The Association of Scapular Kinematics and Glenohumeral Joint Pathologies

[ CLINICAL COMMENTARY ]
PAULA M. LUDEWIG, PT, PhD¹@ED7J>7D<$H;ODEB:I" PT, PhD²
The Association of Scapular Kinematics

and Glenohumeral Joint Pathologies
I
houlder pain and associated glenohumeral joint movement The pathogenesis of rotator cuff ten-
dysfunctions are common and debilitating conditions.12,84,117 dinopathy is not precisely known and
is somewhat controversial; however, a
The most frequently occurring problems include shoulder
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multifactorial etiology is likely.81,106 Pro-

impingement and associated rotator cuff disease or tendinopathy, posed mechanisms include (1) anatomic
which can progress to rotator cuff tears,24,84 as well as glenohumeral reductions in the available space beneath
joint instability and adhesive capsulitis. With the exception of adhesive the coracoacromial arch or within the
capsulitis, the majority of these shoulder complaints are related to supraspinatus outlet area leading to sub-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
acromial impingement,129 (2) intrinsic

occupational or athletic activities that in- tendon either beneath the coracoacro- tendon degeneration from eccentric over-
volve frequent use of the arm at, or above, mial arch (subacromial) or between the load, ischemia, aging, or inferior tissue
shoulder level. The point prevalence of undersurface of the rotator cuff and the properties,106 and (3) scapular or humeral
shoulder pain in certain sports or occu- glenoid or glenoid labrum (internal). Re- movement alterations compromising the
pations can reach 40% or higher.31,41,68 petitive impingement is one of multiple rotator cuff tissues through subacromial
Shoulder impingement has been de- proposed mechanisms for the develop- or internal impingement.84 There is evi-
fined as compression, entrapment, or ment of rotator cuff disease, as well as dence in an animal model for eccentric
mechanical irritation of the rotator cuff progression to partial or full-thickness overuse, or eccentric overuse combined
Journal of Orthopaedic & Sports Physical Therapy®
structures and/or long head of the biceps rotator cuff tearing.87,106 with reduced available subacromial
space (subacromial impingement), as a
TIODEFI?I0 There is a growing body of serratus anterior and increased upper trapezius factor resulting in the development of
literature associating abnormal scapular positions activation. Scapular kinematic alterations similar rotator cuff tendinopathy.106 Such factors
and motions, and, to a lesser degree, clavicular to those found in patient populations have been are likely of greatest interest to physical
kinematics with a variety of shoulder pathologies. identified in subjects with a short rest length of therapists, as rehabilitation programs are
The purpose of this manuscript is to (1) review the pectoralis minor, tight soft-tissue structures in
often directed at correction of posture or
the normal kinematics of the scapula and clavicle the posterior shoulder region, excessive thoracic
during arm elevation, (2) review the evidence for kyphosis, or with flexed thoracic postures. This
movement deviations believed to reduce
abnormal scapular and clavicular kinematics in suggests that attention to these factors is war- the subacromial space, or directed at im-
glenohumeral joint pathologies, (3) review poten- ranted in the clinical evaluation and treatment of provement of tissue properties through
tial biomechanical implications and mechanisms these patients. The available evidence in clinical stretching and strengthening. Regardless
of these kinematic alterations, and (4) relate these trials supports the use of therapeutic exercise in of initial etiology, movement deviations
biomechanical factors to considerations in the rehabilitating these patients, while further gains in
patient management process for these disorders. that further compromise the subacromial
effectiveness should continue to be pursued.
There is evidence of scapular kinematic alterations space or contribute to internal impinge-
TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports
associated with shoulder impingement, rotator ment are presumed undesirable in the
Phys Ther 2009; 39(2):90-104. doi:10.2519/
cuff tendinopathy, rotator cuff tears, glenohumeral presence of a rotator cuff or long head
jospt.2009.2808
instability, adhesive capsulitis, and stiff shoulders.
of the biceps tendinopathy. The majority
There is also evidence for altered muscle activation TA;OMEH:I0 acromioclavicular joint, biome-
in these patient populations, particularly, reduced chanics, rotator cuff, scapula, shoulder of rotator cuff tears are believed to be a
progression of cumulative trauma from
1
Associate Professor, Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, The University of Minnesota, Minneapolis, MN. 2 Doctoral Graduate,
Program in Rehabilitation Sciences, Department of Physical Medicine and Rehabilitation, The University of Minnesota, Minneapolis, MN; Co-owner, Reynolds Rehab Physical
Therapy, Minneapolis, MN. Address correspondence to Dr Paula M. Ludewig, Program in Physical Therapy, MMC 388, 420 Delaware St SE, Minneapolis, MN 55455. E-mail:
Ludew001@umn.edu
90 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
shoulder impingement or progressive
rotator cuff disease, rather than a conse-
quence of acute trauma.87
Glenohumeral joint instability is gen-
erally classified as traumatic or atrau-
matic in origin, as well as by direction of
the instability (anterior, posterior, infe-
rior, or multidirectional). Instability can
also occur from repetitive microtrauma,
particularly in overhead athletes. Pri-
mary complaints may relate to dysfunc-
tion or pain, with underlying instability
often contributing to the development of
secondary impingement or rotator cuff
tendinopathy. Adhesive capsulitis, which <?=KH;$Scapular motions from (A) posterior (upward/downward rotation), (B) superior (internal/external
is often idiopathic in origin, can also con- rotation), and (C) lateral (anterior/posterior tilting) views. Axes of rotation are indicated as black dots. Reprinted
with permission from Borich et al.2
tribute to secondary impingement or ro-
tator cuff disease.
There is a growing body of litera- The motion of the scapula with regard IYWfkbWhA_d[cWj_Y7bj[hWj_edi_dIêkb-
ture associating abnormal scapulotho- to changes in scapular internal rotation Z[h?cf_d][c[djehHejWjeh9k÷:_i[Wi[
racic kinematics, and, to a lesser degree, angle shows more variability across sub- The largest number of studies investi-
clavicular kinematics, with a variety of jects, investigations, planes of elevation, gating scapular kinematic alterations
shoulder pathologies. Abnormal scapu- and point in the range of motion of eleva- have been completed in the area of
lar or clavicular kinematics have been tion.4,78 Slight increases in scapular inter- shoulder impingement or rotator cuff
identified in populations with shoulder nal rotation may be normal early in the disease.25,38,44,58,64,71,73,77,82,107,123 Substantial
impingement,25,44,58,64,71,73,77,123 rotator cuff range of arm elevation in scapular plane variations are present across studies with
tendinopathy,64,82 rotator cuff tears,20,82,92 abduction and flexion. It is generally ac- regard to subject demographics, clinical
shoulder instability,46,90,91,92,119,123 and ad- cepted that end range elevation in healthy presentation, measurement methodolo-
hesive capsulitis.28,65,99,118 The purpose of subjects involves some scapulothoracic gies, arm movements tested, scapular
this manuscript is to (1) review the normal external rotation, although limited data kinematic descriptions, and portions of
kinematics of the scapula and clavicle dur- are available.78 the range of motion where deviations
ing arm elevation, (2) review the evidence Scapulothoracic kinematics involve were described. However, identified de-
for abnormal scapular and clavicular kine- combined sternoclavicular (SC) and ac- viations can be generally summarized as
matics in the above identified glenohumer- romioclavicular (AC) joint motions.69,78,110 presence or absence of significant altera-
al joint pathologies, (3) review potential Substantive 3-dimensional motions oc- tions in scapular upward rotation, pos-
biomechanical implications and mecha- cur at both the SC and AC joints during terior tilt, internal rotation, clavicular
nisms of these kinematic alterations, and arm elevation in healthy subjects.69,78,110 elevation or retraction, scapular symme-
(4) relate these biomechanical factors to The clavicle demonstrates a pattern of try and topography, or scapulohumeral
considerations in the clinical evaluation slight elevation and increasing retraction rhythm (J78B;').
