mean
age of 15 years or older, with or without shoulder
pathology. The study had to investigate a variable factor
regarding glenohumeral joint translation and had to
measure the direction of translation of the humeral head
on the glenoid fossa during normal or simulated, active or
passive physiological shoulder movement. The reviewers
decided upon inclusion by means of consensus (Oxman et
al., 1994; Jadad et al., 1996).
Data were extracted from the included reports and
summarized on a standardized data collection form by
two independent, masked reviewers. The form provided
for the gathering of information on the study design,
subgroups, exposure or intervention, study population,
research methodology, data analysis, main results,
hypotheses, and any other relevant data (Oxman et al.,
1994; Elwood, 2002; Scholten-Peeters et al., 2003;
Tugwell et al., 2003). The data were recorded (by means
of consensus) as stated in the report. Where data were
unclear and biased recording a possibility, it was clearly
indicated (Scholten-Peeters et al., 2003).
2.2. Quality assessment of the clinical trials
The quality of the clinical trials were assessed by means
of the 11-item Physiotherapy Evidence Database (PEDro)
scale which was developed by the Centre for evidence-
based Physiotherapy, University of Sydney. The PEDro
scale measures the internal validity and the sufficiency of
the statistical information provided by a clinical trial. The
scale assesses criteria such as random allocation, conceal-
ment of allocation, comparibility of groups at baseline,
blinding of patients, therapists and assessors, analysis by
intention to treat, adequacy of follow-up, between group
statistical comparisons, report of point estimates, and
measures of variability. Though the PEDro scale does not
usually assess the external validity of a trial, this item from
the Delphi list (upon which the PEDro scale is based), was
included in the assessment. Verhagen et al. (1998)
reported that external validity should form part of any
concept of quality (Verhagen et al., 1998; Woolf, 2000;
‘‘PEDro: frequently asked questions’’, 2003).
Two masked reviewers independently scored the quality
of the studies (Jadad et al., 1996; Moher et al., 1996;
Dickersin & Berline, 1997). Criteria were rated as yes when
they were clearly satisfied on reading of the report, as no
when an unbiased decision could be made that the criteria
were not satisfied, and as don’t know when the information
was insufficient or unclear and a biased decision possible.
Points were allocated for all the clearly satisfied items
(Verhagen et al., 1998; ‘‘PEDro: the PEDro scale’’, 2003).
The mean quality score, the total frequency results, as
well as the frequency results on each item were
5
calculated. A study was considered as high quality if it
satisfied at least 50% of the criteria (X5.5 points)
(Maher et al., 2003; Scholten-Peeters et al., 2003). The k
statistic and the 95% confidence level provided for
measurement of interobserver agreement (Maher et al.,
2003; Scholten-Peeters et al., 2003).
2.3. Meta-analysis
Clinical trials were considered for meta-analysis regard-
less of their quality score in order to reduce bias (Guyatt et
al., 1995; Woolf, 2000). The following study characteristics
were compared by two independent reviewers in order to
identify the possibility of statistical pooling of results: (i)
the study populations, (ii) the interventions, (iii) the sample
sizes, (iv) the availability and format of the results, (v) the
statistical methodology used for analysis, and (vi) the
hypotheses tested (Dickersin and Berline, 1997).
2.4. Weighting of the evidence
The strength of the scientific evidence was rated by two
analysts according to two classification systems (Moher
et al., 1996; Elwood, 2002; Mays and Pope, 2002) namely,
(i) a hierarchy of evidence (Table 1) relevant to human
health studies (Elwood, 2002) and (ii) the modified
classification of the Agency for Health Care Policy and
Research (AHCPR) guidelines (Table 2) on acute low
back problems in adults (Ejnisman et al., 2002).
3. Results
3.1. Study characteristics
Fig. 1 depicts the results yielded by the search and
selection process. Eighteen clinical trials, seven compara-
tive, and five descriptive studies were included in the
review. Summary of the data indicated major methodolo-
gical heterogeneity. Researchers used various protocols
and measuring instruments such as magnetic tracking
devices or position sensors (n ¼ 11), three-dimensional
magnetic resonance imaging (n ¼ 4), computertomogra-
phy (n ¼ 3), ultrasonic devices (n ¼ 2), potentiometers
(n ¼ 3), radiographs (n ¼ 6), and arthroscopy (n ¼ 1) for
investigation. Eleven studies were conducted in vivo and
19 in vitro. Movements were either done passively (n ¼ 15)
or actively (n ¼ 14); simulated, static or continuous, while
the plane of motion also varied. Data were gathered on
eight different physiological movements performed
through a variety of ranges of motion. The movements
of active flexion, active extension, and passive horizontal
extension were not included in any investigation.
The literature indicated six main factors to explain
the translational behaviour of the humeral head namely,
the influence of (i) the capsulo-ligamentous structu-
res (n ¼ 17), (ii) neuromuscular control (n ¼ 17),
 ARTICLE IN PRESS
6 C. Brandt et al. / Manual Therapy 12 (2007) 3–11