and treatment of these disorders. as arm elevation progresses overhead.69,78 Overall, the evidence for scapular
Simultaneously, the scapula is upwardly kinematic alterations in patients with
I97FKB7HA?D;C7J?9I rotating, internally rotating, and pos- impingement or rotator cuff symptoms
:KH?D=7HC;B;L7J?ED teriorly tilting relative to the clavicle at is substantial, with 9 of 11 cited studies
the AC joint.110 Scapulothoracic “trans- identifying a significant group difference
lations” of elevation/depression and ab- in at least 1 variable (J78B;').25,38,44,58,64,71,73,
I
capular position on the thorax
77,82,107,123
and control during motion is a criti- duction/adduction have also traditionally However, there are discrepancies
cal component of normal shoulder been described.73,110 These motions actu- regarding the consistency of findings and
function. During elevation of the arm ally derive from clavicular motions at the direction of deviations noted. Of the stud-
overhead, the scapula should upwardly SC joint. Scapulothoracic elevation is a ies specifically investigating scapular up-
rotate and posteriorly tilt on the tho- result of SC elevation, and abduction/ ward rotation during arm elevation, 4 of 9
rax (<?=KH;).78 Upward rotation is the adduction is a result of SC protraction/ found decreased upward rotation,25,64,71,107
predominant scapulothoracic motion. retraction.110 1 increased upward rotation,77 and 4 no
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 91
Investigations of Abnormal Scapular Kinematics During Humeral Elevation
J78B;'
in Subjects With Shoulder Impingement or Rotator Cuff Tendinopathy
?dl[ij_]Wj_ed =[d[hWbC[jêZi IWcfb[ Fei_j_ed7bj[hWj_ed?dl[ij_]Wj[Z I_]d_ÓYWdj:[l_Wj_ed?Z[dj_Ó[Z

123
Warner et al Moiré topographic analysis 22 controls, 7 with impingement, IYWfkbWhWiocc[jho"_dYh[Wi[Z ?dYh[Wi[ZWiocc[jhoWdZjefe]hWfô_d
17-47 years old, both genders topography or winging impingement group
Lukasiewicz et al73 Static digitizing, comparisons 20 nonimpaired, 17 with impinge- KfmWhZhejWj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
between groups and sides ment, 25-66 years old, both Feij[h_ehj_bj :[Yh[Wi[Z_dj^[_cf_d][c[dj]hekfWdZ
genders side of impingement
?dj[hdWbhejWj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
;b[lWj_ed ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf
Ludewig and Cook71 Electromagnetic surface sensors 26 controls, 26 with impingement, KfmWhZhejWj_ed :[Yh[Wi[Z_dj^[_cf_d][c[dj]hekf
20-71 years old, males only, Feij[h_ehj_bj :[Yh[Wi[Z_dj^[_cf_d][c[dj]hekf
overhead construction workers ?dj[hdWbhejWj_ed ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf
Graichen et al38 Ikf_d[ijWj_YCH?"YecfWh_iedi 14 controls, 14 with unilateral im- KfmWhZhejWj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
between groups and sides pingement, no full-thickness tear,
22-62 years old, both genders
Endo et al26 Static radiographs, comparisons 27 with unilateral impingement, KfmWhZhejWj_ed :[Yh[Wi[Zedj^[i_Z[e\_cf_d][c[dj
between sides 41-73 years old, both genders Feij[h_ehj_bj :[Yh[Wi[Zedj^[i_Z[e\_cf_d][c[dj
Hebert et al44 Optical surface sensors, compari- 10 healthy, 41 with impingement, KfmWhZhejWj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
sons between groups and sides 30-60 years old, both genders Feij[h_ehj_bj Dei_]d_ÓYWdjZ_÷[h[dY[i
?dj[hdWbhejWj_ed ?dYh[Wi[Zedj^[i_Z[e\_cf_d][c[dj
Su et al107 Static digital inclinometer, com- 20 healthy, 20 with impingement, KfmWhZhejWj_ed :[Yh[Wi[ZW\j[hfhWYj_Y[_dj^[_cf_d][-
parisons between groups and 18-35 years old, both genders, ment group
before and after swim practice swimmers
Mell et al82 Electromagnetic surface sensors 15 healthy, 13 with rotator cuff tendi- IYWfkbe^kc[hWbhôj^c Dei_]d_ÓYWdjZ_÷[h[dY[i
nopathy, no full-thickness tears,
30-74 years old, both genders
McClure et al77 Electromagnetic surface sensors 45 controls, 45 with impingement, KfmWhZhejWj_ed ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf
24-74 years old, both genders Feij[h_ehj_bj ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf
;b[lWj_ed ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf
H[jhWYj_ed ?dYh[Wi[Z_dj^[_cf_d][c[dj]hekf

Lin et al64 Electromagnetic surface sensors 25 controls, 21 with shoulder KfmWhZhejWj_ed :[Yh[Wi[Z_dj^[iêkbZ[hZoi\kdYj_ed
dysfunction, 27-82 years old, group
males only Feij[h_ehj_bj :[Yh[Wi[Z_dj^[iêkbZ[hZoi\kdYj_ed
group
;b[lWj_ed ?dYh[Wi[Z_dj^[iêkbZ[hZoi\kdYj_ed
group
Laudner et al58 Electromagnetic surface sensors 11 controls, 11 with internal impinge- KfmWhZhejWj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
ment, 18-30 years old, males Feij[h_ehj_bj ?dYh[Wi[Z_dj^[_dj[hdWb_cf_d][c[dj
only, throwers group
;b[lWj_ed ?dYh[Wi[ZWj^_]^[hWd]b[i_dj^[_dj[hdWb
impingement group
H[jhWYj_ed Dei_]d_ÓYWdjZ_÷[h[dY[i
differences38,44,58,73 in symptomatic sub- 7 studies found an increase in internal this variable.58,64,73,77 Clavicular retraction
jects, when compared to asymptomatic rotation in symptomatic subjects,44,71 in subjects with impingement was found
individuals. Somewhat greater consis- and the remaining 5 found no signifi- to be increased in 1 study77 and not sig-
tency in findings is present for measure- cant differences between symptomatic nificantly altered in the other.58
ments of scapular posterior tilt during and asymptomatic individuals.25,58,64,73,77 The inability to detect significant dif-
arm elevation, with 4 of 7 studies find- Findings for alteration in clavicular or ferences between groups for all variables
ing decreased posterior tilt in symptom- scapular elevation were most consistent consistently across investigations is not
atic subjects,25,64,71,73 2 increased posterior across studies with elevation being sig- fully surprising. Investigations are of-
tilt,58,77 and 1 no significant difference.44 nificantly increased in symptomatic sub- ten undertaken with small sample sizes,
For scapular internal rotation, only 2 of jects in all 4 of the studies investigating resulting in limited statistical power for
some comparisons, given the large varia- ment. Additionally, the impact of factors rotation may be a positive compensation
tion in movement patterns of healthy such as age, arm dominance, gender, and in the presence of rotator cuff dysfunc-
subjects.71,78 The 2 investigations noted upper extremity “exposure” to occupa- tion. Variations in scapular upward rota-
above as finding no group differences38,82 tional or athletic activities on scapular tion findings during arm elevation across