Table 1
Elwood’s hierarchy of evidence

Level Definition of type of evidence

1 Randomized intervention trials, properly performed on an adequate number of subjects, in a human situation.
1m Results from a meta-analysis of trials.
1s One or more individual trials.
2 Observational studies, namely cohort and case–control designs, of appropriately selected groups of subjects.
2m Results from a meta-analysis of such studies.
2s One or more individual studies.
3 Comparative studies that compares groups of subjects representative of different populations or subject groups. For example:
correlation studies of populations in which data on each individual are not assessed separately and informal comparisons between
patients.
4 Case series, descriptive studies, professional experience. The evidence is largely anecdotal, unsystematically recollected (for example
‘‘clinical judgement’’ and ‘‘experience’’), conclusions based on traditional practice, information derived from other species, in vitro
testing, basic physiological principles and indirect assessments.

Table 2
The modified classification of the AHCPR guidelines on acute low back problems in adults

Level Definition of type of evidence

A Strong research-based evidence provided by generally consistent findings in multiple (more than one) high-quality randomized
clinical trial (RCT).
B Moderate research-based evidence provided by generally consistent findings in one high-quality RCT and one or more low-quality
RCT, or generally consistent findings in multiple low quality RCTs.
C Limited research-based evidence provided by one RCT (either high or low quality) or inconsistent or contradictory evidence
findings in multiple RCTs.
D No research-based evidence: no RCTs.

(iii) articular geometry/congruency/conformity (n ¼ 8),
(iv) negative intra-articular pressure (n ¼ 4), (v) rigidi-
fication of musculature (n ¼ 1), and (vi) gravity (n ¼ 1).
Agreement between the reviewers were 100% for the
data extracted on the sample and methodological
characteristics. Disagreement occurred only on the
study design in two of the studies which was resolved
by means of consensus.
3.2. Methodological quality
The mean PEDro score of the clinical trials equalled
51.27%. Table 3 summarizes the individual results. The
inter-rater agreement for quality assessment was poor
(k ¼ 0:611). This was confirmed by the 95% con-
fidence level of [0.8661;0.3562].
3.3. Meta-analysis
Heterogeneity among studies, insufficient reported
data, and poor study quality precluded statistical
pooling of results.
3.4. Level of the evidence
Twenty-five of the reviewed studies were analysed
qualitatively. Five studies were excluded due insufficient
information provided for classification purposes.
According to Elwood’s classification (Table 1), one
study fulfilled the criteria for level 2 s evidence, five
for level 3 and 19 studies for level 4 evidence. The
level 2 s evidence found (i) translation to be in the
opposite direction during active physiological move-
ment in pathological joints and (ii) the humeral
head to remain centered during active physiologi-
cal movement in normal joints (Paletta et al., 1997).
For all other stratified movement planes, only levels
3 and 4 evidence were found. Table 4 summar-
izes the amount and level of evidence found on the
direction of the translational movement of the humeral
head.
According to the AHCPR rating system (Table 2),
level C evidence is contradictory on the direction of
translation during active and passive lateral rotation in
901 of elevation in normal and reconstructed joints
(Karduna et al., 1997; Williams et al., 2001). Only
inconsistent, level D evidence could be found on the
translation occurring during physiological movements
in other planes.
Inclusion of only higher quality clinical trials (quality
score X54.5%) in the weighting of the evidence indu-
ced the following changes: according to Elwood‘s
classification, only level 4 evidence was now available,
while the level of evidence according to the AHCPR
rating system, remained unchanged.
 ARTICLE IN PRESS
C. Brandt et al. / Manual Therapy 12 (2007) 3–11 7

COMPUTER-BASED SEARCH
of databases: 555 citations

6 articles not available First screening: retrieved and

internationally read 56 articles

Articles included for quality

assessment = 11

21 articles were selected,

summarized, and data extracted

10 articles were excluded from

quality assessment because of
study design

REFERENCE CHECKING: 26
articles identified, 21 retrieved
and screened

5 articles not available

internationally

Articles included for quality

assessment = 7

9 articles were selected,

summarized, and data extracted
2 articles were excluded from
quality assessment because of
study design

RESPONSE FROM EXPERTS:

00 articles

Total relevant articles

reviewed = 30

Fig. 1.

4. Discussion results (to be discussed in the next section). According to

4.1. Methodological quality of the clinical trials
Analysis of the methodology used by some of the
included studies lead to serious concerns regarding the
biomechanical and neurophysiological validity of their
the PEDro scale, methodological shortcomings of the
clinical trials concerned mostly the insufficient reporting
of random allocation, insufficient reporting of conceal-
ment of allocation, and insufficient or unclear descrip-
tion of blinding of therapists and assessors. This may
indicate that many of the clinical trials were, in fact, not
 ARTICLE IN PRESS
8 C. Brandt et al. / Manual Therapy 12 (2007) 3–11

randomized, which may raise some concern regarding A quality score of 50–60% have been suggested as a
the appropriateness of the PEDro scale for assessing cut-off to distinguish between good and poor quality
these trials (Verhagen et al., 1998). It should be noted, studies (Maher et al., 2003; Scholten-Peeters et al.,
though, that poor reporting does not necessarily imply 2003). The mean quality score of 51.27% together with
that the criteria were not satisfied during the execution the poor inter-rater agreement (k ¼ 0:611) necessitated
of the trial (Elwood, 2002). careful consideration regarding the methodological
quality of the included clinical trials (Oxman et al.,
Table 3 1994; Elwood, 2002; Scholten-Peeters et al., 2003).
Summary of the quality scores of clinical trials The best approach when comparing the agreement
between two raters is to calculate the k statistic. Similar
Study Mean quality scores to other methods, such as McNemar’s test which was
(out of 11)
also calculated (0.3103), small frequency tables (in this
Level 2s evidence study n ¼ 30) present difficulties associated with the use
Paletta et al. 1997 5 and interpretation of kappa (Altman, 1996; Elwood,
Level 4 evidence 2002). The problem most cited is that the value of k
Karduna et al. (1997) 7
depends upon the proportion of subjects in each
Harryman et al. (1992) 6
Harryman et al. (1990) 6 category. Landis and Koch (1977), as well as Elwood
McMahon et al. (1995) 4.5 (2002), have characterized ranges of values for kappa
Gohlke et al. (1994) 6 with respect to the degree of agreement they suggest.
Vaesel et al. (1997) 5 Values greater than 0.75 may be taken to represent
Novotny et al. (1998) 4.5
excellent agreement beyond chance, values below 0.40
Williams et al. (2001) 6.5
Apreleva et al. (1998) 6 may be taken to represent poor agreement beyond
Wuelker et al. (1994) 6 chance, and values between 0.40 and 0.75 may be taken
Loehr et al. (1994) 5 to represent fair to good agreement beyond chance.
Karduna et al. (1996) 6
Thompson et al. (1996) 5
Helmig et al. (1993) 6
4.2. The evidence on the arthrokinematics of the
Wuelker et al. (1998) 6 glenohumeral joint
Debski et al. (1995) 5
Total mean score 5.64 The best evidence (level 2 s), as well as many of the
selected studies (n ¼ 17), supported the hypotheses of

Table 4
Levels of evidence

Physiological movement Direction of translation of humeral head

Same Opposite Centered Non-uniform

Active: normal joints n¼8 n¼2 n¼5 —

Level: 3 (n ¼ 1) Level: 3 (n ¼ 1) Level: 2s (n ¼ 1)
4 (n ¼ 7) 4 (n ¼ 1) 3 (n ¼ 1)
4 (n ¼ 3)
Level: C Level: C Level: D Level: D
Active: pathological joints n¼7 n¼3 n¼2 —
Level: 3 (n ¼ 1) Level: 2s (n ¼ 1) Level: 4 (n ¼ 2)
4 (n ¼ 6) 3 (n ¼ 1)
4 (n ¼ 1)
Level: C Level: C Level: D Level: D