had only 14 and 13 subjects with im- kinematics are not well understood and investigations of subjects with shoulder
pingement or tendinopathy, respectively. vary substantially across investigations. impingement might relate to the limited
Investigators have tested various planes Finally, progression of tendinopathy to clinical knowledge of status or severity of
of shoulder elevation, with and without partial- or full-thickness rotator cuff involvement of the rotator cuff, particu-
external loading or other factors, such tearing is considered a continuum of the larly with regard to full- or partial-thick-
as fatigue. The most common measure- disease process.87 Although most studies ness tearing. Increased use of ultrasound
ment method uses surface motion sen- attempt to exclude full-thickness tearing imaging in the diagnosis of cuff integrity
sors whose precision is impacted by skin based on clinical examination, only 2 in- may be helpful in future work to clarify
motion artifact.52 More precise imaging vestigations used imaging methods to ex- disparate findings.112
methods, such as 3-dimensional mag- clude subjects with full-thickness rotator
netic resonance imaging, have, to date, cuff tears from their tested samples. 38,82 J^[eh_p[Z;÷[Yjie\IYWfkbWh
been primarily limited to static imaging No investigations used diagnostic meth- A_d[cWj_Y7bj[hWj_edi
in supine positions without normal gravi- ods able to exclude partial-thickness cuff Without the ability to follow human sub-
tational loading.38 tears. jects longitudinally, it is difficult to fully
Lack of significant differences be- The effect of rotator cuff tears on discern if alterations found in scapular
tween groups also likely relates to the scapular kinematics may be of particular kinematics are compensatory or con-
presumed multifactorial etiology of im- interest with regard to the discussion of tributory to an impingement mechanism
pingement and the limitations of clini- disparate results between studies. Five of rotator cuff disease. Further insight
cal diagnosis. Even if one assumes that investigations to date have compared may be gained, however, through inves-
scapular kinematic alterations are one of the scapular kinematics of small subject tigations linking kinematic alterations to
the definite causative mechanisms of im- samples (6 to 20 individuals with cuff reductions in the subacromial space, or
pingement and rotator cuff tendinopathy, tear) with known full-thickness tears to proximity of structures such as the gle-
not all subjects in a particular sample are controls during arm elevation.20,38,82,92,128 noid and cuff undersurface in internal
likely to have scapular position or motion All of those studies noted tendencies impingement. Based on anatomical re-
deviations. Furthermore, different scap- toward increased scapular upward rota- lationships, it is generally believed that
ular kinematic alterations may be pres- tion during arm elevation, although only reductions in scapular upward rotation
ent in different subgroups of subjects. 2 investigations measured differences and posterior tilt during arm elevation
These subgroup deviations may not be showing statistically significant altera- could reduce the available subacromial
detected in group averages.38 Currently, tions in scapulohumeral rhythm.20,82 All space, thus contributing to development
the presence, absence, or type of specific authors suggested that these alterations or progression of impingement as well as
scapular kinematic deviation is not well were compensatory to maximize arm el- a poorer environment for tissue healing.84
distinguished in the clinical diagnostic evation in the absence of intact rotator How scapular internal rotation might im-
process inherent to the inclusion crite- cuff function. Interestingly, in 1 investi- pact the subacromial space is less clear,
ria of most investigations. In particular, gation, surgical cuff repair appeared to as increased scapular internal rotation
individuals with internal impingement “normalize” the presumed compensa- without altering humeral position should
may have very different scapular kine- tion.92 Further support for a theory of result in greater glenohumeral joint exter-
matic alterations as compared to those compensatory scapular upward rotation nal rotation. Humeral external rotation
with subacromial impingement. Only 1 in the absence of an intact rotator cuff is is presumed beneficial to the subacro-
group of investigators to date has com- provided by an investigation of healthy mial space, allowing improved clearance
pared a small sample of 11 subjects with subjects before and after a suprascapu- for the greater tuberosity.30 However, a
internal impingement to a control group lar nerve block to produce experimental relative increase in glenohumeral joint
of throwers,58 and this is 1 of the 2 investi- dysfunction of the supraspinatus and external rotation via increased scapular
gations with disparate findings regarding infraspinatus muscles.79 Following nerve internal rotation might increase the risk
scapular posterior tilt. Other investigators block, subjects demonstrated significant for posterior cuff internal impingement.93
have predominately presumed that their increases in scapular upward rotation The potential impact of clavicular motion
subject sample’s impingement is subac- and external rotation during arm eleva- alterations on subacromial space or in-
romial but have not identified criteria to tion.79 Consideration of these findings ternal impingement is even less well un-
distinguish or exclude internal impinge- suggests that increased scapular upward derstood. Increased clavicular elevation
may improve the available subacromial impact the subacromial space.51,105 Ad- significantly greater.92
space through superior movement of the ditional investigations linking scapular Similar to comparisons between sub-
acromioclavicular joint. Alternatively, kinematic alterations to the magnitude jects with impingement and controls, the
increased elevation may couple with in- of available subacromial space and prox- cross-sectional nature of these investiga-
creased anterior tilt of the scapula, thus imity of potential impinging structures tions does not provide definitive evidence
possibly compromising the available sub- are needed to further ascertain the clini- for either a causative or compensatory
acromial space.110 cal and biomechanical importance of the mechanism of kinematic alterations.
Through magnetic resonance imag- kinematic alterations identified in patient Mechanically, however, reduced scapular
ing, significant movement-related reduc- populations. upward rotation is believed to be detri-
tions in the acromiohumeral distance in mental to maintaining inferior stability
the symptomatic shoulder of individuals IYWfkbWh A_d[cWj_Y 7bj[hWj_edi 7iieY_- at the glenohumeral joint.47 This suggests
with impingement have been found.37,43 Wj[Zm_j^=b[de^kc[hWb@e_dj?dijWX_b_jo that these reductions in scapular upward
However, these reductions were not The available literature investigating rotation in individuals with multidirec-
linked to specific motion deviations of scapular kinematic abnormalities associ- tional instability do not represent a posi-
the scapula or humerus. Only 2 inves- ated with glenohumeral joint instability tive compensation but likely contribute to
tigations were located to date that have is also increasing. There are again wide inferior glenohumeral joint instability.47
attempted to directly link alterations in variations in study samples and meth- Increased scapular internal rotation is
scapular kinematics to reductions in the odologies, but more consistency in re- believed to mechanically reduce anterior
subacromial space.51,105 In a very small in- sults reported. Five investigations have bony stability; however, a cadaver investi-
vestigation of 4 healthy subjects, supine compared subjects with multidirectional gation reported increased glenohumeral
magnetic resonance images were ob- instability to control subjects during ele- joint capsular tension with scapular pro-
tained with sandbags holding the scapu- vation of the arm.46,90,91,119,123 Four of these traction, which may contribute to over-
lae into “protracted” (scapular abduction) investigations assessed scapular upward all stability.125 Interestingly, in healthy
or “retracted” (scapular adduction) posi- rotation either directly, or indirectly by subjects, glenohumeral elevation and
tions.105 Subsequently, subacromial width assessing scapulohumeral rhythm.46,90,91,119 internal and external rotation strength
and angle were measured in both posi- All 4 identified significantly less scapular is decreased during isometric testing
tions. Significant reductions in the subac- upward rotation or a significantly greater in scapular protracted positions, which
romial parameters were identified in the scapulohumeral rhythm ratio (indica- incorporate clavicular protraction and
protracted position.105 Review of these tive of a lesser scapular upward rotation scapulothoracic internal rotation.103,104
sagittal plane changes, however, appears component) in the subjects with insta- Likewise, when overhead athletes with
consistent with what would occur with bility.46,90,91,119 Two of these studies also and without impingement symptoms
increased anterior tilt of the scapula, assessed scapular internal rotation and were manually repositioned into in-
rather than scapular protraction.105 Us- both found significantly greater scapular creased scapular retraction and posterior
ing a cadaver model of subacromial clear- internal rotation in the subjects with in- tilting, there were significant increases in
ance (superior humeral translation prior stability.90,119 In their Moiré topographic shoulder elevation strength.109 Further
to significant subacromial contact force), analysis, Warner and colleagues123 also investigation is also needed in subjects
Karduna and colleagues51 investigated assessed subjects with instability and with glenohumeral joint instability to
the impact of imposed scapular positions reported significantly more scapular better understand the compensatory or
of upward rotation, internal rotation, “winging” in these subjects. This wing- causative nature and biomechanical con-
and posterior tilt on the available supe- ing is defined as greater prominence of sequences of their scapular kinematic
rior humeral translation. No significant the scapular medial border consistent alterations.
differences were found with changes in with increased internal rotation.123 In the
scapular internal rotation and posterior single study found that compared sub- IYWfkbWhA_d[cWj_Y7bj[hWj_edi7iieY_-
tilt.51 Contrary to expectations, increased jects with anterior glenohumeral joint Wj[ZM_j^7Z^[i_l[9Wfikb_j_iehIêkb-
scapular upward rotation reduced rather instability to controls, significant differ- Z[hIj_÷d[ii
than increased the magnitude of avail- ences in scapulohumeral rhythm were Only recently have investigators started
able superior humeral translation.51 Al- observed between groups.92 Early in the to study scapular kinematics during hu-
though the MR investigation provides range of motion (0°-90°), subjects with meral elevation in subjects with adhesive
support for common presumptions of instability had a lesser scapular upward capsulitis or shoulder stiffness.28,65,99,118
subacromial space reduction, this cadaver rotation contribution to arm elevation, Three studies identified significant in-
study challenges the common presump- whereas later in the arm elevation range creases in scapular upward rotation on
tions of how scapular alterations might of motion, the scapular contribution was the affected side of subjects with adhesive
capsulitis as compared to their nonaf-
Summary of Scapular Kinematics
fected side.28,99,118 Vermeulen et al118 were
J78B;( During Arm Elevation in Healthy
also able to show a change toward a more
and Pathologic States
“normalized” scapular upward rotation
after physical therapy intervention, sup- ?cf_d][c[djeh =b[de^kc[hWb
porting the premise that the increased =hekf >[Wbjô HejWjeh9k÷:_i[Wi[ @e_dj?dijWX_b_jo 7Z^[i_l[9Wfikb_j_i
scapular upward rotation was compen- Primary scapular Upward rotation Lesser upward rotation Lesser upward Greater upward rotation
satory to maximize overall range of mo- motion rotation
tion overhead in the presence of reduced Secondary scapular Posterior tilting Lesser posterior No consistent No consistent evidence
motion tilting evidence for for alteration
mobility at the glenohumeral joint. alteration
Lin and colleagues65 separated “stiff
Accessory scapular Variable internal/ Greater internal rotation Greater internal No consistent evidence
shoulders” into anterior and posterior motion external rotation rotation for alteration
stiffness at the glenohumeral joint. They
Presumed Maximize shoulder Presumed contributory Presumed contribu- Presumed compensa-
found those with anterior glenohumeral implications range of motion to subacromial or tory to lesser infe- tory to minimize
joint tightness demonstrated greater and available sub- internal impingement rior and anterior functional shoulder
acromial space joint stability range-of-motion loss

scapular upward rotation and less pos-
terior tilt as compared to the individuals
in the group with posterior tightness.65 soft tissue tightness, muscle activation or frozen shoulder,66 throwers with anterior
However, they did not compare the scap- strength imbalances, muscle fatigue, and glenohumeral instability,35 overhead ath-
ular kinematics to a control group or to thoracic posture.84 Muscle activation in letes with impingement syndrome,14 or
the unaffected arm. In addition, their patient populations is the most common persons with various glenohumeral joint
subjects’ range-of-motion deficits were factor investigated; but these muscle ac- pathologies.95 Significantly less protrac-
predominately in humeral internal/exter- tivity alterations are not typically directly tion force has also been identified in over-
nal rotation rather than humeral eleva- linked to scapular kinematic alterations. head athletes with shoulder impingement
tions.65 As such, these subjects were not In subjects with impingement or shoul- as compared to their noninvolved side or
identified as representing a group with der dysfunction, significantly less ser- a control group.17 None of these latter
adhesive capsulitis but described as hav- ratus anterior muscle activation and investigations, however, simultaneously
ing anterior or posterior stiffness.65 greater upper trapezius activation were measured scapular kinematics.