Passive: normal joints n¼6 n¼2 n¼1 n¼4

Level: 3 (n ¼ 1) Level: 3 (n ¼ 1) Level: 4 (n ¼ 1) Level: 3 (n ¼ 1)
4 (n ¼ 5) 4 (n ¼ 1) 4 (n ¼ 3)
Level: C Level: C Level: D Level: D
Passive: pathological joints n¼7 n¼3 n¼1 n¼2
Level: 3 (n ¼ 1) Level: 4 (n ¼ 3) Level: 4 (n ¼ 1) Level: 3 (n ¼ 1)
4 (n ¼ 6) 4 (n ¼ 1)
Level: C Level: C Level: D Level: D

Levels of evidence are indicated according to Elwood’s classification system (normal print) and according to the AHCPR’s guidelines (in italics).
—, No evidence; n ¼ amount of studies.
 ARTICLE IN PRESS
C. Brandt et al. / Manual Therapy 12 (2007) 3–11
capsulo-ligamentous structures and neuromuscular con-
trol influencing the translation of the head of the
humerus (HOH). The capsulo-ligamentous structures
may be responsible for an obligatory translation of the
humeral head at the end range of motion when the
capsule and/or ligaments are tensioned. This was
especially observed during passive motion in the absence
of rotator cuff activity (Howell et al., 1988; Harryman
et al., 1990, 1992; Gohlke et al., 1994; Debski et al.,
1995; Karduna et al., 1996, 1997; Paletta et al., 1997;
Novotny et al., 1998; Rhoad et al., 1998; Baeyens et al.,
2000; Williams et al., 2001). During active movement the
stabilizing effect of the rotator cuff on the humeral head
causes a centring motion (Poppen and Walker, 1976;
Howell et al., 1988; Gohlke et al., 1994; Wuelker et al.,
1994, 1998; Debski et al., 1995; Karduna et al., 1996;
Thompson et al., 1996; Karduna et al., 1997; Paletta
et al., 1997; Apreleva et al., 1998; Rhoad et al., 1998;
Graichen et al., 2000; Williams et al., 2001; Von
Eisenhart-Rothe et al., 2002). Any loss of or defect in
the stabilizing mechanism of the shoulder joint may
increase or disrupt normal translational patterns,
depending on the involved structure and its role in the
gliding of the humeral head (Poppen and Walker, 1976,
1978; McGlynn and Caspari, 1984; Howell et al., 1988;
Ozaki, 1989; Harryman et al., 1990; Helmig et al., 1993;
Loehr et al., 1994; Debski et al., 1995; McMahon et al.,
1995; Deutsch et al., 1996; Thompson et al., 1996;
Karduna et al., 1997; Paletta et al., 1997; Apreleva et al.,
1998; Novotny et al., 1998; Wuelker et al., 1998;
Baeyens et al., 2000, 2001; Graichen et al., 2000; Von
Eisenhart-Rothe et al., 2002). Pain, muscle spasm, and
loss of proprioception associated with shoulder dysfunc-
tion may lead to neurophysiological responses. Imbal-
ance/incoordination of the shoulder musculature may
influence the translation of the humeral head (Poppen
and Walker, 1976; Wuelker et al., 1994, 1998; Bertoft,
1999; Graichen et al., 2000; Von Eisenhart-Rothe et al.,
2002).
In correllation with the original theory of MacConaill
and Kaltenborn, some studies did report that geome-
trical factors, such as the size of the humeral head, may
determine translation. Increased head size seems to
distension the capsule and thus reduce translation
(Vaesel et al., 1997; Rhoad et al., 1998).
To relate the findings of this review on the translational
direction of the humeral head to the Kaltenborn rule, the
best evidence will be considered (Elwood, 2002). The level
2 s evidence (quality score o50%) found translation to be
in the opposite direction during active horizontal
extension with lateral rotation and in the same direction
during active abduction in anterior unstable joints and
joints with rotator cuff tears. The humeral head remained
centred during active abduction in normal shoulder joints
(Paletta et al., 1997). According to the AHCPR
classification, level C evidence (n ¼ 2, quality scores
9
450%) were contradicting regarding the translational
direction during active and passive lateral rotation in 901
of elevation in normal and reconstructed joints (Karduna
et al., 1997; Williams et al., 2001).
Considering Table 4, interpretations with regards to the
convex–concave rule need to be made with caution due to
the following limitations: (i) the table is not representative
of all physiological movements since certain motion planes
were not investigated by any of the studies; (ii) findings
regarding the direction of translation were inconsistent for