In summary, scapular or clavicular found in the same subjects with less Timing of scapulothoracic muscle
motion or position alterations are pres- scapular upward rotation and posterior activation has also been investigated.
ent in persons with a variety of shoulder tilt,64,71 as well as greater scapular eleva- The temporal recruitment pattern of the
disorders (J78B;(). But the causative or tion.64 Considering these findings with an upper and lower trapezius and serratus
compensatory nature of these kinematic understanding of these muscles’ ability to anterior displayed significantly greater
alterations and their associated biome- produce or control scapular rotations,29,48 variability in competitive freestyle swim-
chanical implications regarding rotator the lesser serratus activations may be mers with shoulder impingement as
cuff function remain speculative. Regard- critical in contributing to the lesser pos- compared to a control group of competi-
less of this compensatory or causative terior tilt and upward rotation observed. tive swimmers.120 Significantly delayed
nature, however, it is of interest to un- The greater upper trapezius activation middle and lower trapezius activation has
derstand the biomechanical mechanisms is likely contributing to the greater el- been demonstrated in overhead athletes
contributing to these alterations. Factors evation of the scapula through greater with shoulder impingement, as com-
contributing to alterations presumed det- clavicular elevation.29,48 It should be kept pared to a control group, in response to
rimental might be the focus of rehabili- in mind, however, that this is an interpre- an unexpected drop of the arm from an
tation. Alternatively, patients might be tation of the results of these studies, as abducted position.16 Similar to kinematic
taught how to produce a compensatory relationships between muscle activation findings, although it is generally believed
deviation deemed beneficial to reducing and scapular kinematics were not direct that these altered muscle activations con-
pain or improving function or stability. findings of these investigations. Several tribute to abnormal scapular kinematics
other investigations provide support for and shoulder pathology, a causative or
Fej[dj_Wb8_ec[Y^Wd_YWbC[Y^Wd_ici the premise of lesser serratus activation compensatory motor control mechanism
9edjh_Xkj_d]je7bj[hWj_edi_dIYWfkbWh and/or greater upper trapezius activa- cannot currently be ascertained.
A_d[cWj_Yi tion in a variety of patient populations The influence of pain on muscle acti-
Potential contributing mechanisms to ab- across a variety of tasks, including swim- vation patterns is also poorly understood.
normal scapular kinematics include pain, mers with shoulder pain,100 persons with Interestingly, experimentally induced
pain produced through injection of hy- changes have primarily been speculated no such deficit.2 Scapular positioning was
pertonic saline directly into the upper, to be positive compensations to maintain measured at end range humeral internal
middle, and lower divisions of the tra- range of motion.22 Although it is clear rotation, with the humerus elevated 90°
pezius in otherwise healthy subjects, re- from these investigations that fatigue of into both flexion and abduction posi-
sulted in decreased upper trapezius and shoulder muscles can alter scapulotho- tions.2 The group with less glenohumeral
increased lower trapezius activation on racic kinematics, direct relationships joint internal rotation range of motion
the painful side and increased trapezius between fatigue of specific and isolated demonstrated significantly greater scapu-
activation on the contralateral side dur- muscles and changes in scapulothoracic lar anterior tilt at end range humeral in-
ing repetitive bilateral flexion.27 Further kinematics are not presently known. ternal rotation positions.2 Both of these
investigation of the influence of induction Also, all of these investigations were investigations tested subjects without
or removal of pain and the relationships completed in healthy subjects; thus the shoulder pain or symptoms, removing
between pain state, muscle activation, clinical significance for patient popula- any confounding effects of pain on the
and scapular kinematics is needed. tions is unknown. kinematic findings.2,6 This investigative
Another model to relate muscle acti- Soft tissue tightness of muscles or approach suggests that these areas of soft
vation patterns to alterations in scapular structures that can restrict normal scap- tissue tightness are potential risk factors
kinematics is the experimental induction ular motions during arm elevation is for scapular kinematic alterations asso-
of muscle fatigue. However, none of the another potential mechanism for devel- ciated with shoulder impingement, but
investigations of shoulder fatigue identi- opment of the scapulothoracic alterations findings need to be confirmed in patient
fied to date have attempted to specifically seen in patients. Two that have been in- populations.
fatigue isolated scapulothoracic muscles, vestigated are pectoralis minor and pos- Thoracic posture has also been re-
and the inability to specifically fatigue a terior shoulder tightness.2,6 The pectoralis lated to alterations in scapular position-
single muscle or muscle group compli- minor, based on its attachments from the ing. When healthy subjects were asked to
cates interpretation of the findings.23,113 coracoid process to the third to fifth ribs, assume a “slouched” sitting posture and
In response to a resisted humeral external is capable of producing scapular internal elevate the arm, significantly reduced
rotation fatigue protocol, one investiga- rotation, downward rotation, and anteri- scapular upward rotation and posterior
tion demonstrated significant reductions or tilt.6 Excess active or passive tension in tilt were reported, as well as increased
in scapular upward rotation, posterior this muscle could subsequently resist the scapular internal rotation and scapular
tilt, and external rotation postfatigue.113 normal scapular upward rotation, poste- elevation.53 Increased scapular anterior
However, another investigation also in- rior tilt, and potentially scapular external tilt and scapular internal rotation have
ducing shoulder fatigue via resisted hu- rotation that should occur during arm el- also been demonstrated with the arm re-
meral external rotation found significant evation. When healthy subjects were cat- laxed at the side in women with increased
increases rather than decreases in scap- egorized as having a short versus a long thoracic kyphosis, as well as increased
ular upward rotation.23 Findings were pectoralis minor resting length, those scapular anterior tilt with increased
similar in direction between the 2 inves- with a short pectoralis minor indicative age.18 Significant correlations between
tigations for reduced posterior tilt post of muscle tightness demonstrated sig- increased age and reductions in posterior
fatigue.23,113 When fatiguing the shoulder nificantly less scapular posterior tilt and tilt and upward rotation have also been
through repetitive overhead activities22 greater scapular internal rotation during identified in elevated arm postures,26
or resisted elevation,80 significant in- arm elevation.6 although thoracic posture as a possible
creases in scapular upward and external Tightness in the posterior capsule contributing factor was not assessed in
rotation, as well as increases in clavicu- of the glenohumeral joint or posterior that investigation.
lar retraction22 or decreases in scapu- shoulder has also been theorized as a In addition to evidence of scapular
lohumeral rhythm ratio, consistent with potential mechanism for altering scapu- kinematic alterations associated with
increased scapular upward rotation,80 lar kinematics by passively “pulling” the glenohumeral joint pathologies, there is
were found postfatigue. Based on elec- scapula laterally over the thorax, partic- scientific support for a number of biome-
tromyographic analysis of median power ularly during humeral internal rotation chanical factors as potential contributing
frequency in these investigations,22,80 fa- in elevated arm positions.54 In a subse- mechanisms to these scapular kinematic
tigue was present in the deltoid muscles, quent investigation, subjects who had no alterations. These include alterations in
as well as the scapulothoracic muscles. shoulder symptoms but a glenohumeral muscle activation (in particular, increased
As all of these investigations attempted internal rotation range-of-motion defi- upper trapezius activation and reduced
to generate or generated fatigue in mus- cit on their dominant arm (indicative of serratus anterior activation), pectoralis
cles acting about the glenohumeral joint, posterior shoulder tightness), were com- minor or posterior shoulder tightness,
the scapular and clavicular kinematic pared to a control group of subjects with and thoracic kyphosis or flexed thoracic
the scapular medial border and infe-
Proposed Biomechanical Mechanisms of
J78B;) rior angle during repetitive concentric
Scapular Kinematic Deviations
and eccentric motion (particularly into
C[Y^Wd_ic 7iieY_Wj[Z;÷[Yji flexion), and with the addition of hand
loads or manual resistance. Addition-
?dWZ[gkWj[i[hhWjkiWYj_lWj_ed Lesser scapular upward rotation and posterior tilt
ally, acceptable interrater reliability has
Excess upper trapezius activation Greater clavicular elevation
been demonstrated for a “scapular assis-
Pectoralis minor tightness Greater scapular internal rotation and anterior tilt tance test,” by which abnormal scapular
Posterior glenohumeral joint soft tissue tightness Greater scapular anterior tilt motions are attempted to be improved
Thoracic kyphosis or flexed posture Greater scapular internal rotation and anterior tilt, lesser through manual assistance provided by
scapular upward rotation the examiner.97 Symptom reduction dur-
ing manual scapular repositioning may
postures (J78B;)). These factors should be examinations. Glenohumeral instabil- help to confirm a scapular contribution
considered in the clinical evaluation and ity may be a distinct diagnosis without to pathology.109 Several investigators have
intervention for such shoulder conditions. substantive rotator cuff irritation (pain ongoing work in the area of visual assess-
is not the primary complaint). However, ment and scapular assistance tests. 32,108
;L7BK7J?ED often glenohumeral instability contrib- More promising in the current litera-
utes to secondary shoulder impingement ture is the objective measurement of static
I
t is beyond the scope of this man- or rotator cuff tendinopathy. Adhesive scapular positions with clinically available
uscript to fully discuss the examina- capsulitis can also contribute to second- tools such as inclinometers.49,59,96,124 John-
tion and evaluation process for each of ary impingement, but is generally easily son et al49 demonstrated that a modified
these glenohumeral joint pathologies.74,126 identifiable due to the substantive losses digital inclinometer placed along the spine
We will therefore provide an overview of in both active and passive range of mo- of the scapula could produce good to ex-
the evaluation process and attempt to tion in multiple directions of motion. In cellent validity and intrarater reliability
highlight and integrate considerations addition to understanding the medical of measurements at rest and in elevated
of scapular kinematic and biomechani- pathology, we believe that it is important arm positions. This high level of intrarater,
cal factors. Assessment of the patient is to identify an underlying movement dis- within-day reliability was also replicated
assumed to include history, systems re- order whenever possible.10,88,89 by a second group of investigators us-
view, range of motion, quality of move- One of the challenges of the clinical ing similar methods.124 Although not yet
ment, strength, and special tests, such as diagnostic process in persons present- investigated, such methods seem quite
joint laxity, labral tests, and impingement ing with shoulder pain is the reliable and plausible for the measurement of clavicu-
tests.74 Based on the previous discussion valid determination of the presence or lar elevation, and may have the potential
of potential scapular contributions to pa- absence of scapular position or motion to be adapted to other scapular position
thologies, assessing the strength of scapu- alterations. In one investigation, using measures. Inclinometer methods have
lothoracic musculature is important in blinded evaluators who assessed video- also been demonstrated to have excellent
addition to that of the glenohumeral joint. taped subjects, moderate kappa values intrarater within-session reliability in the
When a patient presents with shoulder for intertester and intratester reliability measurement of thoracic kyphosis.62
pain and or dysfunction, it is important were obtained.56 Poorer interrater reli- Recent recommendations are avail-
to rule out cervical pathologies, thoracic ability was obtained in another investi- able in the literature regarding the per-
outlet syndrome, circulatory and cardiac gation in which subjects were videotaped formance of shoulder strength tests.83 In
disorders, symptoms originating from the and analyzed by therapists who did not general, greater objectivity and reliabil-
periscapular region rather than the gle- know the symptom status of the sub- ity can be obtained by using handheld
nohumeral joint, and glenohumeral ar- jects.45 These reliability values are less dynamometers during strength testing.83
thritis.74 The latter requires radiographic than optimally desirable for routine clin- Michener et al83 demonstrated high intra-
imaging. Although there are clinical tests ical usage. It is possible that improved rater reliability between days using hand-
that attempt to diagnose full-thickness reliability could be obtained with direct held dynamometry to assess strength of
rotator cuff tears, we believe accurate evaluation (as compared to videotape), the 3 portions of the trapezius and the
diagnosis of these pathologies requires improved training, or refinement of defi- serratus anterior in subjects with shoul-
diagnostic imaging, such as ultrasound nitions of movement categories. General der pain and functional loss. Based on
or magnetic resonance.74,111,112 recommendations for visual assessment the previous discussion of scapular pro-
Assessment of joint hypermobility or of dynamic scapular motion alterations, traction position affecting glenohumeral
hypomobility is also inherent to clinical or “dyskinesia,” include observation of muscle strength testing, control of scapu-
cuff disease rather than instability or ad-
Summary Intervention Considerations for
J78B;* hesive capsulitis.
Subacromial Shoulder Impingement
In general, we recommend targeting
IY_[dj_ÓYWbboIkffehj[ZIYWfkbWh?dj[hl[dj_edi muscles or structures that can limit de-
Serratus anterior strengthening or retraining sired scapular motions for stretching and
Upper trapezius activation reduction targeting muscles that can produce de-
Posterior shoulder stretching sired scapular motions for strengthening
Pectoralis minor stretching (J78B;*). It is important to recognize that
Thoracic extension posture and exercise muscle strengthening is not specific to the
production of muscle hypertrophy, but also
lar protraction position during shoulder reliable within and between sessions by includes neuromuscular contributions to
strength testing is advised. This prem- several investigators.67,86,114 However, the increase of muscle force production or
ise is supported by significantly higher the measures may be less reliable over improvement of muscle activation or tim-
strength values for supraspinatus test- extended periods during which clinical ing. Many exercise programs in clinical
ing in a scapular retraction position in intervention might occur.7 Additional practice use light or moderate resistance
patients, healthy controls, and overhead investigation is warranted to expand the below a threshold that would generate
athletes with and without impingement battery of reliable and valid clinical tools muscular hypertrophy. Subsequently,
symptoms.55,109 to assist in the evaluation process for pa- strength improvements noted from such
Recommendations regarding im- tients presenting with shoulder pain. exercises are related to neuromuscular
pingement tests can also be made based adaptations. Resistance exercises target-
?DJ;HL;DJ?ED
on recent literature. Typically, if used in ing specific muscles are most commonly
isolation, these tests have demonstrated investigated in the literature and will be
high diagnostic sensitivity but low speci- discussed below. However, other neuro-
J
he intervention plan should
ficity.11,61 Subsequently, accurate diag- follow directly from the clinical muscular exercise approaches127 deserve
nosis of impingement requires multiple evaluation and should incorporate further investigation.