different physiological motion planes, and (iii) hetero-
geneous shoulder pathologies were grouped together,
although these may affect translation in different manners
(Burkhart, 1994; Meister, 2000).
4.3. Relating the findings to Kaltenborn‘s rule and theory
Kaltenborn and MacConaill based their hypotheses
of normal and abnormal intra-articular dynamics on the
geometry of the articulating surfaces and location of the
movement axis alone (MacConaill, 1953; Kaltenborn
and Evjenth, 1989). The evidence indicates (i) different
arthrokinematic behaviour for normal and dysfunc-
tional joints and (ii) that not only the passive subsystem,
but also the active and control subsystems may
determine intra-articular gliding motion.
It appears that Kaltenborn’s rule for the treatment of
restricted joint motion may be valid if the intention of
the treatment is to stretch a tight capsulo-ligamentous
structure causing limitation of the physiological joint
motion. By gliding the humeral head in the opposite
direction of the restricted physiological bone movement,
the restricting capsulo-ligamentous structure may be
stretched. According to the evidence, however, this
motion performed by the therapist may not necessarily
mimic the true gliding taking place due to the tight
structure.
4.4. Implications and recommendations
Clinically authors postulate that the validity of the
Kaltenborn rule might not be accepted dogmatically.
The arthrokinematics of each patient might need to be
considered in the context of existing neuro-musculoske-
letal and biopsychosocial dysfunction which requires the
process of clinical reasoning. Scientifically such a
recommendation still lacks evidence.
Methodologically sound, randomized, clinically con-
trolled, in vivo, and homogeneous primary studies are
needed on this subject. As such studies emerge, this
review should be updated and reproduced. To ensure a
meta-analysis in future reviews, the following criteria
need to be considered: (i) movement should be classified
as active or passive, (ii) the plane and the range of
motion investigated should be similar, (iii) homogeneous
pathologies should be grouped, and (iv) measuring
 ARTICLE IN PRESS
10 C. Brandt et al. / Manual Therapy 12 (2007) 3–11
instruments, exposures or interventions, as well as the
hypotheses tested, should be similar.
4.5. Limitations of this review
Bias needs to be considered. Only one reviewer was
involved in the initial screening of the 555 citations. A
few articles could not be retrieved internationally and
attempts to retrieve unpublished literature yielded no
results.
Working with such considerable amounts of evidence
could not exclude the possibility of including multiple
publications from the same large trial. Careful inspec-
tion, though, did not reveal any such errors. Informa-
tion from papers concerning the same variables or
cohorts, may influence the quality rating of similar
papers later on. Earlier papers can provide the reviewers
with additional information on validity.
This review lacks statistical strength due to the
preclusion of a meta-analysis and the poor kappa value
calculated for inter-rater agreement. The findings should
be interpreted with caution due to the limitations of a
qualitative/categorical analysis.
5. Conclusion
Inconsistent evidence, poor methodological quality
and heterogeneity among the reviewed studies precluded
the drawing of any firm conclusions regarding the
direction of translation of the humeral head on the
glenoid. The indirect method using Kaltenborn‘s con-
vex–concave rule, as applied to the glenohumeral joint,
need to be investigated appropriately by primary studies
to determine its validity. It can only be postulated that
not only the passive subsystem, as proposed by Kalten-
born, but also the active and control subsystems may
need to be considered when determining the direction of
the translational gliding movement of the humeral head.
It is suggested that clinical decisions of appropriate
gliding directions in the assessment and treatment of a
patient with shoulder dysfunction should be considered
carefully at this stage.
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