positive impingement tests, as well as a current understanding of shoulder bio- Based on the biomechanical factors
a cluster of other positive findings such mechanics, kinematic alterations, and discussed above, with regard to stretch-
as a painful arc of motion and pain with proposed biomechanical mechanisms of ing, the pectoralis minor and posterior
resisted shoulder motions.11,61 Recent kinematic alterations. In addition to pain shoulder and glenohumeral joint cap-
literature suggests these traditional im- control, the current state of practice pre- sule are potential candidates for stretch-
pingement tests are potentially creat- dominately incorporates therapeutic exer- ing in patients with scapular kinematic
ing internal impingement, as well as, or cise into the conservative management of alterations.2,6 This approach presumes
rather than, subacromial impingement.94 shoulder disorders.127 Consistent with the confirming concerns with the targeted
A posterior internal impingement test emphasis of this manuscript, our discus- muscles or structures during the clini-
should be considered as well, which in- sion will focus on treatment directed at cal evaluation process. For instance, if a
volves pain reproduction by placing the identified scapular kinematic and muscle patient does not present with any indi-
subject’s arm in 90° abduction and exter- activity alterations. We are not advocat- cations of posterior shoulder tightness,
nal rotation.36 ing lack of attention to the glenohumeral posterior shoulder stretching is not ad-
In addition to the more traditional joint in the treatment plan. In fact, recent vocated. The rationale for stretching at
evaluation procedures, we believe each investigations of eccentric training in the the posterior glenohumeral joint relates
of the potential biomechanical contrib- rehabilitation of tendon pathology sug- to the alterations in scapular position
uting factors discussed previously should gest that consideration of this approach demonstrated in subjects with posterior
also be considered in the evaluation of may be beneficial for some patients with shoulder tightness.2 Various methods of
patients with shoulder pain. As noted rotator cuff tendinopathy.50,98 Greater stretching have been advocated for both
above, thoracic kyphosis can be reliably emphasis on training of the rotator cuff of these tissues. Although the literature
assessed using inclinometer methods.62 is also likely required for patients for is limited, there are investigations that
Pectoralis minor resting length can be ac- whom glenohumeral instability is the have compared across methods regard-
curately assessed clinically using a tape primary complaint, or contributing to ing improvements in range of motion or
measure or caliper placed between at- secondary impingement. However, this potential to adequately lengthen the tar-
tachment landmarks.3 Clinical measure- manuscript focuses on scapular aspects geted tissue.5,75 McClure et al75 compared
ment of posterior and anterior shoulder of rehabilitation, as well as rehabilitation the effectiveness of a “sleeper stretch,”
tightness has been reported to be highly for shoulder impingement and rotator believed to better stabilize the scapula,
to a more traditional cross-body stretch literature demonstrates reduced activa- Modification of the dynamic hug into gle-
for posterior capsule tightness. Asymp- tion in subjects with shoulder pain and nohumeral external rotation theoretically
tomatic subjects’ passive internal rota- impingement.64,71 The role of the serratus should produce similar levels of serratus
tion range of motion was the outcome anterior as an external rotator of the scap- activation, with less potential risk of re-
measure after a 4-week stretching pro- ula may at first seem counterintuitive, as ducing the subacromial space.
gram.75 Both stretching groups were also its lateral line of pull around the thorax Another muscle that can be used to
compared to a control group who did not has resulted in the serratus anterior of- stabilize the scapula and facilitate upward
stretch. Both stretching groups showed ten being described as creating shoulder rotation is the lower trapezius. Exercises
significant within-subject improvements protraction. This protraction occurs with that have been shown to elicit a favorable
in range of motion, as compared to their the clavicle protracting on the thorax at ratio of lessening upper trapezius activ-
nonstretched side.75 Surprisingly, how- the SC joint.115 Before this secondary joint ity and increasing lower trapezius activ-
ever, only the cross-body stretch group rotation can occur, the line of action of ity are shoulder flexion in the side-lying
demonstrated significant improvement the serratus anterior will first pull the position up to 135°, prone horizontal
as compared to the control group.75 The vertebral border and inferior angle of the abduction with external rotation, and
mean length change with 3 proposed scapula towards the chest wall, creating shoulder external rotation in side lying.15
stretches for the pectoralis minor has external rotation of the scapula at the If improved scapular external rotation
also been compared in healthy subjects.5 AC joint, and stabilizing the scapula on during arm elevation is the therapeutic
The stretches included a unilateral self the thorax as protraction of the clavicle goal, strengthening of middle and lower
stretch or “corner stretch,” and sitting occurs.115 trapezius will be an important focus of
and supine manual stretches.5 The uni- Based on electromyographic assess- rehabilitation.29 Because currently there
lateral corner stretch involves standing ments, typically in healthy subjects, a is less evidence for excess scapular inter-
facing the corner of 2 walls, placing the number of exercises have been advocat- nal rotation in persons with subacromial
hand of the shoulder to stretch on the ed to activate the serratus anterior mus- shoulder impingement,44,71 our therapeu-
wall with the humerus abducted 90° and cle.19,42,60,72 These have included push-up tic exercise programs70 focus more on
the elbow flexed 90°. The patient then plus and push-up progression exercises, serratus anterior exercises and less on
rotates the torso away from the shoulder the “dynamic hug,” supine “punch,” and middle trapezius or rhomboid exercises.
to be stretched until a gentle stretch of wall slide exercises.19,42,60,72 If a patient is As the available literature continues to
the pectoral muscles is perceived.5 The also demonstrating excess clavicular el- expand, it is anticipated that a greater
corner stretch demonstrated the great- evation during humeral elevation, excess understanding of the appropriate bal-
est length change, followed by the supine activation of the upper trapezius may be ance of muscular control for producing
manual stretch.5 This suggests that a occurring. If so, high serratus activation optimal scapular kinematics will further
corner stretch may be more effective in may be desired in the presence of lesser refine therapeutic exercise approaches.
lengthening the pectoralis minor; how- upper trapezius activation, where push- We believe that prior to strengthening
ever, subjects were not followed over time up plus and supine punch exercises may of the rotator cuff muscles the clinician
in a randomized controlled trial.5 Further be beneficial, as these exercises demon- should also work on facilitating correct
investigation is warranted regarding the strate minimal upper trapezius activa- timing of muscular recruitment.16,120 Ag-
most effective approaches for stretching tion.72 Other considerations in the choice gressive strengthening in the presence of
both of these tissues. of serratus exercises include the ability faulty scapular control will only serve to
We also believe strengthening or re- of the patient to prevent excess scapular reinforce poor kinematics and likely not
training of the serratus anterior muscle internal rotation, or winging, during the provide relief for the patient in terms of
deserves substantial attention in the performance of the exercise, and avoid- pain or improved function.
treatment of patients with shoulder pain ance of impingement positions. Patients Given the evidence for altered scapu-
and associated scapular motion altera- having difficulty with scapular control lar kinematics with thoracic kyphosis
tions. This recommendation is based on may benefit from the initial use of an ex- or flexed thoracic postures,18,53 thoracic
the biomechanical capabilities of the ser- ercise, such as the supine punch, where posture should also be addressed in the
ratus anterior, as the only scapulothoracic the scapula is stabilized against the table. rehabilitation of patients with shoulder
muscle that can produce all of the desired The “dynamic hug” exercise, as originally impingement or rotator cuff tendinopa-
3-dimensional scapular rotations of up- described,19 should also be used judicious- thy. This includes attention to maintain-
ward rotation, AC joint posterior tilting, ly, as it places the glenohumeral joint into ing erect postures during the performance
and AC joint external rotation.21,29,115 It a position of flexion, adduction, and in- of daily activities involving elevation of
has large moment arms for producing ternal rotation that may be painful for a the arm, as well as during shoulder exer-
these scapular rotations,21,29,115 and the patient with subacromial impingement. cises. Exercises directed toward improv-
ing thoracic extension range of motion, thy.1,8,9,13,33,34,39,40,70,76,85,102,122 There is also ment deviations and develop and refine
strength, and endurance should also be some evidence that the addition of man- clinical practice guidelines supported
considered where appropriate to the pa- ual therapy to stretching and strength- by research data. For example, a patient
tient presentation, while also realizing ening exercises can further improve presenting with a medical diagnosis of
that normal thoracic extension during outcome.1,13,102 However, the evidence that subacromial shoulder impingement con-
arm elevation is only 10° or less.116 We scapular kinematic alterations identified sistent with subacromial pain and a pri-
would caution, however, to avoid exces- in these populations can be changed is mary movement dysfunction of scapular
sive emphasis on shoulder retraction less strong.57,76,121 One investigation dem- anterior tilting during arm elevation may
exercises for rhomboid strengthening as onstrated significantly decreased thoracic benefit most from a program of serratus
part of a postural exercise program, given spine “anterior inclination,” decreased anterior strengthening and pectoralis
this muscles’ capabilities as a downward scapular upward rotation, and decreased minor and posterior capsule stretching,
rotator of the scapula. Joint mobilization scapular elevation after a 6-week exercise as well as attention to thoracic posture.
to the thoracic spine may be another re- program in healthy subjects.121 Another Based on biomechanical considerations,
habilitation approach to consider. In a demonstrated that a 6-week program, such a patient is less likely to benefit from
randomized clinical trial, the addition of which included stretching for anterior trapezius strengthening, as the trapezius
manual therapy to a supervised exercise shoulder muscles and strengthening for cannot substantively posteriorly tilt the
program for shoulder impingement dem- posterior shoulder muscles, significantly scapula.29,48,115 Alternatively, another pa-
onstrated significantly greater improve- reduced “forward shoulder posture” in tient presenting with a medical diagnosis
ment than supervised exercise alone.1 It competitive swimmers as compared to a of shoulder impingement consistent with
should be noted, however, that any use of control group of swimmers.57 However, posterior impingement and a primary
thoracic mobilization in this trial was case in the only published investigation, where movement dysfunction of excess scapu-
specific and clearly not the only difference both functional outcome and scapular ki- lar internal rotation during arm eleva-
between the 2 treatment groups.1 nematics were assessed in subjects with tion may benefit from a program of both
The use of therapeutic taping in impingement, no significant kinematic trapezius and serratus anterior strength-
shoulder pain has also been recently in- differences were found after a 6-week ening, pectoral stretching, and attention
vestigated.63,101 Using thoracic and scapu- exercise program, despite significant im- to thoracic posture.29 This premise of
lar taping intended to change posture in provements in functional status and re- targeted exercise programs requires fur-
both subjects with shoulder impinge- ductions in pain.76 It should be recognized ther investigation in patient populations.
ment and healthy subjects, significant that the clinical trials currently available Clearly, despite the growing expanse of
changes in posture and increases in arm in the literature vary substantially with clinically applicable literature regarding
elevation pain-free range of motion were regard to the choice of specific stretch- glenohumeral joint pathologies, there re-
noted with taping in both groups.63 No ing and strengthening exercises used, mains much work to be done.
significant reduction in pain during arm “doses” of exercise application, additional
elevation was achieved in the group with interventions, length of intervention and IKCC7HO
impingement. However, the point in follow-up, and subject demographics and
I
the range of motion at which increased clinical presentation. A further confound- n summary, there is evidence of
pain was first perceived was significantly er of the effectiveness of any exercise pro- scapular kinematic alterations associ-
higher (average of 15° and 16° increase gram is patient compliance. ated with shoulder impingement, rota-
in pain-free range of motion for scapular Although there is substantive evi- tor cuff tendinopathy, rotator cuff tears,
plane abduction and flexion, respective- dence that therapeutic exercise pro- glenohumeral instability, adhesive cap-
ly).63 Another investigation demonstrated grams are beneficial, it is also clear that sulitis, and stiff shoulders. There is also
reduced upper trapezius and increased not all subjects are improving, nor do the evidence for altered muscle activation in
lower trapezius electromyographic acti- overall levels of improvement represent these patient populations, in particular,
vation with use of taping in subjects with complete elimination of symptoms.70 We reduced serratus anterior and increased
shoulder impingement during arm eleva- are hopeful that the ability to clinically upper trapezius activation. Scapular ki-
tion.101 Further study of this approach in discern and diagnose specific shoulder nematic alterations similar to those found
patient populations appears warranted. movement dysfunctions, and our under- in patient populations have been identi-
Through clinical trials, there is mount- standing of the underlying tissue pathol- fied in subjects with a short rest length
ing evidence to support the effective- ogies, will improve in the future. If that of the pectoralis minor, tight posterior
ness of therapeutic exercise approaches can be achieved, clinicians and research- shoulder, thoracic kyphosis, or with flexed
in the management of shoulder im- ers may be better able to target specific thoracic postures. This suggests that at-
pingement and rotator cuff tendinopa- exercise programs to identified move- tention to these factors is warranted in
the clinical evaluation and treatment of 9.8hen@?"IjW÷F>"B`kd]]h[d7;"8h[l_a@?$ nohumeral kinematics. J Electromyogr Kinesiol.
Arthroscopic surgery compared with super- 2006;16:224-235. http://dx.doi.org/10.1016/j.
these patients. The available evidence in
vised exercises in patients with rotator cuff jelekin.2005.06.015
clinical trials supports the use of thera- Z_i[Wi[ijW][??_cf_d][c[djiodZhec[$BMJ. ()$ Ebaugh DD, McClure PW, Karduna AR. Scapu-
peutic exercise in rehabilitating these pa- 1993;307:899-903. lothoracic and glenohumeral kinematics fol-
tients, while further gains in effectiveness 10. Caldwell C, Sahrmann S, Van Dillen L. Use of lowing an external rotation fatigue protocol.
a movement system impairment diagnosis for J Orthop Sports Phys Ther. 2006;36:557-571.
should continue to be pursued. T
physical therapy in the management of a patient http://dx.doi.org/10.2519/jospt.2006.2189
with shoulder pain. J Orthop Sports Phys Ther. (*$ Ellenbecker TS, Derscheid GL. Rehabilitation
ACKNOWLEDGEMENTS: This work was sup- 2007;37:551-563. http://dx.doi.org/10.2519/ of overuse injuries of the shoulder. Clin Sports
ported by NIH grants K01HD042491 and jospt.2007.2283 Med. 1989;8:583-604.
11.9Wb_iC"7a]kdA"8_hjWd[C"AWhWYWd?"9Wb_i>" 25.;dZeA"?aWjWJ"AWjeÎ"JWa[ZWO$HWZ_e]hWf^_Y
R03HD053399 from the National Institute Tuzun F. Diagnostic values of clinical diagnostic assessment of scapular rotational tilt in chronic
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Institutes of Health. ')$ Conroy DE, Hayes KW. The effect of joint mo- 27. Falla D, Farina D, Graven-Nielsen T. Experimental
bilization as a component of comprehensive muscle pain results in reorganization of coor-
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The Association of Scapular Kinematics and Glenohumeral Joint Pathologies

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[ CLINICAL COMMENTARY ]

PAULA M. LUDEWIG, PT, PhD¹@ED7J>7D<$H;ODEB:I" PT, PhD²